68

ADDICTIVE Original Article

DISORDERS
& THEIR
TREATMENT
Volume 13, Number 2
June 2014

Pattern of Risky Sexual Behaviors in

Opioid-dependent Egyptian Adults
Mohammed Elhammady, MBBCH, MSC, MD,* Maha Mobasher,
MBBCH, MSC, MD,w and Hamdy F. Moselhy, MBBCH, MSC, MD,
FRCPsych, MRCPsychz

Abstract
Aim:
To describe the reported sexual behaviors of opioiddependent young adults in a Cairo psychiatric hospital, Egypt, and examine the association between
drug consumption, sexual behaviors, and family
attitudes.

Method:
A total of 48 patients with opioid dependency according to DSM-IV-TR were recruited from inpatient
psychiatric attendees at a psychiatric hospital, Cairo,
Egypt. A face-to-face semistructured interview was
conducted to obtain information on detailed clinical
history, mental status, drug use history, psychosexual history, and family attitudes from patients.

Results:

From the *Faculty of Medicine,

Benha University, Banha,
Qalyubia; wFaculty of Medicine,
Cairo University, Giza, Egypt;
and zDepartment of Psychiatry
and Behavior Sciences, Faculty
of Medicine and Health Sciences,
UAE University, Abu Dhabi, UAE.

The most frequent age group at the time of presentation of the sample was 15 to 25 years (47.9 %). The
mean age of start of drug abuse was 15.8 years
(SD = 2.6; 11 to 25 y). The entire group was dependent on opioid and 46 (95.5%) were dependent on
cannabis at the same time, and 19 (39.6%) were
dependent on alcohol. The main opioids abused by
the entire group were heroin (8, 16.7%), tramadol
(synthetic opioid) (37, 77.1%), and codeine (cough
syrup) (14, 29.2%). High rates of risky sexual behaviors were observed, particularly in tramadol users.
They reported high rates of sexual activity over
the previous 3 months, commercial sex work, large
number of casual sex partners, and lifetime hepatitis C.

Conclusion:
These findings point to a clear need for interventions
aimed at decreasing risky sexual behaviors among
individuals with opioid dependency.
Key Words: sexual behavior, risky factors, Egyptian

The authors declare no conflict

of interest.

(Addict Disord Their Treatment

2014;13:6874)

Reprints: Hamdy F. Moselhy,

MBBCH, MSC, MD, FRCPsych,
MRCPsych, Department of
Psychiatry and Behavior
Sciences, Faculty of Medicine
and Health Sciences, UAE
University, Al Ain P.O.
Box 17 666, Abu Dhabi, UAE
(e-mail: hamdy.fouad@
fmhs.uaeu.ac.ae).

Copyright r 2013 by Lippincott

Williams & Wilkins

isky sexual behaviors of young

adults have received increasing attention in the last 2 decades.15 Youths
who become both sexually active and
involved with drugs during adolescence
are especially vulnerable to high-risk
sexual behavior.6 Risky sexual behaviors
are defined as sexual activities that may
compromise an individuals health by
exposing him or her to the risk of
www.addictiondisorders.com

infection with sexually transmitted diseases and/or the human immunodeficiency virus (HIV).7 Previous research
conducted mainly in developed countries has found that high-risk sexual
behaviors are associated with an individuals history of drug and alcohol
consumption.810 It is likely that varying
cultural and environmental factors related to young adults sexual practices
(such as how acceptable it is for a young
man to be initiated into sex by having
sex with a sex worker or having casual
partners) and drug use (such as the
availability or popularity of different
types of drugs) influence this association in different ways in different regions of the world.1114
Several causal paths that could
explain the association between illicit
drug use and risky sexual behaviors
have been suggested. Some researchers1519 suggest that illicit drug use,
much like alcohol, increases the probability of risky sexual behavior by interfering with cognitive functioning and
rational decision making. An alternative
possibility is that the relationship between drug use and risky sexual behaviors is reversed. More specifically,
engaging in risky sexual behaviors at
a young age may be associated with
subsequent drug use by alienating the
adolescent from more conventional
contexts, thus fostering attachment to
deviant peers and facilitating exposure
to illicit substances.20 For example,
Kandel and Davies21 found that early
sexual intercourse (risky sexual behavior) was an important predictor of
experimentation with cocaine. A third
possibility is that risky sexual behaviors
and drug use may share a common
factor that underlies and is antecedent
to both behavioral manifestations, such
DOI: 10.1097/ADT.0b013e3182898216

Pattern of Risky Sexual Behaviors

as a familiar factor or a personality factor.7

Theories of social control maintain that
adolescents initiation into experimenting
with drugs and/or other deviant behaviors
including risky sexual behaviors is caused
by the lack of conventional attachments to
societal values, its institution, and particularly the family.2225
It is believed that >2 million adolescents become infected with HIV worldwide every year. The most common form
of transmission in this group is sexual
intercourse. Within at-risk populations,
young adults are at highest risk of acquiring sexually transmitted infections (STIs)
and HIV because most are sexually active,
single, have multiple partners as they are
not in established monogamous relationships, engage in intercourse with sex
workers, and frequently mix sex with
alcohol or drugs.78,2627
Several studies on sexual behavior
among young adults have been conducted in Africa,28 Asia,29,30 and Latin
America.3133 The data make it clear that
there has been no consistent trend
across these countries toward sexual
behavior. They have found, for example, that 80% of young adults between
18 and 29 years of age in Peru have had
intercourse and that, of this group, 30%
of young men have had intercourse with
a sex worker.31 However, few studies
have focused on the sexual behavior of
this population in Egypt. Refaat34 found
that nearly 10% of university students
had had sex; median starting age was
16 years. One third of them did not use
any contraception and 61.5% did nothing to protect themselves from STI.
About one third did not have enough
knowledge on AIDS. In the same group,
alcohol was tried by 14.4%, marijuana
by 6.8%, and 1.2% had ever used intravenous drug injection. Meanwhile,
among street children, 67% were sexually active, most reported multiple
partners (54%), and none used condoms (52%).35 Nevertheless, information about patterns of sexual behaviors
among drug users and family attitudes is
scarce in this specific context.
This study describes the reported
sexual behaviors of opioid-dependent
young adults in a Cairo psychiatric hospital, Egypt, and examines the association between drug consumption, sexual
behaviors, and family attitudes.
www.addictiondisorders.com

METHODS
Participants and Procedure
Participants were recruited from
among hospitalized inpatients at a psychiatric hospital, Cairo, Egypt, between
January 2008 and December 2008. Patients aged between 18 and 60 years
with DSM-IV-TR36 opioid-dependence
syndrome were included in the study.
A sample size of 100 was aimed for, and
all consecutive hospitalized patients
were interviewed after being detoxified,
until this number was reached. Patients
were excluded from the study if they
had any current medical problems, sensory or physical disability, current severe psychotic symptoms, or learning
disability (mental retardation) that
could threaten the validity of the results.
All eligible subjects (based on self-reports of drug use) were then subjected
to a urinalysis for psychoactive substances to confirm their use of drugs. Three
patients had current severe psychotic
symptoms, 1 had learning disability, 11
had medical problems or physical disability, and 37 refused to participate in
the study. All of these patients were
excluded and a final number of 48
patients participated in the study. The
nature and scope of the study was discussed with each patient and written
informed consent was obtained from all
patients before the interview. The psychiatric hospital Ethics Committee approved this study.

Measures
Data were collected through a
face-to-face semistructured interview. A
predesigned questionnaire was used to
obtain information on sociodemographic characteristics, detailed clinical
history, mental status, drug use history,
psycho-sexual history, and family attitudes from patients. The questionnaire
used as our study instrument was completely devised by us and had not been
validated in any earlier study. However,
a pilot analysis was undertaken on 10
patients and then it was revised. We
found the final form useful and easy to
apply without leaving behind too many
ambiguities.

ADDICTIVE
DISORDERS
& THEIR
TREATMENT
Volume 13, Number 2
June 2014

69

70

ADDICTIVE Elhammady et al
DISORDERS
& THEIR
TREATMENT
Volume 13, Number 2
June 2014

Statistical Analysis
Descriptive statistical analyses
were performed for the study sample
on the demographic and clinical variables. The data are presented as mean
and SD; 2-tailed tests were used and a P
value r0.05 was regarded as significant. Data analysis was carried out using
SPSS, version 19.0. Pearson correlation
coefficients were used to assess the
relationship among various risky behaviors and family attitudes.
Logistic regression was used to
estimate the association between different types of drugs abused and risky
sexual behaviors, controlling for sociodemographic variables. Standard demographic variables adjusted for included
age, marital status, employment, and
educational level. The dependent variable was exchange of sex for drugs
during the past 3 months and the independent variables included types of

drugs abused, risky sexual behaviors,

which included engaging in sex with
potentially high-risk sexual partners,
such as casual partners, same-sex partners, and/or sex workers for money, and
whether they had ever had an STI.

RESULTS
The most frequent age group at the
time of presentation of the sample was 15
to 25 years (47.9%). All those who participated in the study were Egyptian
males with the highest level of education
for the majority of them, 23 (47.9%)
being Vocational Education and Training
(VET), 35 (72.9%) were single, and 37
(77.1%) were living in urban areas. The
mean age of starting drug abuse was 15.8
years (SD = 2.6; 11 to 25 y). The main
opioids abused by the entire group were
heroin (8, 16.7%), tramadol (synthetic

TABLE 1. Sample and Family Characteristics

Variables

Total
N = 48
(%)

Age (y)
15-25
25.1-35
35.1-50

23 (47.9)
22 (45.8)
3 (6.3)

Education
Secondary
University
Vocational education
and training
Marital status
Single
Married

6 (12.5)
19 (39.6)
23 (47.9)

35 (72.9)
13 (27.1)

Current drug abused

Opioid
Heroin
Tramadol
Codeine (cough syrup)

8 (16.7)
37 (77.1)
14 (29.2)

Cannabis
Alcohol
Benzodiazepine
Barbiturate
Amphetamine

46 (95.8)
19 (39.6)
9 (18.8)
3 (6.3)
1 (2.1)

48 (100)

2013 Lippincott Williams & Wilkins

Characteristics
Mean of family number
Parental relationship
+

Fathers attitude
+

Refused to answer
Mothers attitude
+

Wifes characteristics
Mean age
Education
Higher school

Total
N = 48 (%)
4.1 (SD = 1.5)
34 (70.8)
14 (29.2)
33 (68.8)
10 (20.8)
5 (10.4)
40 (83.3)
8 (16.7)
27.2 (SD = 3.7)
4 (30.8)

University
Employment
Employed
Unemployed

9 (69.2)
6 (46.2)
7 (53.8)

Mean duration of marriage (y)

Wifes attitude
+

Cooperation of wife in treatment

+

17.7
10 (76.9)
3 (23.1)
8 (61.5)
5 (38.5)

www.addictiondisorders.com

Pattern of Risky Sexual Behaviors

opioid) (37, 77.1%), and codeine (cough

syrup) (14, 29.2%). Some patients used
>1 opioid at the same time.

Sample and Family Characteristics

Both patients and family characteristics are outlined in Table 1.

Sexual Behaviors
The entire sample (100%) reported ever having sex. The age of
sexual initiation was very early (13.7
years). Sexual orientation was mostly
heterosexual in all age groups (46 participants (95.8%)], which is statistically
significant (x = 16.5, df 4, P = 002). Extramarital sexual relationship was high
among married men (12 of 13, 92.3%,
x = 43.1, df = 1, P = 0.0001). Most of
the subjects reported having casual female partners (81.3%) and reported
having sex with commercial sex workers
either for money (72.9%) or for drugs
(50%). In addition, the main opioid
used among patients who exchanged
sex for drugs was tramadol, which is
significant (24, 88.9%, x = 3.9, df = 1,
P = 0.04); this was the case among patients who masturbated as well (35,
83.3%, x = 5.0, df = 1, P = 0.03). Cannabis abuse was significant among married men who continued to have a
sexual relationship with their wives (9,
81.8%, x = 7.0, df = 1, P = 0.008) and
also among married men who had extramarital relationships (10, 83.3%,
x = 6.3, df = 1, P = 0.01). Table 2 shows
the detailed sexual behaviors.

Consequences of Drug Abuse

The most common physical complication among opioid dependents was
overdose (72.9%), which was statistically
significant in the age group of 25.1 to
35 years (20, 41.7%,x = 7.7, df = 2, P =
0.02); infection with hepatitis C was significant in the same age group (3, 50%,
x = 8.7, df = 2, P = 0.01). Work deterioration was significant among singles (24,
64.9%, x = 5.3, df = 1, P = 0.02) and
among those in the age group of 25.1
to 35 years (22, 45.8%, x = 15.5, df = 2,
P = 0.001). Academic deterioration was
significant in the age group of 15 to 25
years (17, 56.7%, x = 6.4, df = 2,
P = 0.04). Legal problems were signifiwww.addictiondisorders.com

cant among single patients (14, 93.3%,

x = 4.6, df = 1, P = 0.03).

Treatment Profiles
Table 3 shows treatment profiles
of the entire group.
Correlation between different risky
sexual behaviors, drug use, and family
attitude shows that having psychiatric
diagnosis is correlated with early initiation of sexual activity (r = 0.5, P =
0.02). There was a negative correlation
between use of tramadol and
codeine (cough medicine) ( 0.49, P =
0.001), which suggests that tramadol
users do not use codeine. Tramadol
users significantly exchange sex for drugs
(r = 0.29, P = 0.04) and both, exchange
of sex for money and exchange for drugs,
are highly significant (r = 0.46, P =
0.001). In addition, positive parental
TABLE 2. Characteristics of Sexual Behaviors
Characteristics
Source of sexual knowledge
Pornography movies
Pornography photos
Sexual relationship
Watching real sexual scene
Ever had sex
Mean age of starting sex
Currently sexually active
Had sexual relationship in the
past 3 months
Sex with wife
Sex with female sex worker for
money
Sex with female sex worker for
drugs
Sex with casual female partner
Sex with male (same-sex
partner)
Sex with male and female
(bisexual)
Sex with multiple partners at
the same time (group sex)
Extramarital sexual
relationship
Masturbation
Confirmed lifetime STI
(syphilis)
Hepatitis A
Hepatitis B
Hepatitis C

N (%)
42 (87.5)
1 (2.1)
4 (8.3)
1 (2.1)
48 (100)
13.7 (SD =
1.1)
48 (100)
48 (100)
11 (22.9)
35 (72.9)
27 (57.4)
39 (81.3)
0 (0.0)
2 (4.2)
1 (2.1)
12 (25)
42 (87.5)
1 (2.1)
0
0
6 (12.5)

STI indicates sexually transmitted infections.

ADDICTIVE
DISORDERS
& THEIR
TREATMENT
Volume 13, Number 2
June 2014

71

72

ADDICTIVE Elhammady et al
DISORDERS
& THEIR
TREATMENT
Volume 13, Number 2
June 2014

TABLE 3. Consequences of Drug Abuse and Treatment Profiles

Consequences
Physical
Overdose
Diseases (hepatitis C)
Accidents
Operations
Psychological
Psychiatric disorders
Social
Academic deterioration
Work deterioration
Legal problems
Family problems

N (%)
35 (72.9)*
6 (12.5)*
6 (12.5)
3 (6.3)
22 (47.7)*
30 (62.5)*
37 (77.1)*
15 (31.3)*
48 (100)

Characteristics
Mean Number of trials to stop
By himself
With others help
Motivation to stop drug abuse
Cooperative
Insight
Services involvement
Outpatient
Inpatient
Narcotic anonymous
Rehabilitation
Psychotherapy
Individual psychotherapy
Group psychotherapy
Cognitive behavior therapy

N (%)

1.4 (SD = 2.2)

0.9 (SD = 1.5)
47 (97.9)
47 (97.9)
9 (18.8)
36 (75)
8 (16.7)
48 (100)
47 (97.9)
47 (97.9)
47 (97.9)

*Pr0.05.

relationship was significantly correlated

with positive paternal (r = 0.56, P =
0.001) and positive maternal (r = 0.57,
P = 0.001) attitude toward the son. Finally, there was no positive correlation
between family attitude and risky sexual
behaviors.
We proceeded to estimate the association between having sex with sex
workers for drugs in the past 3 months
and the use of tramadol as the significant
opioid used in bivariate analysis. Initial
analyses revealed that being single with
VET education and using tramadol
(OR = 10.5; 95% CI, 1.3-84.6; P = 0.02)
are all significantly associated with having
sex with sex workers in exchange for
drugs in the past 3 months. In adjusting
for sociodemographic variables (age
group, marital status, education, and
work status), tramadol use remained
marginally significant (OR = 4.3; 95%
CI, 1.05-19.5; P = 0.05).

DISCUSSION
In this study, the use of opioids is
associated with some high-risk sexual
behaviors and a reported early age of
sexual initiation in Egyptian adult drug
users in Cairo. Participants in the study
reported high rates of sexual activity
over the previous 3 months, commercial sex work, exchange of sex for drugs
or money, large number of casual sex
partners, and lifetime hepatitis C. High
r

2013 Lippincott Williams & Wilkins

rates of risky sexual behaviors were

observed, particularly in tramadol
users. The data reported by the study
sample are consistent with those obtained in previous research. Substantial
literature finds evidence of the association of high-risk adult sexual behaviors
and use of alcohol and/or drugs.810
However, the age of sexual initiation
in our sample (13.7 years) is very early
when compared with that of the normal
Egyptian population (16 years)34 and of
street children (14 years).35 In addition,
our entire sample was sexually active
compared with 10% of Egyptian adolescents of the normal population and
67% of street children. The differences
could be because of the selectivity of
our sample, as all were drug users
admitted for treatment in addiction
service. In addition, our sample was
small and included only the male sex,
as males tend to have risky sexual behaviors, including early sexual activity,
compared with females.33 Furthermore,
drug use could be a predisposing factor
for risky sexual behaviors. Finally, the
reverse relationship could be true in
our sample, where the mean age of
onset of start of drug use (15.8 years)
was higher than the age of initiation of
sexual activity (13.7 years). One possible factor that intervenes between early
risky sexual behavior and later illegal
drug use is the peer group. Adolescents
who engage in early risky sexual behavior are more likely to be involved with
www.addictiondisorders.com

Pattern of Risky Sexual Behaviors

adolescents who engage in other problem behaviors, such as illegal drug

use.37,38 The difficulties that illegal drug
users are exposed to are likely to be
exacerbated by the damaging consequences of such risky sexual behaviors
as unprotected sex.7
Our results of a significant correlation between earlier age of sexual
activity and psychiatric diagnosis suggest another mechanism through interpersonal functioning. There is growing
recognition that drug use is associated
with psychiatric disorders.3941 Psychiatric disorders are also related to risky
sexual behavior.42 Another explanation
for the positive correlation of earlier
onset of sexual behavior among psychiatric patients could be impulsivity, including sexual impulsivity, as a
characteristic of borderline personality
disorder or bipolar disorder.

Limitation
Several limitations of this study
should be noted. First, this study was a
cross-sectional retrospective work with
a limited sample size that comprised
only the male population. Second, all
our measures were self-reported. Thus,
associations between variables could be
the result of shared-method variance.
However, previous research43 has demonstrated the validity of self-report data
in the area of adolescent drug use.
Furthermore, all self-reported drug
users were subjected to urinalysis for
psychoactive substances to confirm
their use of drugs. Finally, retrospective
reporting of the age at first drug use may
be subject to error, given that respondents are being asked about events that
may have occurred years ago. However,
the present study provides a good opportunity to examine 2 very sensitive
issues in an Islamic conservative society.
Future research needs to assess the
mechanisms that intervene between
illegal drug use and risky sexual behaviors.36

CONCLUSIONS
High rates of risky sexual behaviors
were seen to be associated with opioid
use among Egyptian adult drug users in a
treatment center. These findings point to
www.addictiondisorders.com

a clear need for interventions aimed at

decreasing risky sexual behaviors among
individuals with opioid dependency.

REFERENCES
1. Hahm HC, Lee J, Ozonoff A, et al. Predictors of STDs
among Asian and Pacific Islander young adults. Perspect Sex Reproduce Health. 2007;39:231239.
2. Magnani RJ, Seiber EE, Gutierrez EZ, et al. Correlates
of sexual activity and condom use among secondaryschool students in urban Peru. Stud Fam Plann.
2001;32:5366.
3. Morrison DM, Gillmore MR, Hoppe MJ, et al. Adolescent drinking and sex: findings from a daily
diary study. Perspect Sex Reproduce Health.
2003;35:162168.
4. Gerressu M, Stephenson JM. Sexual behaviour in
young people. Curr Opin Infect Dis. 2008;21:3741.
5. Cavazos-Rehg PA, Spitznagel EL, Bucholz KK, et al.
The relationship between alcohol problems and
dependence, conduct problems and diagnosis, and
number of sex partners in a sample of young adults.
Alcohol Clin Exp Res. 2007;31:20462052.
6. Li X, Stanton B, Cottrell L, et al. Pattern of initiation of
sex and drug-related activities among urban lowincome African-American adolescents. J Adolesc
Health. 2001;28:4654.
7. Brook DW, Brook JS, Pahl T, et al. The longitudinal
relationship between drug use and risky sexual behaviors among Colombian adolescents. Arch Pediatr
Adolesc Med. 2002;156:11011107.
8. Tubman JG, Gil AG, Wagner EF, et al. Patterns of
sexual risk behaviors and psychiatric disorders in a
community sample of young adults. J Behav Med.
2003;26:473500.
9. Sly DF, Quadagno D, Harrison DF, et al. The association between substance use, condom use and sexual
risk among low-income women. Fam Plann Perspect. 1997;29:132136.
10. OHare T. Risky sex and drinking contexts in freshman first offenders. Addict Behav. 2005;30:585588.
11. Nazar-Beutelspacher A, Tapia-Conyer R, VillaRomero A, et al. Factors related to drug use by
adolescents in urban areas of Mexico. Salud Publica
Mex. 1994;36:646654.
12. Becher JC, Garcia JG, Kaplan DW, et al. Reproductive
health risk behavior survey of Colombian high school
students. J Adolesc Health. 1999;24:220225.
13. Peres CA, Rutherford G, Borges G, et al. Family structure
and adolescent sexual behavior in a poor area of Sao
Paulo, Brazil. J Adolesc Health. 2008;42:177183.
14. Castro R, Orozco E, Eroza E, et al. AIDS-related illness
trajectories in Mexico: findings from a qualitative
study in two marginalized communities. AIDS Care.
1998;10:583598.
15. Millstein SG, Moscicki A. Sexually-transmitted disease
in female adolescents: effects of psychosocial factors
and high risk behaviors. J Adolescent Health.
1995;17:8390.
16. Ericksen KP, Trocki KF. Behavioral risk factors for
sexually transmitted diseases in American households. Soc Sci Med. 1992;34:843853.
17. Halpern-Felsher BL, Millstein SG, Ellen JM. Relationship of alcohol use and risky sexual behavior: a
review and analysis of findings. J Adolesc Health.
1996;19:331336.
18. Howard J, Taylor JA, Ganikos ML, et al. An overview of
prevention research: issues, answers, and new agendas. Public Health Rep. 1988;103:674683.

ADDICTIVE
DISORDERS
& THEIR
TREATMENT
Volume 13, Number 2
June 2014

73

74

ADDICTIVE Elhammady et al
DISORDERS
& THEIR
TREATMENT
Volume 13, Number 2
June 2014

19. Fromme K, DAmico EJ, Katz EC. Intoxicated sexual

risk taking: an expectancy or cognitive impairment
explanation? J Stud Alcohol. 1999;60:5463.
20. Jersild AT, Brook JS, Brook DW. The Psychology of
Adolescence. 3rd ed. New York: Macmillan Publishing Co Inc.; 1978.
21. Kandel DB, Davies M. Cocaine use in a national
sample of US Youth (NLSY): epidemiology, predictors, and ethnic patterns. In: Schade C, Schober S,
eds. The Epidemiology of Cocaine Use and Abuse.
Rockville, MD: National Institute on Drug Abuse;
1990:151188. NIDA Research Monograph.
22. Hawkins JD, Weis JG. The social development model:
an integrated approach to delinquency prevention.
J Prim Prev. 1985;6:7397.
23. Elliott DS, Huizinga D, Ageton SS. Explaining Delinquency and Drug Use. Thousand Oaks, California:
Sage Publications; 1985.
24. Elliott DS, Huizinga D, Menard S. Multiple Problem
Youth: Delinquency, Subatance Use, and Mental
Health Problems. New York: Springer-Verlag NY
Inc.; 1989.
25. Kaplan HB, Martin SS, Johnson RJ, et al. Escalation of
marijuana use: application of a general theory
of deviant behavior. J Health Soc Behav. 1986;27:
4461.
26. Alemu H, Mariam DH, Belay KA, et al. Factors predisposing out-of-school youths to HIV/AIDS-related
risky sexual behaviour in northwest Ethiopia.
J Health Popul Nutr. 2007;25:344350.
27. Staton M, Leukefeld C, Logan TK, et al. Risky sex
behavior and substance use among young adults.
Health Soc Work. 1999;24:147154.
28. Zabin LS, Kiragu K. The health consequences of
adolescent sexual and fertility behavior in sub-Saharan
Africa. Stud Fam Plann. 1998;29:210232.
29. Haque N, Zafar T, Brahmbhatt H, et al. High-risk
sexual behaviors among drug users in Pakistan:
implications for prevention of STDs and HIV/AIDS.
Int J STD AIDS. 2004;15:601607.
30. Pisani E, Sucahya PK, Kamil O, et al. Sexual behavior
among injection drug users in 3 Indonesian cities
carries a high potential for HIV spread to noninjectors. Epidemiol Soc Sci. 2003;34:403406.

2013 Lippincott Williams & Wilkins

31. Cotrina A, Garcia P, Carcamo C. Encuesta Nacional de

Prevalencia de ITS y VIH en Poblacion General. In:
Preven, ed. Presentacion de Resultados Proyecto
PREVEN 2008 Lima., 2008;12.
32. Sanchez J, Gotuzzo E, Escamilla J, et al. Gender
differences in sexual practices and sexually transmitted infections among adults in Lima, Peru. Am J
Public Health. 1996;86:(pt 1):10981107.
33. Galvez-Buccollini JA, DeLea S, Herrera PM, et al.
Sexual behavior and drug consumption among
young adults in a shantytown in Lima, Peru. BMC
Public Health 2009, 9: 23. Available from: http:/
www.biomedcentral.com/1471-2458/9/23. Accessed
August 2, 2012.
34. Refaat A. Practice and awareness of health risk behavior among Egyptian university students. East Mediterr Health J. 2004;10:7281.
35. Nada K, Suliman EA. Violence, abuse, alcohol and drug
use, and sexual behaviors in street children of greater
Cairo and Alexandria, Egypt. Aids. 2010;24:S39S44.
36. American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders IV-TR. Arlington,
VA: 1000 Wilson Boulevard. 2004;2220923901.
37. Jassor R, Donovan JE, Costa FM. Beyond Adolescence: Problem Behavior and Young Adult Development. Cambridge: Cambridge University Press; 1991.
38. Jassor R, Jassor SL. Problem Behavior and Psychosocial
Development. New York: Academic Press Inc; 1977.
39. Campbell BK, Stark MJ. Psychopathology and personality characteristics in different forms of substance
abuse. Int J Addiction. 1990;25:14671474.
40. Stephens RS, Roffman RA, Simpson EE. Adult marijuana users seeking treatment. J Consult Clin Psychol. 1993;61:11001104.
41. Swift W, Williams G, Neill O, et al. The prevalence of
minor psychopathology in opioid users seeking treatment. Br J Addict. 1990;85:629634.
42. Ramrakha S, Caspi A, Dickson N, et al. Psychiatric
disorders and risky sexual behavior in young adulthood: cross sectional study in birth cohort. BMJ.
2000;321:263266.
43. Bachman JG, Wadsworth KN, OMally PM, et al. Smoking, Drinking, and Drug Use in Young Adulthood.
Mahwah, NJ: Lawrence A Eribaum Associates; 1997.

www.addictiondisorders.com