Prevalence o f Attention deficit hyperactivity disorder and its associated factors among Women
in sex work(WSW) attending a special clinic in a tertiary hospital
Kasthuri Pandiyan MD,DPM, (Carried out the actual research work)
Shankar Kumar MD*, (Planning the research, making the protocol and preparing manuscript)
Chandrashekar Hongally MD. ( Help in conducting the study)
Dept of Psychiatry, Bangalore Medical College and Research institute, Bangalore.
*Address for correspondence:- Dr.Shankar Kumar, Dept of Psychiatry, Victoria hospital,
Bangalore Medical college and research institute, Fort, Bangalore 560002, India.
Conflict of interest:- None
Abstract:Background and objective- There is a paucity of data on the prevalence of Attention deficit
hyperactivity disorder(ADHD) among women with risky sexual behavior. This study was
undertaken to describe the prevalence and presence of psychiatric comorbidity among young
women in sex work(WSW) attending a special clinic in a tertiary care psychiatry set-up.
Methods- 50 consenting participants in the age goup of 18-30years were recruited and were
administered a sociodemographic questionnaire with details of risky sexual behaviors, Adult
ADHD self report scale(ASRS) and Wender Utah rating scale(WURS) to assess for ADHD, HIV
risk tak ing behavior scale (HRBS) for risky sexual behavior, MINI neuropsychiatric interview for
psychiatric comorbidities, the Beck s depression inventory(BDI 2) for severity of depression if
present.
Results- 34% of the study population(n=17) had ADHD when a cut off of 14 on ASRS and 46 on
WURS was taken.Those with ADHD were significantly younger(p-0.005), had lesser years of
schooling(p-0.001), were less employed(p-0.004) and had lesser income(p-0.013) than those
without ADHD. Those with ADHD had significantly less consistent condom use(p-0.03), more
sex partners(p-0.01), more injection drug use before sex(p-0.03). Overall, there was high
prevalence of substance use, depression in the sample, though there was no statistical significance
between the groups. Those with ADHD had higher odds of having risky sexual behavior(Odds
Ratio-1.20) which was statistically significant.
Conclusion- ADHD is highly prevalent in female sex workers and high risk sexual behavior may
be predicted by ADHD symptoms and co morbid substance use may further increase the risk.
Prevention strategies for STI s should also assess ADHD in this high risk group and research
targeting interventions in this group is also warranted.
Key words- Attention Deficit Disorder with Hyperactivity, Female, Sex Workers, Risk-Taking,
Sexual Behavior.
Introduction:Attention deficit hyperactivity disorder (ADHD) affects a significant proportion of adults unlike
previous thinking that it is exclusively a childhood disorder. l%-6°/o of adults meet DSM-IV
threshold for a diagnosis of adult ADHD.(l). Those affected in childhood or in adults are at increased risk of a number of adverse outcomes, including unemployment, low income(2), poor
academic performance(3), and strained family and peer relationships(4).
Another association with ADHD is poor sexual health. Limited data is available describing the
relationship between ADHD and sexual health in adults, as the majority of research has focused on
young children's behaviors or outcomes. Longitudinal studies have reported that childhood ADHD
is associated with high risk sexual behaviors such as casual sex, infrequent condom use, and
multiple sex partners in adulthood(5). Studies have also indicated that ADHD is linked with early
initiation of sexual activity or failure to use condoms(6).
Most ADHD studies have focused on male participants, with very scanty literature of
ADHD-related outcomes among females. Persistent impulsivity with added risk factors like poor
maternal attachment, conduct disorder(CD) may be associated with high risk sexual behavior
among young women as described in a recent study(7).
This cross-sectional study is sought to find the prevalence of ADHD and associated factors such as
presence of psychiatric comorbidity among women in sex work(WSW) in Bangalore city.
Methodology:Study sampleParticipants were recruited from a special clinic catering to mental health needs of WSW in
Department of Psychiatry, Victoria hospital. Patients to this clinic are brought by counselors from
v o l u n t a r y agencies w h i c h d e a l w i t h preventing HIV/AIDS & STIs among WSW and to
improve their overall quality of life (n=50). All the participants were asked to register their
understanding and consent to participate in the study by oral consent signed in the form by an
impartial witness. The approval for the study was taken from the Institutional ethical
committee(IEC).
50 consenting participants took part in the study. We hypothesized that ADHD may be associated
with early onset risky sexual behavior. Thus, we included only those in the age group of 18- 30yrs
for the study.
Interviews were conducted at Victoria hospital Bangalore. The interview was conducted by the
principal investigator in a place which ensured visual and auditory privacy.
A semi-structured interview was used to elicit the following details- Socio demographic data: Age,
residence, marital status, educational status, employment status, income, number of living
children.
1. Adult ADHD Self Report Scale (ASRS) was used to screen for ADHD symptoms. The
ASRS was developed by the World Health Organization and the short form of the screener
consists of a checklist of six questions regarding symptoms of ADHD based on the
diagnostic criteria of DSM-IV-TR . Each item requires respondents to rate on a five-point
response scale from "never" [0] to "very often" [4] how frequently a particular symptom of
ADHD occurred over the past six months(8). A cut-off of 14 for the first 6 items of the
screener was used as described by Kessler,2007(9). In addition, as described by Kessler,
subjects who scored a total of 9 or more of the shaded boxes of the whole scale were only
considered as having symptoms of ADHD.
2. Wender Utah rating scale(WURS) was used to assess presence of childhood ADHD
symptoms. A diagnosis of ADHD was made if an individual scored over a cut-off of 24 on
the ASRS with a WURS score of 46 or above indicating presence of ADHD symptoms in
childhood in those individuals who scored above the cut-off on ASRS (10).
3. HIV risk behavior scale(HRBS) was used to screen for high risk sexual behavior(11).
4. MINI neuropsychiatric interview was used to screen for presence of psychiatric co
morbidities(12).
5. Beck's Depression inventory 2(self rated) was used to assess the severity of depression when
present(13).
6. HIV and treatment status, if infected were also noted.
Results:Table 1- Socio-Demographic characteristics of the sample:-
l.Age (yrs)
2.Years of schooling (yrs)
3.Marital status (Number married)
4.Having regular employment
(Number)
5.Income (Rupees in thousand)
ADHD (n=17)
23.5±4.5
04.5±2.25
06.0(35.2%)
11.0(64.7%)
05.5± 2.5
No ADHD(n=33)
26.50±2.75
08.25±2.75
25.00(75.7%)
26.00(78.7%)
08.75±2.75
P value
0.005*
0.001*
0.004*
0.321
0.013*
Note- 1)1,2,5(unpaired t-test) are expressed as mean ± standard deviation.
2) 3,4 (Fisher's exact test) are expressed as numbers and percentage.
3) * indicates statistical significance (p<0.05).
4) Those with ADHD had significantly lesser age, had lesser years of schooling, were less
employed and had lesser income than those without ADHD.
Table 2-
High risk sexual behaviours of the sample:ADHD n=17(%)
1.Consistent condom use
No ADHD n=33(%) P value
05 (29.4)
21(63.7)
0.03*
2.More than 5 partners
10 (58.8)
07(21.2)
0.01*
3.Group sex
06 (35.3)
08(24.2)
0.51
4.Injection drug use before sex
07 (41.2)
04(12.1)
0.03*
5.Alcohol use before sex
14 (82.3)
25(75.7)
0.72
Note- 1)* indicates statistical significance (p<0.05).
2) Those with ADHD had significantly less consistent condom use, more sex partners, more
injection drug use before sex (Fisher s exact test).
Table 3- Mean scores of ADHD, Depression and Risky sexual behavior:Mean
SD
ADHD score(ASRS)
17.86
3.20
Depression(BDI)
16.63
6.39
4.76
2.63
Risky sexual behavior(HRBS)
Note- The mean of those with depression falls in the “Mild Depression” range as per the score on
Beck’s Depression inventory(BDI) scores.
Table 4- Psychiatric and medical comorbidities in the sample:ADHD (n=17,%) No ADHD(n=33,%) P value
1.Substance use disorder(SUD)
15(88.2)
25(75.7)
8(24.2)
0.46
2.Depression
6(35.3)
3.Adjustment disorder
3(17.7)
4.Anxiety disorder
2(11.8)
9(27.2)
0.29
5.HIV
3(17.7)
0(0.0)
--
6.Other STI s
8(47.0)
16(48.5)
1.00
15(45.4)
0.51
0.06
Note- A majority of the sample had SUD(80%) and depression(28%), adjustment disorder(36%),
anxiety disorder(22%), STI other than HIV(48%). However, there was no statistically significant
difference between the groups. However, only those with ADHD had comorbid HIV
Table 5- Predicting odd s of risky sexual behavior of the sample using ADHD scores,
Depression score and status of substance use:-
Variable
Standard
error
0.06
Odd s ratio
95% CI
P value
ADHD score
Co
efficient
0.189
1.20
1.0578 -1.3813
0.005*
Depression score
-0.028
0.09
0.97
0.8198 -1.1529
0.742
1.348
1.35
3.82
0.2682 -54.598
0.321
Substance use
Overall Model Fit...
Chi Square= 17.2487; df=3; p= 0.0017
Note- Predictor variable= presence of risky sexual behavior.
Dependent variables=ADHD scores, depression scores, presence of substance use.
Overall model fit is statistically significant. Those with ADHD had higher odds of having risky
sexual behavior which was statistically significant but not depression score or presence of
substance use.
Discussion:1. Sociodemographic variables- (refer Table 1)Those with ADHD were younger, had lesser
years of schooling, less likely to be married with lower income.ADHD is associated with
younger age of onset of risky sexual behavior(14) which is replicated in the study.
Studies have shown that those with ADHD consistently have lower academic grades, tend
to leave school at an early age due to inattention or low self esteem. They also have less
income due to multiple factors such as absenteeism, dismissals from work and multiple re
employments as a result of the symptoms of the disorder(15).
2. High risk sexual behaviors- (refer Table 2)Those with ADHD had less consistent condom
use, higher number of partners and substance use before indulging in sexual activity. This
is in concordance with previous literature(16). The core symptoms of the disorder along
with executive impairments such as deficient behavioral inhibition(17) could contribute to
higher risky behaviors in adults with ADHD.
3. Psychiatric and medical comorbidities- (refer Table 4) A majority of the sample had
Substance Use Disorders(SUD)(80%) with depression(28%), adjustment disorder(36%),
anxiety disorder(22%) respectively. Comorbidity with depression, substance use
disorders, anxiety disorders are commonly described with ADHD (18). Among medical
comorbidities, STI s other than HIV(48%) were there in a majority of the study sample.
However, only those with ADHD had comorbid HIV. ADHD has had significant
association with HIV in male subjects in a preliminary study by the same authors(19). The
low sample size could explain absence of significance of these comorbidities between both
the groups as we had postulated that depression and substance use would be more in those
with ADHD which could probably predispose them to higher risky sexual behavior.
4. When a multiple logistic regression was performed with high risk sexual behavior as the
dependent variable and ADHD scores, presence of substance use, and depression as
predictor variables, the overall model fit was statistically significant (p=0.0017) (refer
Table 5). However, ADHD symptoms (after controlling for SUD and Depression) was a
significant predictor of risky sexual behavior in this sample. This is in line with findings
from Monawar Hosain's study of ADHD symptoms and risky sexual behavior in young
adult women(20).
Limitations1. Low sample size
2. Cross- sectional study design.
3. The study sample was brought by counselors which could indicate that those taken up for
the study already were having some psychiatric morbidity( not a indicator of a community
sample)
4. Assessment of severity of substance use and personality factors was not done.
Conclusion and future directions:ADHD is prevalent in female sex workers and risky sexual behavior is predicted by ADHD
symptoms with co morbid substance use increasing the risk.
Prevention strategies for STI s should also assess ADHD in this high risk group and research
targeting interventions in this group is also warranted.
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