Maclean Johanna Catherine, Xu Haiyong, French Michael T, Ettner Susan L
Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania; 1316 Blockley Hall, 423 Guardian Drive, Philadelphia PA, 19104, USA,
J Ment Health Policy Econ. 2013 Dec;16(4):187-208.
Several economic studies link poor mental health and substance misuse with risky sexual behaviors. However, none have examined the relationships between DSM-IV Axis II mental health disorders (A2s) and risky sexual behaviors. A2 disorders are a poorly understood, yet prevalent and disabling class of mental health conditions. They develop early in life through an interaction of genetics and environment, and are persistent across the life course. Common features include poor impulse control, addiction, social isolation, and elevated sexual desires, although the defining features vary substantially across disorder.
To investigate the association between A2 disorders and three measures of risky sexual behavior.
We obtain data on adults age 20 to 50 years from Wave II of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC). Our outcome measures include early initiation into sexual activity, and past year regular use of alcohol before sex and sexually transmitted disease diagnosis. NESARC administrators use the Alcohol Use Disorder and Associated Disabilities Interview Schedule to classify respondents as meeting criteria for the ten A2 disorders recognized by the American Psychiatric Association. We construct several measures of A2 disorders based on the NESARC administrators' classifications. Given their comorbidity with A2 disorders, we explore the importance of Axis I disorders in the estimated associations.
We find that A2 disorders are generally associated with an increase in the probability of risky sexual behaviors among both men and women. In specifications that disaggregate disorders into clusters and specific conditions, the significant associations are not uniform, but are broadly consistent with the defining features of the cluster or disorder. Inclusion of A1 disorders attenuates estimated associations for some risky sexual behaviors among men, but not for women.
We find positive associations between A2 disorders and our measures of risky sexual behaviors. Our findings are subject to several data limitations, however. The NESARC lacks information on more advanced risky sexual behaviors and our measure of early initiation into sexual activity is retrospective. Identifying the causal effects of mental health and risky sexual behaviors is complicated due to bias from reverse causality and omitted variables. We believe these sources of bias are less of a concern in our study, however. Specifically, A2 disorders develop early in life and pre-date the risky sexual behaviors, thus negating reverse causality. Because the NESARC contains a rich set of personal characteristics, we are also able to minimize potential omitted variable bias.
A2 disorders are significantly associated with risky sexual behaviors, which could lead to greater utilization and cost of health care services.
Health care providers should consider A2 disorders when developing health promotion recommendations as these disorders may place individuals at elevated risk for unsafe sexual behaviors.
Future studies should examine the causal mechanisms between A2 disorders and risky sexual behaviors.
多项经济学研究将心理健康状况不佳和药物滥用与危险性性行为联系起来。然而，尚无研究考察《精神疾病诊断与统计手册》第四版（DSM-IV）轴II心理健康障碍（A2s）与危险性性行为之间的关系。A2障碍是一类人们了解甚少但普遍存在且使人致残的心理健康状况。它们在生命早期通过基因与环境的相互作用而形成，并在整个生命过程中持续存在。其共同特征包括冲动控制能力差、成瘾、社交孤立以及性欲望增强，尽管不同障碍的界定特征差异很大。
调查A2障碍与三种危险性性行为指标之间的关联。
我们从全国酒精及相关状况流行病学调查（NESARC）的第二波数据中获取了20至50岁成年人的数据。我们的结果指标包括过早开始性行为，以及过去一年中在性行为前经常饮酒和性传播疾病诊断情况。NESARC的管理人员使用酒精使用障碍及相关残疾访谈表将受访者分类为符合美国精神病学协会认可的十种A2障碍的标准。我们根据NESARC管理人员的分类构建了几种A2障碍的指标。鉴于它们与A2障碍的共病情况，我们探讨了轴I障碍在估计关联中的重要性。
我们发现A2障碍通常与男性和女性危险性性行为发生概率的增加有关。在将障碍细分为不同类别和具体情况的分析中，显著关联并不一致，但大致与类别或障碍的界定特征相符。纳入轴I障碍会减弱男性某些危险性性行为的估计关联，但对女性则不然。
我们发现A2障碍与我们的危险性性行为指标之间存在正相关。然而，我们的研究结果存在一些数据局限性。NESARC缺乏关于更高级危险性性行为的信息，并且我们对过早开始性行为的衡量是回顾性的。由于反向因果关系和遗漏变量导致的偏差，确定心理健康与危险性性行为之间的因果效应很复杂。然而，我们认为这些偏差来源在我们的研究中不太值得担忧。具体而言，A2障碍在生命早期形成且早于危险性性行为，因此排除了反向因果关系。由于NESARC包含丰富的个人特征信息，我们也能够将潜在的遗漏变量偏差降至最低。
A2障碍与危险性性行为显著相关，这可能导致医疗保健服务的更多利用和成本增加。
医疗保健提供者在制定健康促进建议时应考虑A2障碍，因为这些障碍可能使个体面临更高的不安全性行为风险。
未来的研究应考察A2障碍与危险性性行为之间的因果机制。
