Influence of physical attractiveness and alcohol on men's perceptions of potential sexual partners and sexual behavior intentions

Measuring Sexual Risk-Taking: A Systematic Review of the Sexual Delay Discounting Task

The Sexual Delay Discounting Task (SDDT; Johnson & Bruner, 2012) is a behavioral economic task that assesses sexual risk-taking by measuring likelihood of immediate and delayed condom use. The SDDT is ecologically valid and has been used to test effects of various substances on sexual risk-taking. However, considerable variety in implementation, analysis, and reporting of the SDDT may limit rigor and reproducibility of findings. The current review synthesized studies that used the SDDT to evaluate these possible variabilities systematically. A two-step search (citation-tracking and keyword-based search) was conducted to identify studies that met inclusion criteria (i.e., used the SDDT). Eighteen peer-reviewed articles met inclusion criteria. The SDDT has been implemented primarily in three populations: individuals who use cocaine, men who have sex with men, and college students. Comparable results across diverse populations support the SDDT's validity. A few studies administered substances before the SDDT. Evidence suggests that while cocaine and alcohol increased sexual risk-taking under some conditions, buspirone decreased preference for immediate condomless sex. There was also heterogeneity in the determination of data orderliness (i.e., outliers) and inconsistent reporting of task design and analysis. Considerable differences present in methodologic approaches could influence results. Reducing variation in the administration, analysis, and reporting of the SDDT will enhance rigor and reproducibility and maximize the task's tremendous potential.

How Alcohol Influences Mechanisms of Sexual Risk Behavior Change: Contributions of Alcohol Challenge Research to the Development of HIV Prevention Interventions

This paper examines the contributions of laboratory-based alcohol challenge research (ACR) to the development of HIV prevention interventions. Following a brief overview of HIV prevention interventions and related health behavior change models, we discuss how alcohol may influence mechanisms of behavior change. The paper highlights the value of ACR for: (1) elucidating mechanisms of action through which alcohol affects sexual risk behavior, (2) testing how alcohol may influence mechanisms thought to underlie HIV prevention interventions, (3) clarifying moderators of the causal influences of alcohol, (4) identifying novel intervention targets, and (5) developing strategies to reduce sexual risk among those who consume alcohol. We conclude with a discussion of the importance of using experimental research to identify mechanisms of behavior change that are specific to populations at high risk for HIV and outline some key implications for developing HIV prevention interventions that integrate the role of alcohol.

Partner Attractiveness and Perceived Sexually Transmitted Infection Risk Among Sexual Minority Men

Men who have sex with men (MSM) are disproportionately impacted by sexually transmitted infections (STIs), but many engage in condomless sex. One factor contributing to condomless sex may be an assumption of low risk of STIs from physically attractive partners. The present study tested the effect of partner attractiveness on perceived STI risk and condom use intentions and examined two mechanisms believed to underlie this effect: implicit personality theory and motivated reasoning. Participants were 197 MSM who viewed photos of attractive and unattractive men and responded to items assessing perceptions of the men's positive traits and STI risk, as well as motivation to have sex with the men and condom use intentions. Sexual arousal was manipulated. Attractiveness reduced perceived STI risk and condom use intentions by increasing both positive perceptions of and motivation to have sex with the person. Findings were not influenced by arousal.

Alcohol and Sexual Health Behavior: "What We Know and How We Know It"

Alcohol, despite salutary associations with sexuality, has been implicated in sexual health problems. This review examines the relationship between alcohol and outcomes related to sexual health. Methodological considerations limiting causal assertions permissible with nonexperimental data are discussed, as are advantages of experimental methods. Findings from laboratory experiments are reviewed evaluating causal effects of acute alcohol intoxication on a variety of outcomes, including sexual arousal, sexual desire, orgasm, and sexual risk behaviors related to sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). Several variables exerting mediating and moderating influences are identified. It is concluded that acute alcohol intoxication is capable of exerting a causal impact on multiple constituent components of sexual responding related to sexual health. Both alcohol expectancy and alcohol myopia theories have been supported as explanations for these causal effects. Furthermore, for sexual risk behavior, noteworthy recent developments include research highlighting the importance of women's sexual victimization history and men's condom use resistance. Limitations and implications associated with this body of research are also discussed.

Perception of physical attractiveness when consuming and not consuming alcohol: a meta-analysis

BACKGROUND AND AIMS

Elucidating why people drink and why drinking can lead to negative psychosocial consequences remains a crucial task for alcohol researchers. Because drinking occurs typically in social settings, broader investigation of the associations between alcohol and social experience is needed to advance understanding of both the rewarding and hazardous effects of alcohol use. This review aimed to (a) estimate alcohol's relation to the perception of others' physical attractiveness and (b) suggest theoretical and methodological considerations that may advance the study of this topic.

METHODS

Systematic review of Scopus and PsycInfo databases was conducted to identify experimental and quasi-experimental studies, with either between- or within-subjects designs, that assessed attractiveness ratings provided by individuals who had and had not consumed alcohol (k = 16 studies, n = 1811). A meta-analysis was conducted to evaluate alcohol's aggregate association with physical attractiveness perceptions. Separate a priori secondary analyses examined alcohol's associations with perception of opposite-sex (k = 12 studies) and same-sex (k = 7 studies) attractiveness.

RESULTS

The primary analysis indicated that alcohol was related significantly to enhanced attractiveness perceptions [d = 0.19, 95% confidence interval (CI) = 0.05-0.32, P = 0.01; I2  = 5.28, 95% CI = 0.00-39.32]. Analysis of alcohol's association with perception of opposite-sex attractiveness similarly yielded a small, significant positive association (d = 0.30, 95% CI = 0.16-0.44, P < 0.01; I2  = 17.49, 95% CI = 0.00-57.75). Alcohol's relation to perception of same-sex attractiveness was not significant (d = 0.04, 95% CI = -0.18 to 0.26, P = 0.71; I2  = 54.08, 95% CI = 0.00-81.66).

CONCLUSIONS

Experimental and quasi-experimental studies suggest that consuming alcohol may have a small effect of increasing perceived attractiveness of people of the opposite sex.

Does being drunk or high cause HIV sexual risk behavior? A systematic review of drug administration studies

HIV sexual risk behavior is broadly associated with substance use. Yet critical questions remain regarding the potential causal link between substance use (e.g., intoxication) and HIV sexual risk behavior. The present systematic review was designed to examine and synthesize the existing literature regarding the effects of substance administration on HIV sexual risk behavior. Randomized controlled experiments investigating substance administration and HIV sexual risk behavior (e.g., likelihood of condom use in a casual sex scenario) were included. Across five databases, 2750 titles/abstracts were examined and forty-three total peer reviewed published manuscripts qualified (few were multi-study manuscripts, and those details are outlined in the text). The majority of articles investigated the causal role of acute alcohol administration on HIV sexual risk behavior, although one article investigated the effects of acute THC administration, one the effects of acute cocaine administration, and two the effects of buspirone. The results of this review suggest a causal role in acute alcohol intoxication increasing HIV sexual risk decision-making. Although evidence is limited with other substances, cocaine administration also appears to increase sexual risk, while acute cannabis and buspirone maintenance may decrease sexual risk. In the case of alcohol intoxication, the pharmacological effects independently contribute to HIV sexual risk decision-making, and these effects are exacerbated by alcohol expectancies, increased arousal, and delay to condom availability. Comparisons across studies showed that cocaine led to greater self-reported sexual arousal than alcohol, potentially suggesting a different risk profile. HIV prevention measures should take these substance administration effects into account. Increasing the amount of freely and easily accessible condoms to the public may attenuate the influence of acute intoxication on HIV sexual risk decision-making.

Physical attractiveness and women's HIV risk in rural Malawi

BACKGROUND

Qualitative evidence from sub-Saharan Africa, where a generalized AIDS epidemic exists, suggests that attractiveness may play a role in shaping individual-level HIV risk. Attractive women, who are often blamed for the epidemic and stigmatized, are believed to pose a higher HIV risk because they are viewed as having more and riskier partners.

OBJECTIVE

We examine the association between perceived attractiveness and HIV infection and risk in rural Malawi in the midst of the country's severe AIDS epidemic.

METHODS

We use interviewers' ratings of respondents' attractiveness, along with HIV test results and women's assessments of their own likelihood of infection, to estimate the association between perceived attractiveness and HIV infection and risk for a random sample of 961 women aged 15-35.

RESULTS

Results show that women who are rated by interviewers as 'much less' or 'less' attractive than other women their age are 9% more likely to test positive for HIV. We also find that attractiveness is associated with women's own assessments of their HIV risk: Among women who tested negative, those perceived as 'much less' or 'less' attractive than average report themselves to be at greater risk of HIV infection.

CONCLUSIONS

These results suggest that attractiveness is negatively associated with HIV risk in Malawi, countering local beliefs that hold attractive women responsible for perpetuating the epidemic.

CONTRIBUTION

This study highlights the need to consider perceived physical attractiveness, and sexual desirability more broadly, as an under-examined axis of inequality in HIV risk in high-prevalence settings.

Alcohol Increases Delay and Probability Discounting of Condom-Protected Sex: A Novel Vector for Alcohol-Related HIV Transmission

BACKGROUND

Alcohol use, especially at binge levels, is associated with sexual HIV risk behavior, but the mechanisms through which alcohol increases sexual risk taking are not well-examined. Delay discounting, that is, devaluation of future consequences as a function of delay to their occurrence, has been implicated in a variety of problem behaviors, including risky sexual behavior. Probability discounting is studied with a similar framework as delay discounting, but is a distinct process in which a consequence is devalued because it is uncertain or probabilistic.

METHODS

Twenty-three, nondependent alcohol users (13 male, 10 female; mean age = 25.3 years old) orally consumed alcohol (1 g/kg) or placebo in 2 separate experimental sessions. During sessions, participants completed tasks examining delay and probability discounting of hypothetical condom-protected sex (Sexual Delay Discounting Task, Sexual Probability Discounting Task) and of hypothetical and real money.

RESULTS

Alcohol decreased the likelihood that participants would wait to have condom-protected sex versus having immediate, unprotected sex. Alcohol also decreased the likelihood that participants would use an immediately available condom given a specified level of sexually transmitted infection (STI) risk. Alcohol did not affect delay discounting of money, but it did increase participants' preferences for larger, probabilistic monetary rewards over smaller, certain rewards.

CONCLUSIONS

Acute, binge-level alcohol intoxication may increase sexual HIV risk by decreasing willingness to delay sex in order to acquire a condom in situations where one is not immediately available, and by decreasing sensitivity to perceived risk of STI contraction. These findings suggest that delay and probability discounting are critical, but heretofore unrecognized, processes that may mediate the relations between alcohol use and HIV risk.

I like people who drink like me: Perceived appeal as a function of drinking status

INTRODUCTION

Individuals rate opposite sex faces as more attractive after consuming or being primed with alcohol. However, other traits such as intelligence and likeability have not been examined and might vary as a function of information about one's drinking habits. We expected social drinkers to be rated more positively than heavy drinkers, abstainers, or recovering alcoholics. We further hypothesized that faces with similar drinking habits to participants would be rated as more appealing.

METHODS

Five hundred ninety-four undergraduates viewed 25 opposite sex faces randomly paired with drinking information, and rated each face on perceived appeal.

RESULTS

Hierarchical linear models revealed that social drinkers were rated as most appealing, as expected. Unexpectedly, recovering alcoholics were rated as the next most appealing, followed by abstainers, then heavy drinkers. The interaction between drinker type and participants' own drinking predicting ratings indicated that the heavier the participant drinks, the more favorably they rated heavy drinkers compared to other types of drinkers. Thus, as expected, ratings varied as a function of participants' own drinking; however, ratings did not vary as a function of participants' alcohol-related problems.

CONCLUSIONS

Findings support hypotheses in that social drinkers were generally perceived as appealing compared to other drinker types, and ratings tended to be influenced by participants' own drinking. Individuals' prototypes and norms regarding drinking may influence how they perceive others when others' drinking habits are known. This might be especially important to consider with heavy drinkers who may seek out others who drink similarly, which could reinforce problematic drinking.

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

Protocol for a Controlled Experiment to Identify the Causal Role of Acute Alcohol Consumption in Condomless Sex among HIV-Positive MSM: Study Procedures, Ethical Considerations, and Implications for HIV Prevention

Although alcohol consumption is frequently perceived as a driver of condomless sex and subsequent HIV acquisition, the causal nature of this relationship remains unclear, and little is known about alcohol's direct versus indirect impact on the sexual risk dynamics of those who are HIV-positive. To address this gap, we present the protocol for an in-progress NIAAA-funded controlled experiment, wherein a sample of HIV-positive men-who-have-sex-with-men (MSM) undergoes an alcohol consumption manipulation (alcohol/placebo/control) and sexual arousal induction (sexually aroused/non-aroused), and then reports intentions to engage in condom-protected and condomless sexual acts with hypothetical sexual partners differing in HIV serostatus (HIV+/HIV-/HIV status unknown), condom use preference (use/don't use/not stated), and physical attractiveness (attractive/unattractive). Study outcomes will identify alcohol's impact on HIV-positive MSM's condomless sex intentions in the context of experimentally-manipulated factors as well as risk-relevant personality traits and alcohol-related expectancies. Detailed experimental procedures, ethical considerations, and potential implications for HIV prevention are discussed.

Alcohol Use Predicts Sexual Decision-Making: A Systematic Review and Meta-Analysis of the Experimental Literature

Alcohol is associated with HIV and other sexually transmitted infections through increased sexual risk-taking behavior. Establishing a causal link between alcohol and sexual behavior has been challenging due to methodological limitations (e.g., reliance on cross-sectional designs). Experimental methods can be used to establish causality. The purpose of this meta-analysis was to evaluate the effects of alcohol consumption on unprotected sex intentions. We searched electronic bibliographic databases for records with relevant keywords; 26 manuscripts (k = 30 studies) met inclusion criteria. Results indicate that alcohol consumption is associated with greater intentions to engage in unprotected sex (d +s = 0.24, 0.35). The effect of alcohol on unprotected sex intentions was greater when sexual arousal was heightened. Alcohol consumption is causally linked to theoretical antecedents of sexual risk behavior, consistent with the alcohol myopia model. Addressing alcohol consumption as a determinant of unprotected sex intentions may lead to more effective HIV interventions.

Neural correlates of HIV risk feelings

Field studies on HIV risk perception suggest that people rely on impressions they have about the safety of their partner. The present fMRI study investigated the neural correlates of the intuitive perception of risk. First, during an implicit condition, participants viewed a series of unacquainted persons and performed a task unrelated to HIV risk. In the following explicit condition, participants evaluated the HIV risk for each presented person. Contrasting responses for high and low HIV risk revealed that risky stimuli evoked enhanced activity in the anterior insula and medial prefrontal regions, which are involved in salience processing and frequently activated by threatening and negative affect-related stimuli. Importantly, neural regions responding to explicit HIV risk judgments were also enhanced in the implicit condition, suggesting a neural mechanism for intuitive impressions of riskiness. Overall, these findings suggest the saliency network as neural correlate for the intuitive sensing of risk.

Alcohol consumption and the intention to engage in unprotected sex: systematic review and meta-analysis of experimental studies

AIMS

To review and analyse in experimentally controlled studies the impact of alcohol consumption on intentions to engage in unprotected sex. To draw conclusions with respect to the question of whether alcohol has an independent effect on the incidence of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs).

METHODS

A systematic review and meta-analysis of randomized controlled studies examined the association between blood alcohol content (BAC) and self-perceived likelihood of using a condom during intercourse. The systematic review and meta-analysis were conducted according to internationally standardized protocols (Preferred Reporting Items for Systematic Reviews and Meta-Analyses: PRISMA). The meta-analysis included an estimate of the dose-response effect, tests for publication bias and sensitivity analyses.

RESULTS

Of the 12 studies included in the quantitative synthesis, our pooled analysis indicated that an increase in BAC of 0.1 mg/ml resulted in an increase of 5.0% (95% CI: 2.8-7.1%) in the indicated likelihood (indicated by a Likert scale) of engaging in unprotected sex. After adjusting for potential publication bias, this estimate dropped to 2.9% (95% CI: 2.0-3.9%). Thus, the larger the alcohol intake and the subsequent level of BAC, the higher the intentions to engage in unsafe sex. The main results were homogeneous, persisted in sensitivity analyses and after correction for publication bias.

CONCLUSIONS

Alcohol use is an independent risk factor for intentions to engage in unprotected sex, and as risky sex intentions have been shown to be linked to actual risk behavior, the role of alcohol consumption in the transmission of HIV and other STIs may be of public health importance.

Implicit and Explicit Processes in Risk Perception: Neural Antecedents of Perceived HIV Risk

Field studies on HIV risk suggest that people may rely on impressions they have about the safety of their partner at the dispense of more objective risk protection strategies. In this study, ERP recordings were used to investigate the brain mechanisms that give rise to such impressions. First, in an implicit condition, participants viewed a series of photographs of unacquainted persons while performing a task that did not mention HIV risk. Second, in an explicit condition, participants estimated the HIV risk for each presented person. Dense sensor EEG was recorded during the implicit and explicit conditions. In the analysis, explicit risk ratings were used to categorize ERP data from the implicit and explicit conditions into low and high HIV risk categories. The results reveal implicit ERP differences on the basis of subsequent ratings of HIV risk. Specifically, the processing of risky individuals was associated with an early occipital negativity (240-300 ms) and a subsequent central positivity between 430 and 530 ms compared to safe. A similar ERP modulation emerged in the explicit condition for the central positivity component between 430 and 530 ms. A subsequent late positive potential component between 550 and 800 ms was specifically enhanced for risky persons in the explicit rating condition while not modulated in the implicit condition. Furthermore, ratings of HIV risk correlated substantially with ratings of trustworthiness and responsibility. Taken together, these observations provide evidence for theories of intuitive risk perception, which, in the case of HIV risk, seem to operate via appearance-based stereotypic inferences.

The effects of acute ethanol consumption on sexual response and sexual risk-taking intent

Two theories of sexual risk taking (disinhibition and alcohol myopia) were tested using genital measures of sexual response and computer measures of sexual risk propensity. A total of 44 men and women completed two sessions comparing responses to erotic films while consuming alcohol (breath alcohol doses were .025 g/kg and .08 g/kg) or juice alone. After consuming alcohol, more sexual arousal was reported in response to neutral films and at a breath alcohol level of .08 g/kg as compared to no alcohol. Genital responses for men and women increased during sexual films, but men did not respond as strongly when breath alcohol level was .08 g/kg. Intentions to have intercourse with a new partner at baseline predicted the level of sexual arousal reported. As self-reported sexual arousal increased in response to sexual films and higher alcohol dose, the intent to engage in intercourse with a new partner increased. Alcohol dose was not related to later sexual intercourse intentions. With no direct relationship of alcohol and intercourse intentions, results appear more consistent with a disinhibition model of sexual arousal.

Indirect effects of acute alcohol intoxication on sexual risk-taking: The roles of subjective and physiological sexual arousal

Three experiments supported the idea that alcohol fosters sexual risk-taking in men and women, in part, through its effects on sexual arousal. In Experiment 1, increasing alcohol dosage (target blood alcohol levels of .00, .04, .08%) heightened men's and women's risk-taking intentions. Alcohol's effect was indirect via increased subjective sexual arousal; also, men exhibited greater risk-taking than women. In Experiment 2, an extended dosage range (target blood alcohol levels of .00, .06, .08, .10%) heightened men's risk-taking intentions. Alcohol's effect again was indirect via subjective arousal. Physiological sexual arousal, which was unaffected by alcohol, increased risk-taking via increased subjective arousal. In Experiment 3, alcohol increased women's risk-taking indirectly via subjective arousal, but alcohol-attenuated physiological arousal had no effect on risk-taking. Implications for alcohol myopia theory and prevention interventions are discussed.

Effects of alcohol and blood alcohol concentration limb on sexual risk-taking intentions

OBJECTIVE

Although there have been numerous investigations of alcohol's relationship to sexual risk taking, the vast majority of these studies have not examined whether the biphasic nature of alcohol intoxication differentially influences risky sexual decisions. Thus, a laboratory study was conducted to investigate the effects of alcohol consumption and blood alcohol concentration (BAC) limb on sexual risk-taking intentions.

METHOD

Participants (N = 150; 51.3% male) were randomly assigned to consume alcoholic drinks (target peak BAC = .08%) or nonalcoholic drinks and then completed a hypothetical sexual risk assessment involving an opposite-gender new partner while on either the ascending BAC limb or descending BAC limb.

RESULTS

Alcohol intoxication resulted in increased sexual risk-taking intentions indirectly through its influence on perceived intoxication and, subsequently, sexual arousal. An interaction of beverage condition and BAC limb condition indicated that alcohol's effects on perceived intoxication varied significantly by limb, with those on the ascending limb reporting greater perceived intoxication than those on the descending limb.

CONCLUSIONS

Findings suggest that future research and prevention efforts would be better informed through a more comprehensive consideration of BAC limb effects on sexual risk behaviors. Moreover, results indicate that prevention programs should address in-the-moment states, such as perceived intoxication and sexual arousal, in interventions targeting risky sexual decision-making processes.

Alcohol and sexuality research in the AIDS era: trends in publication activity, target populations and research design

Research addressing relationships between alcohol and human sexuality has proliferated, due in part to efforts to characterize alcohol's role in HIV risk behavior. This study provides a descriptive review of the alcohol-sexuality literature, using abstracts from 264 identified studies to estimate changes in publication activity, target populations, and the prevalence of HIV-related studies over time. We also examine methodological trends by estimating the prevalence of experimental vs. non-experimental studies. Findings show considerable increases in research activity and diversity of populations studied since the mid-1980's and highlight the emergence of HIV-related studies as a focal point of alcohol-sexuality research efforts. Results also demonstrate a substantial decline in the proportion of studies utilizing experimental methods, in part because of frequent use of non-experimental approaches in studies of alcohol and HIV risk behavior. We discuss implications and review the role of experiments in evaluating causal relationships between alcohol and sexual risk behavior.