Letters to the Editor
Substance Use, Sexual Intercourse, and Condom Nonuse Among Depressed
Adolescents and Young Adults: Scientific Views
To the Editors:
We read with much interest the article by Shrier et al. [1].In
the study, it was observed that substance use was associated
with increased odds of sex on the same day, but not after adjust-
ing for weekend. There was no main effect of substance use on
condom nonuse. The authors concluded that contextual factors,
not intoxication, influence associations of substance use with
sexual behavior in depressed youth.
The study population was not described in terms of the sub-
stance use status. It was not clearly stated whether the individ-
uals in the sample population were having substance use disor-
ders such as substance dependence or substance abuse. In this
regard, we would like to highlight an earlier study that reported
that individuals with substance dependence diagnoses were less
likely to reliably use condoms [2]. It was reported that adoles-
cents and young adults with substance use disorders were less
consistent in using condoms compared with nonabusing com-
munity youth [3]. Youth identified with substance problems
were more likely to engage in risky sexual behaviors during
adolescence and to continue to do so to the extent that substance
problems persist. These findings underscore the importance of
making the correct diagnosis of substance abuse or dependence
in the patients.
Another issue to highlight is that the formal Axis I diagnosis of
the patients was not specified in the study. Patients were re-
cruited if they had clinically significant depressive symptoms.
However, depression may be a symptom of major depressive
disorder, dysthymia, bipolar mood disorder, and borderline per-
sonality disorder. Having bipolar disorder may increase a per-
son’s risk to engage in unhealthy and unsafe sexual behaviors,
such as condom nonuse. Bipolar patients often act impulsively.
This can result in high-risk behavior, such as repeated intoxica-
tion, and risky sexual behavior. Similarly, patients with border-
line personality disorder may have various forms of impulsivity,
including sexual impulsivity. The existing empirical literature
indicates that patients with borderline personality disorder ap-
pear to differ from others without this personality disorder.
Specifically, those with borderline personality disorders are
more likely to exhibit greater sexual preoccupation, have earlier
sexual exposure, engage in casual sexual relationships, and re-
port having a greater number of different sexual partners (pro-
miscuity). In addition, these patients appear to be characterized
by greater number of high-risk sexual behaviors [4]. Thus, we
need to determine the psychiatric diagnosis before we can estab-
lish the association of substance use with sexual behavior in
depressed youth.
Ahmad Hatim Sulaiman, M.B.B.S., Ph.D.
Department of Psychological Medicine
Faculty of Medicine
University of Malaya
Kuala Lumpur, Malaysia
Mas Ayu Said, M.B.B.S., M.P.H.
Department of Social and Preventive Medicine
Faculty of Medicine
University of Malaya
Kuala Lumpur, Malaysia
Srijit Das, M.B.B.S., M.S.
Department of Anatomy
Universiti Kebangsaan Malaysia
Kuala Lumpur, Malaysia
References
[1] Shrier LA, Walls C, Lops C, et al. Substance use, sexual intercourse, and
condom nonuse among depressed adolescents and young adults. J Adolesc
Health 2012;50:264 –70.
[2] Newville H, Haller DL. Psychopathology and transmission risk behaviors in
patients with HIV/AIDS. AIDS Care 2010;22:1259 –68.
[3] Tapert SF, Aarons GA, Sedlar GR, Brown SA. Adolescent substance use and
sexual risk-taking behavior. J Adolesc Health 2001;28:181–9.
[4] Sansone RA, Sansone LA. Sexual behavior in borderline personality: A review.
Innov Clin Neurosci 2011;8:14 –8.
The Authors reply:
In their letter, Drs. Sulaiman, Said, and Das raise two impor-
tant points salient to the discussion of substance use and sexual
behavior in depressed youth. First, adolescents with substance
use disorders are at higher risk of condom nonuse and other
sexual risk behaviors than those without substance abuse or
dependence [1]. However, only two participants in our sample
(5%) had a diagnosis of a substance use disorder according to
their referring provider [2]. Second, individuals with both bipolar
disorder [3] and borderline personality disorder [4] have in-
creased rates of engaging in impulsive sexual behavior. In our
sample, only one participant was diagnosed with bipolar disor-
der and one with borderline personality disorder. These low
prevalence rates may reflect the presence of subthreshold psy-
Journal of Adolescent Health 50 (2012) 654 –655
www.jahonline.org
1054-139X/$ - see front matter ᭧ 2012 Society for Adolescent Health and Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2012.02.019