- Professional overview
Dr. Stephanie Cook aims to understand the pathways and mechanisms linking attachment, minority stress, and health among disadvantaged individuals. She examines how the inter- and intra- personal features of close relationships influence the health of racial/ethnic and sexual minorities.
Through her development of an integrated theory of adult attachment (i.e., the development, or lack, of strong socio-emotional bonds) and minority stress (i.e., social stress experienced by individuals in minority social groups), she seeks to better understand the poor health and HIV prevention needs of disadvantaged youth transitioning into adulthood. She then utilize this theoretical framework of attachment and minority stress to inform effective prevention programs for vulnerable racial/ethnic and sexual minority youth transitioning to adulthood.
As the Principal Investigator and Director of the Attachment and Health Disparities Research Lab, her team assesses the association of attachment-related functioning on health disparities among racial/ethnic and sexual minority youth. Dr. Cook is first exploring how adult attachment orientation is associated with HIV risk in a community sample of Black gay and bisexual men transitioning into adulthood. Second, she illustrates how transitions in attachment during adolescence are associated with trajectories of depression among a community based cohort sample of African-American youth. Third, she seeks to understand how adult attachment, in the context of minority stress, is associated with biomarkers of physical health.
Dr. Cook teaches Global Issues in Social and Behavioral Health and Regression and Multivariate Analysis. At the Center for Health, Identity, Behavior, and Prevention Studies, she conducts research and has published numerous peer-reviewed articles.
BA, Psychology and Women’s Studies, University of Michigan, Ann Arbor, MIMPH, Sociomedical Sciences, Columbia University, New York, NYDrPH, Sociomedical Sciences, Columbia University, New York, NY
- Honors and awards
Matilda White Riley Distinguished Early Stage Investigator Award, National Institutes of Health (Office of Behavioral and Social Sciences) (2016)Outstanding Postdoctoral Fellow Award, The University of Michigan (2015)American Psychological Association Smoking Dissemination Award (2015)Poster Award, Excellence in Innovation and Advanced Research in the Field of Sexual Health, American Public Health Association (2014)Excellence in Abstract Submission, American Public Health Association (2011)
- Areas of research and study
BiostatisticsCenter for Health, Identity, Behavior and Prevention StudiesHIV/AIDSMinority HealthSocial BehaviorsStress
Cortisol profiles differ by race/ethnicity among young sexual minority menCook, S., Juster, R.P., Calebs, B.J., Heinze, J., & Miller, A.L.
Much of the extant scientific research examining hypothalamic-pituitary-adrenal (HPA)-axis functioning is conducted among White heterosexuals. Very little research examines HPA-axis functioning between different minority groups. Individuals who identify as both sexual and racial minorities may experience increased stigma and discrimination that can affect HPA-axis functioning. In the current study, we examined diurnal cortisol rhythm in young White gay men (WGM) compared to young Black gay men (BGM). The sample consisted of 70 healthy gay men (mean [SD] age = 22.9 [3.2]: 68% White and 38% Black) who collected four saliva samples daily for five days. Repeated measures analysis of covariance and post-hoc tests revealed that BGM had higher cortisol levels than WGM in the evening. Secondary analyses revealed no significant group differences for the cortisol awakening response or systemic output throughout the day. However, BGM compared to WGM had a lower drop from peak (morning) to lowest (evening) cortisol concentrations. Taken together, these findings reveal a flatter diurnal cortisol rhythm among BGM compared to WGB. The functional significance of these preliminary findings must be explored further with assessment of psychosocial factors among sexual minorities at the intersection of multiple identities. In summary, we expand health disparities research aimed at delineating sexual minority and race/ethnic variation in stress physiology.
Minority males: Cultural stressors and their impact on health and well-beingCook, S., Calebs, B., Perry, M., & Hopkins, R.
The American Psychological Association working group report on health disparities in boys and menPowell, W., Blume, A., Cook, S., Courtenay, W., Griffith, D., Halkitis, P., … Watkins, D.C.
Adult Attachment as a Moderator of the Association Between Childhood Traumatic Experiences and Depression Symptoms Among Young Black Gay and Bisexual MenCook, S., Valera, P., Calebs, B.J., & Wilson, P.A.
Journal titleCultural Diversity and Ethnic Minority Psychology
Objective: The present study examined the moderating effect of adult attachment on the association between childhood traumatic experiences, (i.e., physical abuse, emotional abuse, emotional neglect, and being bullied), age of childhood traumatic experience, and young adult depression symptoms among young Black gay and bisexual men (YBGBM). Method: Self-report measures of attachment, childhood traumatic experiences, and depression symptoms were collected from a community-based sample of YBGBM living in New York City (n = 228). Regression analyses were conducted to address the study goals. Results: Findings indicated that YBGBM who were more anxious in their adult attachment style and experienced being bullied or physically abused by a non-family member during childhood experienced greater depression in young adulthood than YBGBM who were less anxious in their adult attachment style. In addition, we found that being bullied later in childhood was associated with greater depression symptoms than being bullied earlier. Lastly, we found that YBGBM who were more avoidant and bullied later in adolescence reported more depression symptoms in young adulthood than YBGBM who were less avoidant in their attachment style. Discussion: The findings suggest that it may be important to utilize an attachment perspective that is sensitive to age of traumatic experience when creating mental health and trauma interventions for YBGBM. (PsycINFO Database Record (c) 2016 APA, all rights reserved).
Attachment orientation and sexual risk behaviour among young Black gay and bisexual menCook, S., Watkins, D.C., Calebs, B.J., & Wilson, P.A.
Journal titlePsychology and Sexuality
This mixed methods study used an explanatory sequential design to examine the relationship between attachment and sexual behaviour among young Black gay and bisexual men (YBGBM). Cross sectional online surveys and sex diaries were completed by a sample of YBGBM in New York City (n = 153) to assess the association between adult attachment insecurity and sexual risk behaviour. The Experiences in Close Relationships Scale-Revised (ECR-R) was used to assess three types of adult attachment (i.e., secure, anxious and avoidant). Participants reported condomless sex encounters, as well as serodiscordant condomless anal sex encounters, as measures of sexual risk. Quantitative findings suggested that there were few associations between attachment type and sexual risk behaviour; only men with attachment avoidance were likely to engage in condomless sex. However, qualitative findings illuminated some of the social complexities of the association between attachment in childhood, attachment in young adulthood and intimate partnerships, which could be linked to young adult sexual risk behaviour. The study findings highlight the need for researchers to further examine the process by which individual differences in attachment orientation are related to YBGBM’s sexual behaviour.
Profiles of Resilience and Psychosocial Outcomes among Young Black Gay and Bisexual MenWilson, P.A., Meyer, I.H., Antebi-Gruszka, N., Boone, M.R., Cook, S., & Cherenack, E.M.
Journal titleAmerican Journal of Community Psychology
Young Black gay/bisexual men (YBGBM) are affected by contextual stressors - namely syndemic conditions and minority stress - that threaten their health and well-being. Resilience is a process through which YBGBM achieve positive psychosocial outcomes in the face of adverse conditions. Self-efficacy, hardiness and adaptive coping, and social support may be important resilience factors for YBGBM. This study explores different profiles of these resilience factors in 228 YBGBM in New York City and compares profiles on psychological distress, mental health, and other psychosocial factors. Four profiles of resilience were identified: (a) Low self-efficacy and hardiness/adaptive coping (23.5%); (b) Low peer and parental support (21.2%); (c) High peer support, low father support (34.5%); and (d) High father and mother support, self-efficacy, and hardiness/adaptive coping (20.8%). YBGBM in profile 1 scored markedly higher on distress (d =.74) and lower on mental health functioning (d =.93) compared to men in the other profiles. Results suggest that self-efficacy and hardiness/adaptive coping may play a more important role in protecting YBGBM from risks compared to social support and should be targeted in interventions. The findings show that resilience is a multidimensional construct and support the notion that there are different patterns of resilience among YBGBM.
Relationship cognitions and longitudinal trajectories of sexual risk behavior among young gay and bisexual men: The P18 cohort studyCook, S., Halkitis, P., & Kapadia, F.
Journal titleJournal of Health Psychology
Sex Differences in Virtual Network Characteristics and Sexual Risk Behavior Among Emerging AdultsCook, S., Bauermeister, J.A., & Zimmerman, M.A.
Journal titleEmerging Adulthood
Emerging adults (EAs) aged 18–24 account for a large proportion of all sexually transmitted infections (STIs), HIV infections, and unintended pregnancies in the United States. Given the increased influence of online media on decision making, we examined how EA online networks were associated with sexual risk behaviors. We used egocentric network data collected from EAs aged 18–24 years old across the United States (N = 1,687) to examine how online social norms (e.g., acceptance of HIV infections, other STIs, and pregnancy) and network characteristics (i.e., network size and density; ties’ closeness, race, age, and sex similarities) were associated with participants’ unprotected vaginal intercourse in the last 30 days. Findings suggested that in male EAs, there was a strong association between online social norms, structural characteristics, and sexual risk behavior compared to females. Researchers and practitioners may wish to address online peer norms and EAs’ online network composition when developing online sexual risk prevention tools.
Sexual identity and HIV status influence the relationship between internalized stigma and psychological distress in black gay and bisexual menBoone, M.R., Cook, S., & Wilson, P.A.
Journal titleAIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV
Experiences of internalized homophobia and HIV stigma in young Black gay and bisexual men (GBM) may lead to psychological distress, but levels of distress may be dependent upon their sexual identity or HIV status. In this study, we set out to explore the associations between psychological distress, sexual identity, and HIV status in young Black GBM. Participants were 228 young Black GBM who reported on their psychological distress, their HIV status, and their sexual identity. Results indicated that internalized homophobia was significantly related to psychological distress for gay men, but not for bisexual men. HIV stigma was related to psychological stress for HIV-positive men, but not for HIV-negative men. Results indicate a need for more nuanced examinations of the role of identity in the health and well-being of men who have sex with men.
The Integrated Attachment and Sexual Minority Stress Model: Understanding the Role of Adult Attachment in the Health and Well-Being of Sexual Minority MenCook, S., & Calebs, B.J.
Journal titleBehavioral Medicine
Gay and bisexual boys and men experience social stigma associated with their sexual minority status that can negatively influence health. In addition, experiencing sexual orientation stigma may be linked to a decreased capacity to effectively form and maintain secure attachment relationships with parents, peers, and romantic partners across the life-course. We proposed that utilizing a framework that integrates the process by which sexual minority men develop attachment relationships in the context of sexual minority stress can lead to a better understanding of health and well-being among sexual minority boys and men. In addition, we highlight where future research can expand upon the presented model in order to better understand the developmental processes through which attachment and sexual minority stress influences health and health behaviors among sexual minority boys and men.
Transitions in Friendship Attachment during Adolescence are Associated with Developmental Trajectories of Depression Through AdulthoodCook, S., Heinze, J.E., Miller, A.L., & Zimmerman, M.A.
Journal titleJournal of Adolescent Health
Purpose Forming secure friendship attachments during adolescence are important for mental health; few, however, have specifically examined the ways in which the transitions in attachment during adolescence may influence future mental health outcomes among African Americans. Methods The present study examines how transitions in attachment in adolescence predicted changes in depression symptoms from late adolescents through adulthood in an African-American sample. We used growth curve modeling to examine the association between transitions in friendship attachment and changes in depression symptoms in adulthood. Results At age 16 years, 346 (64.0%) adolescents reported secure attachment with 195 (36.0%) reporting either avoidant or resistant attachment. At age 17 years, 340 (62.9%) reported secure attachment and 201 (37.2%) reported avoidant or resistant attachment. The largest percentage of participants (46.2%) reported stable-secure attachment across the two time points. Results of the growth model indicated that adolescents who reported a stable-secure attachment style had lower levels of depression symptoms during adulthood than those individuals who transitioned from secure-to-insecure, from insecure-to-secure, or were in the stable-insecure group. Interestingly enough, individuals in both the attachment transition groups had a faster declining rate of depression symptoms over time compared to the two stability groups. Conclusions Data support existing research showing an association between transitions in attachment during adolescence and depression through adulthood. Furthermore, these study findings suggest there may be protective features associated with transitioning between attachment styles during adolescence on later depression, compared to African Americans who remain stable in their attachment style.
HIV status disclosure, depressive symptoms, and sexual risk behavior among HIV-positive young men who have sex with menCook, S., Valera, P., & Wilson, P.A.
Journal titleJournal of Behavioral Medicine
The rate of HIV infection among young men who have sex with men (YMSM) is increasing in the United States, and targeted research is needed to inform interventions aimed at reducing HIV transmission in this population. This study aims to understand the association between HIV status disclosure and sexual risk behavior among HIV-positive YMSM. A particular focus is given to depressive symptoms and their potential role in explaining the association between HIV disclosure and sexual risk behavior. In a sample of 991 YMSM receiving care at 20 clinics across the United States, Univariate and multivariate analyses were conducted to explore these associations. Approximately one-half (52.4 %) of participants reported disclosing to their current sexual/romantic partner. Disclosure to family members was negatively associated with sexual risk behavior. Also, depressive symptoms were positively associated with sexual risk behavior. We discuss the implications of our findings for future research and intervention.
The Smoking Behaviors and Cancer-Related Disparities Among Urban Middle Aged and Older Men Involved in the Criminal Justice SystemValera, P., Anderson, M., Cook, S., Wylie-Rosett, J., Rucker, J., & Reid, A.E.
Journal titleJournal of Cancer Education
This study examined cancer knowledge, mental health, and tobacco use in formerly incarcerated men. The Cancer-Health Research Study with Formerly Incarcerated Men in New York City used a cross-sectional research design to examine cancer knowledge and prevention (CKP) outcomes among 259 justice-involved males, ages 35–67. CKP was assessed using items from the National Cancer Institute’s Health Information National Trends Survey. Psychological symptoms were examined using the Brief Symptom Inventory. Of the 259 men who completed the survey, 76 % of the respondents self-reported as current smokers. Current smokers smoked between 1 and 40 cigarettes per day. The mean number of cigarettes smoked per day was 10.37 (SD = 6.76). Sixty-five percent (n = 165) of the respondents underwent cancer-screening tests. CKP scores ranged from 2 to 28; the mean was 15.05 (SD = 5.49), indicating that the men scored very low in terms of CKP. CKP scores were negatively associated with the number of cigarettes smoked per day, τ = −.13, p =.01. These results have important implications for enhancing access to cancer-health education programs in justice-involved settings.
What does attachment have to do with HIV transmission among young gay black and bisexual men?Cook, S.
"They are not taking cigarettes from me... I'm going to smoke my cigarettes until the day I die. I don't care if I get cancer": Smoking behaviors of men under community supervision in New York CityValera, P., Cook, S., Darout, R., & Dumont, D.M.
Journal titleNicotine and Tobacco Research
Introduction: Cigarette smoking declined from 42.4% in 1965 to 19.3% in 2010 among the general population, but it remains the leading cause of preventable death and illness in the United States, especially among high-risk populations, including those with criminal justice involvement. Methods: A mixed-methods approach was used to investigate the smoking behaviors of men under parole or probation. Phase I focused on qualitative data of 30 semi-structured interviews of men who were recently released from a state prison and/or jail. Phase II analyzed quantitative data resulting from a study that examined smoking characteristics and treatment approaches of 259 participants, 197 of whom were cigarette smokers. Results: The survey participants' age of tobacco initiation ranged from 7 to 45 years of age. Participants smoked between 1 and 40 cigarettes per day; the mean number of cigarettes smoked per day was 10.37. Men released from prison used cigarettes for more years on average than men released from jail (t = -2.22, p < .05). A linear regression procedure revealed that the influence of friends and family significantly predicted smoking behavior (β = .25, p < .0001). The qualitative data revealed the following themes: unintended consequences of the prison smoking ban, smoking as anxiety management, smoking cigarettes as part of a daily routine, and barriers to quitting. Conclusions: Given the rapid growth of individuals under community supervision, public health and policy makers are missing an opportunity to develop strategies that promote smoking cessation treatments, especially among men who are serving parole or probation and during the incarceration period itself.
Conducting Health Disparities Research with Criminal Justice Populations: Examining Research, Ethics, and ParticipationValera, P., Cook, S., Macklin, R., & Chang, Y.
Journal titleEthics and Behavior
This study explored the challenges of informed consent and understanding of the research process among Black and Latino men under community supervision (e.g., parole and/or probation). Between February and October 2012, we conducted cognitive face-to-face interviews using open-ended questions on the significant areas of research participation (i.e., the informed consent process, confidentiality, compensation, what is meant by human subject and clinical trials) among 259 men aged 35 to 67 under community supervision in Bronx, New York. Content analysis of the open-ended questions revealed limited knowledge concerning the understanding of research participation. The study participants appeared to generally understand concepts such as compensation after research participation and confidentiality. Participants demonstrated a lack of understanding of certain aspects of the research process-informed consent, human subject, Institutional Review Board, and clinical trials. These findings are informative to researchers conducting studies with criminal justice populations and Institutional Review Boards reviewing research studies.
Understanding the role of mhealth and other media interventions for behavior change to enhance child survival and development in low-and middle-income countries: An evidence reviewHiggs, E.S., Goldberg, A.B., Labrique, A.B., Cook, S., Schmid, C., Cole, C.F., & Obregón, R.A.
Journal titleJournal of Health Communication
Given the high morbidity and mortality among children in low-and middle-income countries as a result of preventable causes, the U.S. government and the United Nations Children's Fund convened an Evidence Summit on Enhancing Child Survival and Development in Lower-and Middle-Income Countries by Achieving Population-Level Behavior Change on June 3-4, 2013, in Washington, D.C. This article summarizes evidence for technological advances associated with population-level behavior changes necessary to advance child survival and healthy development in children under 5 years of age in low-and middle-income countries. After a rigorous evidence selection process, the authors assessed science, technology, and innovation papers that used mHealth, social/transmedia, multiplatform media, health literacy, and devices for behavior changes supporting child survival and development. Because of an insufficient number of studies on health literacy and devices that supported causal attribution of interventions to outcomes, the review focused on mHealth, social/transmedia, and multiplatform media. Overall, this review found that some mHealth interventions have sufficient evidence to make topic-specific recommendations for broader implementation, scaling, and next research steps (e.g., adherence to HIV/AIDS antiretroviral therapy, uptake and demand of maternal health service, and compliance with malaria treatment guidelines). While some media evidence demonstrates effectiveness in changing cognitive abilities, knowledge, and attitudes, evidence is minimal on behavioral endpoints linked to child survival. Population level behavior change is necessary to end preventable child deaths. Donors and low-and middle-income countries are encouraged to implement recommendations for informing practice, policy, and research decisions to fully maximize the impact potential of mHealth and multimedia for child survival and development.
Exploring the relationship between gender nonconformity and mental health among black South African gay and bisexual menCook, S., Sandfort, T.G.M., Nel, J.A., & Rich, E.P.
Journal titleArchives of Sexual Behavior
Online Network Influences on Emerging Adults' Alcohol and Drug UseCook, S., Bauermeister, J.A., Gordon-Messer, D., & Zimmerman, M.A.
Journal titleJournal of Youth and Adolescence
Researchers have reported that network characteristics are associated with substance use behavior. Considering that social interactions within online networks are increasingly common, we examined the relationship between online network characteristics and substance use in a sample of emerging adults (ages 18-24) from across the United States (N = 2,153; M = 21 years old; 47 % female; 70 % White). We used regression analyses to examine the relationship between online ego network characteristics (i.e., characteristics of individuals directly related to the focal participant plus the relationships shared among individuals within the online network) and alcohol use and substance use, respectively. Alcohol use was associated with network density (i.e., interconnectedness between individuals in a network), total number of peer ties, and a greater proportion of emotionally close ties. In sex-stratified models, density was related to alcohol use for males but not females. Drug use was associated with an increased number of peer ties, and the increased proportion of network members' discussion and acceptance of drug use, respectively. We also found that online network density and total numbers of ties were associated with more personal drug use for males but not females. Conversely, we noted that social norms were related to increased drug use and this relationship was stronger for females than males. We discuss the implications of our findings for substance use and online network research.
Participation in research involving novel sampling and study designs to identify acute HIV-1 infection among minority men who have sex with men.Rodriguez, K., Castor, D., Mah, T.L., Cook, S., Auguiste, L.M., Halkitis, P., & Markowitz, M.
Journal titleAIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV
HIV-1 infection disproportionally affects African-American and Latino men who have sex with men (MSM). Their inclusion in biomedical and behavioral research is critical to understanding and addressing HIV vulnerability. Using focus groups, we sought to understand the perceptions related to participating in biomedical research of acute/recent HIV-1 infection (AHI) using complex sampling and data collection methods to reach this hidden group at highest risk of acquiring and transmitting HIV. Given the potential impact of AHI on HIV transmission in MSM, it is important to understand this intersection for HIV prevention, care, and treatment purposes. The aim of this study was to understand how recruitment and data collection methods affect AHI research participation willingness particularly among MSM of color. Findings suggest that major barriers to research participation with complex sampling to identify AHI and intensive risk behavior collection such as diary methods are lack of anonymity, partner disclosure, and study fatigue. The authors explore implications for future study designs and development based on these findings.
Substance use and sexual risk behavior in HIV-positive men who have sex with men: An episode-level analysisBoone, M.R., Cook, S., & Wilson, P.
Journal titleAIDS and Behavior
Men who have sex with men (MSM) make up nearly half of all people living with HIV in the United States. The prevalence of the epidemic in this population makes it vitally important to understand the transmission of the infection and to develop methods to prevent its spread. The current study uses longitudinal diary methods to examine relationships between substance use and unprotected anal intercourse in a sample of 158 HIV-positive, mostly ethnic minority MSM. Results indicate that both general substance use and use of specific drugs (i.e., inhalants, cocaine, crack, and club drugs) have a substantial impact on the sexual risk behavior of this population.
Deficits in dopamine D 2 receptors and presynaptic dopamine in heroin dependence: Commonalities and differences with other types of addictionMartinez, D., Saccone, P.A., Liu, F., Slifstein, M., Orlowska, D., Grassetti, A., … Comer, S.D.
Journal titleBiological Psychiatry
Positron emission tomography (PET) imaging studies have shown that addiction to a number of substances of abuse is associated with a decrease in dopamine D 2/3 receptor binding and decreased presynaptic dopamine release in the striatum. Some studies have also shown that these reductions are associated with the severity of addiction. For example, in cocaine dependence, low dopamine release is associated with the choice to self-administer cocaine. The goal of the present study was to investigate these parameters of striatal dopamine transmission in heroin dependence and their association with drug seeking behavior. Heroin-dependent and healthy control subjects were scanned with [ 11C]raclopride before and after stimulant administration (methylphenidate) to measure striatal D 2/3 receptor binding and presynaptic dopamine release. After the PET scans, the heroin-dependent subjects performed heroin self-administration sessions. Both striatal D 2/3 receptor binding and dopamine release were reduced in the heroin-dependent subjects compared with healthy control subjects. However, neither PET measure of dopamine transmission predicted the choice to self-administer heroin. These findings show that heroin addiction, like addiction to other drugs of abuse, is associated with low D 2/3 receptor binding and low presynaptic dopamine. However, neither of these outcome measures was associated with the choice to self-administer heroin.
Intimate-partner violence and HIV in South African womenCastor, D., Cook, S., Leclerc-Madlala, S., & Shelton, J.
Journal titleThe Lancet
Situational predictors of sexual risk episodes among men with HIV who have sex with menWilson, P.A., Cook, S., McGaskey, J., Rowe, M., & Dennis, N.
Journal titleSexually Transmitted Infections
Background: Men with HIV who have sex with men (MSM) represent the largest group of people living with HIV/AIDS in the United States. It is important to understand the sexual risk-taking behaviours that may be linked to the transmission of HIV and other sexually transmitted infections in this population. Models of HIV risk that focus solely on personal factors have been demonstrated to be ineffective at explaining risk behaviour. Rather, in order to fully understand sexual risktaking, it is important to examine the factors linked to high-risk sexual situations and not solely the factors linked to potentially high-risk people. Methods: A diverse sample of 100 MSM with HIV completed a 6-week internet-based sex diary that collected detailed information on recent sexual encounters. In total, information on over 250 sexual episodes was collected and analysed. Generalised linear mixed models were used to examine situational predictors of risk episodes. Results: Analyses revealed that drug use by self and sex partners (examined individually and together) were positively related to risk episodes. Likewise, having a sex partner met online and having a sexual encounter in a sex party or bathhouse setting was linked to risk episodes. Sexual episodes that involved a sex-partner who was perceived as sexually desirable and those involving communication about HIV and/or condom use with partners each were negatively related to risk. Conclusions: Situational factors play an important role in explaining sexual risk-taking among MSM with HIV. Researchers should place a greater focus on drug use and characteristics of sex partners and settings in which sexual behaviours occur as situational predictors of risk in order to comprehensively understand sexual risk-taking in this population.