Sexual Risk Behaviors Among People With Schizophrenia

Sexual Risk Behaviors Among People With Schizophrenia and Their Association With Psychiatric and Situational Factors

Most studies of sexual risk behavior among people with psychiatric disorders have not linked behaviors to biological outcomes, but risk for HIV transmission is potentially very high; the role of sexual transmission in HCV infection is weak and poorly understood even in the general population.

Sexual risk behaviors among people in psychiatric treatment are common, with interview studies in Brazil, Canada, Spain, and the United States revealing that a majority of patients were sexually active with a partner in the past year (Acuda and Sebit 1996; Carey et al. 1997; Chuang and Atkinson 1996; Oliveira 1997). Moreover, reports of multiple sex partners are common among sexually active psychiatric patients (Chuang and Atkinson 1996). The sexual activity of people with serious mental illness also is characterized by a lack of condom use in a majority of sexual occasions, a finding true for both men and women (Carey et al. 1997; Cournos et al. 1993; Hanson et al. 1992).

Few studies have differentiated risks by psychiatric diagnosis, so critical information is lacking about patients with schizophrenia-spectrum illnesses; however, data on diagnostic and symptom contributions to sexual risk behavior are beginning to appear. Being sexually active has been found to be associated with a diagnosis of schizophrenia but not with bipolar disorder. Trading sex for money or drugs was more than three times as likely among patients with schizophrenia than among those with other diagnoses, and more than five times as likely among those with certain positive symptoms such as delusions (McKinnon et al. 1996).

Situational factors also appear to contribute to sexual risk taking. Extended periods of institutionalization in same-sex units in hospitals, shelters, or prisons may foster high-risk same-sex activity, often among those who do not identify themselves as gay or lesbian. This behavior is particularly risky for men. One study that directly compared psychiatric patients with nonpsychiatric groups found that psychiatric patients are more likely to engage in same-sex activity (McDermott et al. 1994).

The best predictor of condom use is having a condom. Institutional obstacles to condom acquisition are another factor likely to impede patients’ initiative and ability to practice safer sex. Making condoms anonymously available to all patients, including inpatients with off-ward privileges or who engage in consensual sex on the ward, has been shown to be a costeffective primary prevention intervention (Carmen and Brady 1990). Sexual victimization, in which there is increased likelihood of unprotected intercourse (Herbert 1995), also has been widely reported by psychiatric inpatients (Goodman and Fallot 1998). Among outpatients, one in eight reported having been pressured, coerced, or forced into unwanted sex in the past year (Carey et al. 1997). Identification of patients in abusive relationships will facilitate their engagement in individual and group interventions to help them practice assertive behaviors and negotiating skills to increase self-protective behaviors, including condom use.

Recurrent institutionalization, homelessness, transient living circumstances, alienation from supportive social relationships, and lack of privacy can all interrupt long-term relationships, reinforcing the tendency to have unfamiliar partners. Studies report that 10% to 16% of psychiatric patients had sex in the past year with someone they had known less than 24 hours (Chuang and Atkinson 1996; Kalichman et al. 1994; Kelly et al. 1992). These conditions also may make changing risk behaviors difficult for people with serious mental illness or may limit sexual opportunities to those that confer greater risk. Unemployment also may contribute to greater sexual risk taking (Acuda and Sebit 1996), possibly through pressures toward engaging in survival sex or commercial sex work. Having a sexually transmitted disease (STD) also renders a person biologically more vulnerable to acquiring subsequent infections when exposed.

Between 9% and 36% of psychiatric inpatients and outpatients are diagnosed with one or more STDs at some time in their lives (Carey et al. 1997; Rosenberg et al. 2001). Moreover, a patient may have an STD without being aware of it, and will likely remain untreated unless screening for STDs is included with other prevention efforts aimed at risk behaviors for sexually transmitted infections.

Milton L. Wainberg, M.D.
Francine Cournos, M.D.
Karen McKinnon, M.A.
Alan Berkman, M.D.


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