An Integrated Theoretical Approach to Substance Use and Risky Sexual Behavior Among Men Who Have Sex with Men

Brooke E. Wells; Sarit A. Golub; Jeffrey T. Parsons


AIDS and Behavior. 2011;15(3):509-520. 

In This Article

Abstract and Introduction


Research demonstrates a consistent association between substance use and sexual risk, particularly among men who have sex with men (MSM). The present study builds upon two existing theories (Cognitive Escape Theory and Expectancy Theory) to examine the synergistic role of sexual conflict (surrounding unsafe sex) and expectancies in sexual behavior among 135 MSM. Two conflicts were examined: (1) The conflict between motivation to practice safer sex and temptation for unprotected sex; and (2) The conflict between motivation to practice safer sex and perceived benefits of unprotected sex. Factorial ANOVAs (2 × 2; high versus low expectancies and conflict versus no conflict) revealed a significant interaction between conflict and expectancies—individuals who reported high levels of conflict were more sensitive to the effect of expectancies than were those experiencing low levels of sexual conflict. Results demonstrate the synergistic effects of conflict and expectancies and highlight the importance of integrating existing theories to more fully consider the intrapsychic operation and experience of sexual conflicts.


Decades of research demonstrate a consistent association between substance use and sexual risk behavior, particularly among men who have sex with men (MSM). MSM who use substances are more likely to engage in sexual risk behavior[1,2] and are more likely to be HIV+ or test positive for a sexually transmitted infection (STI).[1,3] Further, situational evidence demonstrates that the concurrency of sexual behavior and substance use predicts risky sexual behavior[4,5] and HIV/STI transmission.[6,7] The mechanism(s) by which these associations occur, however, is still not entirely clear. While some studies suggest that personality factors, namely sensation seeking, may explain the association between substance use and sexual risk behavior,[8,9] longitudinal research shows that MSM engage in more risky sex during periods of heavy substance use compared to periods of abstinence or lighter substance use,[10] indicating that overarching personality factors may not fully explain the substance use-risk association. Further, despite the evidence for a causal link, there are certainly MSM who engage in sexual risk behavior without using substances and there are men who engage in substance use but do not engage in sexual risk behavior.[11] Thus, it is important to more thoroughly examine for which individuals and under which conditions the co-occurrence of substance use and sex is likely to lead to sexual risk behavior.

Accordingly, this paper integrates two theories regarding the association between substance use and sexual risk in an exploratory attempt to improve our understanding of the mechanisms underlying sexual risk under the influence. Identifying mechanisms of risk under the influence will lead to more targeted and specific points of intervention and prevention as well as provide a more nuanced profile of those at risk for the deleterious sexual effects of substance use.

Theoretical Understandings of the Association Between Substance Use and Sexual Risk

Various underlying mechanisms of causation may explain the differential associations between substance use and risk. Specifically, two primary theories have been developed to understand the association between substance use and sexual risk behavior: Expectancy Theory and Cognitive Escape Theory. Research increasingly points to the utility of considering both of these theoretical constructs simultaneously and to the need to more explicitly extend these theories to account for the effects of sexual conflict, as described below.

Expectancy Theory Expectancy theory[12–15] focuses on the importance of internalized cultural and social expectations about the effects of substances on sexual behavior. In this theory, individuals' expectations that substance use lowers sexual inhibitions and/or enhances sexual pleasure moderates its relationship to sexual behavior, making sexual behavior under the influence more likely and more risky as such expectations increase. For example, individuals who drink report beliefs that alcohol reduces sexual inhibitions, helps them feel closer or more open to other people, and enhances sexual pleasure.[16] There is evidence that expectancies alone, even in the absence of actual alcohol consumption, are enough to change people's behavioral intentions. For example, in a balanced placebo design study, individuals who believed they had consumed alcohol, but who had actually consumed a placebo drink, reported stronger intentions to engage in unsafe sex and lower perceptions of risk when compared to those who consumed a placebo and did not believe they were drinking alcohol.[17] In research with MSM, those who reported unprotected sex more strongly believed in the sexual effects of substances, when compared to men who did not engage in unprotected sex [18].

Cognitive Escape Theory Cognitive Escape Theory[19] builds upon the social psychological literature regarding the cognitive load imposed by behavioral restraint, e.g., dieting, avoiding alcohol. McKirnan et al.[19] hypothesize that constantly avoiding sexual risk becomes cognitively burdensome, motivating a behavioral "rebound" that allows individuals to escape from this constraint. For example, constant thought suppression regarding desire to engage in sexual risk behavior predicts unsafe sexual encounters occurring through public or internet meeting venues.[20–22] As such, cognitive restraint or burden is considered a vulnerability in the escape model. Expectancies are also considered a vulnerability in the escape model, with McKirnan et al. hypothesizing that, cognitive restraint, "when combined with specific expectancies or personality dispositions, lead people to use substances strategically to induce a state of cognitive escape regarding personal risk" [19, p. 660]. Substance use is a strategy used to facilitate cognitive escape and facilitates general cognitive disengagement, wherein people are more sensitive to external pressures. For example, research shows that the association between substance use and unsafe sex was stronger among men who score higher on a measure of effortful sexual restraint when compared to men whose scores reflected less effortful adherence to safer sex norms.[23] McKirnan et al.[24] also found that gay men who both frequently used drugs and strongly expected that alcohol and drugs facilitated cognitive escape, reported more sexual risk behavior than those with weaker expectancies.

Sexual Conflict Borrowing from the ideas of cognitive dissonance, wherein an individual may simultaneously hold inconsistent beliefs, motivations, or other cognitions, research suggests that sexual conflict, or conflicting thoughts or beliefs about unprotected sex, may also predict risky sex. For example, an individual may simultaneously be strongly motivated to engage in safer sex, but also strongly believe in the benefits of unprotected sex. Research indicates that conflict regarding sexual identity (e.g., internalized homophobia), ambivalence toward sexual behavior, and internalization of sexual double standards are associated with risk-taking behavior, including decreased condom and contraceptive use among both men and women,[25–27] as well as increased alcohol or substance use in sexual situations.[28] These sexual conflicts likely create the kind of cognitive burden and/or necessitate the cognitive restraint discussed in Cognitive Escape Theory. In other words, these conflicts may be one of the underlying intrapsychic operations that lead to cognitive burden. As such, we propose an integrated model that extends Cognitive Escape Theory to encompass sexual conflict, described below.

Integrating the Theories

Clearly, each of these bodies of literature contributes to our understanding of the association between substance use and sexual risk behavior. Integrating these literatures into one model and extending our understanding of the intrapsychic operation of sexual conflict, as proposed in this paper, is useful for two primary reasons. First, to our knowledge, no studies have examined cognitive burden and expectancies in one model; rather, research has relied on one or the other characteristic to support cognitive escape theory (c.f.[24,29]). Second, we posit that sexual conflict may be a critical antecedent to cognitive burden in that these conflicts likely increase the restraint necessary to prevent unprotected sex. As such, it is important to consider both the factors leading to cognitive restraint or burden and expectancies in one integrated model. As proposed in Cognitive Escape Theory, these intrapsychic sexual conflicts may interact with expectancies to produce a state in which an individual feels conflicted about his behavior and recognizes that substance use may remove, albeit temporarily, those conflicting feelings. Consequently, we propose a theoretical integration, which focuses on the synergistic effect of sexual conflict and expectancies.

This model, depicted in Fig. 1, highlights the interacting effects of sexual conflict and expectancies on sexual behavior under the influence of substances. Utilizing this integrated theoretical model, we propose that individuals who are both sexually conflicted and strongly believe in the sexual effect of substances will engage in a higher percentage of their sexual acts under the influence and will engage in more of their risk behavior while under the influence, compared to those who are either not conflicted (with high or low expectancies) and those who are conflicted, but have low sexual expectancies associated with substance use. Evidence for this model will also provide two distinct places for intervention and prevention efforts. First, intervention development might focus on dismantling sexual expectancies and eliminating beliefs that substance use is an effective means of escape from conflict around sexuality. Second, efforts might target sexual conflicts themselves, helping individuals to reduce conflicting attitudes and desires about their sexual behavior, thereby reducing the need for conflict resolution through substance use.

Figure 1.

Hypothesized association between expectancies, conflict, and sexual behavior under the influence (UI)

Present Study

The current study presents a preliminary exploration of the proposed integrated model. Informed by critical components of each theory, we hypothesize that individuals who are both conflicted and strongly believe that substance use influences their sexual behavior will behave differently from those who are either conflicted but do not hold strong expectancies or those who are not conflicted, regardless of their expectancies. Specifically, we hypothesize that individuals who are both conflicted about their behavior and strongly believe that substance use influences their sexual behavior will engage in more of their sexual activity under the influence of substances and will report that more of their high risk sexual activity (unprotected sexual activity with a casual partner) occurs under the influence, in comparison to the other groups (conflicted-low expectancies, not conflicted-low expectancies, not conflicted-high expectancies). In other words, we posit that expectancies will function most strongly among those who are highly conflicted, as illustrated in Fig. 1. Because we believe that individuals who are both conflicted and strongly believe in the sexual influence of substances are conceptually distinct, we have chosen to examine these variables categorically, in a 2 × 2 design (conflict versus no conflict, high expectancies versus low expectancies). As this is an exploratory study of the proposed integrated model, evidence of the utility of the constructed measures of conflict and a significant interaction between conflict and expectancies will highlight the utility of this approach and the need for additional research.


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