Sexual orientation of men with pathological gambling: Prevalence and psychiatric comorbidity in a treatment-seeking sample

Abstract

Although gay men represent a high-risk group for psychiatric illness and impairment, they are largely an understudied population. The purpose of the present study was to examine the sexual orientation and clinical correlates of men with pathological gambling (PG). Sexual orientation was assessed in 105 men presenting with PG. Gay and bisexual men with PG were compared with heterosexual men in terms of gambling symptoms, impairment, and co-occurring psychiatric disorders. Of 22 men (21.0%) with PG, 15 were gay (14.3%) and 7 were bisexual (6.7%). Gay and bisexual men vs heterosexual men were more likely to be single (81.8% vs 21.7%; chi(2)(2) = 28.2; P < .001), have a lifetime (81.8% vs 44.6%; chi(2)(1) = 9.7; P = .002) or current (68.2% vs 34.9%; chi(2)(1) = 7.9; P = .005) impulse control disorder, and have a lifetime substance use disorder (59.1% vs 31.3%; chi(2)(1) = 5.7; P < .05). Gay and bisexual men with PG also showed a trend toward greater impairment (P = .04). Psychiatric comorbidity and impairment are high in gay and bisexual men with PG. Research is needed to optimize patient care for gay and bisexual men with PG.

Full text

Sexual orientation of men with pathological gambling: prevalence
and psychiatric comorbidity in a treatment-seeking sample
Jon E. Grant
a,*
and Marc N. Potenza
b
a Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55454, USA
b Department of Psychiatry, Yale University Medical School, New Haven, CT 06519, USA
Abstract
Although gay men represent a high-risk group for psychiatric illness and impairment, they are largely
an understudied population. The purpose of the present study was to examine the sexual orientation
and clinical correlates of men with pathological gambling (PG). Sexual orientation was assessed in
105 men presenting with PG. Gay and bisexual men with PG were compared with heterosexual men
in terms of gambling symptoms, impairment, and co-occurring psychiatric disorders. Of 22 men
(21.0%) with PG, 15 were gay (14.3%) and 7 were bisexual (6.7%). Gay and bisexual men vs
heterosexual men were more likely to be single (81.8% vs 21.7%;
χ
2
2
= 28.2
; P < .001), have a lifetime
(81.8% vs 44.6%;
χ
1
2
= 9.7
; P = .002) or current (68.2% vs 34.9%;
χ
1
2
= 7.9
; P = .005) impulse control
disorder, and have a lifetime substance use disorder (59.1% vs 31.3%;
χ
1
2
= 5.7
; P < .05). Gay and
bisexual men with PG also showed a trend toward greater impairment (P = .04). Psychiatric
comorbidity and impairment are high in gay and bisexual men with PG. Research is needed to
optimize patient care for gay and bisexual men with PG.
1. Introduction
Although sexual orientation is a complex construct, the National Health and Social Life Survey
found that approximately 3% of men in a community sample identified as gay or bisexual
[1]. Gay and bisexual men experience high rates of depression, anxiety, and substance use
disorders [2–9]. In fact, some studies suggested that almost half of gay and bisexual men (42%–
49%) suffer from a psychiatric disorder [10]. In particular, gay and bisexual men appear to
suffer from substance use disorders at 2 to 3 times the rate found in the general population
[11,12]. Gay as compared with heterosexual men also report lower qualities of life [2,10].
Together, these findings suggest that gay men represent a high-risk group for various
psychiatric illnesses, particularly addictive disorders.
Pathological gambling (PG) is a relatively prevalent impulse control disorder more frequently
found in men [13]. Because of its phenomenological similarities to substance use disorders,
PG has been described as a behavioral addiction [14]. Pathologic gambling is associated with
functional impairment and high rates of psychiatric comorbidity [15–17]. Although past-year
adult prevalence rates for PG are estimated at 1%, PG has not been assessed in most
epidemiological studies on psychiatric disorders [18], including those investigating sexual
orientation [6].
This study had 3 purposes: (1) to examine the relationship of sexual orientation to psychiatric
disorders by examining the sexual orientation of men with PG; (2) to compare the rates of
* Corresponding author. Tel.: +1 612 273 9736; fax: +1 612 273 9779., E-mail address: grant045@umn.edu (J.E. Grant)..
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psychiatric disorders in gay and bisexual men with PG with those of heterosexual men with
PG; and (3) to examine how these 2 groups differ in terms of psychosocial functioning.
2. Methodology
2.1. Subjects
Participants were 105 consecutive male outpatients aged 18 years or older and who met
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for
PG. Participants were recruited by advertisements and referrals for a cognitive-behavioral
study, pharmacologic studies, or outpatient treatment. The institutional review boards of the
University of Minnesota and the Butler Hospital approved the studies and consent statements.
All participants provided written informed consent.
2.2. Assessments
All subjects met DSM-IV criteria for PG using the clinician-administered Structured Clinical
Interview for Pathologic Gambling, a valid and reliable diagnostic instrument [19]. Psychiatric
diagnoses for mood, anxiety, substance use, psychotic, somatoform, eating, and adjustment
disorders were assessed using the Structured Clinical Interview for DSM-IV (Table 1) [20].
Subjects were individually and privately interviewed by the first author regarding their same-
sex sexual relationships and sexual orientation. Specifically, subjects were asked about their
sexual behavior, attraction, and sexual identity. Subjects were classified as gay or bisexual
based on their sexual identity. In addition, subjects who identified as gay or bisexual were
asked if they currently lived with a partner. Information were elicited without the use of a
standardized assessment.
Impulse control disorders were examined using the Minnesota Impulsive Disorders Interview,
a reliable and valid semistructured clinical interview for trichotillomania, pyromania,
intermittent explosive disorder, kleptomania, compulsive buying, and compulsive sexual
behavior (Table 2) [21]. In a study on co-occurring impulse control disorders in psychiatric
inpatients, the Minnesota Impulsive Disorders Interview demonstrated the following
classification accuracy rates for each impulse control disorder based on subsequent structured
clinical interviews: compulsive buying, sensitivity of 100% and specificity of 96.2%;
kleptomania, sensitivity of 89.5% and specificity of 93.0%; PG, sensitivity of 100% and
specificity of 98.4%; intermittent explosive disorder, sensitivity of 100% and specificity of
97.4%; compulsive sexual behavior, sensitivity of 80.0% and specificity of 96.9%; pyromania,
sensitivity of 100% and specificity of 100%; and trichotillomania, sensitivity of 100% and
specificity of 98.5% [21].
The Sheehan Disability Scale (SDS), a 3-item reliable and valid self-report measure of
functioning at work, in social/leisure activities, and in home/family life, assessed functional
impairment [22]. The SDS total score ranges from 0 to 30, with higher scores reflecting greater
functional impairment.
2.3. Statistical analysis
Subjects grouped by sexual orientation (gay and bisexual vs heterosexual) were compared on
measures of sociodemographics; lifetime and current rates of impulse control disorder as well
as nonimpulse control disorder psychiatric comorbidity; and impairment. Between-group
differences were tested using Pearson χ
2
analysis, Fisher exact test, or t test (two tailed).
Because we performed multiple comparisons, we used an adjusted α level of P < .01; we did
not adjust the α level to reflect all statistical comparisons because this is the first study on this
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topic and is therefore exploratory—in addition, the Bonferroni correction tends to be overly
conservative [23].
3. Results
One hundred five consecutive male subjects (mean age ± SD = 46.1 ± 11.5 years; range = 21–
75 years) were assessed. Twenty-two (21.0%) subjects identified themselves as gay or bisexual
(95% confidence interval [CI] = 13.2%–28.8%): 15 (14.3%) identified as gay (95% CI = 7.6%–
21.0%) and 7 (6.7%) identified as bisexual (95% CI = 1.9%–11.5%). Most subjects were white
(n = 102; 97.1%) and had some college education (n = 82; 77.1%). Gay and bisexual men were
more likely to live alone (
χ
2
2
= 28.2; = 28.2; P <.001). There was no significant difference in
terms of age, education, or race/ethnicity between the gay and bisexual and heterosexual male
gamblers.
Gay and bisexual men were more likely than heterosexual men to report a lifetime (81.8% vs
44.6%;
χ
1
2
= 9.7; P = .002) or current (68.2% vs 34.9%;
χ
1
2
= 7.9; P = .005) impulse control
disorder (Table 2). Of those with impulse control disorders, proportions acknowledging
compulsive sexual behaviors differed most between gay and bisexual men and heterosexual
men (lifetime: 59.1% vs 16.9%,
χ
1
2
= 16.2, P <.001; current: 50.0% vs 9.6%,
χ
1
2
= 19.1, P <.
001). Gay and bisexual men were more likely than heterosexual men, on a trend level, to report
a co-occurring lifetime nonimpulse control psychiatric disorder (95.5% vs 73.5%;
χ
1
2
= 4.9;
P = .03). Of those with these disorders, proportions acknowledging substance use disorders
differed most between gay and bisexual men and heterosexual men (59.1% vs 31.3%;
χ
1,103
2
= 5.7; P <.05). Proportions acknowledging current substance use disorders did not differ
significantly between gay and bisexual men and heterosexual men (13.6% vs 9.6%; P = .16).
Gay and bisexual men vs heterosexual men scored higher on the SDS, although this did not
reach statistical significance (14.7 vs 12.8; t
1,103
= −2.1; P = .04).
4. Discussion
To our knowledge, this is the first study to examine the relationship between sexual orientation
and psychopathology in men with PG. Although general sociodemographic characteristics
between gay and bisexual men and heterosexual men with PG were largely similar, gay and
bisexual men were more likely to report living alone without a partner, consistent with
population-based surveys of gay men [6]. However, the proportion of gay and bisexual men
in this study (20.1%) is considerably higher than that in the general population (3%), raising
the possibility that gay and bisexual men might be at increased risk for PG, as appears to be
the case for other psychiatric disorders [6,8,10]. These findings suggest the need to include PG
and sexual orientation measures in future psychiatric epidemiological studies. Specifically,
because of the complexity of sexual orientation, measures should assess sexual identity, sexual
attraction, sexual fantasy, and sexual behavior [24,25].
More frequent acknowledgement of impulse control disorders and other psychiatric disorders
was observed in gay and bisexual men compared with heterosexual men with PG. These
between-group differences appeared largely attributable to higher proportions of gay and
bisexual men acknowledging compulsive sexual behaviors and substance use disorders. These
findings suggest that PG in gay and heterosexual men is associated with impaired impulse
control over a wider range of addictive activities than in heterosexual men with PG. The
diagnosis of compulsive sexual behavior has merited some skepticism, particularly in the
context of gay men who may simply have more sexual outlets than heterosexual men. The
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sexual behaviors described by this sample, however, were consistent with the diagnosis of
compulsive sexual behavior proposed by various clinicians [26,27].
The observed rate of lifetime substance use disorder in gay and bisexual men with PG (59%)
is notably higher than the rates reported in the general population (26.6%–29.0%) [18] or in
general surveys of gay men [6]. In addition, the lifetime rate of substance use disorders in the
heterosexual men in this sample is slightly lower than the rates found in other samples of
individuals with PG (36%–63%) [13]. The lifetime rate of substance use disorders in this entire
sample was approximately 37.1%, but the rate of lifetime substance use disorders in the
heterosexual gamblers was only 31.3%. Although exact reasons for this difference are unclear,
one possible explanation may be that this sample consisted of treatment-seeking pathologic
gamblers and that these subjects may have less lifetime comorbidity as compared with general
population samples of gamblers. In addition, no previous study examined whether the elevated
rates among gamblers were associated with gay or bisexual orientation. Because both
individuals with PG and gay men appear to be at risk for substance use disorders, gay gamblers
may be at even greater risk of developing a substance use disorder.
Furthermore, although the rates of current and lifetime compulsive sexual behaviors found in
this study’s entire sample (18.1% and 25.7%, respectively) are consistent with those reported
among pathologic gamblers (23%) [13], the rates of current and lifetime compulsive sexual
behaviors among gay and bisexual male pathologic gamblers in this sample (50% and 59%,
respectively) are notably higher. Future studies should assess more closely the role of sexuality
in patients with co-occurring addictions.
The greater impairment in gay and bisexual men as compared with heterosexual men with PG
is consistent with findings in other populations of gay men. Decreased scores on quality-of-
life measures have been linked to low self-esteem in gay men [2]. The extent to which these
factors influence addictive behaviors such as PG remains to be explored.
Identification of sexual orientation among gamblers may have treatment implications. Given
the elevated rates of other addictive behaviors, gay and bisexual male pathologic gamblers may
require more intensive or specialized treatment services as compared with heterosexual
gamblers and the treatment interventions may need to address a wide range of impulsive
behaviors and disinhibition. Systematic PG efficacy studies to date have not examined the
differential treatment response of PG based on sexual orientation; future studies should
investigate this issue.
This study has several limitations. Subjects were categorized based on self-identification of
their sexuality. Sexual orientation was not assessed with a standardized instrument. Because
sexuality is often a difficult issue for men, gay or bisexual orientation may be underreported.
Conversely, however, the subjects may be generally more disinhibited and therefore more
likely to accurately report their sexual orientation despite society’s lack of acceptance.
Treatment-seeking pathologic gamblers may differ from individuals who do not seek treatment
or have a less severe form of gambling pathology. The extent to which these results generalize
to the larger population of pathologic gamblers warrants future study.
5. Conclusions
The results of this exploratory study suggest that a gay or bisexual orientation may be common
in people with PG and frequently co-occurs with other addictive behaviors. Additional research
on this topic are needed, including larger prevalence studies and studies that may shed light on
the relationship between sexual orientation and PG (eg, prospective studies and studies on
etiology and pathophysiology). Also greatly needed are treatment studies to identify efficacious
treatments for gay and bisexual patients with multiple addictive behaviors.
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Acknowledgements
This research was supported in part by a Career Development Award (JEG-K23 MH069754-01A1) and the Clinician
Scientist Training Program (MNP-K12 DA 00167). The research was also funded in part by unrestricted educational
grants from BioTie Therapies of Turku, Finland, and Forest Laboratories (New York, NY).
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Table 1
Psychiatric comorbidity in gay/bisexual men compared with heterosexual men with PG
Gay/Bisexual men (n = 22) Heterosexual men (n = 83)
SCID diagnosis Lifetime Current Lifetime Current
Any mood disorder 6 (27.3) 0 (0) 25 (30.1) 5 (6.0)
Any anxiety disorder 4 (18.2) 2 (9.1) 28 (33.7) 7 (8.4)
Substance use disorder
13 (59.1)
*
3 (13.6) 26 (31.3) 8 (9.6)
Psychotic disorder 0 (0) 0 (0) 0 (0) 0 (0)
Somatoform disorder
2 (9.1)
*
1 (4.5) 0 (0) 0 (0)
Eating disorder
2 (9.1)
*
0 (0) 0 (0) 0 (0)
Adjustment disorder 2 (9.1) 0 (0) 3 (3.6) 0 (0)
Any SCID diagnosis
21 (95.5)
*
6 (27.3) 61 (73.5) 16 (19.3)
Values are expressed as n (%). SCID indicates Structured Clinical Interview for DSM-IV.
*
P < .05, significantly different from heterosexual male gamblers.
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Table 2
Impulse control disorders in gay/bisexual men compared with heterosexual men with PG
Gay/Bisexual men (n = 22) Heterosexual men (n = 83)
MIDI diagnosis Lifetime Current Lifetime Current
Compulsive buying 5 (22.7) 4 (18.2) 12 (14.5) 10 (12.0)
Compulsive sexual behavior
13 (59.1)
***
11 (50.0)
***
14 (16.9) 8 (9.6)
Kleptomania 1 (4.5) 0 (0) 3 (3.6) 2 (2.4)
Intermittent explosive disorder 2 (9.1) 1 (4.5) 4 (4.8) 4 (4.8)
Trichotillomania 0 (0) 0 (0) 2 (2.4) 2 (2.4)
Pyromania 0 (0) 0 (0) 0 (0)
Any MIDI diagnosis
18 (81.8)
**
15 (68.2)
**
37 (44.6) 29 (34.9)
Values are expressed as n (%). MIDI indicates Minnesota Impulsive Disorders Interview.
**
P < .01, significantly different from heterosexual male gamblers.
***
P < .001, significantly different from heterosexual male gamblers.
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