Sexual Risk Behaviors and Current Substance Use Among Sexually Active Adolescents in the United States: Differences by Sex, Race, and Sexual Identity

Substance use and high-risk sexual behaviors remain pressing public health challenges among U.S. adolescents, with tobacco, alcohol, and marijuana being the most used substances. While previous research has shown an association between substance use and risky sexual behavior, there is limited data on how these associations vary based on demographic modifiers such as race, sex, and sexual identity among sexually active adolescents. This study explores the association between current substance use (cigarettes, e-cigarettes, alcohol, and marijuana) and high-risk sexual behaviors (having multiple sexual partners and lack of condom use), examining how these associations vary by race, sex, and sexual identity. The 2023 Youth Risk Behavior Survey (YRBS) data was analyzed for 5420 adolescents attending U.S. public and private high schools. Multiple Logistic regression was used to examine associations, and interaction effects for race, sex, and sexual identity were introduced to the model to determine variations in associations. Overall adjusted analyses revealed current use of cigarette, e-cigarette, and alcohol was associated with higher likelihood of having multiple (2 or more) sexual partners in the past 3 months. Additionally, current marijuana use was associated with a higher likelihood of not using a condom during last sexual intercourse. A statistically significant interaction was observed only for the association between current marijuana use and condomless sex during last sexual intercourse (p = 0.010). Stratified analyses indicated that this association varied by sexual identity and was stronger among heterosexual students compared to Lesbian, Gay, Bisexual, Queer, and other (LGBQ+) students. Results confirm the link between substance use and high-risk sexual behavior among youth, reinforcing our need for increased programming around substance use prevention and sexual health education. Heterosexual youth may be at increased risk for high-risk sexual behavior associated with their marijuana use, calling for tailored interventions that target the unique needs of this demographic subgroup.