The association between monetary and sexual delay discounting and risky sexual behavior in an online sample of men who have sex with men

A Behavioral Economic Examination of Sexual Behaviors in the Era of Pre-exposure Prophylaxis via Explanatory Sequential Mixed Methods

Pre-exposure prophylaxis (PrEP) use may be associated with condom use decisions. The current investigation examined sexual decision-making in the context of PrEP among young adult men who have sex with men (MSM) between 18 and 30 years old, using an explanatory sequential mixed methods design. For the quantitative aim, 99 MSM currently taking PrEP (i.e., PrEP-experienced) and 140 MSM not currently taking PrEP (i.e., PrEP-naive) completed an online survey, including the Sexual Delay Discounting Task (SDDT), which captures likelihood of condom use. For the qualitative aim, 15 people from each group were interviewed about their (1) conceptualizations of risky sex and (2) ways they manage their sexual risk. Participants were, on average, 25.69 years old (SD = 3.07) and 64% White. Results from the quantitative aim revealed, controlling for covariates, PrEP-experienced participants exhibited significantly lower likelihood of (1) using an immediately available condom and (2) waiting for a delayed condom (i.e., sexual delay discounting) compared to PrEP-naive participants. Qualitative themes explaining what young adult MSM consider to be risky sex included: (1) any sex as risky sex, (2) risky sex as "sex without a conversation," and (3) risky sex as sex with risk for physical harm. Themes on ways young adult MSM manage sexual risk were classified as proactive, reactive, and passive. Results suggest that PrEP use is related to condom use decisions. Taken together, quantitative differences in sexual delay discounting, but qualitatively similar conceptualizations and management of risky sex, suggest that the SDDT may be a useful tool in sex research to capture processes (i.e., delay discounting) underlying sexual decision-making that may be missed by traditional self-reports. Implications of results, including potentially providing (good quality) condoms with every PrEP prescription, and future research topics are discussed.

Use of preexposure prophylaxis and condom purchasing decisions

Preexposure prophylaxis (PrEP) prevents human immunodeficiency virus (HIV) but not other sexually transmitted infections (STIs). Men who have sex with men (MSM) who take PrEP tend to report reduced condom use, but little is known about the underlying mechanisms. For this study, MSM who take PrEP (i.e., PrEP experienced; n = 88) and MSM who do not (i.e., PrEP naïve; n = 113) completed an online study, including the condom purchase task (CoPT). The CoPT assesses decisions to purchase condoms across escalating prices (range: free-$55) for sex with different types of hypothetical partners: those least likely to have an STD (least STD) and those that participants most want to have sex with (most want sex with). When condoms were free, PrEP-experienced MSM had a lower rate of condom purchasing than did PrEP-naïve MSM. For both partner types, PrEP-experienced MSM reached a price break point (i.e., would not buy condoms) at a lower price than did PrEP-naïve pariticipants. For the most-want-sex-with partner at the price at which participants elected not to buy condoms, only 23% of PrEP-experienced MSM chose to abstain from sex when not purchasing condoms versus 53% among PrEP-naïve MSM. Similar patterns were observed for the least-STD partner. The results support the potential utility of the CoPT in identifying behavioral mechanisms related to condom use and PrEP.

Do risk, time and prosocial preferences predict risky sexual behaviour of youths in a low-income, high-risk setting?

Young people in sub-Saharan Africa are particularly at high risk of sexually transmitted infections. Little is known about their preferences and even less about their association with risky sexual behaviour. We conducted incentivized economic experiments to measure risk, time and prosocial preferences in Zimbabwe. Preferences measured at baseline predict biomarker and self-reported measures of risky sexual behaviour gathered 12 months later. We find robust evidence that individuals more altruistic at baseline are more likely to be Herpes Simplex Virus Type-2 (HSV-2) positive 12 months later. Analysis by sex shows this association is driven by our sample of women. Having more sexual partners is associated with greater risk tolerance amongst men and greater impatience amongst women. Results highlight heterogeneity in the association between preferences and risky sexual behaviour.

Delay Discounting and Sexual Decision-Making: Understanding Condom Use Behavior Among U.S. College Students

Condoms provide protection against sexually transmitted diseases; however, condomless sex remains common among college students and intentions to use condoms do not consistently translate into condom use. This study tested which indicator of condom use intentions from a delay discounting paradigm of condom-protected sex best accounted for variance in condom use behavior. The sample consisted of 187 sexually active college students (51.9% female) who completed measures of condom use during vaginal and anal sex over the past three months and a decision-making paradigm regarding condom intentions with hypothetical sexual partners. In separate models, condom behavior was regressed on one of three indicators of condom intentions: initial intentions to use a condom, delay discounting of condom-protected sex, and overall area under the curve across all trials. Results showed that delay discounting of condom-protected sex best accounted for variance in absolute frequency of condomless sex, whereas initial intentions to use a condom best accounted for variance in relative proportion of condomless sex. Future research directions and implications for interventions are discussed.

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

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

Effects of substance use on monetary delay discounting among people who use stimulants with and without HIV: An ecological momentary assessment study

Exploration of the real-time relationship between substance use and delay discounting may reveal potential mechanisms driving high-risk behaviors. We conducted an ecological momentary assessment (EMA) study to investigate the effects of substance use on delay discounting in a sample of people who use stimulants (HIV+: 30; HIV-: 34). Participants completed multiple EMAs throughout the day for 28 days. The EMAs collected data on delay discounting and substance use (time since last substance use and level of intoxication). Delay discounting was assessed using a brief Monetary Choice Questionnaire (MCQ). Analyses were conducted using linear mixed effects modeling. Most participants (99.1%) used cocaine as their primary stimulant. Among participants without HIV, MCQ score remained relatively stable during the first 2 hr after stimulant use, followed by an increase during 2-6 hr (p < .05), before decreasing again. For alcohol and marijuana, the MCQ score was stable during the first 4 hr after use, with a sharp increase at 4-6 hr (p < .05), before decreasing again. Among participants with HIV, there were no changes in MCQ score as a function of time since recent substance use. These findings provide evidence of a plausible connection between delay discounting and acute withdrawal that may have relevance for risky behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Sexual discounting: A systematic review of discounting processes and sexual behavior

Behavioral processes underlying sexual behavior are important for understanding normal human functioning and risk behavior leading to sexually transmitted infections (STIs). This systematic review examines delay and probability discounting in human sexual behavior through synthesis of 50 peer-reviewed, original research articles. Sixteen studies focusing exclusively on monetary delay discounting found small effect size positive correlations with sexual risk behaviors. Eleven studies examined delay or probability discounting of sexual behavior itself using tasks that varied duration, frequency, or quality of sex to determine value. Results show delay and uncertainty of sex causes systematic decreases in value. These studies also show consistent medium effect size relationships between sexual discounting measures and sexual health and substance use, supporting utility above and beyond monetary discounting. Twenty-three studies have modeled clinically relevant decision-making, examining effects of delay until condom availability and STI contraction probability on condom use. Observational and experimental designs found condom-use discounting is elevated in high-risk substance use populations, is sensitive to context (e.g., partner desirability), and is more robustly related to sexual risk compared with monetary discounting or condom use decisions when no delay/uncertainty was involved. Administering cocaine, alcohol, and, for some participants, methamphetamine increased condom-use discounting with minimal effect on monetary discounting or condom use when no delay/uncertainty was involved. Reviewed studies robustly support that sexual behavior is highly dependent on delay and probability discounting, and that these processes strongly contribute to sexual risk. Future research should exploit these systematic relationships to design behavioral and pharmacological approaches to decrease sexual risk behavior. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Brain multimodal co-alterations related to delay discounting: a multimodal MRI fusion analysis in persons with and without cocaine use disorder

BACKGROUND

Delay discounting has been proposed as a behavioral marker of substance use disorders. Innovative analytic approaches that integrate information from multiple neuroimaging modalities can provide new insights into the complex effects of drug use on the brain. This study implemented a supervised multimodal fusion approach to reveal neural networks associated with delay discounting that distinguish persons with and without cocaine use disorder (CUD).

METHODS

Adults with (n = 35) and without (n = 37) CUD completed a magnetic resonance imaging (MRI) scan to acquire high-resolution anatomical, resting-state functional, and diffusion-weighted images. Pre-computed features from each data modality included whole-brain voxel-wise maps for gray matter volume, fractional anisotropy, and regional homogeneity, respectively. With delay discounting as the reference, multimodal canonical component analysis plus joint independent component analysis was used to identify co-alterations in brain structure and function.

RESULTS

The sample was 58% male and 78% African-American. As expected, participants with CUD had higher delay discounting compared to those without CUD. One joint component was identified that correlated with delay discounting across all modalities, involving regions in the thalamus, dorsal striatum, frontopolar cortex, occipital lobe, and corpus callosum. The components were negatively correlated with delay discounting, such that weaker loadings were associated with higher discounting. The component loadings were lower in persons with CUD, meaning the component was expressed less strongly.

CONCLUSIONS

Our findings reveal structural and functional co-alterations linked to delay discounting, particularly in brain regions involved in reward salience, executive control, and visual attention and connecting white matter tracts. Importantly, these multimodal networks were weaker in persons with CUD, indicating less cognitive control that may contribute to impulsive behaviors.

Steep Discounting of Future Rewards as an Impulsivity Phenotype: A Concise Review

This chapter provides an overview over the behavioral economic index of impulsivity known as delay discounting. Specifically, delay discounting refers to an individual's preference for smaller immediate rewards over a larger delayed rewards. The more precipitously an individual discounts future rewards, the more impulsive they are considered to be. First, the chapter reviews the nature of delay discounting as a psychological process and juxtaposes it with nominally similar processes, including other facets of impulsivity. Second, the chapter reviews the links between delay discounting and numerous health behaviors, including addiction, attention deficit/hyperactivity disorder, and obesity. Third, the determinants of individual variation in delay discounting are discussed, including both genetic and environmental contributions. Finally, the chapter evaluates delay discounting as a potentially modifiable risk factor and the status of clinical interventions designed to reduce delay discounting to address deficits in self-control in a variety of maladaptive behaviors.

Delay Discounting of Protected Sex: Relationship Type and Sexual Orientation Influence Sexual Risk Behavior

Sexual discounting, which describes delay discounting of later protected sex vs. immediate unprotected sex (e.g., sex now without a condom vs. waiting an hour to have sex with a condom), is consistently linked to sexual risk behavior. Estimates suggest that over two-thirds of HIV transmissions occur between individuals in committed relationships, but current sexual discounting tasks examine sexual discounting only with hypothetical strangers, leaving a gap in our understanding of sexual discounting with committed sexual partners. We used the Sexual Discounting Task (SDT) to compare discounting rates between men who have sex with men (MSM; n = 99) and heterosexual men (n = 144) and tested a new SDT condition evaluating sexual discounting with main partners. MSM in committed relationships discounted protected sex with their main partner at higher rates than heterosexual men, and discounting rates correlated with self-report measures of condom use, impulsivity/sensation seeking, and substance use. These findings suggest that sexual discounting is a critical factor potentially related to increased HIV transmission between MSM in committed relationships and may be an important target for intervention and prevention.

Delay discounting and household food purchasing decisions: The SHoPPER study

OBJECTIVE

Delay discounting is a neurocognitive trait that has been linked to poor nutritional health and obesity, but its role in specific dietary choices is unclear. This study tested whether individual differences in delay discounting are related to the healthfulness of household food purchases and reliance on nonstore food sources such as restaurants.

METHOD

The food purchases of 202 primary household food shoppers were objectively documented for 14 days through a food receipt collection and analysis protocol. The nutrient content of household food purchases was derived for each participant, and the overall diet quality (Healthy Eating Index-2015) and energy density (kcal/g) of foods and beverages were calculated. The proportion of energy from nonstore food sources was also derived. Delay discounting was assessed with a choice task featuring hypothetical monetary rewards.

RESULTS

Data were available for 12,624 foods and beverages purchased across 2,340 shopping episodes. Approximately 13% of energy was purchased from restaurants and other nonstore food sources. Steeper discounting rates were associated with lower overall Healthy Eating Index-2015 scores and a higher energy density (kcal/g) of purchased foods. Associations were attenuated but remained statistically significant when accounting for body mass index and sociodemographic variables. Discounting rates were unrelated to reliance on nonstore food sources or the energy density of purchased beverages.

CONCLUSIONS

Delay discounting is related to the healthfulness of food purchases among primary household shoppers. As food purchasing is a key antecedent of dietary intake, delay discounting may be a viable target in dietary and weight management interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).