Data collection and procedure
Data collection was performed between July and October 2021 by means of an online survey. Before participation, all individuals were informed that the current study aimed at assessing different sexual behaviors and at comparing these sexual behaviors between individuals with and without an ADHD diagnosis. Furthermore, participants were informed that all information were collected anonymously, that participation was entirely voluntary, that they had to be at least 18 years of age to be allowed to participate, and that they could stop participating by simply closing the window of their internet browser. Before participants could start answering the survey questions, they had to hit a button at the end of the study information stating that they had read and understood the study information and that they were willing to voluntarily participate in the present study.
The online survey included the German versions of internationally established questionnaires, such as the Self-Report Wender-Reimherr Adult Attention Deficit Disorder Scale (SRWRAADDS) (29, 30), the Sexual Risk Survey (SRS) (31), the Hypersexual Behavior Inventory (HBI-19) (32, 33), the Sexual Behavior Questionnaire (34), and the Questionnaire on Sexual Experiences and Behaviour (Q-SEB) (35). However, for the present study, only the SR-WRAADDS, the HBI-19 and the Q-SEB were analyzed. Furthermore, demographic and clinical data were assessed.
Individuals with ADHD were mainly recruited via the ADHD outpatient care center of the Department of Psychiatry and Psychotherapy of the University Medical Center Mainz. At the ADHD outpatient care center, individuals are diagnosed with ADHD after an extensive diagnostic process consisting of questionnaires, a clinical interview and neuropsychological testing. At the end of the diagnostic process, individuals were asked whether they were willing to participate in this study and received the link to the online survey via email. Non-ADHD participants were recruited online by displaying the study call on different social media platforms and by spreading the study call through different mailing lists.
Sample
In total, N = 344 individuals started answering the online survey. However, we excluded all individuals who did not complete the whole questionnaire because it had to be assumed that these individuals had withdrawn their consent. The drop-out rate did not differ significantly between the ADHD group and the healthy control group (χ2 = 2.34; p = .13). ADHD participants who were excluded did not score significantly higher on the SR-WRAADDS than ADHD participants who completed the whole questionnaire. Thus, it is unlikely that non-completion of the study varied systematically depending on ADHD symptom severity. Thus, our final sample consisted of n = 234 participants of whom n = 160 individuals were diagnosed with ADHD (102 women, 51 men, 4 diverse, 3 missing) and n = 75 individuals who were not previously diagnosed with ADHD (48 women, 23 men, 3 diverse, 1 missing). As the sample size of individuals who assigned themselves to the gender “diverse” was too small, it was not possible to use their data in the gender-specific analyses.
The ADHD group was on average M = 37.6 years old (SD = 10.6, range 18–63), while the non-ADHD group was on average M = 34.0 years old (SD = 11.27, range 18–65). The ADHD group was significantly older than the non-ADHD group (T = 2.230; p = .027). Distribution of gender (χ2 = .417; p = .81) did not differ significantly between the ADHD and non-ADHD participants. The ADHD group had a significantly higher SR-WRAADDS sum score than the non-ADHD group (ADHD: M = 205.45, SD = 30.94; HCs: M = 149.82, SD = 52.32; T = 8.05 p > .001) and significantly higher scores on all subscales (for more details see Gregório Hertz et al. (16)) indicating, as expected, clearly more intense ADHD symptomatology in the ADHD group.
Measures
Self-Report Wender-Reimherr Adult Attention Deficit Disorder Scale (SR-WRAADDS) (29, 30)
The SR-WRAADDS consists of 53 questions that assess ADHD symptomatology on ten subscales: attention difficulties, hyperactivity/restlessness, temper, affective lability, emotional over reactivity, disorganization, impulsivity, oppositional symptoms, academic problems, and social attitudes. All items have to be answered on a five-point Likert scale ranging from 1 “does not apply at all to me” to 5 “applies very well to me”. Higher scores on each subscale represent stronger ADHD symptomatology. The German version has yielded good to excellent psychometric properties with a Cronbach’s alpha of .95 for the total score and Cronbach’s alphas ranging from .70 to .87 for the subscales.
Hypersexual Behavior Inventory (HBI-19) (32, 33)
The HBI-19 is a self-report measure of hypersexual behaviors consisting of 19 items grouped to three subscales: a.) attempting to control sexual thought, feelings, and behaviors, b.) attempting to cope with unwanted emotions and life stressors, and c.) experiencing undesirable consequences related to problematic sexual behaviors. All items have to be answered on a five-point Likert scale ranging from 1 “never” to 5 “very often”. Higher scores represent more symptomatology and scores equal or above 53 can be considered as clinically relevant levels of hypersexuality. The German version has yielded good to excellent psychometric properties with a Cronbach’s alpha of .90 for the total score and Cronbach’s alphas ranging from .78 to .86 for the subscales.
Questionnaire on Sexual Experiences and Behaviour (Q-SEB) (35)
Altogether, the Q-SEB consists of 120 items assessing information about sexual socialization, sexual behaviors and different sexual practices including paraphilic fantasies and behaviors. For the purpose of the present study, only items concerning paraphilic fantasies and behaviors were analyzed. All items refer to an observational period of the last 12 months and all items can be answered on a five-point Likert scale ranging from 1 “not at all” to 5 “very” sexually arousing. The following paraphilias can be assessed with the questionnaire: voyeurism, transvestic fetishism, fetishism, sexual masochism, sexual sadism, exhibitionism, frotteurism, and pedophilia. The questionnaire is only available in German and has not been validated yet. However, it has been previously used in different studies (35).
Statistical Analyses
We calculated the prevalence of each paraphilic interest as a function of masturbation fantasies and sexual behaviors for both the ADHD- and the non-ADHD group separated by gender. Thereby, all participants who answered that they would rate a specific paraphilic interest as at least little sexually arousing (item score of 2) during their masturbation fantasies or sexual behaviors were considered as having this specific paraphilic interest. In order to analyze the prevalence of practically relevant paraphilic interests in masturbation fantasies and sexual behaviors, we analyzed the prevalence of each paraphilic interest by only considering those participants who answered that they viewed a specific paraphilic interest as quite sexually arousing (item score of 4) or as very sexually arousing (item score of 5). Differences in the prevalence were calculated between the groups for both female and male gender separately using chi-square tests.
Furthermore, we analyzed the relationship between the number of paraphilic interests in masturbation fantasies and sexual behavior and hypersexuality by means of spearman correlations in both the ADHD and the non-ADHD group. Additionally, the prevalence of practically relevant paraphilic masturbation fantasies and sexual behaviors was calculated in the ADHD-group under consideration of hypersexuality, whereby differences between hypersexual and non-hypersexual ADHD participants were examined using chi-square tests. Finally, we calculated a binary logistic regression with presence of any paraphilic sexual fantasy or behavior as outcome criterion and the HBI-19 sum score, the SR-WRAADDS sum score as well as all subscale scores as predictors.
The statistical significance value was set on a threshold of p < .05 for all the statistical analyses. All statistical analyses were performed using SPSS 26 (IBM).