Predictors of Sexual Addiction among Medical Undergraduates during the COVID-19 Pandemic: A Cross-sectional Survey

INTRODUCTION

The adverse psychological impact of the COVID-19 pandemic is widely documented. Medical students have been identified as a group at risk for mental health problems with higher rates of depression, suicidal tendencies, substance abuse etc. coupled with less likelihood of care seeking. The situation has only been worsened by the pandemic as suggested by studies of psychological effects among medical students in various countries including India.¹

Behavioral addictions during the pandemic were found to be prevalent in around 11.1% irrespective of type of addiction as per a meta-analysis. Internet use was a predictor of many of the behavioral addictions studied especially sexual addiction.²

Studies of data from Google Trends revealed relative search volumes of “pornography” increased with declaration of COVID-19 as a pandemic by the WHO. It was seen to be associated with increasing daily cases and increasing awareness about social distancing.³

Behavioral addictions, especially internet addiction, are common among medical students given the ubiquity of the use of smartphone devices and dependence on internet for learning, especially in the setting of the pandemic. Those with trait neuroticism may be especially vulnerable.⁴

Neuroticism traits present with negative emotionality in situations of threat, frustration, loss associated with maladaptive coping strategies, such as substance misuse, excess internet use, etc. leading to addictive behavior. Considering the stressful situation created by the pandemic, vulnerable individuals are at risk of these addiction.^5,6

Considering the common vulnerabilities exist for various addictions, sexual addictions can also be expected to be more in these individuals, in these times. As there is a dearth of literature exploring the links between sexual addiction, internet addiction, substance use, perceived support, loneliness, family functioning and fear of COVID-19, the current study was undertaken.

MATERIALS AND METHODS

Following approval from the Institutional ethics committee, this cross-sectional analytical study was carried out among MBBS students in a medical college in Karnataka. Data were collected via Google forms after getting an informed consent and giving assurance of confidentiality. Contact information was provided in the Google Form to facilitate help seeking for problem behaviors. Convenience sampling was done with subjects being recruited using the snowball technique.

Apart from demographic data and data regarding pattern of internet use various self-rated questionnaires were included. To assess sexual addiction, the sexual addiction screening test (SAST-R) was used which is a reliable and valid scale developed by Dr Patrick Carnes. It comprises “yes/no” questions to identify compulsive sexual behaviors and a score of 6 or more on the core item scale (items 1–20) may indicate sexual addiction.⁷

The Young’s internet addiction consists of 20 items measured on a 5-point Likert scale (1-rarely to 5- always) with a cut off score of 80 suggesting problematic internet usage. Numerous studies have tested its validity and reliability. Additionally, its reliability among Indian college students has been established.⁸

WHO ASSIST was found to be valid tool for screening for substance use disorders in a multisite international study that included Indian subjects. It screens subjects for various illicit substances and grades the risk of the use from low to high and recommends the need for brief intervention or intensive treatment accordingly.⁹

The 21-item Depression, Anxiety, Stress scale (DASS 21) is a widely used tool to screen for psychological distress and has been validated in adult Indian population.¹⁰

The multidimensional scale of perceived social support (MSPSS) is a 12-item scale scored on a 7-point Likert scale (1-very strongly disagree to 7-very strongly agree) which divided in to factor groups based on source of social support namely friends, family and significant other. It has been validated in an Indian setting.¹¹

The McMaster Family Functioning Device-General Functioning Subscale (FAD-GF) is a 12-item scale with 6 items each representing healthy and unhealthy family functioning. It has been found to have good internal consistency and has been validated in South-East Asian population.¹²

The UCLA Loneliness scale is a 20-item scale with 9 positively worded and 11 negatively worded items which has been validated in an Indian context.¹³

The positive and negative affect schedule (PANAS) is a 20-item scale with 10 items each for Positive and Negative emotional states that are graded on a 5-point Likert scale (1: very slightly to 5: extremely). It is validated for Indian population.¹⁴

The fear of COVID-19 scale is a 7-item scale graded on a 5-point Likert scale (1: strongly disagree to 5: strongly agree). It has been validated in an Indian context among college students.¹⁵

The data were statistically analyzed using SPSS and Chi-square test to analyze qualitative variables, and one-way ANOVA to analyze the quantitative variables. All statistical correlations were considered significant if the value of p < 0.05. Association of the various variables with sexual addiction was tested using Chi- square test and independent sample t-test. Multiple stepwise linear regression was done to identify risk factors that predicted sexual addiction in our population.

RESULTS

A total of 106 participants answered the survey who were included in the statistical analysis. It comprised of 51.9% male respondents and had a mean age of 21.6 (±1.74) years. Most were interns (26.4%) followed by third (24.5%) and fourth year (20.8%) students. Around 55% had been using the internet for 6–10 years with 25% having used it for longer. Close to 20% of the sample screened positive for sexual addiction and around 38% for internet addiction. Alcohol and tobacco were the two most common substances that was used in our study sample with moderate to high-risk use being present in 15% and 13% respectively (Table 1).

On Chi-square test significant association of sexual addiction was found with internet addiction, alcohol use and stress (Table 2).

Association was further measured between sexual addiction and various psychological parameters using the independent sample t-test. Internet addiction, low perceived social support from friends and family, alcohol use, depression and stress were found to have significant association with sexual addiction. Fear of COVID-19 was not found to be associated (Table 3).

A stepwise multiple linear regression analysis was performed and a model predicting risk of sexual addiction was formulated. Alcohol use, low perceived social support from friends and time management and performance domain of internet addiction test (IAT) were found to be risk factors (Table 4).

DISCUSSION

Our study aimed at assessing risk factors that may be associated sexual addiction among medical undergraduates. We found nearly one in five participants screened positive for sexual addiction. There was significant co-occurrence of internet addiction and substance abuse (mainly alcohol and tobacco) in these individuals. Among the various parameters considered problematic alcohol use, low perceived support from friends and time management and performance domain of IAT predicted risk of screening positive for sexual addiction. Fear of COVID-19 was not found to be associated with positive screen for sexual addiction.

Nearly, two-thirds of our study participants screened positive for moderate-to-severe depression (50% male) and anxiety (49% male) and about one-third had similar levels of stress (51% male). Of the study subjects 58.4% met the cut off scores for problematic family screener with nearly equal proportion of males and females. Nearly, 10% of individuals in our study experienced low perceived social support from friends (85% male), family (77% male) or significant others (50% male).

Prevalence of sexual addiction in our study of 19.8% (90.5% male) was comparable to the prevalence of 23.4% (93.8% male) among medical students in Telangana.¹⁶ Kadavala et al. in their multicenter study in medical undergraduates of Gujrat (n = 1,926) found a slightly lower prevalence of problematic pornography use of 14.6% which could be due to the choice of screening instrument and a larger sample size. Of those 93.6%, individuals were male which was comparable with our study.¹⁷ A meta-analysis on behavioral addictions among the general population during the pandemic reported a prevalence of 9.4% for sexual addiction after correcting for publication bias.² The higher prevalence encountered in our study may be due to the study population being medical students who as a group are more at risk for behavioral addictions.⁴

We hypothesized a possible increase in sexual addiction during the COVID-19 pandemic due to the negative affect that was commonly experienced. However, sexual addiction was not significantly associated with fear of COVID-19 in our study population. This is unlike the findings of studies reporting increased behavioral addictions in the pandemic. Servidio R et al. in their study conducted during the first national lockdown in Italy found fear of COVID-19 to mediate link between anxiety and internet addiction in a study among students.¹⁸ The discordance might be due to the study being conducted during the third wave. Habituation is known to occur to repeated exposure to the same stressor wherein there is reduction in the physiological response elicited.¹⁹ A similar effect may be at play with the study subjects becoming less afraid of COVID-19 infection and its consequences. This decrease of pandemic-related vigilance or stress has been termed as pandemic fatigue. A longitudinal study by Gassen J et al. examined this over three sessions, each 4 weeks apart, between July and November 2020. They reported a decrease in self-reported stress and negative affect across the study sessions with an increase in positive affect. There was also a decrease in various physiological markers (blood pressure, pulse, and temperature). This occurred while there was an increase in cases, hospitalizations and deaths both locally and globally.²⁰

Ballester-Arnal R et al. reported significant comorbid substance abuse/dependence (especially alcohol) and depression with sexual addiction.²¹ Ho RC et al. in their meta-analysis comprising of eight studies (1,641 patients) report similar association of comorbid alcohol abuse and depression with internet addiction.²² These findings are in concordance with our study where problematic alcohol use, moderate-to-severe depressive symptom scores and problematic internet use was associated a positive sexual addiction screen. With sexual addiction being associated with low perceived social support, and moderate-to-severe symptoms of depression and stress in our study, we find further evidence for negative affectivity underlying addictive behavior. Similar associations have been reported with internet addiction.^8,23

Behavioral addictions in particular are a means of coping with negative affect which can be a state or trait feature. A study during the pandemic found higher levels of neuroticism to be associated with lower mood overall among 484 students. The effect of the pandemic can thus be understood as a state-related worsening of negative affect experienced by vulnerable individuals.²⁴

Sexual addiction and internet addiction can be conceptualized as similar expressions of underlying vulnerabilities. In extension, we found substantial overlap in individuals screening positive for behavioral addictions and problematic alcohol use. Efrati Y et al. in a recent review article identified common vulnerabilities underlying addiction spectrum disorders, such as high neuroticism, novelty seeking and low conscientiousness, agreeableness, effortful control. This offers an explanation for our findings.²⁵

The strengths of our study lie in the variety of psychological factors that were considered to potentially contribute to sexual addiction. Studies including such a wide array of factors were not encountered in our literature review.

Our study however is not without limitations. Firstly, given that ours was an online survey, the findings are cross-sectional and therefore would not capture the inherent variability in such behaviors that are known to occur. Also, those with these problem behaviors may be hesitant to participate in such surveys likely rendering our sample to not be representative of the intended study population. Secondly, the snowball technique used to gather samples was not ideal and direct interaction with students might have motivated higher participation. Thirdly, the sample was relatively small and therefore the study might be underpowered limiting its generalizability. Lastly, the instruments used to assess psychological distress, behavioral or substance addictions were broad screening tools which unlike structured interviews might not accurately capture the frequency and severity of the parameters being assessed.

Further studies that are of larger scale, adequately powered and use structured interviews are needed to replicate these findings in order for them to be generalizable. These findings must pave way for interventions which keep these risk factors in sight so as to improve outcomes in the affected individuals.

ORCID

Pranjal Sharma https://orcid.org/0000-0002-3695-731X

Vallabh Shet https://orcid.org/0000-0002-4203-3623

Shankar Kumar https://orcid.org/0000-0002-8002-4576

Sharanya Kaushik https://orcid.org/0000-0002-3310-4792

Mohammed Shoyaib Khazi https://orcid.org/0000-0003-4682-0306

Yamasandhi Mallegowda Jeevan https://orcid.org/0009-0009-2277-4553

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