Risky sexual behavior and associated factors among patients with bipolar disorders in Ethiopia

Risky sexual behavior (RSB) is commonly defined as behavior that increases the risk of contracting sexually transmitted infections and experiencing unintended pregnancies [1]. They include having sex at an early age, having multiple sexual partners, having sex while under the influence of alcohol or drugs, and unprotected sexual behaviors [2]. Usually RSBs are considered as a sexual behavior that increases the chance of negative social impact. These impacts include family conflicts, damage to relationships, legal disputes and even financial problems. Overall definition of RSB is in close relation with dynamic transmission of sexually transmitted infections (STI) due to unsafe sex [3‐5].

Being the sixth leading disability in the world, bipolar disorder (BD) is a severe mood disorder characterized by cyclical shifts in mood, alternating between mania and depression [6]. One of the defining symptoms of mania is the tendency to engage in pleasurable activities without regard to potentially dangerous consequences [7]. The constellation of manic symptoms, including euphoria, grandiosity, hyper sexuality, impulsivity, and poor judgment often results in risky behaviors. Because of symptoms like hyper sexuality and impulsivity people with bipolar disorder are highly engaged in RSBs [8, 9]. A comparative study conducted in United States of America (USA) demonstrated that patients with mood disorder reported more frequent sexual intercourse, higher frequencies of unprotected sex, a higher history of sexually transmitted diseases and more sexual partners [10]. A large cross-sectional study conducted in Brazil reported that over 90% of bipolar patients reported life time unprotected sex, 30% had exchanged money for sex, and 26.8% had more than 10 sexual partners [11]. Another study from Nigeria reported that (45.7%) of the adolescents with BD had positive history of risky behavior [12]. Local available data revealed that, high prevalence of RSB have been documented in high school, college students and street people in Ethiopia [13‐16]. However, there are no figures for prevalence of RSB among bipolar patients in Ethiopia.

Some factors have been implicated with RSB of such as, being single, low economic status, low educational back ground, unemployment, HIV infection and life time history of homelessness were associated with high rate of RSB [11, 17‐19]. In addition early onset of illness and previous history of hospitalization were significantly associated with risky sexual behavior among bipolar patients [12]. Behavioral factors such as alcohol consumption and cigarette smoking are commonly reported risk factor due in part to disinhibition, increased libido and impairing judgment [11, 20, 21]. Estimation of RSBs on bipolar patients would help to develop risk reduction strategy for those individuals who are suffering from the problem. Therefore, this study is aimed at assessing prevalence and factors associated with RSB among patients diagnosed with bipolar disorders.

Among the total participants 297 (70.0%) were recently sexually active or had sex in previous 12 months. According to a score of sexual risk indicators the overall prevalence of risky sexual behavior was 49.5, 95%CI (43.8, 55.6). This finding is higher than studies conducted in Argentina (23.9%) [22], New Zealand (16.4%) [23] and USA (26.6%) [24]. The variation could be due to differences in study design, sample size and study population in which a study in Argentina used a comparative study design involving only 60 women’s with bipolar disorder who were in a stable relationship while majority of the participants in our study were males and singles in relationship which may in turn increased RSB. Whereas, the study conducted in New Zealand included only a specific age of patients and the assessment on sexual behaviors was presented using computer with an interviewer present who could not see the subjects’ response. On the other hand, the USA finding had used a comparative study including 32 bipolar patients all subjects were literate and married. In contrary, the current finding is lower as compared with another study done in USA [25] and a study conducted in Brazil [26]. The possible reasons for this variation could be due to the fact that the USA study included higher portion of schizophrenic patients and illicit drug users in addition to bipolar patients. The inclusion of schizophrenic patients and illicit drug users in that study could increase the magnitude of RSBs because of continuous nature of schizophrenia and higher effect of illicit drugs on impairing judgment [27]. However the current finding is in line with two studies conducted in Nigeria (17) (18) and with another study done in USA [28].

In this study the odds of engaging in RSB is 2.2 times higher among males than females. Similar studies indicated that males were more likely to be involved in RSBs than females [11‐13, 18]. According to the current finding the possible reasons could be substance use such as alcohol and Khat that were more commonly used among males than females. The current study found that likelihood of having RSB was higher among patients between age ranges of 18–24 than other age groups. This finding is consistent with previous study [29]. This could be explained that psychiatric disorders and RSBs both peak in young adulthood as indicated in other study findings [30, 31]. Furthermore, low self-esteem and high internal stigmatization in younger adults with mental illness may result in a failure to provide healthier romantic relationship and associated with failure to advocate for safer sex [32]. The current study also revealed that, patients who were on recent manic phase of the disorder were more likely to be engaged in RSBs as compared to those in depressive state. Previous studies also supported this finding [11, 12]. During manic episode of bipolar disorder, patients exhibit high sexual desire and frequency to engage into sexual activities which might make them more prone to exhibiting sexual risk behavior and its negative consequences. Unlike this, bipolar patients in depressive state reported loss of interest in sex [33]. Our study also indicated that substance use related problems particularly, alcohol consumption was found to increase the risk of having RSBs than those who are currently using alcohol. Many studies claim that alcohol has a disinhibiting effect and power to influence an individual’s decision making. This could lead individuals to pass wrong and unbalanced decision including entering oneself in RSBs without weighing any damage following the behavior [10, 17, 34].

In general, the present study reported the burden of RSBs and associating factors among bipolar disorder patients. However, the cross sectional nature of this study cannot allow for making cause and effect relationship between RSBs and patients characteristics. In addition, sensitive nature of sexual behaviors on face to face interview could have a social desirability bias. Moreover, this study is institution-based study. Therefore, the findings cannot be generalized to those who remain undiagnosed or untreated in the community.

High prevalence of risky sexual behavior was identified among people with bipolar disorder at AMHH. Current manic episode and the consumption of alcohol were found to aggravate the risky sexual behavior. To reduce the burden of risky sexual behaviors, mental health services which focus on sexual behaviors of bipolar patients is required. Screening and intervening of risk reduction strategies for those highly vulnerable group of people should be designed. In addition, the causal mechanisms and effect between risky sexual behavior and bipolar disorder should be examined.