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In this issue of the journal, Crawford et al1 make a useful contribution to the ongoing debate regarding whether alcohol screening and brief intervention for excessive drinkers should be delivered within sexual health clinics.
Alcohol misuse in the UK is responsible for considerable morbidity and mortality, as well as financial cost to the National Health Service, estimated at £2.9 billion in 2008–2009.2 The National Institute for Health and Care Excellence advises that all sexual health clinics should routinely screen patients for excessive alcohol use and deliver a brief alcohol behavioural intervention (ABI) when problem dinking is identified.2
A commonly held view is that intoxication due to alcohol directly causes unsafe sexual behaviour, which in turn leads to higher rates of sexually transmitted infections (STI) and unwanted pregnancies, but the evidence does not support this simplistic model. A substantial body of evidence has established that alcohol misuse is associated with both high-risk sexual behaviour, including unprotected sex with multiple partners, underage or early sexual intercourse and emergency contraception use, and with negative sexual health outcomes.3 A systematic review found that eight of 11 relevant studies showed a significant association between alcohol misuse and STI.4 However, this association does not prove causation and may be due to either confounding bias (an underlying common cause) or reverse causation. Reviews of the evidence have failed to establish a causal relationship between use of substances, including alcohol, and high-risk sexual behaviour. …