Drinking games, binge drinking and risky sexual behaviors among college students.

Dear Editor:

During the past few decades, there has been an increase in the number of investigations on the co-occurrence of drinking games and binge drinking on college campuses. Drinking games foster socialization by bringing different groups of students together in shared competitions and tasks (Adams and Nagoshi, 1999), and the level of game participation is governed by a set of rules designed to ensure binge drinking (Baer, 2002). Binge drinking refers to five plus drinks per drinking episode for males and four plus drinks per drinking episode for females, and one out of four students drink at a binge level (Wechsler & Wuethrich, 2002). Students who participate in drinking games expect alcohol to facilitate social interactions with peers, drink heavily and experiment with drugs. Nagoshi and colleagues (1994) found a positive relationship between drinking game participation and heavy drinking among 202 undergraduate students. Similarly, Adams and Nagoshi (1999) replicated Nagoshi's study (1994) and found that game playing and socialization (i.e. celebration) positively predict drinking among freshman students after conducting a pre-post survey with 195 students enrolled in introductory psychology courses. Drinking games may reduce social anxiety levels associated with new environments and unfamiliar social surroundings for first-year students, which in turn may facilitate a cycle of social and heavy drinking.

Research on binge drinking and risky sexual behaviors is mixed. Leigh and Shafer (1993) propose that there are salient cues associated with safe and unsafe sex while under the influence depending on if the partner is new (i.e. situational association) and whether the sexual encounter is reoccurring (i.e. event association), and the quantity and frequency of alcohol consumption (i.e. global association). Corbin and Fromme (2002) found that situational and event associations mediate the link between drinking and risky sexual behaviors with a new sexual partner when they conducted a pre-post test study using self-report questionnaires with 576 college students. Results from their study indicate that students who had sex with a new partner were more likely to use condoms while under the influence but only with a first sexual encounter. Findings from this study further suggest that a sexual partner (i.e. new vs. regular) and a sexual event (i.e. first vs. recent) moderate the level of sexual risk. Similarly, Dermen and Cooper (2000) fund an indirect relationship between drinking and risky sexual behaviors when they assessed 392 college students in an introductory psychology course. In this study, alcohol use predicted condom use with first and recent sexual encounters regardless of partner status. They surmised that alcohol use is positively associated with condom use and that sexual risk taking is an independent predictor in this covarying relationship.

Social norms underlie the context of the college environment and drinking games and binge drinking are common practices that are apart of campus (Baer 2002; Wechsler & Wuethrich, 2002). Drinking games may foster drinking and drug use, and alcohol and drug use may be directly linked to risky sexual behaviors because alcohol intoxication lowers inhibitions and distorts cognitive abilities to make constructive choices regarding partner selection and safe sex precautions, therefore understanding these covarying relationships should be explored if prevention efforts are to advance. The extent to which drinking games and binge drinking co-occur to casually promote risky sexual behaviors has not been investigated. The current study addresses this paucity of research by investigating the relationship between drinking games, binge drinking and risky sexual behaviors. Specifically, this study asked two questions: (1). Is there a significant relationship among drinking game participation, binge drinking, alcohol and drug use frequencies and severities, and risky sexual behaviors, and (2). Are there differences in risky sexual behaviors between binge drinkers and non-binge drinkers? The term "risky sexual behaviors" refers to unplanned, unprotected and unsafe sex, sex with a stranger, multiple partners, and a failure to discuss sexual practices prior to intercourse in this study.

METHOD

A survey research design with questionnaires assessing retrospective and prospective data on drinking, drug use and risky sexual behaviors were administered to 225 college students. Students enrolled in introductory psychology courses during the spring of 2002 through the spring of 2003 were trained to select a research participant and administer a survey on drinking patterns, and most of them recruited participants from dormitories, classes, and campus organizations. Participants completed the survey at their own pace (approximately 20 minutes), placed it in a confidential envelope, and gave it to the student recruiter who in turn gave it to the researcher during the first two weeks of the semester for course credit. This study was conducted in accordance with the ethical standards of the psychology department and of the social science division.

The majority of participants (46% male, 54% female) were Caucasian (77%), single (99%), and freshman (80%) with on-campus housing (77%), and the average age was 19 years (SD = 1.30). More than half of the participants reported having sex (70%), and out of them, they were sexually active for almost three years (M = 2.83, SD = 2.18). Students' average number of lifetime sexual partners was 2.14 (SD = 1.46) and their average number of sexual partners since college was 1.09 (SD = .99). Slightly over a third (36%) of students report using a condom consistently and the rate of risky sexual behaviors for male and female students are shown in Table 1.

Most of the students consumed alcohol (85%) with 71% of them meeting the criteria for binge drinking. Out of these students, most of them participated in drinking games (72%) but less than half of them (30%) used drugs. The rate of binge drinking is similar to national averages but the rate of drug use is substantially lower than averages for college students as presented in Table 2.

A survey with embedded questionnaires measuring socio-demographic characteristics, drinking and drug use, and risky sexual behaviors was used for this study.

Demographic Questionnaire. A self-report survey was used to collect descriptive information on gender, race, age, religion, and marital status, and employment status, types of student, and year in school.

Alcohol and Drug Measure. This questionnaire measured the amount, type, and frequency of alcohol and drug use. Items were abstracted and incorporated into a self-report format from the drug and alcohol section of the Addiction Severity Index, 5th Edition developed by McLellan, Urshel, and Blair (1997) and the alcohol and other drug measure developed by Nagoshi and colleagues (1994). The Addiction Severity Index (ASI) is the most widely used instrument in addiction treatment. The ASI is a structured, 30-40 minute clinical research interview designed to assess problem severity in seven areas commonly affected among substance using individuals. These areas include alcohol and drug use, medical, legal, employment, family/social problems, and psychiatric problems. In each of the areas, verifiable questions are asked, measuring the number, frequency, intensity, and duration of problem symptoms in the patients' lifetime and during the past 30 days (McLellan et al., 1997).

Binge Drinking. Items measuring the type, frequency and quantity of alcohol and drug use during the past year were abstracted from the alcohol and drug use measure (Nagoshi et al., 1994). Responses were recoded by multiplying frequencies and quantities to produce a full score of total monthly alcohol use. Then this variable was recoded into a dichotomized variable as "0" indicating no binge (less than 5 drinks per sitting) and "1" indicating binge (5 or more drinks per sitting) which is consistent with previous investigations on binge drinking (Wechsler & Nelson, 2001).

Risky Sexual Behaviors. Items were abstracted from the Risk Assessment Form developed by Keeling (1989) and combined with a truncated version of the Risk for AIDS Behaviors Scale developed by the National Institute of Drug Abuse (1990) for a total of 22 questions assessing sexual behaviors, e.g. "the frequency with which I use alcohol to enhance my sexual encounters" and "how many times have you had sex with a stranger, etc." Individuals responded to each of the 18 items on either a 3-point or 5-point Likert type scale, indicating the frequency of engaging in risky sexual behaviors. 3-point responses include never (0), occasionally (1), and frequently (2), and 5-point responses include never (0), once (1), twice (2), three times (3) and more than three times (4). Inter-correlations among item scores ranged from .36 to .41, and individual response items with categorical response items were used for the analyses. The remaining four items that assessed sexual behavior required students to either circle the number that described their behavior or fill in the blank, i.e.) "how many sexual partners have you had in your lifetime," or how long have you been sexually active."

Drinking Games. A questionnaire developed by Wood, Johnson and Sher (1992a) measured the frequency of drinking game participation. Subjects rated their frequency of playing drinking games and typical quantity of playing drinking games. Items were recoded to produce a dichotomized variable for either "1" drinking game participation or "0" no participation.

RESULTS

A Forward Step-wise Regression Analysis was repeated with eight risky sexual behavior measures as criterion variables: number of one-night stands, sex with a stranger, number of sexual partners, number of sexual partners since college, awoke unsure if had sex with a stranger, awoke unsure if had sex with someone familiar, and negotiation and discussion of safe sex practices with partner. A Forward Step-Wise Regression method was used to identify the amount of the variance in the criterion variable (i.e. risky sexual behaviors) from the least to the most significant predictors. Predictor variables that were entered into each model included: drinking game participation, binge drinking, monthly drug frequency, monthly alcohol frequency and severity, and yearly alcohol frequency and severity. Monthly drug use frequency positively predicted number of one-night stands ([beta] = .38, t [173] = 5.53, p <.000), number of sexual partners ([beta] = .32, t [173] = 4.52,p <.000), sex with a stranger ([beta] = .34, t [176] = 4.90, p <.000), and awoke unsure if had sex with someone familiar ([beta] = .28, t [176] = 3.95, p <.000).

Monthly alcohol use negatively predicted safe sex discussions ([beta] = -. 16, t [169] = -2.18, p <.05), while drinking game participation positively predicted safe sex negotiations ([beta] = .18, t [170] = 2.53, p <.05). Monthly alcohol use severity ([beta] = .07, t [174] = 4.44, p <.000), yearly drug use frequency ([beta] = .06, t [173] = 2.26, p <.05), and drinking game participation ([beta] = -.28, t [172] = -1.98, p <.05) also predicted awoke unsure if had sex with a stranger.

A Factorial ANOVA was conducted with eight dependent variables: number of one-night stands, sex with a stranger, awoke unsure if had sex with a stranger, awoke unsure if had sex with someone familiar, and frequency and severity of alcohol and drug use before sex between binge and non-binge drinkers. There was a significant main effect for drinking severity before sex (F [1,173] = 5.87, p <.05) between binge drinkers ([chi] = .93) and non-binge drinkers ([chi] = .36). Binge drinkers ([chi] = .43) also had greater frequency of drinking before sex scores (F [1,172] = 5.70, p <.05) than non-binge drinkers ([chi] = .27).

DISCUSSION

There has been a tremendous amount of prevention research and policy reform of drinking practices on college campuses during the past few years. Despite these developments, research on social norms and risky sexual behaviors for college students is scant. The present study was designed to address this paucity of information by asking: (1). Is there a significant relationship among drinking game participation, binge drinking, and risky sexual behaviors in this sample, and (2). Are there differences in risky sexual behaviors between binge drinkers and non-binge drinkers?

Most of the students report participating in drinking games and binge drinking however few of them engaged in risky sexual behaviors. Less than half of the students report having a one-night stand or sex with a stranger, and less than twenty percent of them report being unsure if they had sex with a stranger or non-stranger. Almost all of the students report drinking or using drugs to enhance sex. In addition, there were few gender differences in sexual practices. Females were more likely to discuss previous sexual encounters, but less likely to use protective contraceptives than males. However, females reported using contraceptives (i.e. birth control pill) and feeling guilty after sex, therefore prevention programs should target female students with gender-specific interventions.

The relationship between drinking games, binge drinking and risky sexual behaviors was partially supported. In fact, monthly drug use, alcohol use, and drinking game participation were associated with specific types of sexual risk-taking and thus demonstrate a trait-level perspective on sexual risk. Drug use was a direct and positive predictor, while alcohol use was a direct and negative predictor, and drinking games was a direct and positive predictor for risky sexual behaviors. Specifically, drug use was associated with students' increased number of one-night stands and sexual partners, and an inability to recall sex with a stranger or with someone familiar, which is consistent with previous findings on global associations of risky sexual behaviors.

Although students' drug use was directly associated with sexual risk-taking, their drinking and game playing were directly linked to their expectancies about risky sex. Students who consumed more alcohol were less likely to have safe sex discussions, and those who played drinking games were more likely to have safe sex discussions. Students who consumed more alcohol, used drug more frequently and abstained from drinking games were more likely to awake unsure if they had sex with a stranger is partially consistent with previous research. Sharer and colleagues (1994) found that the majority of young adults who drink and use drugs were more likely to have unprotected sex. In addition, research on situational and extent associations indicate that college students were likely to have safe sex depending on partner status (i.e. first or regular) and type of sexual encounter (i.e. new or recurrent) (Corbin & Fromme, 2002; Dermen & Cooper, 2000). A possible explanation for inconsistent findings between current and previous research is that drug use and drinking games were not assessed, and the majority of students in this study participated in drinking games. It is plausible that having a history of drug use is a precursor for drinking game participation and game playing produces an inverse relationship, which suggests that drinking games may be indirectly associated with risky sexual behaviors.

A unique contribution was that students' who participated in drinking games were more likely to report safe sex discussions and reduced risky sexual behaviors (i.e. awoke unsure if had sex with a stranger). These findings indicate that game playing may serve as a protective factor for risky sexual behaviors and are inconsistent with previous research (Corbin & Fromme, 2002; Dermen and Cooper, 2000; Sharer et al., 1994). However, investigations on sexual risks may not have assessed the variance from drinking games on risky sexual behaviors and drinking games may account for a greater proportion of the variance in predicting unsafe sexual behaviors, but if scientific exploration of this variable is to advance, definition and measurement of it will need to develop further.

The co-occurrence of drinking games and binge drinking did not influence risky sexual behaviors but there were significant differences between binge and non-binge drinkers. Binge drinkers consumed alcohol more often and more heavily before sex than non-binge drinkers are consistent with findings on binge drinking (Wechsler and Wuethrich, 2002). Binge drinking may serve as a risk factor for a specific type of sexual risk, but further exploration of binge drinking is necessary to determine the direct and indirect relationship between binge drinking and sexual risk.

The hypothesized relationship between drinking game participation, binge drinking and risky sexual behaviors was partially supported. In fact, game playing was not a precursor for binge drinking and binge drinking was not a precipitating factor for risky sexual behaviors. The link between drinking game participation, binge drinking and risky sexual behaviors is neither simple nor direct and requires moving beyond a cognitive-expectancy paradigm. Drinking game participation and binge drinking precipitate different sexual risks adds support for the trait-level perspective on risky sexual behaviors. Implications from this study suggest that the relationship between drinking games, binge drinking and risky sexual behaviors may be mediated by the social norms of a particular college campus. Theoretical underpinnings of drinking games, binge drinking, patterns of alcohol and drug use, and risky sexual behaviors need to be further explored to better understand this relationship.

The current findings add to the literature on collegiate drug use and may be potentially useful to prevention professionals, although results should be viewed in light of a few key limitations. First, the data are only generalizable to a private college population at one university in the eastern United States. Second, the data were collected using self-report methodology and students may not have answered questions honestly or recalled answers accurately. It is possible that students may have over or under reported rates of alcohol and drug use and sexual activity. Finally, the sample size yielded only a third of drug users. A national study would likely address all of these limitations. Future research may address these limitations by employing randomization, multiple self-report measures and follow-up assessments, and large diverse samples of students from different institutions.

References

Adams, C. E., & Nagoshi, C. T. (1999). Changes over one semester in drinking games and alcohol use and problems in a college student sample. Substance Abuse, 20 (2), 97-106.

Baer, J. S. (2002). Student factors: Understanding individual variation in college drinking. Journal Studies on Alcohol, 12, 40-53, 2002.

Corbin, W. R., & Fromme, K. (2002). Alcohol use and serial monogamy as risks for sexually transmitted diseases in young adults. Health Psychology, 21, 229-236.

Dermen, K.H., & Cooper, M. L. (2000). Inhibition conflict and alcohol expectancy as moderators of alcohol's relation to condom use. Experimental and Clinical Psychopharmacology, 8, 198-206.

Keeling, R. P. (1989). Risk Assessment Form. AIDS on the College Campus. Washington, DC: American College Health Association.

Leigh, B. C., & Schafer, J. C. (1993). Heavy drinking occurrences and the occurrence of sexual activity. Psychology of Addictive Behaviors, 7, 197-200.

McLellan, A. T., Urschel, H. C., & Blair, J. (1997) Addiction Severity Index, 5th Edition.

Nagoshi, C. T., Wood, M. D., Cote, C. C., & Abbit, S. M. (1994). College drinking game participation within the context of other predictors of alcohol use and problems. Psychology of Addictive Behaviors, 8, 203213.

National Institute on Drug Abuse, Risk for AIDS Behaviors. Rockville, MD, 1990.

Schafer, J., Blanchard, L., & Fals-Stewart, W (1994). Drug use and risky sexual behavior. Psychology of Addictive Behaviors, 8, 3-7.

Wechsler, H. & Nelson, T. F. (2001). Binge Drinking and the American College Student: What's five drinks? Psychology of Addictive Behaviors, 14 (2), 287-291.

Wechsler, H. & Wuethrich, B. (2002). Dying to Drink: Confronting Binge Drinking on College Campuses. United States: Rodale.

Wood, M. D., Johnson, T. J. & Sher, K. J. (1992a). Characteristics of frequency drinking game participants in college: An exploratory study Alcoholism: Clinical and Experimental Research, 16, 417.

Lori Simons, Valerie Lantz, Stephanie Klichine & Laura Ascolese Widener University 

Table 1. Percent Responding "Yes" to Risky Sexual Behavior Questions
by Gender

                                                                 [chi
Survey Question                                 Males  Females  square]

 1. The frequency with which I use alcohol
    to enhance my sexual encounters              52      41      4.52
 2. The frequency with which I use drugs
    to enhance my sexual encounters              22      17       .88
 3. My sexual partner and I have described our
    previous sexual behavior and experiences
    with each other                              50      67      6.21 *
 4. I negotiate for safe sex practices           76      82      1.05
 5. In your lifetime, how often did you use a
    condom                                       45      29     11.09 *
6a. I.U.D. as a primary birth control method      3      27
6b. Birth Control Pill as a primary birth
    control method                               14      35     15.36 *
6c. Withdrawal as a primary birth control
    method                                       19      13
6d. Depo Provera as a primary birth control
    method                                        1       2
6e. Condom as a primary birth control method     42      27
6f. Diaphragm as a primary birth control
    method                                        3       1
6g. Rhythm as a primary birth control method      1      .9
6h. Foam/Jelly as a primary birth control
    method                                        0      .9
 7. How much of the time do you drink (beer,
    wine, liquor) before having sex              61      55      3.70
 8. How much of the time do you smoke
    marijuana before having sex                  22      19      2.02
 9. How much of the time do you use drugs
    before having sex                             9      10      3.94
10. Have you ever been diagnosed with a STD       1       5      2.89
11. How many times have you woke-up with a
    stranger and were unsure if you had sex      20      19      2.80
12. How many times have you woke-up with
    someone that you knew but were unsure if
    you had sex                                  13       7      4.89
13. How many one-night stands did you have       31      27      3.89
14. How many times have you been diagnosed
    with more than 1 STD                          2       5      6.87
15. Have you felt guilty or remorseful after
    having sex during the past 30 days           20      24      8.87
16. How often during your lifetime have you
    felt guilty or remorseful after having sex   24      45     12.43 *
17. Have you ever been concerned about a STD     43      47       .56
18. Have you ever been concerned about HIV       31      32       .01

* p < .05

Table 2. Percentages of Alcohol and Drug Use Among College
Students (n = 225)

Variables                               %

Alcohol Frequency/Mo.
Nearly Everyday                         5
Weekly                                 49
1-3 Times/Mo.                          31
None                                   15

Alcohol Severity/Mo.
1-3 glasses of wine, shots, beers      18
4-6 glasses of wine, shots, beers      33
7-11 glasses of wine, shots, beers     26
More than 12 glasses of wine,
shots, beers                            7
More than 12 glasses of wine,
shots, beers                            1
None                                   15

Variables                               %

Drug Use/Yr.
Nearly Everyday                        10
Monthly                                10
Weekly                                 10
5-6 Times                               4
3-4 Times                               5
1-2 Time(s)                             7
None                                   54

Type of Drug Use/Yr.
Amphetamines                            5
Barbiturates                            2
Cocaine                                 5
Crack                                   1
Marijuana                              46
Hallucinogens                           6
Ecstacy                                10

Alcohol Frequency/Yr.
Nearly Every day                        2
Weekly                                 23
Monthly                                32
3-6 Times                              13
7-11 Times                             16
None                                   14

Alcohol Severity/Yr.
1-3 glasses of wine, shots, beers      24
4-6 glasses of wine, shots, beers      28
7-11 glasses of wine, shots, beers     30
More than 12 glasses of wine,
shots, beers                            2
More than 18 glasses of wine,
shots, beers                            2
None                                   14
Binge Drinking                         71
Drinking Game Participation            72
Inhalants                               3
Sedatives                               6
Opiates                                 4

Drug Use Frequency/Mo.
Nearly Every Day                       11
Monthly                                 6
Weekly                                 12
None                                   71

Type of Drug Use/Mo.
Amphetamines                            2
Barbiturates                            2
Cocaine                                 5
Marijuana                              31
Ecstasy                                 1
Hallucinogens                           4
Inhalants                               3
Opiates                                 2
Sedatives                               5