Archives of Sexual Behavior

, Volume 39, Issue 3, pp 724–734 | Cite as

Relationship Between Mental Disorders/Suicidality and Three Sexual Behaviors: Results from the National Comorbidity Survey Replication

  • Natalie P. Mota
  • Brian J. Cox
  • Laurence Y. Katz
  • Jitender Sareen
ORIGINAL PAPER

Abstract

The present study examined the relationship between sexual behaviors and mental disorders and suicidality in the National Comorbidity Survey Replication, a representative sample of adults ages 18 years and older (N = 5,692). The World Health Organization Composite International Diagnostic Interview was used to make DSM-IV based disorder diagnoses. Participants were also asked about suicidality and sexual behaviors. Multiple logistic regression analyses adjusted for sociodemographic variables were used to examine the relationships of three sexual behaviors (age of first intercourse, number of past year partners, and past year condom use) with 15 mental disorders (clustered into any mood, anxiety, substance use, and disruptive behavior groups) and suicidality (ideation and attempts). Compared to ages 15–17, those with age of first intercourse between 12 and 14 had increased rates of lifetime disruptive behavior, substance use, and any mental disorder, and suicidal ideation and attempts (adjusted odds ratio (AOR) range, 1.46–2.01). Those with age of first intercourse between ages 18–25 and 26–35 were at decreased likelihood of several lifetime disorder groups (AOR range, 0.19–0.81). Individuals who had two or more sexual partners in the past year had increased rates of all past year disorder groups examined (AOR range, 1.44–5.01). Never married participants who rarely/never used condoms were more likely than those who always used condoms to experience any mood, substance use, and any mental disorder, and suicide attempts (AOR range, 1.77–8.13). Future research should longitudinally examine these associations and account better for possible familial and personality confounders.

Keywords

Sexual behaviors Age of first intercourse Depression Anxiety Substance use 

Introduction

A considerable proportion of the adolescent and adult population engage in sexual behaviors, such as having multiple partners in a specified time period (e.g., past year) and infrequently using condoms or other contraceptive methods (Anderson, Mosher, & Chandra, 2006; Brener, Kann, Lowry, Wechsler, & Romero, 2006; Santelli, Brener, Lowry, Bhatt, & Zabin, 1998; Santelli, Lindberg, Abma, McNeely, & Resnick, 2000). Furthermore, 30–50% of adolescents under 17 years of age have reported having sexual intercourse (Abma, Martinez, Mosher, & Dawson, 2004; Grunseit & Richters, 2000; Kaestle, Halpern, Miller, & Ford, 2005; Leigh, Morrison, Trocki, & Temple, 1994). Behaviors such as having sex for the first time in earlier adolescence, infrequently using condoms, and having a higher number of sexual partners have been shown to be associated with sexually transmitted diseases in representative samples in Britain and in the U.S. (Fenton et al., 2001; Kaestle et al., 2005). In addition, studies have also shown a link between these behaviors and an increased likelihood of mental disorders (e.g., Carey et al., 2004; Hallfors, Waller, Bauer, Ford, & Halpern, 2005; Kessler et al., 1997; Ramrakha, Caspi, Dickson, Moffitt, & Paul, 2000) but several gaps remain in this body of literature.

The majority of studies examining the relationship between mental disorders and sexual behaviors have been conducted exclusively using samples of adolescents and young adults. In samples from Columbia, New Zealand, and the U.S., cross-sectional and/or longitudinal associations have been found between sexual behaviors (e.g., a high number of sexual partners, irregular condom use, and an earlier age of first sexual intercourse) and an increased likelihood of mood disorders (Hallfors et al., 2004, 2005; Kessler et al., 1997; Lehrer, Shrier, Gortmaker, & Buka, 2006; Ramrakha et al., 2000; Waller et al., 2006) and substance use (Brook, Brook, Pahl, & Montoya, 2002; Kessler et al., 1997; Lavan & Johnson, 2002; Lehrer et al., 2006; Ogletree, Dinger, & Vesely, 2001; Ramrakha et al., 2000; Santelli et al., 1998; Staton et al., 1999; Tubman, Andres, & Wagner, 2003). Furthermore, a number of studies have also found a significant positive relationship between behaviors such as having numerous sexual partners and inconsistent contraceptive use and conduct disorder (antisocial disorders) (Kessler et al., 1997; Lavan & Johnson, 2002; Ramrakha et al., 2000; Tubman et al., 2003). However, no relationship was found between these sexual behaviors and anxiety (Kessler et al., 1997; Lavan & Johnson, 2002; Ramrakha et al., 2000; Tubman et al., 2003). In relation to suicidality, abstinence has been identified as having an indirect protective effect on suicide attempts in Caucasian adolescents through its direct relation to other protective variables of attempts in a path analysis (Thatcher, Reininger, & Drane, 2002). Other studies have found the kinds of sexual behaviors mentioned above to be associated with increased suicidal behavior (Burge, Felts, Chenier, & Parrillo, 1995; Hallfors et al., 2004; King et al., 2001; Ogletree et al., 2001) in adolescent and young adult samples.

Studies that have examined the relationship between sexual behaviors and mental disorders in a wider age range of adults have generally done so using very restricted samples and a limited number of disorders (mainly depression and substance use). In samples of individuals with mental disorders in the U.S. and China, both affective disorders and substance use have been associated with a range of sexual behaviors such as substance use before sex, sex trading, a high number of partners, and a higher rate of unprotected intercourse (Carey, Carey, Maisto, Gordon, & Vanable, 2001; Carey et al., 2004; Meade & Sikkema, 2007; Williams & Latkin, 2005; Yang, Latkin, Celentano, & Luo, 2006). However, these studies have lacked a comparison group of non-drug using individuals or persons without a mental disorder. Finally, almost no research exists examining the relationship between suicidality and sexual behaviors in samples of adults of an extended age range.

It remains unknown whether a relationship exists between sexual behaviors (specifically age of first intercourse, number of past year sexual partners, and frequency of condom use), and mental disorders and suicidality in a general population sample of adults. Behaviors that have been previously linked with a higher likelihood of mental disorders occur more frequently in adolescence and young adulthood (Fergus, Zimmerman, & Caldwell, 2007). However, sexual behaviors could hold different associations with mental disorders at other ages as well, and it is important not to generalize previous findings to these groups. Furthermore, even the few existing epidemiological studies examining these associations in samples of select age groups have used much smaller samples and/or DSM-III-R diagnoses of mental disorders in their investigations. Finally, we speculated that a U-shaped association may exist between mental disorders and age of first sexual intercourse, with individuals reporting both a younger age of first intercourse (12–14 years old) and a much older one (26–35 years) having an increased likelihood of mental disorders. A careful search of the literature did not find any studies that had examined this question of a U-shaped relationship.

In order to fill these gaps as well as to resolve some of the limitations of previous studies, the present study examined the following hypotheses: (1) whether a U-shaped relationship exists between age of first sexual intercourse and a comprehensive range of 15 lifetime mental disorders grouped into mood, anxiety, substance use, and disruptive behavior groups, as well as suicidal ideation and attempts; (2) whether there are positive associations between number of sexual partners in the past year and past year mental disorders and suicidal behavior; and (3) whether less frequent condom use increases the likelihood of having past year mental disorders and suicidality, as diagnosed using the DSM-IV in a nationally representative sample of individuals ages 18 and older from the National Comorbidity Survey Replication (NCS-R).

Method

Participants

A summary of the National Comorbidity Survey Replication (NCS-R) can be found elsewhere (Kessler et al., 2004; Kessler, Berglund, Demler, Jin, & Walters, 2005a). The NCS-R was a 2001–2003 national survey of the United States (excluding Alaska and Hawaii) of individuals 18 years of age and older, not including those residing in institutions. The survey consisted of two parts, Part I and Part II, and the Part II sample was examined in the current study because it included all questions regarding sexual behaviors as well as the additional assessment of disruptive behavior disorders and posttraumatic stress disorder. This subsample of 5,692 Part I participants comprised all individuals who were diagnosed with a lifetime mental disorder in Part I as well as a probability sampling of 25% of the rest of the participants. The overall response rate was 70.9%, and trained lay interviewers conducted household, face-to-face interviews with all participants using computer-assisted interviewing.

Measures

Age of First Sexual Intercourse and Sexual Behaviors

Participants were asked three questions in the current study: (1) “How old were you the first time you had sexual intercourse?”, (2) “How many people have you had sexual intercourse with in the past 12 months?”, and (3) “During the past 12 months, how often did you or your sexual partner(s) wear a condom (“rubber”) while having sex—always, most of the time, sometimes, rarely, or never?” In Question 1, several participants gave very young ages of first sexual intercourse (e.g., age 0), which we thought was likely an indication of childhood sexual abuse rather than consensual early sexual activity. Therefore, we excluded all those participants (n = 110) who reported an age of first intercourse younger than 12 for two reasons: (1) the largest increase was from 11 to 12 in terms of number of participants endorsing this age as age of first intercourse, and (2) age 12 is viewed as the typical transition age between childhood and adolescence. In order to minimize cases of rape in Question 1, we excluded all cases where participants reported the same age for age of first intercourse as they did for age of rape. The remaining participants were divided into four age groups: those who had indicated their age of first sexual intercourse as being between ages 12–14, 15–17, 18–25, and 26–35. We chose the reference category to be ages 15–17 based on it being the group with the largest increase in prevalence from the previous age range. The number of sexual partners reported by participants was divided into three categories: 0 partners, 1 partner, and 2 partners or more. Condom use in the past year was also divided into three groups: those wearing a condom always, mostly/sometimes, and rarely/never in the past year. Several recent studies have shown high test-retest reliability in the self-reporting of a range of sexual behaviors (e.g., number of sexual partners, unprotected sex) via face-to-face interviews (Durant & Carey, 2000, 2002; Schrimshaw, Rosario, Meyer-Bahlburg, & Scharf-Matlick, 2006).

Mental Disorder Diagnoses

Mental disorders were diagnosed based on DSM-IV criteria using version 3.0 of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), which consists of a screening component and 40 assessment sections, 22 of which involve the diagnosing of mental disorders (Kessler & Ustun, 2004). A program was used to produce mental disorder diagnoses based on participant replies to interviewer inquiries, which were entered into a computer. The WMH-CIDI has been shown to have moderate to good agreement with individual-level clinician-based lifetime diagnoses using the Structured Clinical Interview for DSM-IV (SCID) for the majority of the lifetime disorders assessed in this study, with a tendency for the WMH-CIDI to under- rather than over-diagnose (Haro et al., 2006). Agreement between the WMH-CIDI and SCID was also good for most past year diagnostic categories (Haro et al., 2006). The following lifetime mental disorders categories were examined in the current study in relation to age of first sexual intercourse: any mood disorder (consisting of major depressive episode, bipolar I disorder, bipolar II disorder, and dysthymia), any anxiety disorder (including agoraphobia without panic, generalized anxiety disorder, panic attacks, posttraumatic stress disorder, social phobia, and specific phobia), any disruptive behavior disorder (oppositional defiant disorder, conduct disorder, attention deficit hyperactive disorder), any substance use disorder (alcohol abuse, alcohol dependence, drug abuse, drug dependence), and any mental disorder. The following past year mental disorder categories, consisting of the same individual mental disorders above, were examined in relation to past year sexual behaviors variables (number of sexual partners and condom use): any mood, anxiety, and substance use disorder, and any mental disorder. For our past year analyses, we refrained from examining disruptive behavior disorders since they are diagnosed before adulthood, and therefore, are not applicable to the majority of the sample.

Suicidal Behavior

Participants were given a booklet which included the experiences “You seriously thought about committing suicide” and “You attempted suicide.” Interviewers asked participants “Did [the experience] ever happen to you?” and “Did [the experience] happen to you at any time in the past 12 months?” in order to create lifetime and past year variables for suicidal ideation and attempts, respectively.

Procedure

Sociodemographic Characteristics

The following sociodemographic variables were used as covariates in the analyses of the present study: sex, age, race, employment status, marital status, education, urbanicity, and income. Table 1 displays how these variables were operationalized. The categories underlying most of these demographic variables were coded as such in the original NCS-R data, and have been utilized in many publications with this survey (e.g., Kessler et al., 2005a; Kessler, Chiu, Demler, & Walters, 2005b). The continuous variable of age was divided into approximate quartiles (18–29, 30–44, 45–59, 60+). Income was divided into four categories according to distance from the national poverty line: poor (less than poverty line–1.5 times more than), low average (1.5–3.5 times more than), average (6 times more than), and high (over 6 times more than), as has been done in a previous study with NCS-R data (Kessler et al., 2005b).
Table 1

Prevalence of sociodemographic variables, sexual behaviors, and mental disorders in Part II NCS-R sample

 

n (%)

Sociodemographic variables

n = 5,692

Sex

    Male

2,382 (47.0)

    Female

3,310 (53.0)

Age

    18–29

1,370 (23.5)

    30–44

1,827 (28.9)

    45–59

1,521 (26.5)

    60+

974 (21.2)

Race

    Hispanic

527 (11.1)

    Black

717 (12.4)

    Other

268 (3.8)

    White

4,180 (72.8)

Employment

    Working

3,918 (66.8)

    Student

143 (3.1)

    Homeworker

340 (5.6)

    Retired

682 (15.0)

    Other

609 (9.6)

Marital status

    Married/cohabitating

3,236 (55.9)

    Separated/divorced/widowed

1,239 (20.8)

    Never married

1,217 (23.3)

Education

    0–11 years

849 (16.8)

    12 years

1,712 (32.5)

    13–15 years

1,709 (27.6)

    >16 years

1,422 (23.2)

Urbanicity

    Metro

2,350 (39.6)

    Other urban

2,028 (28.7)

    Non-urban

1,314 (31.8)

Income

    Poor

1,182 (22.4)

    Low average

1,263 (22.8)

    High average

1,886 (33.8)

    High

1,165 (21.1)

Sexual behaviors

Age of first intercoursea

n = 4,926

    12–14

563 (10.6)

    15–17

1,971 (39.4)

    18–25

2,273 (47.1)

    26–35

119 (2.9)

Number of partners in past year

n = 5,570

    0 Partners

1,229 (24.0)

    1 Partner

3,763 (65.9)

    2 Partners or more

578 (10.1)

Condom use in past year (in never married individuals)b

n = 765

    Always

310 (41.2)

    Mostly/sometimes

205 (30.2)

    Rarely/never

250 (28.6)

Lifetime mental disordersc

n = 5,692

Any mood disorder

1,857 (19.9)

Any anxiety disorder

3,281 (40.9)

Any disruptive behavior disorder

848 (10.7)

Any substance use disorder

1,144 (14.7)

Any mental disorder

4,166 (52.7)

Lifetime suicidal ideation

1,345 (15.6)

Lifetime suicide attempt

468 (5.0)

Past year mental disordersc

n = 5,692

Any mood disorder

844 (8.8)

Any anxiety disorder

2,006 (23.4)

Any substance use disorder

268 (3.6)

Any mental disorder

2,377 (27.9)

Past year suicidal ideation

229 (2.6)

Past year suicide attempt

49 (0.5)

Note: Displaying unweighted n (weighted %)

aExcluding those individuals reporting first intercourse under 12 years of age and those reporting age of rape at the same age as first intercourse

bPrevalence of condom use excluded those individuals who did not report having intercourse. Figures are shown only for never married individuals in the attempt to exclude as many individuals as possible who rarely/never used a condom due to being in a monogamous relationship

cThe any mood disorder category included major depressive episode, bipolar I disorder, bipolar II disorder, and dysthymia. The any anxiety disorder category included agoraphobia without panic, generalized anxiety disorder, panic attacks, posttraumatic stress disorder, social phobia, and specific phobia. The any disruptive behavior disorder category included oppositional defiant disorder, conduct disorder, and attention deficit hyperactive disorder. The any substance use disorder category included alcohol abuse, alcohol dependence, drug abuse, and drug dependence

Weights were applied to all analyses so as to ensure the national representation of the population of the United States. Taylor Series Linearization, a variance estimation technique that corrects for the sampling design of the NCS-R, was also applied to all analyses using the SUDAAN program (Research Triangle Institute, 2000).

Chi square analyses were used to examine differences within our sexual behaviors variables and sociodemographic characteristics. All analyses adjusted for these sociodemographic variables. Multiple logistic regression analyses were used in order to examine the relationships between one of our three predictor variables, age of first sexual intercourse, and our criterion variables, lifetime mental disorders and suicidality. Our reference category for these analyses was 15–17 year olds. Multiple logistic regression analyses were also used to examine the relationships of our other two predictor variables, number of past year sexual partners and past year condom use, with our criterion variables, past year mental disorders and suicidal behavior. Our reference category for these analyses was 0 partners and always wearing a condom, respectively. It should be noted that our selection of reference categories does not reflect either normalizing or pathologizing these behaviors. In examining past year condom use, we attempted to exclude those individuals who rarely/never used a condom because of being involved in a monogamous relationship by stratifying all analyses by marital status and focusing only on never married individuals. Given the high degree of comorbidity amongst mental disorders (Kessler et al., 2005b), a second, more stringent logistic regression model adjusting for both sociodemographic factors and every other mental disorder diagnostic category and suicidal behavior was used to examine all associations. Supplementary logistic regression analyses stratified by gender were also conducted in order to examine associations between mental disorders and the three sexual behaviors separately in males and females.

Results

Table 1 displays the prevalence in the NCS-R Part II sample of sociodemographic characteristics, of lifetime and past year mental disorder categories, and of each sexual behavior examined in the current study. The greatest proportion of individuals reported their age of first intercourse as being between 18 and 25 years old, although almost 40% of the sample had their first intercourse between 15 and 17 years of age. Furthermore, almost three percent of the sample reported having sex for the first time between ages 26–35, comparable to the prevalence of sexually inexperienced individuals found in this age range in another study (Leigh, Temple, & Trocki, 1993). The majority of participants also reported having had only 1 partner in the past year, likely reflecting that over half the sample was married or cohabitating. Finally, a considerable percentage (28.6%) of never married individuals rarely or never used condoms in the past year.

Results of χ2 analyses for all sociodemographic characteristics and each of the sexual behavior variables showed significant differences across age of intercourse groups and between number of past year sexual partners groups on every variable except urbanicity. In chi square analyses for sociodemographic variables and past year condom use in never married individuals, however, no variable was found to be significantly different within groups (data not shown but available from the corresponding author upon request).

Table 2 shows the results of analyses examining the relationship between age of first sexual intercourse and lifetime mental disorders. Of the four lifetime mental disorder summary categories examined, individuals reporting age of first intercourse between the ages of 12–14 were more likely than those who had first intercourse between 15 and 17 to have substance use, disruptive behavior, and any mental disorder, as well as suicidal ideation and attempts. On the other hand, individuals reporting their age of first intercourse between 18 and 25 were less likely than the reference group to have disorders from every summary group except anxiety, and had a lower likelihood of suicidal ideation and attempts. Participants reporting their age of first intercourse at 26–35 years followed much the same pattern, being less likely than the reference group to have every outcome variable examined. In analyses where other mental disorders were also adjusted for, some associations became no longer significant. The relationship between age of first intercourse and any substance use disorder, however, among several others, remained strong.
Table 2

Relationship between age of first intercourse and mental disorders

 

12–14

15–17

18–25

26–35

Mental disorder categories

Lifetime mood disorder

    n (%)

196 (23.5)

683 (22.2)

719 (18.6)

28 (9.8)

    AOR-1 (95% CI)

1.22 (0.97–1.55)

1.00

0.79 (0.67–0.93)**

0.45 (0.25–0.80)**

    AOR-2 (95% CI)

0.96 (0.75–1.24)

1.00

0.88 (0.74–1.04)

0.64 (0.39–1.05)

Lifetime anxiety disorder

    n (%)

328 (45.1)

1,185 (43.4)

1,291 (40.0)

54 (25.5)

    AOR-1 (95% CI)

1.15 (0.90–1.48)

1.00

0.90 (0.74–1.09)

0.51 (0.32–0.83)**

    AOR-2 (95% CI)

0.92 (0.68–1.24)

1.00

1.01 (0.84–1.22)

0.67 (0.43–1.07)

Lifetime disruptive behavior disorder

    n (%)

190 (25.5)

350 (13.8)

190 (5.7)

6 (2.40)

    AOR-1 (95% CI)

1.79 (1.34–2.39)***

1.00

0.68 (0.52–0.89)**

0.36 (0.14–0.91)*

    AOR-2 (95% CI)

1.51 (1.11–2.05)**

1.00

0.73 (0.55–0.98)*

0.51 (0.19–1.35)

Lifetime substance use disorder

    n (%)

237 (33.1)

472 (18.4)

299 (9.2)

8 (4.0)

    AOR-1 (95% CI)

2.01 (1.59–2.53)***

1.00

0.55 (0.43–0.72)***

0.22 (0.10–0.48)***

    AOR-2 (95% CI)

1.78 (1.42–2.24)***

1.00

0.56 (0.43–0.73)***

0.28 (0.12–0.64)**

Lifetime any mental disorder

    n (%)

463 (67.8)

1,513 (57.4)

1,599 (49.2)

71 (32.8)

    AOR-1 (95% CI)

1.67 (1.22–2.28)**

1.00

0.80 (0.66–0.97)*

0.44 (0.26–0.77)**

    AOR-2 (95% CI)

1.60 (1.14–2.23)**

1.00

0.82 (0.68–1.00)*

0.50 (0.29–0.86)*

Lifetime suicide ideation

    n (%)

173 (23.4)

485 (17.3)

488 (13.2)

13 (4.8)

    AOR-1 (95% CI)

1.49 (1.16–1.92)**

1.00

0.81 (0.66–0.99)*

0.32 (0.13–0.76)*

    AOR-2 (95% CI)

1.24 (0.92–1.67)

1.00

1.01 (0.80–1.26)

0.52 (0.21–1.24)

Lifetime suicide attempt

    n (%)

76 (9.0)

183 (6.1)

131 (3.2)

2 (0.7)

    AOR-1 (95% CI)

1.46 (1.07–1.98)*

1.00

0.61 (0.46–0.81)**

0.19 (0.04–0.96)*

    AOR-2 (95% CI)

0.84 (0.61–1.18)

1.00

0.62 (0.44–0.88)**

0.40 (0.07–2.45)

Note: AOR-1 Adjusted odds ratio 1—Adjusted for sex, age, race, employment status, marital status, education, urbanicity, and income

AOR-2—Adjusted for sociodemographic variables, other mental disorder diagnostic categories, and suicidal behavior (any mental disorder adjusted for suicidal ideation and suicide attempts)

* p ≤ .05, ** p ≤ .01, *** p ≤ .001

Table 3 shows the results of analyses examining the relationships between number of sexual partners in the past year and past year mental disorders. Individuals who had two or more partners in the last year were more likely than those who had not had any partners to have disorders from all diagnostic categories. Individuals reporting one past year partner versus no partners were also at increased likelihood of having any anxiety, substance use, and overall mental disorder. Associations, for the most part, remained significant even after adjusting for every other mental disorder category.
Table 3

Relationship between number of sexual partners in last 12 months and past year mental disorders

 

0 Partners

1 Partner

2 Partners or more

Mental disorder categories

Past year mood disorder

    n (%)

185 (8.2)

499 (7.9)

143 (16.8)

    AOR-1 (95% CI)

1.00

1.14 (0.85–1.52)

2.17 (1.58–2.98)***

    AOR-2 (95% CI)

1.00

0.97 (0.65–1.44)

1.84 (1.24–2.72)**

Past year anxiety disorder

    n (%)

423 (20.7)

1,296 (23.5)

242 (30.4)

    AOR-1 (95% CI)

1.00

1.44 (1.08–1.92)*

1.44 (1.07–1.96)*

    AOR-2 (95% CI)

1.00

1.46 (1.06–2.02)*

1.11 (0.79–1.55)

Past year substance use disorder

    n (%)

25 (1.5)

140 (2.6)

102 (16.2)

    AOR-1 (95% CI)

1.00

1.73 (1.12–2.68)*

5.01 (3.15–7.99)***

    AOR-2 (95% CI)

1.00

1.67 (1.09–2.56)*

4.77 (3.03–7.49)***

Past year any mental disorder

    n (%)

476 (23.4)

1,509 (27.1)

340 (45.5)

    AOR-1 (95% CI)

1.00

1.45 (1.10–1.91)**

2.22 (1.64–3.01)***

    AOR-2 (95% CI)

1.00

1.51 (1.14–1.99)**

2.24 (1.67–3.02)***

Past year suicide ideation

    n (%)

62 (2.9)

116 (1.9)

43 (5.7)

    AOR-1 (95% CI)

1.00

0.79 (0.51–1.22)

1.30 (0.80–2.09)

    AOR-2 (95% CI)

1.00

0.56 (0.35–0.90)*

0.73 (0.38–1.39)

Past year suicide attempts

    n (%)

9 (0.4)

23 (0.4)

16 (1.9)

    AOR-1 (95% CI)

1.00

0.97 (0.37–2.57)

1.70 (0.57–5.02)

    AOR-2 (95% CI)

1.00

1.22 (0.45–3.27)

1.53 (0.49–4.75)

Note: All n’s were unweighted. All percents were weighted

AOR-1—Adjusted for sex, age, race, employment status, marital status, education, urbanicity, and income

AOR-2—Adjusted for sociodemographic variables, other mental disorder diagnostic categories, and suicidal behavior (any mental disorder adjusted for suicidal ideation and suicide attempts)

* p ≤ .05, ** p ≤ .01, *** p ≤ .001

Table 4 displays the results of regression analyses examining the relationships between past year condom use and mental disorder groups among never married individuals. Those participants reporting rarely/never using a condom in the past year were more likely than those always using a condom to have a past year mood, substance use, and any mental disorder, and an increased likelihood of suicide attempts. Individuals who mostly/sometimes wore a condom in the past year were also more likely to have a past year mood disorder. Most relationships remained significant even after adjusting for other mental disorder categories.
Table 4

Relationship between condom use and mental disorders among unmarried individuals

 

Not married

Always

Mostly/sometimes

Rarely/never

Past year mood disorder

    n (%)

43 (7.7)

55 (16.1)

61 (16.0)

    AOR-1 (95% CI)

1.00

2.68 (1.56–4.62)***

2.21 (1.48–3.32)***

    AOR-2 (95% CI)

1.00

2.21 (1.28–3.81)**

1.60 (0.92–2.78)

Past year anxiety disorder

    n (%)

115 (26.1)

95 (32.3)

123 (39.3)

    AOR-1 (95% CI)

1.00

1.57 (0.86–2.87)

1.72 (0.93–3.16)

    AOR-2 (95% CI)

1.00

1.36 (0.75–2.47)

1.51 (0.81–2.82)

Past year substance use disorder

    n (%)

41 (10.9)

32 (10.5)

43 (18.0)

    AOR-1 (95% CI)

1.00

1.16 (0.71–1.90)

2.21 (1.34–3.63)**

    AOR-2 (95% CI)

1.00

1.06 (0.63–1.81)

2.06 (1.25–3.38)**

Past year any mental disorder

    n (%)

157 (36.6)

127 (43.4)

152 (50.7)

    AOR-1 (95% CI)

1.00

1.59 (0.96–2.64)

1.77 (1.04–3.01)*

    AOR-2 (95% CI)

1.00

1.58 (0.97–2.57)

1.69 (1.02–2.80)*

Past year suicide ideation

    n (%)

14 (3.1)

16 (5.3)

23 (6.1)

    AOR-1 (95% CI)

1.00

1.99 (0.76–5.23)

1.87 (0.66–5.27)

    AOR-2 (95% CI)

1.00

0.86 (0.35–2.10)

0.64 (0.22–1.81)

Past year suicide attempts

    n (%)

2 (0.3)

6 (1.6)

7 (2.2)

    AOR-1 (95% CI)

1.00

4.72 (0.85–26.19)

8.13 (1.51–43.89)*

    AOR-2 (95% CI)a

Note: All n’s were unweighted. All percents were weighted

AOR-1—Adjusted for sex, age, race, education, employment status, urbanicity, and income

AOR-2—Adjusted for sociodemographic variables, other mental disorder diagnostic categories, and suicidal behavior. (Any mental disorder adjusted for suicidal ideation and suicide attempts)

Results of the relationships between mental disorders and sexual behaviors in both “married/cohabitating” and “separated/widowed/divorced” groups are available upon request

p ≤ .05, ** p ≤ .01, *** p ≤ .001

aModel was over-specified

Supplementary Gender Stratified Analyses

Results of gender stratified analyses examining the relationships between sexual behaviors and mental disorders showed some differences in men and women. However, the general pattern of findings was similar overall in males and females (all data available upon request). One interesting finding emerged in analyses examining associations between number of sexual partners in the past year and mental disorders. Women (but not men) who reported having one partner in the past year versus no partners were more likely to have any anxiety, substance use, and overall mental disorder (AOR range, 1.58–4.28).

Discussion

The results of the present study should be interpreted in light of the following limitations. First, the NCS-R was a cross-sectional survey that precludes any causal interpretations regarding our findings. The possibility that the presence of a mental disorder leads to earlier sexual intercourse, more sexual partners, and infrequent condom use or, conversely, that engagement in these types of behaviors influences the development of mental disorders remains equally plausible. Longitudinal support exists in select samples (adolescents, young adults, drug users) for a relationship in both directions between different sexual behaviors and depressive symptomatology and substance use (Hallfors et al., 2005; Lehrer et al., 2006; Staton et al., 1999; Williams & Latkin, 2005), but more longitudinal studies are required with adequate controlling for possible confounders such as personality traits and reaction patterns. Second, mental disorder diagnoses were produced by computer programs based on responses recorded by trained lay interviewers. However, they have been shown to have overall moderate concordance with clinician-based diagnoses (Haro et al., 2006). Third, retrospective self-report of age of first intercourse and sexual behaviors by participants may have introduced recall bias and/or inaccurate reporting into the results. Finally, in regard to condom use, we are aware that individuals in committed relationships may not use condoms for reasons such as use of other contraceptive methods combined with trusting that their partner is free of STD’s. Filtering our analysis by marital status to examine only never married individuals was the closest we could come to excluding these individuals. Unfortunately, however, being “never married” does not necessarily mean being single, and our findings may be confounded by the inclusion of committed monogamous relationships in this category. Despite these limitations, several important findings emerged.

First, adults who reported age of first sexual intercourse between the ages of 12–14 were more likely than those reporting intercourse between 15 and 17 years to have numerous mental disorders, as well as to have experienced suicidal ideation and attempts. These findings replicate previous literature in adolescent and young adult samples that have found positive associations between mental disorders, suicidality, and early sexual behavior (Hallfors et al., 2004, 2005; Ramrakha et al., 2000; Waller et al., 2006), and extend it to a wide age range of adults in a much larger sample.

Individuals reporting age of first intercourse as being between 18 and 25 were less likely than the reference group to have almost every mental disorder class examined. One possibility for this finding may be that, in the 15–17 year old age range, individuals may find sexual relationships distressing due to not yet having reached full psychological maturity in being able to assess future consequences (Cauffman & Steinberg, 2000). Surprisingly to us, individuals reporting first intercourse between ages 26–35 were also less likely than the 15–17 year old group to have most of the mental disorder categories examined. It seems that it is a common societal belief that sexually inexperienced older individuals are lonely or socially awkward; thus, we hypothesized that a U-shaped relationship would be found between first intercourse and mental disorders, with this age range being associated with a higher likelihood for a disorder. Several factors, however, such as religiosity (e.g., de Visser, Smith, Richters, & Rissel, 2007), social support, and personality traits, could be acting as protective factors in this relationship.

Second, several associations were found between mental disorders and sexual behaviors in the past year. Individuals reporting two or more sexual partners were more likely to have disorders from all diagnostic categories, while never married individuals who rarely/never used condoms were also at an increased likelihood of any mood, substance use, and overall mental disorder, as well as suicide attempts. These associations are generally consistent with previous research in other samples (e.g., Carey et al., 2001, 2004; Kessler et al., 1997; Lavan & Johnson, 2002; Lehrer et al., 2006; Ramrakha et al., 2000). Unfortunately, this study and most previous studies of the relationship between number of sexual partners and mental disorders have not assessed whether partners occur serially or simultaneously during the time period examined.

Several possible mechanisms exist that could explain the relationship found in the current study between mental disorders and both early and past year sexual behavior. In general, these may include low self-esteem and a negative self-concept which have overall been shown to be related both to engagement in sexual behaviors such as less condom use and more sexual partners, and to depression and suicidality in several countries (Boden & Horwood, 2006; Evans et al., 2005; Lejuez, Simmons, Aklin, Daughters, & Dvir, 2004; Sterk, Klein, & Elifson, 2004; Thatcher et al., 2002; Wild, Flisher, & Loombard, 2004). Additionally, a recent study in a Swedish sample found that individuals who engaged in high rates of “impersonal sex” (engaging in sex merely for the purpose of the act) were at increased likelihood of having “adverse family backgrounds, a variety of negative health indicators, and dissatisfaction with life in general” (Langstrom & Hanson, 2006, p. 49). It is possible that the individuals in the current study who have a younger age of first intercourse and who use condoms infrequently with multiple sexual partners are also those who engage in “impersonal sex.” Finally, childhood abuse and neglect could play a role in explaining these associations (Klein, Elifson, & Sterk, 2007; Nelson et al., 2002; Wilson & Widom, 2008).

Surprisingly, women who reported having had one partner in the past year versus no partners were also at increased likelihood of any anxiety, substance use, and overall mental disorder. However, the expected protective effect of marriage and cohabitation (i.e., a monogamous relationship with only one sexual partner) has not been found for all mental disorders (e.g., Kessler et al., 2005b). It is possible that the stresses of being in a committed, monogamous relationship may lead to increased anxiety and substance use in women. Additionally, the prevalence of intimate partner violence, which has been found to be associated with a range of negative mental health outcomes (Afifi et al., 2008), is likely to be higher in women reporting one sexual partner versus none, and could be mediating the associations.

With regard to the relationship between substance use disorders and sexual behaviors, disinhibition has been proposed as driving this association. Similarly, it is possible that the impulsive nature inherent in individuals with disruptive behavior disorders is influencing the association between these disorders and earlier intercourse. Several studies, for example, have shown associations between the sexual behaviors examined in this study and impulsivity in different samples (Apostolopoulos, Sonmex, & Yu, 2002; Devieux et al., 2002; Hayaki, Anderson, & Stein, 2006; Lejuez et al., 2004). Additionally, personality characteristics such as novelty seeking or a genetic propensity towards addiction may be involved as mechanisms in this relationship (Heath et al., 1997) or familial characteristics in childhood such as education level of mother (Fergusson & Woodward, 2000). In fact, a recent rat study found that those rats who were separated from their mothers for several hours a day during infancy showed significantly more engagement in impulsive conduct than the control group during their adolescent phase (Colorado, Shumake, Conejo, Gonzalez-Pardo, & Lima, 2006).

This study found a positive association between anxiety disorders and number of sexual partners, while previous studies have found no significant relationships between sexual behaviors and the anxiety disorder diagnostic category in adolescents or young adults (Kessler et al., 1997; Lavan & Johnson, 2002; Ramrakha et al., 2000; Tubman et al., 2003). However, the current study used a much larger sample than in previous research, and still, the relationship between any anxiety disorder and sexual partners was the weakest of the significant findings. Future studies may find it useful to consider the relationships between sexual behaviors and individual anxiety disorders, as these disorders are a very heterogeneous class. One might not expect, for example, the same pattern of associations between the sexual behaviors examined and social phobia, (where individuals have difficulty meeting and interacting with people), as between sexual behaviors and specific phobia or panic.

Finally, it should be noted that in stringent analyses adjusting for other mental disorder categories, some of the previously significant associations between mental disorders and sexual behaviors were no longer significant. However, since Axis I mental disorders co-occur frequently (Kessler et al., 2005b) rather than present in their “pure” form, it is important to assess and consider a patient’s entire clinical picture when engagement in some of these sexual behaviors is reported.

The present study showed several strong positive relationships of earlier sexual intercourse, having one sexual partner or more, and infrequent condom use with mental disorders in a nationally representative sample of adults. Future research should more closely examine the directionality and possible, up to now unmeasured, confounding factors of these associations in order to gain a more complete understanding of the existing patterns.

Notes

Acknowledgements

The National Comorbidity Survey Replication (NCS-R) was supported by the National Institutes of Mental Health (NIMH). Natalie Mota was supported by a Social Sciences and Humanities Research Council Canada Graduate Scholarship-Master’s Award. Dr. Jitender Sareen is supported by a Canadian Institutes of Health Research (CIHR) New Investigator Award #152348 and a CIHR operating grant. Dr. Brian Cox is supported by a CIHR operating grant and by the Canada Research Chairs Program.

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Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Natalie P. Mota
    • 1
    • 3
  • Brian J. Cox
    • 1
    • 2
    • 3
  • Laurence Y. Katz
    • 3
  • Jitender Sareen
    • 1
    • 2
    • 3
  1. 1.Department of PsychologyUniversity of ManitobaWinnipegCanada
  2. 2.Department of Community Health SciencesUniversity of ManitobaWinnipegCanada
  3. 3.Department of PsychiatryUniversity of ManitobaWinnipegCanada

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