Time preferences are related to health investment and health status and self-reported health. Several studies characterize addictive behaviors, including cigarette smoking, alcohol consumption and illicit drug use, as a special case of discounting. A review of gambling and substance use studies found consistent evidence that high rates of discounting are associated with a range of addictive behaviors with adverse health consequences.Discount rates have also been linked to alcohol dependence, alcohol abuse disorder, and moderate levels of alcohol use, including heavy social drinking. These effects are seen early in life, as discounting is positively correlated with age of first alcohol use and number of passed out episodes among adolescents. Illicit drug use also shows a consistent relationship, with higher discount rates among heroin and opioid-dependent individuals compared to non-drug users. Discount rates have also been studied in relationship to eating behavior and obesity, and may be closely related to food rewards among children. There are mixed results of monetary discounting and BMI in adults.The trade offs between longer-term goals and immediate rewards of unprotected sex fit a discounting framework. A qualitative study exploring determinants of inconsistent contraceptive use found that eroticism of unprotected sex and misunderstanding the risk of conception was a powerful explanatory factor. In one of the only articles to propose the connection between contraceptive use and behavioral economic interventions, Stevens and Berland note the connection of present-biased preferences to long acting reversible contraceptive use. They suggest that present bias in use of LARC could be leveraged by reducing the actual or perceived costs of obtaining LARC methods, such as higher cost if insurance is unavailable and discomfort of the procedure, in favor of long term benefits . While these types of changes to clinical encounters make intuitive sense based on behavioral economics,indoor cannabis grow system no research directly links delay discounting to contraceptive method choice. However, literature about other reproductive and sexual decisions may offer insight into the connection with contraceptive use. Individual decision-making is also shaped by perception of risk. Prospect theory describes decision-making in the context of risk.
The theory posits that people take greater risks to avoid loss than to realize gain even if the loss and gain are equal. It has gained credibility in the arena of health decision-making in comparison to the standard economic model, which assumes people are rational agents who make choices to maximize utility. Risk preferences are frequently studied in social science and are established as strong determinants of financial decision-making, including investment and savings. Risk preferences are generally measured as willingness to take gambles with income.People willing to take fewer gambles are generally deemed risk averse and those more willing to take gambles risk tolerant. Prospect theory also described lossaverse behavior in the context of risk, where individuals are more sensitive to potential losses than gains. A few studies have examined risk preferences and health behaviors. Anderson found that an experimental measure of risk aversion was negatively associated with several health behaviors, including smoking, heavy drinking, obesity, and non-use of a seat belt. A seminal study in the Health and Retirement Study found that an economic measure of risk tolerance predicted risk behavior including smoking and drinking. Loss aversion has also been linked to reduced cancer screening behavior among those with chronic disease who would be most sensitive to health losses. Willingness to accept risk has intuitive connection to sexual and reproductive health behaviors. The consequences of sexual and reproductive behavior, including unintended pregnancy to STI transmission, are probabilistic rather than certain. Thus an individual’s tolerance for risk may affect their willingness to engage in unprotected sex. Although it is clear that individual decision-making affects sexual and reproductive health behaviors, including contraceptive method choice, consistency of condom use, number of sexual partners, and use of substances while engaging in sex, literature exploring the connection of discounting and risk tolerance has emerged only recently. This systematic scoping review examines the literature suggesting how two decisional preferences from behavioral economics, temporal discounting and risk tolerance, may influence sexual and reproductive behavior. The review seeks to contribute to the literature on sexual and reproductive health by assessing the state of the evidence available and offering suggestions for future work.
Descriptions from the 20 included articles are displayed in Table 1. Sixteen studies utilized cross-sectional designs, three were longitudinal, and one embedded within a randomized trial. Four of the studies tested correlations between the preference measure of interest and one or more health behaviors and did not control for confounding variables, making causal assessment of findings difficult. Participants were recruited from university courses or psychology labs, general populations or subgroups of the general population clinical samples, Facebook, or MTurk. Overall 10 studies focused on adolescents or young adults. These studies noted that adolescents are a particularly important subgroup to study in the context of sexual risk behavior, as they have heightened risk of STI and also unintended pregnancy. Five papers focused on college students above 18. Three studies included general samples of young people including 16-24 year old Swiss young adults, 18-24 year olds from urban centers, and 14-30 year olds from and medical and STI clinics. Two studies included even younger samples of Appalachian youth aged 10-17 at recruitment, and 10-12 year olds in Philadelphia. Three studies focused on sexual risk behavior among men who have sex with men. One study included only male heterosexual college students, 21-32, and another only heterosexual women from the PSID. Four studies required hazardous alcohol or substance use dependence for eligibility.The dependent and independent variables of interest as well as the results are summarized in Table 2. The majority of the articles examined delay or probability discounting while only three assessed a measure of risk tolerance. Earlier studies of discounting and sexual behavior used survey measures of monetary discounting: a trade off between present and future monetary rewards. More recently,cannabis grow equipment in recognition of domain specific preferences, discounting measures have been developed for discounting relating to sexual rewards. There is a further distinction between delay discounting and probability discounting, of both money and sex. Probability discounting tasks entail choices between smaller sooner rewards and delayed uncertain rewards. The reviewed articles can be divided into those that use measures of monetary discounting, sexual discounting, or both. Studies that assessed monetary discounting most often used the Monetary Choice Questionnaire , a 27-item measure involving choices between smaller immediate rewards and larger delayed rewards developed by Kirby.
One study used the MCQ but added a time perspective measure to assess future uncertainty. Chesson used a three-item hypothetical payoff measure. One study included probability discounting of money in addition to delay discounting.Sexual delay discounting tasks were used in several studies. Participants were asked to consider 60 photographs of people and to rank who they most want to have sex with, least want to have sex with, who is most likely to have an STI and least likely to have an STI. The chosen photos were then shown to participants to assess willingness to wait for condom-protected sex with a higher ranked partner versus immediate unprotected sex as a form of sexual delay discounting. Both studies found that sexual discounting differed as a function of the stated partner characteristics. Darioitis found that youth discounted significantly more with partners they ‘most want to have sex with’ and partners whom they thought were ‘least likely to have an STI.’ The sexual probability discounting tasks extend this same logic as the delay tasks, but instead of a delay they use varying chances of engaging in sex with the preferred partner. One study modified the SDDT for use with MSM. Two studies included both measures of monetary and sexual discounting. Johnson and Bruner were the first to find evidence of sexual domain specificity, as they not find evidence of monetary discounting with HBRS measure. Lawyer proposed another specification of the sexual discounting task. This task did not use hypothetical partner images, but instead asked participants about a trade off between more minutes of the sexual activity with some delay or fewer minutes immediately. The study used several scales that are validated in sexuality research and correlated with behavior. Sexual delay and probability discounting were associated with the measure of sexual excitability, but not with other non-sexual measures. Additionally monetary discounting was not associated with sexual outcomes, lending support to the domain specificity of sexual discounting. In the three articles focusing on risk tolerance, each used a different measure. Brobdeck used a risk preference and hedonism scale from the Trier Integrated Personality Inventory developed by Becker. Schmidt used a measure of hypothetical gambles over lifetime income that is modeled after the Health and Retirement Study in the PSID. Szrek et al employed four risk-taking propensity measures, including the a general measure of risk-taking propensity derived from a one-item survey question , a risk aversion index calculated from a set of incentivized monetary gambles , a measure of risk taking derived from an incentive compatible behavioral task—the Balloon Analog Risk Task , and a composite score of risk-taking likelihood in the health domain from the Domain-Specific Risk Taking scale.
Seventeen of the 20 articles evaluated the effect of discounting or risk tolerance on sexual behavior and outcomes. Of these, seven examine these relationships in the context of substance use. The sexual discounting task was repeatedly associated with sexual behavior. All studies assessed self-report of sexual risk behavior, and Chesson also included laboratory measures of STIs. Daugherty and Base, included a measure of sociosexual orientation , a measure of degree to which individual is more comfortable engaging in sexual behaviors without mental or emotional commitment. Lawyer examined sexual excitability rather than self reported behavior. Johnson and Bruner examined HIV risk behaviors, finding a significant relationship between greater discounting and history of high-risk sex. Dariotis and Johnson extended these findings from older high-risk sample to a sample of youth, finding that the four components of the SDT were negatively correlated with several reported sexual behaviors, including number of lifetime risky sexual partners. In addition, they found that less favorable attitudes towards risk were correlated with lower discounting, or preference for postponed protected sex under the ‘most want to have sex with’ and ‘least likely to have an STI’ components. Jarmolowizc applied the SDT task to promiscuity, finding that number of sexual partners selected on discounting task was related to higher rates of delay discounting, which was predictive of sexual behavior. Collado et al. examined sexual delay discounting and self-reported STI risk sex behaviors, HIV knowledge and STI risk perception among college students. They found that higher values of each of the four SDT measures were associated with self-reported risk behaviors. Hermann et al. extended the SDT to men who have sex with men and found discounting of condom protected anal intercourse to be hyperbolic, meaning that participants discounted using condoms as delays to CPAI increased. Steeper discounting of CPAI was associated with unprotected anal intercourse, substance use, not having been tested for HIV, sex under the influence of substances. One study examined risk tolerance, and argued that risk taking is domain specific, comparing four risk propensity measures with health risk behavior including sexual risk behavior. The found the Dohmen measure of general risk propensity was positively correlated with sexual risk behavior along with problem drinking and seat belt use. A risk aversion index calculated from a set of incentivized monetary gambles and the BART, and the DOSPERT scale were each uncorrelated with sexual risk behavior. Adolescence is a critical period for sexual behavior, as risk behavior emerges and peaks during the period . In one of the few studies to have self-reported data along with laboratory measures of STIs, higher discount rates were associated with ever having sexual intercourse, sexual intercourse before age 16, and ever having gonorrhea or chlamydia, controlling for demographics among a sample of adolescents and young adults.They did not find significant association of discount rates with unprotected sex or HSV-2 testing or infection. Khurana enrolled 10-12 year olds and examined the role working memory on adolescent early sexual initiation two years later and potential meditational pathways of impulsivity.