Functional magnetic resonance imaging in studies of the neurobiology of suicidal behavior in adolescents with alcohol use disorders

Functional MRI of the brain is a technique that localizes regions of activity in the brain following task activation. It is useful to neuroscientists interested in interrogating the localization of certain brain functions. Alcohol misuse is a complex, multidimensional disorder involving problematic ethanol ingestion and reflected in behavior. Genetic factors play an important role in the etiopathogenesis of alcohol abuse in adolescents. Alcohol use disorders tend to run in families with 40-60% of the variance of risk explained by genetic influences. Numerous well-designed twin, adoption, and family studies have demonstrated that genetic factors are important in determining vulnerability to alcohol use disorders. There is a tendency for people who misuse alcohol to marry individuals who also abuse alcohol (assortative mating). Thus, many adolescent alcohol misusers are from families with a high proportion of alcohol abuse or dependence. It has been shown that alcohol abusing adolescents have a number of cognitive deficits. Neuropsychological studies of adolescents with alcohol use disorders have reported decrements in language skills, problem solving, verbal and non-verbal retention, working memory, and visuospatial performance. Some cognitive deficits may be present before an adolescent starts drinking and contribute to the development of alcohol use disorders. Data suggest that neuropsychological dysfunction may play a role in determining risk for suicidal acts. Therefore, studies of cognitive impairments and the neural substrate of these impairments in alcohol abusing adolescents may help develop methods of identifying teenagers who are at increased risk for suicide and contribute to our knowledge of the neurobiology of suicidal behavior and may lead to the development of new treatment methods.     

Teenage smoking and substance use as predictors of severe alcohol problems in late adolescence and in young adulthood.

PURPOSE: To study the association between adolescent alcohol use, smoking, other substance use, and later substance-use-related problems in a large general population sample in Northern Finland. METHODS: Data from the Northern Finland 1966 Birth Cohort (n = 11,017) were linked with National Crime Registers and the Finnish Hospital Discharge Register. Information on adolescent alcohol use, smoking, and other substance use was gathered via a questionnaire in 1980 and 1981, when subjects' age was 14 years. Logistic regression analyses were performed to examine the association between alcohol use frequency, tendency for heavy drunkenness, smoking and other substance use in adolescence, and drunk driving offenses between ages 15 and 32 years and hospital-treated substance use disorders between ages 16 and 31 years, adjusting for parental social class, family type, and school performance. RESULTS: The most powerful predictor for drunk driving was regular smoking at the age of 14 years (AOR 6.8, 95% CI 4.6-10.1 for males and 6.3, 95% CI 1.9-20.6 for females). Hospital-treated substance use disorders were associated with male regular smoking (AOR 9.4, 95% CI 4.6-19.2) and female regular alcohol use (AOR 7.5, 95% CI 2.6-21.5), and having often been heavily drunk (AOR 12.7, 95% CI 4.0-40.4) at the age of 14 years. CONCLUSIONS: Teenage regular and heavy alcohol use and smoking are important predictors for substance-use-related problems later in adolescence and in young adulthood. Adolescents with early onset regular smoking and with drunkenness-oriented alcohol use are especially at risk for developing hazardous substance use later in life.     

School performance and alcohol use problems in early adulthood: a longitudinal study

There is inconsistent evidence about the association between school performance and subsequent use of alcohol and alcohol problems in adolescents and young adults. This study examines whether school performance at 14 years is associated with drinking problems in early adulthood; and whether this association is explained by family and individual factors in childhood and adolescence. Data were from a 21-year follow-up of 3,478 Australian young adults from birth to the age of 21 years when data on use of alcohol were collected. Child school performance (CSP) was assessed at 14 years via self- and maternal report. Alcohol consumption at 21 years was measured via self-report, and alcohol abuse and dependence were assessed by the computerized version of Composite International Diagnostic Interview (CIDI-Auto). Potential confounding factors were prospectively measured between the child’s birth and age of 14 years. School performance at 14 years predicted young adults’ alcohol consumption and alcohol use disorders (AUDs). After controlling for confounding, children who had lower school performance had increased risk of drinking more than two glasses of alcohol per day in early adulthood (odds ratio = 1.7; 95% confidence interval: 1.1–2.6). There was a similar pattern of association between CSP and young adults’ alcohol abuse and dependence (AUD) measured by CIDI-Auto. Level of academic performance in high school children predicts their drinking problems as young adults, independently of a selected group of individual and family confounders. Exploration of the pathway linking school performance and alcohol problems in young people may help identify opportunities for preventive interventions.     

Alcohol consumption among men and women with tuberculosis in Tomsk, Russia

Drinking behavior among Russian women remains poorly described. We analyzed gender differences in alcohol use among 374 tuberculosis patients in Tomsk, Siberia. Twenty-six (28.3%) women had lifetime alcohol abuse or dependence, compared with 70.6% of men. Women with alcohol use disorders drank 12.7 +/- 14.0 standard drinks per day and > or = 34.6% drank 2 three days per week. Among individuals with a lifetime alcohol use disorder, age of onset and typical consumption did not differ significantly by gender. We conclude that Russian women with alcohol use disorders consume almost as much alcohol as men and may be at greater risk for negative social and medical consequences.     

Posttraumatic Stress Symptoms and their Relationship to Drug and Alcohol use in an International Sample of Latino Immigrants

We identify the prevalence and correlates of posttraumatic stress (PTSD) symptoms and their relationship to alcohol and substance use disorders (AUD/SUD) among Latino immigrants in two countries. A screening battery assessing PTSD symptoms (PCL-C), alcohol use (AUDIT), drug abuse (DAST), and psychological measures was administered to 562 Latino immigrants recruited in clinics. We used logistical regression analyses to evaluate the relationship between PTSD symptoms and AUD/SUD. Prevalence of elevated PTSD symptoms was high (53.7 % in Boston, 47.9 % in Madrid and, 43.8 % in Barcelona). Screening positive for psychological measures was significantly correlated to screening positive on the PCL-C (p < 0.001). Significant gender differences in risk of AUD/SUD were moderated by PTSD symptoms. Presence of any PTSD symptoms predicted problems with benzodiazepine misuse. Given the high rates of co-morbidity between PTSD symptoms and AUD/SUD, we recommend early interventions for dual pathology for Latino immigrants with trauma history.     

Opportunities for prevention of alcohol-related death in primary care: Results from a population-based cross-sectional study

The mortality rate from alcohol-related conditions has risen sharply in the United Kingdom and it is not known whether opportunities for preventive interventions could be improved. The purpose of our study was to identify opportunities to detect, assess, and manage alcohol problems in primary care according to evidence-based guidelines. We carried out a cross-sectional study on patients who died from alcohol-related conditions in the calendar year 2003 within National Health Service Greater Glasgow Health Board area, Scotland (population 920,000). We described patient characteristics and care recorded in health service records, comparing it with best evidence-based practice in Scottish Intercollegiate Guidelines Network and Health Technology Board for Scotland recommendations on the management of harmful drinking and alcohol dependence. 501 deaths occurred from an alcohol-related cause. The mean age at death was 57.5 years and 72% were male. The most common causes of death, recorded by the International Classification of Diseases, revision 10, excluding accidents, were alcoholic liver disease (290, 57.9%) and mental and behavioural disorders due to alcohol (70, 14.0%). Lifetime mean consultations at primary care general practitioner and hospital outpatient departments were 24 in males and 5 in females. All individuals who died from an alcohol-related cause had at least one biochemical or physical indicator suggestive of alcohol misuse. 21% (95% CI 13–33%) had no record of having been advised to abstain from alcohol and 23% (95% CI 15–35%) had received brief interventions. 58% (95% CI 46–70%) had been referred to specialist alcohol services but a third of them did not attend. The majority of patients (83%, 95% CI 72–90%) had no evidence of shared health service and social work care. We concluded that individuals who died from alcohol-related conditions were usually in contact with statutory and voluntary services but further efforts were required to use these opportunities to detect, assess, and manage serious alcohol problems according to evidence-based guidelines.     

The role of the hypothalamic-pituitary-adrenal axis dysfunction in the pathophysiology of alcohol misuse and suicidal behavior in adolescents

Alterations in the mechanisms that regulate hypothalamic-pituitary-adrenal (HPA) axis activity predate the development of alcohol use disorders. Human and animal studies indicate that chronic alcohol consumption induces a persistent impairment in the ability of the HPA axis to respond to stress. Therefore, HPA axis abnormalities may contribute to the development of alcohol use disorders and may be a result of alcohol misuse. HPA axis interacts with serotonergic mechanisms. Hippocampal function is modulated by serotonergic projections mostly from dorsal raphe nucleus in the midbrain. Glucocorticoids modulate the activity of this raphe-hippocampal system in various ways. These effects are mediated via central corticosteroid receptors, which include glucocorticoid and mineralocorticoid receptors located in the hippocampus and in other cortical structures. An association between suicidal behavior and hyperactivity of the HPA axis has been suggested. An abnormal interaction between the HPA mechanisms and serotonergic systems may substantially contribute to suicidal behavior in adolescents, because abnormalities in HPA and serotonin functions may be inherited and may manifest at young age. Vulnerability to alcohol use disorders and suicide is likely to be due to multiple interacting genetic loci of small to modest effects. The identification and treatment of adolescents at risk for suicide is one of the most critical issues in adolescent psychiatry. The identification of alcohol and drug misuse is critical to the proper assessment of suicide risk in adolescents. HPA dysregulation may contribute to both alcohol abuse and suicidal behavior in adolescents. Studies of HPA function in alcohol abusing adolescents may lead to the development of new diagnostic tests for predisposition to suicidal behavior. Furthermore, study of biological markers may help us towards an understanding of the neurophysiological substrates of severe dysphoric mood states, alcohol and substance abuse, and suicidal behavior in adolescents.     

Typologies of alcohol consumption in adolescence: predictors and adult outcomes

AIMS: Data from the 1970 British Cohort Study were used to examine the effects of alcohol expectancies, norms, and openness of communication with parents on typologies of adolescent alcohol use and the subsequent risk of adult alcohol misuse from adolescent use. METHODS: Of a population originally defined as all children born in the UK in 1 week of April 1970, 69.4% were interviewed at age 16 and 70.1% at age 30. Missing information was imputed using the multivariate imputation by chained equation (MICE) method, yielding a sample size of 7023 for men and 6896 for women. Four adolescent drinking typologies were defined by frequency and quantity of alcohol consumption at age 16. RESULTS: Positive alcohol expectancies predicted all types of adolescent alcohol use in young men and women. Norms affected frequency of alcohol use over quantity, while openness of communication with parents affected quantity of alcohol use. All men who drank alcohol in adolescence were at risk of alcohol misuse (defined by the CAGE questionnaire) in adulthood, whereas the risk for women was limited to frequent drinkers. CONCLUSIONS: Drinking typologies were useful for understanding the mechanisms of adolescent alcohol use. Early prevention may be required to reduce alcohol related problems in later life.     

Intermittent ethanol access schedule in rats as a preclinical model of alcohol abuse

One of the major challenges in preclinical studies of alcohol abuse and dependence remains the development of paradigms that will elicit high ethanol intake and mimic the progressive transition from low or moderate social drinking to excessive alcohol consumption. Exposure of outbred rats to repeated cycles of free-choice ethanol intake and withdrawal with the use of intermittent access to 20% ethanol in a 2-bottle choice procedure (IA2BC) has been shown to induce a gradual escalation of voluntary ethanol intake and preference, eventually reaching ethanol consumption levels of 5–6 g/kg/24 h, and inducing pharmacologically relevant blood ethanol concentrations (BECs). This procedure has recently been gaining popularity due to its simplicity, high validity, and reliable outcomes. Here we review experimental and methodological data related to IA2BC, and discuss the usefulness and advantages of this procedure as a valuable pre-training method for initiating operant ethanol self-administration of high ethanol intake, as well as conditioned place preference (CPP). Despite some limitations, we provide evidence that IA2BC and related operant procedures provide the possibility to operationalize multiple aspects of alcohol abuse and addiction in a rat model, including transition from social-like drinking to excessive alcohol consumption, binge drinking, alcohol seeking, relapse, and neuroadaptations related to excessive alcohol intake. Hence, IA2BC appears to be a useful and relevant procedure for preclinical evaluation of potential therapeutic approaches against alcohol abuse disorders.     

Prevalence and socioeconomic characteristics of alcohol disorders among men and women in the Eastern Cape Province,South Africa

There is growing concern about alcohol problems in low‐ and middle‐income countries. More research is required, particularly among the younger generation. The aim of this study was to investigate the prevalence of alcohol disorders and associated socioeconomic characteristics among young men and women living in the Eastern Cape Province, South Africa. This was a cross‐sectional population‐based study of 977 participants (52% male and 48% female) aged 18–40, the majority of whom lived in low‐income areas. Data collection was carried out in 2012 by trained fieldworkers. The Mini International Neuropsychiatric Interview (DSM‐IV) was used to investigate the prevalence of alcohol dependence (increased tolerance to alcohol, failed attempt to cut down, risk of physical and mental effects) and alcohol abuse (harmful use, consistent intoxication, risk behaviour, physically hazardous, social problems). A high 12‐month prevalence of alcohol dependence was found (26.5% in total; 39.0% among men and 19.1% among women) as well as of alcohol abuse (9% in total; 19.0% among men and 6.0% among women). Few socioeconomic differences emerged among the men, except older men (OR 1.94, CI 1.11–3.42) and those supported by social grants (OR 2.28, CI 1.06–4.93), who presented higher odd ratios for alcohol dependence than the reference groups. Among the women, more differences emerged: women who were widowed/single (OR 2.35, CI 1.20–4.62), had no education (OR 3.41, CI 1.04–11.21), had a low income (OR 3.26, CI 1.55–6.80) and had no social support from friends when ill presented higher odd ratios (OR 1.73, CI 1.07–2.80). In the adjusted model, marital status and low income remained statistically significant. With regard to alcohol abuse, fewer socioeconomic differences emerged. Interventions need to address the early onset of alcohol misuse in order to meet both current needs and long‐standing mental and physical illness.     

Stigma and alcohol misuse during adolescence

Stigma associated with alcohol misuse can have serious consequences for adolescents, who may be at risk of developing abuse and dependence disorders. Adolescence is a period that involves wide use of psychoactive substances. During this developmental phase, adolescents are strongly influenced by peer group norms, which do not necessarily stigmatize alcohol use. Unintentionally, a significant subgroup of adolescents may develop problems that are a result of alcohol misuse. The stigma about alcohol problems may keep adolescents from admitting that their difficulties are exacerbated by misuse of alcohol. When their behavior crosses the line from norm to inappropriate, the label of alcoholic may be applied and the stigma that is attached to the label will have additional consequences. This includes withdrawal of social supports and even access to treatment. Adolescents with alcohol use problems may be reluctant to identify themselves with these difficulties, because of their concern about being rejected. These adolescents may present with emotional or behavioral problems, rather than alcohol concerns. Clinicians may avoid inquiring about alcohol use, because of their own negative and pessimistic perceptions of this disorder. Clinicians can be important resources for these adolescents, but this requires that clinicians examine their own prejudgments about alcohol abuse and dependence. This can facilitate meaningful inquiry about alcohol use and begin to offset the stigma and negative self-worth of these adolescents.     

Alcohol misuse,depressive symptoms,and HIV/STI risks of US Hispanic women

Objectives: Alcohol misuse and depressive symptoms have been linked to HIV/STI risk, but studies have rarely included Hispanic women, who have over four times greater HIV incidence than white, non-Hispanic women. Understanding the connections among alcohol misuse, depressive symptoms, and HIV/STI risks may suggest ways to meet specific needs of Hispanic women. This study’s objective is to examine the relationships among alcohol misuse, depressive symptoms, and seven HIV/STI risk factors.

Design: Five hundred forty-eight US Hispanic women with intake data from a randomized trial were assessed for alcohol misuse (CAGE) and depressive symptoms (CES-D). GZLM and path analyses tested relationships between alcohol misuse or depressive symptoms and HIV/STI risk factors.

Results: Self-efficacy and condom use were not related to alcohol misuse or depressive symptoms, but only 15% of women reported consistent condom use. After controlling for demographics, women with alcohol misuse had significantly more perceived HIV/STI risk (OR?=?2.15) and better HIV/STI knowledge (β?=??.54); and women with depressive symptoms had significantly more perceived HIV/STI risk (OR?=?1.76) and worse HIV/STI knowledge (β?=?.37).

Conclusions: Interventions to increase condom use for Hispanic women are needed, regardless of mental disorders. Working with Hispanic women with alcohol misuse or depressive symptoms presents a need (and opportunity) to address issues directly related to HIV/STI risk. Women’s health practitioners have an excellent opportunity to reach women by implementing regular screening programs in clinics that serve Hispanic women. For women with high depressive symptoms, poor HIV/STI knowledge should also be addressed. Future studies should test whether integrated and tailored risk reduction interventions affect these factors and lower HIV/STI risk for Hispanic women.     

Early Onset of Sexual Intercourse and Parental Incarceration among African American Youth Living in Urban Public Housing

Mass incarceration, substance use, and adolescent early onset of sex (e.g., initiate sexual intercourse at 13 years of age or younger) are social problems with disparate impacts on low-income African American communities. Two out of every five inmates in state and federal prisons are African American and the vast majority of these inmates are from low-income communities. Furthermore, this population experiences more severe consequences of substance use and abuse compared to other populations. In sum, African American youth endure the lion share of problems that mass incarceration and substance use leave in their wake. It is likely that the early onset of sex reported by African American youth in national data is related to mass incarceration and substance use in their communities. Using a sample of 142 African American youth, this paper assesses whether parental incarceration or substance, or both, are related to the likelihood of early onset of sex. Analytic procedures included chi-square and sequential logistic regression. The sample reported a mean age of 19 and 36% reported early onset of sex. Being male, paternal incarcerated, and maternal alcohol problems were associated with an increased likelihood of early onset of sex. Results point to a need for supportive services for the children of incarcerated parents, particularly those living in urban public housing developments.     

Associations of Drug Use,Violence, and Depressive Symptoms with Sexual Risk Behaviors Among Women with Alcohol Misuse

Background

Alcohol misuse is associated with increased human immunodeficiency virus sexual risk behaviors by women. Drug use, intimate partner violence (IPV), and depressive symptoms frequently co-occur, are well-recognized alcohol misuse comorbidities, and may interact to increase risk behaviors. Using a syndemic framework we examined associations between drug use, IPV, and depressive symptoms and sexual risk behaviors by 400 women with alcohol misuse attending an urban sexually transmitted infections clinic.

Childhood abuse and adolescent suicidality: a direct link and an indirect link through alcohol and substance misuse

Childhood abuse is responsible for a variety of outcomes that are characterized by maladjustment and maladaption. Two of the most significant results are suicide and alcohol and substance misuse. This paper explores the direct link between childhood abuse and adolescent suicide, the direct link between childhood abuse and adolescent alcohol and substance misuse, the indirect link between childhood abuse and adolescent suicide through alcohol and substance misuse, and finally implications of these links for practitioners working with adolescents who are experiencing or who have experienced childhood abuse. Both suicide and alcohol and substance misuse are prevalent in the adolescent population; however those adolescents who were victims of childhood abuse show an even greater prevalence of both suicidality and substance and alcohol misuse. Additionally adolescents who exhibit alcohol or substance misuse show greater rater of suicidality than those without alcohol and substance misuse. It appears that abuse is a risk factor for eventual suicidality. Practitioners working with children or adolescents who have experienced abuse need to work towards secondary prevention by identifying, predicting and treating those at risk for substance abuse and/or suicide; and those working with adolescents who are already abusing substances and/or are suicidal should work with the adolescent to identify and examine life events such as abuse that may have triggered the chain towards substance misuse and/or suicidal ideation.     

Mental disorders as risk factors for the development of cocaine abuse/dependence: case-control study

OBJECTIVE: To evaluate the role of psychiatric disorders and alcohol dependence as possible risk factors for cocaine abuse/dependence. METHODS: The case-control study used the "snowball" technique in order to select untreated cocaine users (cases) and to match sex, age and friendship. Information was gathered using the Composite International Diagnostic Interview (CIDI), and computer diagnosis were generated according to the DSM-III-R criteria. The analysis was performed through the logistic conditional regression. RESULTS: The study included 208 subjects. The main results showed that having a history of alcohol dependence was independently associated with an increased risk of cocaine abuse/dependence (OR=15,1; 95% CI 3,8-60, 2); no other psychiatric disorder was significantly associated with an increase in this risk after the multivariate analysis. An increased risk of cocaine abuse/dependence was also found for those who related suicide thoughts (OR=3,1; 95% CI 0,91-10,8), suggesting an association between more severe manifestations of depression and cocaine abuse. CONCLUSIONS: These findings suggest that programs directed towards the treatment and prevention of cocaine abuse must be prepared to address issues related to comorbidity of drug abuse with alcohol and other psychiatric disorders     

Prevalence of gambling disorders in a primary care setting

BACKGROUND: Pathologic gambling prevalence seems to be increasing as opportunities for gambling increase. Prevalence may be different in a primary care setting compared with population-based studies. OBJECTIVES: To determine the gambling disorder prevalence in a primary care setting and to investigate associations between gambling disorders and proximity to a casino, substance abuse, health ratings, age, sex, and socioeconomic status. DESIGN: Cross-sectional survey of 1394 patients presenting to their primary care physicians between November 1, 1997, and April 1, 1998. SETTING: Three primary care clinics in Wisconsin. PATIENTS: Adults aged 18 years and older. MAIN OUTCOME MEASURES: Gambling disorders, defined by scores of 3 or greater on the South Oaks Gambling Screen (SOGS), and information about drug use (alcohol, tobacco, and marijuana), overall health, specific health symptoms, age, sex, race, and socioeconomic status. RESULTS: A total of 1051 patients completed the survey. More than 80.0% of the patients had gambled, and 6.2% met the criteria for gambling disorders. Gambling disorders were more prevalent in men, nonwhites, and patients from lower socioeconomic groups. Patients with gambling disorders were more likely to use tobacco and abuse alcohol compared with nonproblem gamblers. No relation was seen between marijuana use and gambling disorders. Patients with gambling disorders rated their health more poorly and reported more severe symptoms of heartburn and backache. CONCLUSIONS: A considerable percentage of patients presenting to primary care clinics are affected by their need to gamble. There is significant comorbidity with tobacco use and alcohol abuse. Primary care physicians should consider asking about gambling habits in high-risk patients.     

A comparison of substance use between female inmates and female substance misusers in treatment

Recent literature documents extensive substance misuse histories among US female prison inmates. The primary purpose of the present study was to determine whether histories of personal and familial substance misuse distinguished female inmates from substance misusers in treatment. After accounting for drug-related offences, we hypothesized that the inmates would have more extensive histories of personal and familial substance misuse and that they would have initiated substance use at an earlier age. Contrary to our expectations, the two samples were similar on many measures of alcohol and drug use. Similarly, differences in family histories of substance misuse were not in the predicted direction. As hypothesized, however, the inmates did report earlier age at onset of drinking. Of particular clinical relevance was the finding that, despite similar alcohol consumption levels, inmates reported fewer alcohol-related adverse medical, legal, and psychosocial consequences than did the treatment sample.     

Preventing suicide in adolescents with alcohol use disorders

Adolescent suicide is an escalating crisis that needs to be addressed by clinicians and researchers. Alcohol use has consistently been implicated in adolescent suicide and it is generally assumed that alcohol use leads to an increased risk in suicidality, suicide attempts and completed suicides. It can lead to adolescent suicidality through alcohol myopia, disinhibition, and impaired judgment. Multiple genetically related intermediate phenotypes might contribute to the risk of alcohol misuse and suicidal behavior in adolescents. Genetic variations that enhance the risk for mood and anxiety symptoms or susceptibility to stress might increase risk through different mechanisms. Comorbid disorders such as depression are frequently exhibited in adolescents who misuse alcohol, therefore any adolescent who appears to be at risk for alcoholism or depression should always be screened for all other psychiatric disorders and for suicidality; some signs suicidal adolescents may exhibit include withdrawal, personality change, and a loss of interest in pleasurable activities. While assessment is important, prevention is crucial in any attempt to decrease the incidence of adolescent suicide. The US Center for Disease Control and Prevention (CDC) has established a set of seven guidelines that can be implemented from kindergarten through high school in order to establish alcohol prevention efforts in schools. Through beginning prevention efforts at a young age, it is hopeful that both alcohol misuse and adolescent suicide can be reduced.     

The social context of gender-based violence,alcohol use and HIV risk among women involved in high-risk sexual behaviour and their intimate partners in Kampala,Uganda

This paper explores the interaction between gender-based violence and alcohol use and their links to vulnerability to HIV-infection in a population of women and their regular male partners in Kampala, Uganda. Data derive from 20 life history interviews (10 women and 10 men). Participants were drawn from a cohort of women at high risk of sexually transmitted infection (including HIV). Six of the women were current or former sex workers. Findings reveal that life histories are characterised by recurrent patterns of gender inequity related to violence, limited livelihood options and socioeconomic disadvantage. Overall, findings suggest women are able to negotiate safer sex and protect themselves better against abuse and violence from clients than from their intimate partners, although the status of men as ‘client’ or ‘partner’ is transitory and fluid. Among male respondents, alcohol led to intimate partner violence and high levels of sexual-risk taking, such as engagement with sex workers and reduced condom use. However, male partners are a heterogeneous group, with distinct and contrasting attitudes towards alcohol, condom use and violence. Actions to address gender-based violence need to be multi-pronged in order to respond to different needs and circumstances, of both women and men.