Archives of Sexual Behavior (2023) 52:2503–2526 https://doi.org/10.1007/s10508-023-02572-z ORIGINAL PAPER Prevalence of Intoxicating Substance Use Before or During Sex Among Young Adults: A Systematic Review and Meta‑Analysis María Isabel Gómez‑Núñez1 · Cristian Molla‑Esparza2 · Natalia Gandia Carbonell3,4 · Laura Badenes Ribera5 Received: 3 February 2022 / Revised: 21 February 2023 / Accepted: 21 February 2023 / Published online: 10 March 2023 © The Author(s) 2023 Abstract Drug use before or during sex is a high-risk sexual behavior associated with adverse health risks and outcomes, such as increas- ing the likelihood of overdoses and of acquiring sexually-transmitted diseases. This systematic review and meta-analysis of three scientific databases examined the prevalence of the use of intoxicating substances, those tending to excite or stupefy the user on a psychoactive level, before or during sex, among young adults (18–29 years old). A total of 55 unique empirical studies met the inclusion criteria (48,145 individuals; 39% males), were assessed for risk of bias using the tools of Hoy et al. (2012), and were analyzed via a generalized linear mixed-effects model. The results produced a global mean prevalence of this sexual risk behavior of 36.98% (95% CI: 28.28%, 46.63%). Nonetheless, significant differences were identified between different intoxicating substances, with the use of alcohol (35.10%; 95% CI: 27.68%, 43.31%), marijuana (27.80%; 95% CI: 18.24%, 39.92%), and ecstasy (20.90%; 95% CI: 14.34%, 29.45%) significantly more prevalent than that of cocaine (4.32%; 95% CI: 3.64%, 5.11%), heroin (.67%; 95% CI: .09%, 4.65%), methamphetamine (7.10%; 95% CI: 4.57%, 10.88%), and GHB (6.55%; 95% CI: 4.21%, 10.05%). Moderator analyses showed that the prevalence of alcohol use before or during sex differed according to geographical sample origin, and increased as the proportion of ethnic whites in samples increased. The remain- ing demographic (e.g., gender, age, reference population), sexual (e.g., sexual orientation, sexual activity), health (e.g., drug consumption, STI/STD status), methodological (e.g., sampling technique), and measurement (e.g., timeframe) variables that were examined did not moderate prevalence estimates. Implications for sexual development interventions were discussed. Keywords Sexual risk behavior · Sex · Drugs · Young adults · Meta-analysis · Substance use Introduction Young adulthood is an intensive developmental period * Cristian Molla‑Esparza often characterized by novel sexual experiences and sensa- Cristian.Molla@uv.es tion seeking, which may lead to increased engagement in sexual risk behaviors with the potential to compromise health 1 Department of Research Methods and Diagnostics (Arnett, 2014; Vail-Smith et al., 2010). The use of intoxicat- in Education, International University of La Rioja, UNIR, Logroño, La Rioja, Spain ing substances before or during sex, which may facilitate 2 sexual contact between youths, is one such experience that Department of Research Methods and Diagnostics in Education, University of Valencia, UVEG, Av. de Blasco has historically been studied (Marcantonio & Jozkowsky, Ibáñez, 30, 46010 Valencia, Spain 2021; Weatherburn et al., 2017). 3 Llaurant la Llum Therapeutic Community, Center While the use of alcohol or other intoxicating substances, for the Treatment, Withdrawal and Detoxification which tend to excite or stupefy the user on a psychoactive of Addictions and Other Associated Disorders, Valencia, level, before or during sex is certainly nothing new, over the Spain last few years several new terms have emerged from aca- 4 Department of Psychobiology and Health Sciences demic literature to describe this behavior, such as “sexualized Methodology, Autonomous University of Barcelona, UAB, drug use” (hereinafter also referred to as SDU) (Edmundson Bellaterra, Spain et al., 2018; González-Baeza et al., 2018). Other terms refer 5 Department of Methodology of the Behavioural Sciences, more specifically to the specific substances used and way University of Valencia, UVEG, Valencia, Spain 13 Vol.:(0123456789) 2504 Archives of Sexual Behavior (2023) 52:2503–2526 of administering them (Race et al., 2021). For example, the large part of the literature has focused on studying sexual- before and during sex use of substances such as mephedrone, related consequences, such as demonstrating that pre-sex crystal methamphetamine, alkyl nitrites (or poppers), gamma drug consumption is associated with an early age of sexual hydroxybutyrate (GHB), and gamma-butyrolactone (GBL), debut (Kebede et al., 2018; Tan et al., 2021), having multiple which are mainly orally or nasally ingested, has been labeled partners (Edmundson et al., 2018; Huibregtse et al., 2021), as “chemsex” (Drevin et al., 2021). The literature has also inconsistent condom use (Ristuccia et al., 2018; Strandberg referred to chemsex, to a lesser extent, using terms such as et al., 2019), or unplanned pregnancies (Dong et al., 2015; “chemsex partying”, “Party and Play” (PnP, P&P), “High Metzger, 2015). Using intoxicating substances before or and Horny” (HnH, H&H), “intensive sex parties”, and “wired during sex has also been associated with various negative play” (Drysdale, 2021; Hurley & Prestage, 2007, 2009; health outcomes, including overdoses (Hammoud et al., Meléndez-Torres & Bourne, 2016; Race, 2015). Sexualized 2017; Hegazi et al., 2017), and a greater likelihood of acquir- drug use via intravenous injection, on the other hand, has ing blood-borne viruses, such as human immunodeficiency been dubbed “slamsex” (Bourne et al., 2015b). virus (HIV), and other sexually transmitted infections (STIs) The main motivation for the use of such intoxicating sub- (González-Baeza et al., 2018; Mayo-Wilson et al., 2020). stances before or during sex is to pursue pleasure, which, in To date, a number of empirical and review studies have turn, involves other motivations, varying from losing inhibi- examined SDU prevalence and its associated outcomes, tions and facilitating the sexual setting to improving sexual predominantly among gay and bisexual communities, and performance and arousal (Bourne et al., 2015a; Piyaraj et al., communities of other men who have sex with men (MSM) 2018; Schmidt et al., 2016). Sexual pleasure seeking and (Edmundson et al., 2018; Guerra et al., 2020; Íncera-Fernán- experimentation have come to involve new behavioral pat- dez et al., 2021; Lafortune et al., 2021; Maxwell et al., 2019), terns concerning the intersection between drug consumption despite SDU not being exclusive to these populations. Two and a variety of sexual practices that transgress normative reviews aimed at estimating SDU and chemsex prevalence means of pleasure (e.g., sober forms of sexual pleasure) and among such populations suggest high and heterogeneous that demand greater consideration when promoting safe and prevalence estimates (Edmunson et al., 2018; Maxwell et al., healthy sexual relationships (Ford et al., 2021a; Piyaraj et al., 2019). One review carried out by Edmunson et al. (2018) 2018). Nonetheless, the most empirical literature seems not found that prevalence estimates of SDU and chemsex ranged to have been overly explicit about specific purposes, favor- from 4 to 41% and 17 to 31%, respectively, among MSM ing the referencing of sexual motivation in general (Guerra in the United Kingdom. Another review, by Maxwell et al. et al., 2020). SDU and its derivative terms have been socially (2019), contributed to the field with an estimated prevalence constructed, and it is, accordingly, likely that the subset of range of chemsex-related behavior between 3 and 29%. In this practices involved varies considerably across countries and study, prevalence estimates were also found to vary accord- over time (Maxwell et al., 2019). ing to the particular substance used: methamphetamines Studies have shown that the consumption of intoxicat- (3–22%), cocaine (2–33%), and ketamine (1–4%). ing substances before or during sexual activity can lead to However, there is a general lack of review studies aimed the loss of inhibitions and an increase in self-confidence at the use of intoxicating substances before or during sex and perceived attractiveness in relation to others (Palamar among young adults in particular, despite there being an et al., 2018b; Santos et al., 2018). For example, one study increasing number of empirical studies aimed at estimating on the sexual effects of drugs in a sample of young adults its prevalence in this age group, with high resulting rates has documented various associated psychophysiological (Meuwly et al., 2021). For example, analyses of a survey of effects, such as greater sexual outgoingness, orgasm inten- United States college students showed that 56% of the sam- sity, and length of sexual interaction (Palamar et al., 2018b). ple had drunk alcohol or used drugs prior to sexual contact Though, such effects may not exclusively be due to the use during the year prior to the survey, with the experience more of recreational intoxicating substances, but also to prescrip- prevalent with increasing age (Powell, 2018). Another study tion or over-the-counter pharmacological treatments aimed of Portuguese university students found that approximately at treating symptoms of a disease or condition (e.g., mental 33% of the sample had had intercourse under the influence of health disorders, impotence), especially in clinical samples. alcohol or while taking drugs during the last twelve months, However, to our knowledge, no empirical studies have yet showing significant statistical differences by the sex of the been carried out specifically to assess potential confounding participants. Specifically, men were more likely to combine factors of sexual experiences and their psychophysiological sex with alcohol (21.4% of women, 51.8% of men) and drugs effects under the influence of intoxicating substances among (4.8% of women, 17.7% of men) (Santos et al., 2018). How- young adult populations. ever, the results of a recent prospective cohort study of high The use of intoxicating substances before or during sex school senior students suggest that women may be making also entails certain adverse health risks and outcomes. A increasing use of alcohol, as they increasingly share common 13 Archives of Sexual Behavior (2023) 52:2503–2526 2505 behaviors and exposures with men, including alcohol con- Meta-Analyses (PRISMA 2020) statement (Moher et al., sumption (McKetta et al., 2022). A further study carried 2009), and the Guidelines for Reporting Systematic Reviews out among United States college students documented that and Meta-Analyses (Rubio-Aparicio et al., 2018). approximately a third of students had consumed substances before having sex the most recent time, and that African Search Strategy American women, in particular, had the lowest frequency of participation in this kind of activity (Vail-Smith et al., The study search was carried out between July and Octo- 2010). This suggests that while direct comparisons cannot ber 2021, mainly using three electronic databases: ISI Web be made a priori, high variations among the prevalence rates of Science (WoS Core Collection) via Thomson Reuters; reported between studies may be explained by demographic, Scopus, via Elsevier; and Psychological Information (Psy- sexual and health factors, as well as measurement and other cINFO), via APA PsycNET. Following the Peer Review methodological factors characterizing the available empirical of Electronic Research Strategies guideline (McGowan studies (Lafortune et al., 2021). et al., 2016), the search strategy was built through an itera- In summary, a lack of reviews of the use of intoxicat- tive process (empirical literature key terms, and database ing substances before or during sex among the young adult consultations), which also considered the aforementioned population, and its potential health implications, supports non-age-specific reviews. The strategy included both highly the need to carry out a thorough review aimed at estimat- sensitive and unspecific, comprehensive search descriptors ing its prevalence. There is also a need to study the hetero- and expressions referring to both the use of intoxicating sub- geneity among prevalence rates, by considering study-level stances before or during sex and young adults as the target characteristics in terms of demographic (e.g., gender, age, population (Supplementary Tables S1a–S1d). The key words ethnicity, sample geographical origin, reference population), were combined in different ways and the search strategy was sexual (e.g., sexual orientation, sexual activity, mean age of modified according to the specific requirements of each data- sexual debut, number of sexual partners), health (e.g., drug base. The search was limited to the timeframe from the year consumption, STI/STD status), methodological (e.g., sam- 2000–2021. The references of relevant published studies pling, administration procedure), and measurement (e.g., were also examined in order to acquire potentially eligible purpose, willingness, substance types, timeframe) variables. documents consistent with our search criteria. Furthermore, Therefore, the main aim of this study is to provide a meta- grey literature was searched via Google and Google Scholar analytic synthesis of the prevalence of the use of intoxicat- to obtain other potentially eligible studies, such as reports, ing substances before or during sex among the young adult theses, unpublished papers, government documents, and so population, as well as examine potential moderators that may on. Finally, emails were sent to the principal researcher of explain the observed heterogeneity in prevalence rates. Due research groups that had published the most about the use of to the disparities among individual empirical studies and the intoxicating substances before or during sex involving young lack of reviews concerning young adults, this research is of adults, with the aim of identifying hitherto unpublished stud- an exploratory nature, and, therefore did not contemplate the ies that might not have been obtained by the other means. formulation of hypotheses. Ultimately, knowing the extent of the use of intoxicating substances before or during sex Study Selection Criteria among the young adult population will facilitate the planning of preventive sexual health strategies and interventions for Studies were included if they: (1) reported a prevalence figure this specific age grouping. of drug use before or during sex, including any prevalence disaggregated by substance or participant sex; (2) provided original empirical data; (3) comprised a sample of partici- Method pants from 18 to 29 years old; and (4) were published or avail- able in English, Spanish or Catalan. Studies were excluded Study Design if they: (1) provided insufficient demographic or methodo- logical descriptions; (2) reported a prevalence not calculable The systematic review and meta-analysis were conducted from the data; or (3) considered the same sample and reported according to an established protocol registered on the Inter- the same results as another of the studies already included. national Platform of Registered Systematic Review and Furthermore, clinical and community specific samples (e.g., Meta-Analysis Protocols (INPLASY No. 2021100077), injected drug users), which might bias the prevalence results, following the Preferred Reporting Items for Systematic were excluded. Study titles and abstracts and full-text inclu- Reviews and Meta-Analyses Protocols (PRISMA-P) guide- sion criteria were screened independently by two research- lines. In particular, the study followed Appendix 1 and 2 of ers. Disagreements were resolved through discussion, and, the Preferred Reporting Items for Systematic Reviews and if necessary, a third researcher was consulted. 13 2506 Archives of Sexual Behavior (2023) 52:2503–2526 Study Coding (5) study response rate. The potential moderating effect of study quality on prevalence estimates was then assessed and The coding process was conducted independently and dupli- is discussed in the results section. cated by another two researchers using a standard data extrac- tion form. Once again, any discrepancies were resolved by Statistical Analysis consensus, and a third researcher was consulted if required. Effect size data included the proportion of participants The meta-analysis was conducted using generalized linear that had used intoxicating substances before or during sex, mixed models (GLMMs) with a logit link function to esti- whether reporting a global prevalence (i.e., any drug) or mul- mate the prevalence of intoxicating substance use before or tiple prevalences disaggregated by substance type. In certain during sex. Previous preliminary meta-analytical studies have studies, additional calculations were required to determine suggested that the use of GLMMs to estimate non-normally prevalence. From longitudinal study designs, only the base- distributed outcomes, as in the case of proportions, show line data were considered. smaller biases and mean squared errors and higher cover- In addition, the following relevant bibliometric, demo- age probabilities than two-step methods (Lin & Chu, 2020). graphic, sexual, health, methodological, and measurement In this study, prevalence estimates are presented with 95% information was extracted: (1) document type (e.g., article, confidence intervals (CIs) and credibility intervals (CRs), degree, master or doctoral thesis, report, peer-reviewed or and all parameters were estimated using the maximum-like- not, under review); (2) publication year; (3) data collection lihood approach. Between-study heterogeneity was analyzed year; (4) sample geographical origin; (5) study design (e.g., using the Higgins’ inconsistency index (I2) and tested using cross-sectional, longitudinal); (6) sampling technique (e.g., the likelihood ratio test. Univariate GLMMs were used to probabilistic, non-probabilistic); (7) reference population explore possible sources of heterogeneity, including potential (e.g., university students; men who have sex with men); (8) categorical (e.g., sampling technique, risk of bias) and quan- sample size; (9) participant gender distribution; (10) par- titative (e.g., data collection year, mean age) moderators as ticipant sexual orientation distribution (i.e., proportion of covariates. Classical recommendations were used to assess heterosexuals); (11) participant ethnicity distribution (i.e., categorical moderators with at least three studies at each proportion of whites); (12) socioeconomic status; (13) range, level, and continuous moderators with at least ten studies mean and standard deviation of the age of participants; (14) per covariate (Borenstein et al., 2009). Funnel plot symmetry administration procedure (e.g., online survey, face-to-face was analyzed to examine potential publication bias, and forest interviews); (15) sexual practice related aspects (e.g., pro- plots were used to visualize the meta-analysis study results. portion of participants sexually active, mean age of sexual A p-value < .05 was considered statistically significant. The debut, mean of sexual partners); (16) drug consumption (e.g., meta-analysis was performed using the metafor package in proportion of consumers of specific intoxicating substances); R (version 3.8-1). (17) relationship context of participants using drugs before or during sex (e.g., romantic, casual); (18) timeframe (e.g., last sex, lifetime); (19) purpose of using drugs before or during Results sex (e.g., to enhance the sexual experience); (20) willing- ness to partake in the use of intoxicating substances before Search Results and Study Characteristics or during sex (e.g., voluntary, solicited); and (21) sexually transmitted disease status. A total of 2589 documents were identified via the aforemen- tioned databases. After duplicates had been eliminated, 1505 Study Quality studies were screened on the basis of their title and abstract. Subsequently, 149 potentially eligible reports were examined The risk of study bias was assessed using an ad-hoc tool on the basis of their full text including references (see Sup- elaborated by the authors and adapted from a tool specifi- plementary Table S2 for exclusions). After a comprehensive cally designed to assess bias in prevalence studies (Hoy analysis, 46 studies from the databases and 9 studies from et al., 2012). This tool evaluates five methodological quality other sources that met the five inclusion criteria were con- domains, three relating to internal validity, and two relat- sidered to form the basis of this meta-analysis (see Fig. 1). ing to external validity: (1) common administration proce- Of the 55 studies selected, a total of 57 analytical samples dures across all participants (yes or no); (2) measure quality were included. The studies included in the meta-analysis are (reported or justified evidence of validity and reliability in the listed in Appendix 3. study sample, or equivalent samples); (3) timeframe (well- The documents thus analyzed were, mainly, articles pub- defined or undefined); (4) representativeness of the target lished in scientific journals and subject to the peer-review population (probabilistic or non-probabilistic sample); and process (k = 49, 89.09%). The remaining documents were 13 Archives of Sexual Behavior (2023) 52:2503–2526 2507 Fig. 1  PRISMA flowchart doctoral theses (k = 6, 10.91%). Most of the selected stud- Study Quality ies were published in the time interval corresponding to the years 2011 to 2021 (k = 38, 69.09%). More than half of the The findings explained below are shown schematically in selected studies were conducted in the United States (k = 36, Table 1. The quality assessment revealed that almost all 64.45%). The most commonly used tools to assess the use of the studies analyzed were cross-sectional studies (k = 45, drugs before or during sex were questionnaires administered 81.82%) and used non-probabilistic sampling techniques online or on paper (k = 46, 83.64%), followed by face-to- (k = 44, 80%). More than three quarters of the study samples face interviews (k = 7, 12.73%), and mixed administration included a complete description of the age of the participants procedures (k = 2, 3.64%). Of the 57 analytical samples, 33 involved (k = 44, 80%). Regarding the measure quality, only reported on university students, whereas 13 reported on gen- fourteen of the included studies reported or justified valid- eral community samples. The remaining samples were of ity and/or reliability of the measure in relation to the study men who have sex with men (5 samples), migrant workers sample or comparable samples (k = 14, 25.45%). The pre- (3 samples) and clinical samples (3 samples). The analytical dominant timeframes in the included studies were in one’s samples involved a total of 48,145 participants (39% males). lifetime or non-defined (k = 17, 30.91%), followed by in the Twenty-one studies reported prevalence rates of using intoxi- last three months (k = 11, 20%), and last year (k = 9, 16.36%). cating substances before or during sex without referring to Almost all of the studies included a common administration specific drugs (k = 21, 38.18%), while thirty-four studies pro- procedure for all participants (k = 53, 96%). Most studies vided a prevalence specifying at least one substance (k = 34, (k = 39, 70.91%) provided no information on the response 61.82%), of which alcohol (k = 33, 60%) and marijuana (k = 6, rate. Among those that reported response rates, these ranged 10.91%) were the most reported, followed by heroin, cocaine, between 63 and 88.50% (in the interquartile range). Lastly, poppers, methamphetamine, and ecstasy (k = 3, 5.45%), GHB regarding risk of bias, a minority of the studies were assessed (k = 2, 3.64%), and crack, sedatives, hallucinogens, lysergic as having a low risk of bias (k = 3, 5.45%), followed by stud- acid diethylamide (LSD), ketamine, and speed (k = 1, 1.82%). ies with a moderate risk (k = 18, 32.73%), and a high risk Only five studies reported disaggregated prevalence of two (k = 34, 61.82%). Supplementary Table S4 shows the detailed or more individual substances. Detailed information on the critical appraisal of the studies. studies included is provided in Supplementary Table S3. 13 2508 Archives of Sexual Behavior (2023) 52:2503–2526 Table 1  Summary of the critical appraisal of the studies included in Meta‑Analytical Results the review Methodological quality domains Studies (k = 55) The mean prevalence of intoxicating substance use before k (%) or during sex without referring to specific substances was Study design Cross-sectional 45 (81.82%) 36.98% (95% CI: 28.28%, 46.63%; I2 = 99.40%). Although Cohort study 3 (5.45%) this is a raw prevalence estimate, it can, however, be used as Age description Full age description 44 (80%) a proxy for the use of intoxicating substances before or dur- Not completely 11 (20%) ing sex. The observed global prevalence and global mean Sampling technique Probabilistic 11 (20%) estimate are illustrated in Fig. 2. As indicated in Table 3, the Non-probabilistic 44 (80%) estimated prevalence of the use of alcohol (35.10%; 95% CI: Measurement quality Reported or justified 14 (25.45%) 27.68%, 43.31%; I2 = 99.12%; see Fig. 3), marijuana (27.80%; validity/reliability 95% CI: 18.24%, 39.92%; I 2 = 97.35%), and of ecstasy Not reported or unclear 41 (74.55%) (20.90%; 95% CI: 14.34%, 29.45%; I 2 = 87.60%) before Timeframe Well defined 38 (69.09%) or during sex were significantly higher than the estimated Lifetime or non-defined 17 (30.91%) prevalence of the use of cocaine (4.32%; 95% CI: 3.64%, Common administra- Yes 53 (96.36%) 5.11%; I2 = .46%), of heroin (.67%; 95% CI: .09%, 4.65%; tion procedure No 2 (3.63%) I2 = 86.62%), of methamphetamine (7.10%; 95% CI: 4.57%, Response rate Reported 16 (29.09%) 10.88%; I2 = 69.55%), and of GHB (6.55%; 95% CI: 4.21%, IQR: 63–88.50% 10.05%; I2 = 71.96%), without overlapping confidence inter- Risk of bias Low 3 (5.45%) vals. No evidence of publication bias was observed for the Moderate 18 (32.73%) global prevalence, or in the case of alcohol use (Appendix High 34 (61.82%) 4 and 5). The consumption prevalence of other substances, such as crack, speed, sedatives (or barbiturates), LSD and “k” = number of studies, “IQR” = Interquartile range ketamine, was not meta-estimated since it was reported in only one study. Measures of Drug Use Before or During Sex Global Prevalence Moderators The findings explained below are shown schematically in Table 2. The use of substances before or during sex were con- The global mean prevalence of intoxicating substance use sidered in the majority of the studies via a mono-item (k = 36, before or during sex among university students was 33.68% 65.45%). The predominant form of response was dichoto- (95% CI: 23.32%, 45.89%), which did not differ from gen- mous (yes/no) in 54.54% of the studies (k = 30), followed by eral community samples (47.77%; 95% CI: 32.59%, 63.38%) different Likert frequency scales (k = 17, 30.91%). A total (p = .19) (see Table 4). Estimates for clinical, migrant worker of 69.09% of the studies (k = 38) considered sexual acts in and MSM samples could not be performed because of an a general way (e.g., sex, sexual encounter, sexual activity). insufficient number of studies. As no statistically significant The presence of penetration was specified in 18.18% of the differences were observed by sample type, subsequent analy- studies (k = 10), while the type of sexual act (e.g., anal, vagi- ses were performed on the total number of analytical samples. nal) was specified in only 7.27% of the studies (k = 4). Other As indicated in Table 4, no significant subgroup differ- aspects considered in a minority of the studies were relation- ences were detected among different categorical modera- ship type (e.g., casual partner) (k = 4, 7.27%) and a specific tors concerning the global prevalence of the consumption circumstance of the act of sex (i.e., unprotected sex) (k = 3, of intoxicating substances before or during sex (e.g., docu- 5.45%). The aspect of participants’ willingness in partaking ment type or measure timeframe). It should also be noted that in the use of intoxicating substances before or during sex was no significant difference was found between men (44.32%; not considered in any of the studies included in the sample. 95% CI: 33.93%, 55.22%) and women (42.53%; 95% CI: Lastly, only one study specified for the purpose of sex in the 32.19%, 53.56%) (p = .82). Certain categorical moderators, measure (k = 1, 1.82%). including risk of bias, sampling technique, administration procedure, and geographical origin of the sample, could not be analyzed due to an insufficient number of studies. Meta-regression findings (Table 5) showed that the mean 13 Archives of Sexual Behavior (2023) 52:2503–2526 2509 Table 2  Analysis of measures Number of studies (k = 55) Number of items used to assess substance use before or during sex 1 item (mono-item) 36 2 or more items 16 Not defined 3 Response type Dichotomous (yes/no) 30 Likert-type scales 17 Open answer 1 Not defined 7 Sexual act type Generic (e.g., sexual encounter, sex, sexual activity) 38 Referring to penetration (e.g., sexual intercourse) 10 Specific (e.g., anal, vaginal) 4 Relationship type Defined (e.g., 2 casual partners, 1 primary partner, 1 non-spousal partner) 4 Not defined 51 Specific circumstance of the sexual act Defined (e.g., unprotected sex) 3 Not defined 52 Substance use purpose Defined (i.e., for the purpose of sex) 1 Not defined 54 Willingness Defined 0 Not defined 55 prevalence of using intoxicating substances before or during Alcohol Prevalence Moderators sex significantly decreased in studies with a higher propor- tion of ethnic whites in their samples (e.g., 65.27%, 95% Prior to describing the results by substance, we would like to CI: 41.53%, 83.26%, when the proportion was .15, versus emphasize that categorical and quantitative moderators could 20.79%, 95% CI: 12.34%, 32.88%, when it was .85, averaging only be analyzed in the case of alcohol. Subgroup analysis all studies reviewed) (p < .01). It was also observed that meta- could not be performed for other substances, including mari- regression by mean age of sample participants revealed an juana, cocaine, heroin, methamphetamine, ecstasy, poppers, increasing trend in the use of intoxicating substances before and GHB, due to an insufficient number of studies. or during sex (e.g., 25.04% at the age of 18, versus 62.99% at The mean prevalence of alcohol consumption before or the age of 26, averaging all studies reviewed), although the during sex among university students was of 31.64% (95% association was not statistically significant. Prevalence was CI: 23.49%, 41.10%). Similar prevalence estimates were also not moderated by data collection year. Certain quantita- obtained from studies considering community samples tive moderators, including the proportion of heterosexuals, (44.19%; 95% CI: 26.60%, 63.37%) and migrant workers of sexually active participants, and the consumption of spe- (35.12%; 95% CI: 15.11%, 62.20%) (p = .51) (Table 4). Esti- cific drugs, also could not be analyzed due to an insufficient mates for clinical and MSM samples could not be performed number of studies. due to an insufficient number of studies. As no statistically 13 2510 Archives of Sexual Behavior (2023) 52:2503–2526 Fig. 2  Forest plot of observed prevalences and global mean estimate of intoxicating substance use before or during sex. “95% CI” = 95% Confi- dence Interval; “FS” = Fall Sample; “SP” = Spring Sample significant differences were observed by sample type, subse- 43.41%, 95% CI: 32.99%, 54.46%, when it was .85, averaging quent analyses were performed on the total number of ana- all studies reviewed) (Table 5). lytical samples. Results also indicated that men (26.73%; 95% CI: 8.63%, As indicated in Table 4, the geographical origin and the 58.50%) and women (20.77%; 95% CI: 6.34%, 50.38%) con- proportion of ethnic whites in samples significantly moder- sumed alcohol equally before or during sex (p = .73). Further- ated the prevalence of using alcohol before or during sex more, it should be noted that the analysis of the timeframe (p < .01 for both). The prevalence of having sex under the of the measure was quasi-significant (p = .07), showing that influence of alcohol in Africa (10.65%; 95% CI: 4.98%, studies assessing the prevalence of consuming alcohol before 21.32%) was significantly lower than in Asia (43.07%; 95% or during sex in timeframes from one to 6 months reported CI: 27.93%, 59.62%), Europe (55.46%; 95% CI: 32.74%, a lower prevalence (24.45%; 95% CI: 14.23%, 38.69%) than 76.10%), and the United States and Canada (36.77%; 95% studies without timeframes or indicated timeframes in excess CI: 28.92%, 45.40%). Moreover, the prevalence of alcohol of six months (40.51%; 95% CI: 30.34%, 51.58%) (Table 4). use before or during sex was higher among studies that sam- The prevalence of alcohol use before or during sex was seen pled a greater proportion of ethnic whites (e.g., 23.44%, 95% to increase as the proportion of sexually active participants CI: 14.26%, 36.05%, when the proportion was .15, versus in samples increased (e.g., 16.98%, 95% CI: 7.70%, 33.38%, 13 Archives of Sexual Behavior (2023) 52:2503–2526 2511 Table 3  Pooled prevalence of intoxicating substance use before or during sex among young adults k eff (%) (95% CI) (95% CRs) Tau2 I2 Tests for heterogeneity Global prevalence 22 36.98 (28.28%, 46.63%) (8.20%, 79.41%) .88 99.40% Wld(df = 21) = 2795.82, p < .01 (various drugs) LRT(df = 21) = 3479.11, p < .01 Marijuana 6 27.80 (18.24%, 39.92%) (8.54%, 61.34%) .45 97.35% Wld(df = 5) = 237.49, p < .01 LRT(df = 5) = 262.19, p < .01 Alcohol 34 35.10 (27.68%, 43.31%) (6.64%, 80.42%) 1.04 99.12% Wld(df = 33) = 2679.60, p < .01 LRT(df = 33) = 3287.62, p < .01 Cocaine 3 4.32 (3.64%, 5.11%) (3.64%, 5.11%) .01 .46% Wld(df = 2) = 5.93, p = .05 LRT(df = 2) = 4.84, p = .09 Heroin 3 .67 (.09%, 4.65%) (.02%, 17.80%) 2.12 86.62% Wld(df = 2) = 4.17, p = .12 LRT(df = 2) = 13.50, p < .01 Methamphetamine 3 7.10 (4.57%, 10.88%) (3.30%, 14.61%) .12 69.55% Wld(df = 2) = 11.51, p < .01 LRT(df = 2) = 12.10, p < .01 Ecstasy 3 20.90 (14.34%, 29.45%) (10.32%, 37.76%) .13 87.60% Wld(df = 2) = 23.42, p < .01 LRT(df = 2) = 24.73, p < .01 Poppers 3 8.38 (2.02%, 28.90%) (.47%, 63.84%) 1.70 98.64% Wld(df = 2) = 144.33, p < .01 LRT(df = 2) = 236.16, p < .01 Gamma Hydroxybutyrate 2 6.55 (4.21%, 10.05%) (3.27%, 12.69%) .08 71.96% Wld(df = 1) = 7.07, p < .01 LRT(df = 1) = 7.30, p < .01 “k” = number of studies included, “eff” = effect size, “95% CI” = 95% Confidence Interval, “95% CRs” = 95% credibility intervals, “Tau2” = esti- mated amount of (residual) heterogeneity, “I2” = I-square, “Wld” = Wald-type test statistic of the test for (residual) heterogeneity, “LRT” = Like- lihood Ratio Test statistic of the test for (residual) heterogeneity The prevalence of Crack, Speed, Sedatives/Barbiturates, Lysergic Acid Diethylamide (LSD) and Ketamine was reported by only 1 study when the proportion was .50, versus 35.93%, 95% CI: concurs with those reported in the abovementioned review 20.53%, 54.90%, when it was .90), although statistical sig- studies that specifically focused on examining SDU among nificance was not reached (p = .08). There was a similar rela- MSM (Edmundson et al., 2018; Maxwell et al., 2019). None- tion (p = .07) between the prevalence of alcohol use before theless, comparisons should be made with caution, consider- or during sex and the proportion of STD/STI infections in ing the differences in the meta-analytical samples. The results samples (26.37% when the proportion was .10, 42.24% when obtained in this research also indicate that the prevalence of it was .25, and 60.60% when it was .50) (Table 5). Prevalence using an intoxicating substance before or during sex varies was not moderated by document type, risk of bias, sampling significantly according to the specific substance used. The technique, administration procedure, data collection year, consumption of alcohol, marijuana, and ecstasy had signifi- proportion of heterosexuals, or sample mean age. cantly higher prevalences than those referring to the use of cocaine, heroin, methamphetamine, and GHB, perhaps due to differences in their acceptance, accessibility, cost, addic- Discussion tive potential, and short- and medium-term health and social consequences (Bourne et al., 2014; Graupensperger et al., This study provides a systematic review and meta-estimate of 2021; Jackson et al., 2021; Rosińska et al., 2018). It is also the prevalence of the use of intoxicating substances before or likely that higher prevalence rates and the decision to use during sex among young adults. To the best of our knowledge, one or another substance depends on the particular effects it this is the first study that specifically examines the prevalence causes during sex. Alcohol may be used to become disinhib- of this behavior in this age grouping. Previous literature has ited before sex (Herbenick et al., 2021), even though it may mainly focused on analyzing SDU in MSM communities make it more difficult to reach orgasm and reduce quality of (Edmundson et al., 2018; Guerra et al., 2020; Íncera-Fernán- sex (George, 2019; Palamar et al., 2018a). Ecstasy, on the dez et al., 2021; Lafortune et al., 2021; Maxwell et al., 2019), other hand, may affect sexual experience the most, for exam- which makes it difficult to assess comparability. ple, by prolonging erection duration (Coyer et al., 2022). Our results have revealed a high global prevalence of Future research should go more deeply into the reasons that the use of intoxicating substances before or during sex, that lead to the choice of one or another drug, considering the is, 28–47% of young adults. This high prevalence estimate 13 2512 Archives of Sexual Behavior (2023) 52:2503–2526 Fig. 3  Forest plot of observed prevalences and global mean estimate of alcohol use before or during sex. “95% CI” = 95% Confidence Interval; “NC” = Non-clinical sample; “C” = Clinical sample sexual act as a complex process (e.g., from flirtation right due to significant continent-level, country-level, region-level, through to after-sex behaviors), distinguishing the type and and population subgroup differences. Though this study’s quantity of substances consumed, and the order in which comparisons are made for descriptive purposes only, sev- they are consumed, if more than one is involved. The deci- eral multi-level societal and individual factors may explain sion to consume one drug or another before or during sex the observed differences in alcohol consumption patterns, may also be associated with individual characteristics (e.g., including economic development, cultural aspects, such as conception of sexuality and attitudes towards substance use cultural norms and religious beliefs, and societal and politi- for pleasure-seeking) and demographic characteristics (e.g., cal aspects, such as rules concerning drug access and use, age and work-related aspects, including income level) and, and the effectiveness of alcohol control policies (Addo et al., for example, older cohorts may use higher-cost and harder- 2018). Future studies may further explore such factors in to-access substances (e.g., methamphetamine and cocaine). order to gain more insight into the driving forces behind such Regarding the geographical origin of samples, it was found variations. that the estimated prevalence of alcohol use before or during The meta-regression analyses of this study additionally sex varied significantly and was lowest on the African conti- indicate that the prevalence of using intoxicating substances nent. Geographical comparisons pose a particular challenge before or during sex differs significantly as a function of 13 Archives of Sexual Behavior (2023) 52:2503–2526 2513 Table 4  Results of categorical moderator variables on the prevalence of intoxicating substance use before or during sex Global Prevalence (various drugs) Alcohol k eff (95% CI) p k eff (95% CI) p Document type 22 .78 34 .99 Not peer-reviewed 3 40.37% (18.78%, 66.47%) 3 35.25% (14.45%, 63.71%) Peer-reviewed 19 36.46% (27.23%, 46.80%) 31 35.08% (27.35%, 43.69%) Risk of bias 22 .40 Low risk 0a 3 50.24% (23.35%, 77%) High risk 22 19 36.70% (26.42%, 48.34%) Reference population .19 .51 General community 7 47.77% (32.59%, 63.38%) 6 44.19% (26.60%, 63.37%) University students 11 33.68% (23.32%, 45.89%) 22 31.64% (23.49%, 41.10%) Men who have sex with men 2 2 Migrant workers 0 3 35.12% (15.11%, 62.20%) Clinical 2 1 Sampling technique 22 34 .82 Non-probabilistic 21 24 32.99% (16.69%, 54.75%) Probabilistic 1a 10 35.47% (27.44%, 44.41%) Administration procedure 22 34 .82 Administered by others 2a 5 32.99% (16.69%, 54.75%) Self-administered 20 29 35.47% (27.44%, 44.41%) Timeframe 22 .93 31 .07 Last sex 5 15.11% (3%, 50.14%) 2 During last one to six months 10 32.72% (22.63%, 44.78%) 9 24.45% (14.23%, 38.69%) During more than last six months 7 39.47% (31.16%, 48.35%) 20 40.51% (30.34%, 51.58%) Geographical origin of the sampleb 22 34 < .01 Africa 1a 4 10.65% (4.98%, 21.32%) Asia 0a 6 43.07% (27.93%, 59.62%) Europe 2a 3 55.46% (32.74%, 76.10%) United States & Canada 18 21 36.77% (28.92%, 45.40%) South America 1a Gender differences 16 .82 .73 Men 8 44.32% (33.93%, 55.22%) 5 26.73% (8.63%, 58.50%) Women 8 42.53% (32.19%, 53.56%) 5 20.77% (6.34%, 50.38%) “k” = number of studies included, “eff” = effect size (mean prevalence), “95% CI” = 95% confidence interval Analyses examining categorical moderator variables such as purpose, willingness or context in which participants used intoxicating substances before or during sex were not carried out because this information was not specified or was not clearly defined in the primary study measures Subgroup analysis could not be performed for the substances Marijuana, Cocaine, Heroin, Methamphetamine, Ecstasy, Poppers and Gamma Hydroxybutyrate because of an insufficient number of studies a Insufficient “k” to make comparisons b Prevalence estimates considering the geographical origin of samples were not compared with a significance test, but are provided for descrip- tive purposes only the ethnic composition of samples. When considering alco- frequently by studies that sampled more ethnic whites (Cun- hol, the prevalence was significantly higher in studies with ningham et al., 2017). However, to our knowledge, reasons a higher proportion of ethnic whites in their samples. This for such differences have not been examined yet in the lit- is in agreement with a previous meta-analysis suggesting erature. Previous empirical studies have suggested that indi- that risky sex and drug-use behaviors were reported most vidual developmental trajectories and socio-cultural and 13 2514 Archives of Sexual Behavior (2023) 52:2503–2526 Table 5  Results of quantitative moderator variables on the prevalence of intoxicating substance use before or during sex Global Prevalence (various drugs) Alcohol k Coefficient/eff (95% CI) p k Coefficient/eff (95% CI) p Year of data collection 17 − .00 (− .06, .05) .87 23 − .02 (− .08, .03) .39 1999 36.08% (23.12%, 51.45%) 41.21% (25.32%, 59.17%) 2009 35.08% (25.89%, 45.52%) 35.35% (26.85%, 44.88%) 2019 34.09% (20.03%, 51.65%) 29.90% (18.12%, 45.12%) Proportion of ethnic whites 12 − 2.81 (− 4.74, − .88) < .01 13 1.97 (.70, 3.24) < .01 .15 65.27% (41.53%, 83.26%) 23.44% (14.26%, 36.05%) .50 41.26% (30.75%, 52.64%) 37.93% (31.34%, 45%) .85 20.79% (12.34%, 32.88%) 54.95% (44%, 65.45%) Proportion of heterosexuals 4a 13 − .91 (− 5.39, 3.57) .69 .15 59.22% (4.65%, 97.74%) .50 51.35% (14.32%, 86.95%) .85 43.41% (32.99%, 54.46%) Mean age of the sample 18 .20 (− .05, .46) .11 30 − .01 (− .26. .24) .91 18 25.04% (13.38%, 41.93%) 35.46% (19.18%, 55.98%) 22 42.99% (29.64%, 57.44%) 34.20% (25.21%, 44.49%) 26 62.99% (28.48%, 87.91%) 32.96% (11.86%, 64.25%) Proportion sexually active 8a,b 11b .08 .50 16.98% (7.70%, 33.38%) .70 25.30% (15.40%, 38.65%) .90 35.93% (20.53%, 54.90%) Have consumed alcoholc 14 .88 .25 36.17% (25.66%, 48.19%) .50 35.44% (24.89%, 47.63%) .75 34.72% (19.67%, 53.61%) Proportion of STD/STI infection 6a 11 .03 (− .00, .06) .07 .10 26.37% (16.28%, 39.74%) .25 42.24% (29.16%, 56.50%) .50 60.60% (30.96%, 84.07%) “k” = number of studies included, “eff” = effect size (mean prevalence), “95% CI” = 95% confidence interval Analyses examining quantitative moderator variables, such as the mean age of sexual debut, mean of sexual partners, and the proportion of users of specific substances in the samples (e.g., marijuana, ecstasy, cocaine, ketamine, gamma-hydroxybutyrate, poppers, heroine, lysergic acid dieth- ylamide, methamphetamine, and injecting drugs), were not carried out due to an insufficient number of studies. Likewise, an insufficient number of studies assessing the proportion of sexually active participants in timeframes equal to or less than twelve months was found in order to con- sider it as moderator Subgroup analysis could not be performed for the substances marijuana, cocaine, heroin, methamphetamine, ecstasy, poppers and gamma hydroxybutyrate, due to an insufficient number of studies a Insufficient “k” to make comparisons b All included studies evaluated the lifetime prevalence of sexually active individuals in the sample c All included studies evaluated the lifetime prevalence of alcohol consumption of individuals in the sample economic factors may help explain ethnic trends and dif- when considering the global prevalence, a significant inverse ferences in drug use among adolescents and young adults relationship is seen. This opposing result is not directly inter- (Chen & Jacobson, 2012; Evans et al., 2017; Vaughn et al., pretable, since there may be compensatory effects deriving 2018), with white youths having higher rates of illicit drug from raw measures that do not distinguish between sub- and alcohol abuse (Johnston et al., 2019; Jones et al., 2020). stances (Cunningham et al., 2017). Other demographic and Future research might explore such aspects in order to sexual variables, such as gender, age or sexual orientation, improve our understanding of protective and risk exposure did not show statistically significant effects on the prevalence factors that may elucidate potential ethnic differences in the of intoxicating substance use before or during sex. Regard- use of intoxicating substances before or during sex. However, ing gender, for example, the findings of our meta-analysis 13 Archives of Sexual Behavior (2023) 52:2503–2526 2515 concur with recent empirical studies suggesting that women drugs differ somewhat, with the most frequently reported present rates of alcohol or other substance use similar to that being exploratory acts (e.g., caressing or touching) (71%) and of men (Ford et al., 2021b; McKetta et al., 2022), although vaginal penetration (64%), while anal sex (12%) and sex with these studies did not focus on consumption before or during erotic toys (8%) were the least frequently reported (Castaño sexual activity. Developmental and sociocultural factors may et al., 2012). Relevant circumstances such as unprotected explain the non-difference concerning these variables. For sex or relationship type were indicated in only a few studies example, young adulthood is a developmental period char- (Wells et al., 2015), while the willingness of participants acterized by the reinforcement of one’s own sexual identity was not made explicit in any measure. Nonetheless, it has and orientation, in which drugs and sex may be taken as a been found that alcohol consumption before sex increases means of experiencing a variety of sexual practices in com- the probability of unprotected sex and higher-risk sexual mon pleasure-seeking (Arnett, 2005, 2007, 2014), regard- encounters (i.e., with non-primary partners), increasing the less of the abovementioned individual participant charac- likelihood of exposure to STIs and other risks (Rizwan et al., teristics (Bourne et al., 2015a; Piyaraj et al., 2018; Schmidt 2014). It should be noted that, although the result was not et al., 2016). This, together with previous arguments on the statistically significant, the proportion of STD/STI infections acceptance and accessibility of intoxicating substances in this in the samples increased as the proportion of the use of alco- age group, could offer a potential explanation of the results hol before or during sex increased. Another key aspect is the obtained in this study. Likewise, it should also be taken into specification of intentionality and purpose involved in the use account that a large part of our meta-analytical samples are of intoxicating substances before or during sex. Both are key studies with university or community samples, which possess indicators when differentiating between planned substance certain common characteristics in their samples (e.g., age use with the purpose of enhancing sexual experience (e.g., range, sexual-developmental stage, educational stage). As SDU, chemsex) from substance use preceding casual sexual several researchers have observed, drug consumption and sex activity. All such measure quality related aspects reasonably are common occurrences in college contexts and populations warrant the wide credibility/prediction intervals obtained (Ford et al., 2021b; McKetta et al., 2022). in our study. The lack of similar operationalizations with a In addition to the above, the low quality of both our meta- minimum of precision makes it difficult to perform plausible analytic sample and its measures are an important aspect comparisons among studies. Thus, clarifying these elements to highlight in our research. The majority of the studies in operational definitions is a priority for future research that reviewed had a high risk of bias, employing a cross-sectional will allow a distinction to be made between planned and design and non-probabilistic sampling techniques, with poor unplanned drug use before or during sex. quality measures. The analysis of the measures used in the primary studies is a differential contribution of this review, Educational Implications yielding important gaps that need to be addressed. Indeed, sex under the influence of intoxicating substances appears to Based on the results of this study and the prevalence of the have hitherto been measured using “summary measures”, for use of intoxicating substances before or during sex, develop- example, mono-items with dichotomous response options, ing educational prevention programs referring to substance that not allow researchers to fully characterize the phenom- abuse and sexual risks remains imperative. Research recom- enon (Wells et al., 2015). What may be more important than mends that such programs should revolve around four fun- assessing whether participants have practiced sex under the damental principles. Firstly, preventative efforts should be influence of intoxicating substance or not is the frequency in approached from an integrative perspective that contemplates which they have engaged in such activity. This is because the biopsychological, social-communitarian and sexual aspects higher the frequency, the greater the probability of exposure through multidisciplinary support (Donnadieu-Rigole et al., to risks and consequences. Another result to be highlighted 2020). In particular, based on the results of the present study, is that operational elements such as the specific sexual act educational interventions should take into account social- (how), relationship type (with who), intentionality (purpose), communitarian characteristic of participants, such as geo- willingness (whether solicited or not), and drug used were not graphical and ethnic origins (e.g., focusing on more disad- made explicit in the majority of the studies reviewed. These vantaged or higher risk populations, or on areas with higher elements were, indeed, often left up to the interpretation of SDU prevalence rates). Secondly, educational measures respondents. The indefiniteness of key operational elements should take into account the implications, that is, the effects may, therefore, be behind the high dispersion in prevalence and consequences, of different substances and types of sexual estimates. However, regarding drug type, our meta-analytical practices (Lafortune et al., 2021; Saengdidtha et al., 2016). results do demonstrate that prevalence differences between This is emphasized in studies that associate, for instance, individual drugs exist. Empirical research has also found substance use before or during sexual activity with nega- that sexual practices under the influence of alcohol or other tive health outcomes such as overdoses (Hammoud et al., 13 2516 Archives of Sexual Behavior (2023) 52:2503–2526 2017; Hegazi et al., 2017) or risky sexual practices such as other aspects such as research objectives, sample sizes, sam- unprotected sex (D’Anna et al., 2021; Ristuccia et al., 2018). ple population characteristics and the specific measures used. Parents and educators should also inform young people on Thirdly, several reviewed articles provided only a crude prev- the implications and sexual health risks involved in having alence regarding the use of intoxicating substances before or sexual experiences with someone you know personally, as during sex, without specifying the particular substance used, opposed to someone met more casually. Thirdly, information forcing us to analyze this as a generalized proxy. However, on ethical issues relating to willingness and consent should such results should be taken with caution because they may be provided (Muehlenhard et al., 2016). Fourthly, young peo- be biased and not necessarily reflect the effective prevalence ple might be encouraged to make greater use of sexual health rate. Fourthly, it was not possible to estimate the prevalence resources if interventions were to focus more on the enjoy- of the use of certain substances such as crack, speed, seda- ment of safe sex and sexual pleasure-seeking, in addition to tives, LSD and ketamine before or during sex due to insuf- discussing sexual risk behaviors (Ford et al., 2021a). Perhaps, ficient data. Furthermore, in the case of the global prevalence a good starting point for educational interventions aimed at and of the use of alcohol, it was not possible to examine the addressing SDU would be an analysis of needs and motiva- effect of certain categorical and quantitative moderators due tions that lead young adults to use intoxicating substances to an insufficient number of studies at some level. Fifthly, before or during sex. If the pursuit of pleasure emerges as socioeconomic status could not be analyzed as a moderating the main motivation, it would, therefore, be a fundamental variable due to deficiencies and divergences in how empiri- element to take into account in order to improve and adapt cal studies have recorded and reported it (e.g., self-reported sexual health interventions. Interventions informing youths income level, social class, education level, occupation). about decisions concerning where (e.g., spaces), how (e.g., Yet another limitation of this meta-analysis is that, despite substance characteristics in terms of effects and conse- including studies from a variety of countries, certain regions quences; information on contraceptive methods; management were particularly underrepresented. Data from developing of sexual acts and potential implications) and with whom countries and non-occidental countries were scarce. Lastly, they have sex may help them both to be more fully aware of because only 5 studies reported prevalence data of at least their sexual practices and to avoid negative sexual experi- two or more substances, due to software limitations, it was ences and adverse health outcomes. Ideally, such educational not possible to compute a multi-level/multivariate meta- measures should be introduced at fairly early ages. Although analysis assuming a generalized linear model. Developing it was non-significant, results of this meta-analysis showed this possibility would allow us to simultaneously analyze that rates of alcohol use before or during sex increased as data from studies with multiple non-normally distributed the proportion of sexually active participants in samples outcomes, taking into account the dependence among effect increased. Thus, it would be logical to start intervening at sizes from the same study. Given all the above limitations, ages when young people begin to experiment with drugs and the generalizability of the meta-analytical results should be have their first sexual relations, with continuity spreading considered with caution. across into other educational courses and contexts, such as compulsory secondary education and university, and beyond Conclusions school curricula, through ad hoc preventative educational programs, accessible community services, and information In conclusion, our meta-analysis results suggest a high mean campaigns. prevalence of intoxicating substance use before or during sex among young adults. The prevalence was highly hetero- Limitations geneous, and moderator analysis revealed the geographical origin and ethnic composition of the sample as significant This study has certain evident limitations, the main one moderators. The results also highlighted the great difficulties being the low quality meta-analytical sample. Indeed, the in accurately determining the prevalence of this behavior, predominant use of observational designs, non-probabilistic underlining the importance of introducing more rigorous, sampling techniques and non-validated measures was seen consistent, and reliable measures to reduce potential bias. to introduce high levels of risk of bias in the primary studies. We, therefore, believe that the results make a valuable con- Secondly, the meta-analytical results showed a significant tribution to improving research in this area, particularly in between-study variability, only partially explained by cer- the design of more suitable operational definitions, and more tain moderator variables. Undeniably, a considerable part of reliable and valid measurement procedures. Higher quality such variability remains unexplained and thus interpretable measures will consequently allow more accurate prevalence by means of the set of moderators and covariates considered. estimates, and a more complete characterization of this The high heterogeneity may also be attributed to a variety of behavior among young adults. 13 Archives of Sexual Behavior (2023) 52:2503–2526 2517 Appendix 1 PRISMA 2020 for Abstracts Checklist Section and topic Item # Checklist item Reported (Yes/No) Title Title 1 Identify the report as a systematic review Yes Background Objectives 2 Provide an explicit statement of the main objective(s) or question(s) the review addresses Yes Methods Eligibility criteria 3 Specify the inclusion and exclusion criteria for the review Yes Information 4 Specify the information sources (e.g. databases, registers) used to identify studies and the Yes sources date when each was last searched Risk of bias 5 Specify the methods used to assess risk of bias in the included studies Yes Synthesis of results 6 Specify the methods used to present and synthesise results Yes Results Included studies 7 Give the total number of included studies and participants and summarise relevant character- Yes istics of studies Synthesis of results 8 Present results for main outcomes, preferably indicating the number of included studies and Yes participants for each. If meta-analysis was done, report the summary estimate and confi- dence/credible interval. If comparing groups, indicate the direction of the effect (i.e. which group is favoured) Discussion Limitations of 9 Provide a brief summary of the limitations of the evidence included in the review (e.g. study Yes evidence risk of bias, inconsistency and imprecision) Interpretation 10 Provide a general interpretation of the results and important implications Yes Other Funding 11 Specify the primary source of funding for the review See funding details Registration 12 Provide the register name and registration number See full-text From: Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L. … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372(71). https://​doi.​org/​10.​1136/​bmj.​n71 For more information, visit: http://​www.​prisma-​state​ment.​org/ Appendix 2 PRISMA 2020 Checklist Section and topic Item # Checklist item Location where item is reported Title Title 1 Identify the report as a systematic review Pg. 1 Abstract Abstract 2 See the PRISMA 2020 for Abstracts checklist Completed Introduction Rationale 3 Describe the rationale for the review in the context of existing knowledge Pg. 2–5 Objectives 4 Provide an explicit statement of the objective(s) or question(s) the review addresses Pg. 5–6 Methods Eligibility criteria 5 Specify the inclusion and exclusion criteria for the review and how studies were grouped for Pg. 7 the syntheses Information 6 Specify all databases, registers, websites, organisations, reference lists and other sources Pg. 6 sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted 13 2518 Archives of Sexual Behavior (2023) 52:2503–2526 Section and topic Item # Checklist item Location where item is reported Search strategy 7 Present the full search strategies for all databases, registers and websites, including any filters Sup. F. 2 and limits used Selection process 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, Pg. 7 including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process Data collection 9 Specify the methods used to collect data from reports, including how many reviewers col- Pg. 7–8 process lected data from each report, whether they worked independently, any processes for obtain- ing or confirming data from study investigators, and if applicable, details of automation tools used in the process Data items 10a List and define all outcomes for which data were sought. Specify whether all results that were Pg. 7–9 compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect 10b List and define all other variables for which data were sought (e.g. participant and interven- Pg. 7–9 tion characteristics, funding sources). Describe any assumptions made about any missing or unclear information Study risk of bias 11 Specify the methods used to assess risk of bias in the included studies, including details of Pg. 8–9 assessment the tool(s) used, how many reviewers assessed each study and whether they worked inde- pendently, and if applicable, details of automation tools used in the process Effect measures 12 Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the Pg. 9 synthesis or presentation of results Synthesis methods 13a Describe the processes used to decide which studies were eligible for each synthesis (e.g. Pg. 7 tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)) 13b Describe any methods required to prepare the data for presentation or synthesis, such as Pg. 7–9 handling of missing summary statistics, or data conversions 13c Describe any methods used to tabulate or visually display results of individual studies and Pg. 8–9 syntheses 13d Describe any methods used to synthesize results and provide a rationale for the choice(s). If Pg. 9 meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used 13e Describe any methods used to explore possible causes of heterogeneity among study results Pg. 9 (e.g. subgroup analysis, meta-regression) 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results Not applicable Reporting bias 14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising Not applicable assessment from reporting biases) Certainty assess- 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an Pg. 6–9 ment outcome Results Study selection 16a Describe the results of the search and selection process, from the number of records identi- Pg. 10 fied in the search to the number of studies included in the review, ideally using a flow diagram 16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and Sup. F 3 and 4 explain why they were excluded Study character- 17 Cite each included study and present its characteristics Sup. F 5 istics Risk of bias in 18 Present assessments of risk of bias for each included study Sup. F 7 studies Results of indi- 19 For all outcomes, present, for each study: (a) summary statistics for each group (where Table 3 and Forest vidual studies appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), plots ideally using structured tables or plots 13 Archives of Sexual Behavior (2023) 52:2503–2526 2519 Section and topic Item # Checklist item Location where item is reported Results of syn- 20a For each synthesis, briefly summarise the characteristics and risk of bias among contributing Table 1 theses studies 20b Present results of all statistical syntheses conducted. If meta-analysis was done, present for Table 3 each the summary estimate and its precision (e.g. confidence/credible interval) and meas- ures of statistical heterogeneity. If comparing groups, describe the direction of the effect 20c Present results of all investigations of possible causes of heterogeneity among study results Tables 4 and 5 20d Present results of all sensitivity analyses conducted to assess the robustness of the synthe- Not applicable sized results Reporting biases 21 Present assessments of risk of bias due to missing results (arising from reporting biases) for Not applicable each synthesis assessed Certainty of 22 Present assessments of certainty (or confidence) in the body of evidence for each outcome Pg. 11–13 evidence assessed Discussion Discussion 23a Provide a general interpretation of the results in the context of other evidence Pg. 15–16 23b Discuss any limitations of the evidence included in the review Pg. 18 23c Discuss any limitations of the review processes used Pg. 21–22 23d Discuss implications of the results for practice, policy, and future research Pg. 15–20 Other information Registration and 24a Provide registration information for the review, including register name and registration Pg. 6 protocol number, or state that the review was not registered 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared Pg. 6 24c Describe and explain any amendments to information provided at registration or in the Not applicable protocol Support 25 Describe sources of financial or non-financial support for the review, and the role of the See funding infor- funders or sponsors in the review mation Competing inter- 26 Declare any competing interests of review authors See competing ests interest’s informa- tion Availability of 27 Report which of the following are publicly available and where they can be found: template See supplementary data, code and data collection forms; data extracted from included studies; data used for all analyses; files other materials analytic code; any other materials used in the review From: From: Page, M. 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