For as long as he could remember, Harry had loved safety pins. He found the shape, colour and shine of them so incredibly beautiful that just holding one gave him an intense feeling of pleasure. He called this special feeling ‘thought satisfaction’. As a child he collected safety pins, and his pockets were always bulging with them. His favourite game was to join them in a long chain and pull them along the floor. He knew it was an unusual and potentially embarrassing habit, so he would hide in the toilet for his special safety pin time, pulling the pins out of his pockets one at a time and staring at them shining in his palm. Sometime during his childhood, the ‘thought satisfaction’ was followed by a ‘blank period’, which was eventually diagnosed as a seizure when Harry was an adult. Somehow he was able to keep this secret from his family, and the first witness to his safety pin habit was his wife.
Harry was 23 years old when his wife found him staring at a safety pin in his palm; he was glassy-eyed, vague and unresponsive. The seizures triggered by the safety pins always followed the same pattern: he would stare at a safety pin and start humming, make sucking movements with his lips, pluck at his clothing, and fall into an unresponsive state for a couple of minutes. Every seizure was triggered by a safety pin, and therefore they were essentially voluntary. It had to be a bright, shiny, undamaged pin, and several were more effective than just one. He had the strongest desire to look at pins during anxiety-provoking and sexual situations. If he fantasised about safety pins during sex, he would have a seizure. Over time, Harry lost all interest in and desire for sex with his wife, became impotent, and only lusted after safety pins. He described the ‘thought satisfaction’ triggered by safety pins as the ‘greatest experience of my life, better than sexual intercourse’.
Harry tried all the anti-seizure medications known at the time – this was the 1950s – with no benefit. He had a routine EEG, which showed a left temporal seizure focus, and was referred for surgery. On 17 March 1953, he underwent a left temporal lobectomy. His surgery was considered a great success: it cured him of both his seizures and his safety pin fetish. The case notes from his review 16 months after his surgery state that he had ‘no desire to look at safety pins and had become as potent as in early marriage’, and that his relationship with his wife improved. It doesn’t provide any more details about their relationship, pre- or post-surgery, but no doubt his wife would have been relieved. If Harry had been alive today, I wonder if our more advanced anti-seizure medications would have been more effective; he may not require a left temporal lobectomy to experience both a seizure and fetish cure now. Although this case study is over 60 years old, it remains extraordinary – for the unique nature of the fetish, its clear association with epilepsy, and its unequivocal evidence that the temporal lobe is a crucial part of the sexual neural network.
According to the current and fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a paraphilia is an intense or persistent sexual interest in something other than ‘genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners’. Common paraphilias are fetishism, or a preference for particular body parts or inanimate objects (such as Harry’s safety pins); voyeurism, which involves spying on others in private activities; and exhibitionism, or exposing genitals. Rarer and less known paraphilias include symphorophilia, or sexual pleasure from watching a disaster such as a car accident (as featured in JG Ballard’s novel Crash and its Oscar-winning 1996 film adaptation); formicophilia, or having insects crawl on your body; and infantilism, or dressing up or wanting to be treated like a baby, which can also involve diaperism, or deriving sexual pleasure from wearing a nappy.
Another rare paraphilia is somnophilia, also known as ‘sleeping beauty syndrome’. It has been represented on screen in the films Sleeping Beauty (2011) and The Little Death (2014), an Australian production that also portrays several other paraphilias. In a case study published by Swiss psychiatrist Francesco Bianchi-Demicheli and his colleagues in 2010, a link was made between this paraphilia and a childhood brain injury. I read it and couldn’t help but say ‘Wow’ out loud to my empty office.
Jim, a 34-year-old man, arrived at an emergency psychiatric unit after physically assaulting his wife. His relationship with his wife had been strained for several years, because over time he had developed ‘a particular and progressive sexual deviant behaviour’: he felt sexually aroused by sleeping women, and liked to attend to their hands and nails while they slept and give them a manicure. During the initial years of his marriage he was able to control these fantasies but, the case study reports, ‘over the years he lost control of his sexual urges’ and acted on them. Initially Jim’s wife agreed to use sleeping pills to fulfil his desires, but she later refused to ‘bend to [the] man’s freakish will’. That’s when he began to secretly administer benzodiazepines – minor tranquillisers, typically prescribed to relieve anxiety and insomnia – to her. When Jim’s wife discovered what he had been doing, their conflict began. It all came to a dramatic head when Jim ‘disguised himself with a latex mask and attacked his wife as she returned from work’, using a capsicum spray to subdue her. His wife managed to pull off his mask, then ran out of the house and called the police.
The results of the psychiatric examination and routine laboratory tests were all normal. The only medical history of note was a traumatic brain injury Jim had suffered at aged ten years, after which he was reportedly in a coma for four days. It doesn’t say how he sustained this injury, but an MRI brain scan showed that it caused damage to his right frontal and parietal regions, specifically ‘moderate atrophy in the frontoparietal region with a diffuse and severe white matter injury compatible with his previous head trauma’. A neuropsychological assessment was said to show ‘moderate dysexecutive syndrome’, which means he did not do so well on the tasks that examine frontal lobe functions, such as response control.
We know the complex array of social and emotional functions the frontal lobes are involved in (see Chapter 2), but what do the parietal lobes do? They process sensory data that enable us to understand spatial information, including where our body is in space – in other words, ‘body awareness’. People with parietal lobe damage can have abnormalities in how they perceive their bodies, which is exactly what Jim showed: he had a fascinating and very specific body disorder characterised by an incomplete mental image of his hands, mostly on the right, called ‘personal representational hemi-neglect’. This was determined by the way he drew a picture of himself – he neglected his hands. The authors concluded that Jim’s paraphilia ‘might be related to his disturbed body image and more specifically to the incomplete hands representation…presumably the occurrence of head trauma might have played a critical role in the development of his sexual self- and body image’.
If a paraphilia causes a person distress in everyday life, impairs them in some way, or puts them or others at risk of harm, it is considered a ‘paraphilic disorder’. Therefore, the term paedophilia, or the sexual preference for prepubescent children, is distinguished from a paedophilic disorder – that is, paedophilia becomes a disorder if these sexual urges have caused distress or interpersonal difficulties, or if the individual has acted on those urges. As a team of neuroscientists stated in a recent review, ‘the mere sexual preference for children has been depathologised’. This means that no therapy or prosecution is required for paedophilia that exists only as a preference or desire and results in no actions, impairment, suffering or harm. The authors of the review do note, however, that a paedophilic sexual preference may be a risk factor for later criminal offending, which warrants preventative measures. So if the desire leads to any sort of action, such as downloading child pornography or any type of sexual offence against a child, then it’s a disorder, and that action is a criminal offence. Preventing these desires from becoming actions and offences is one of the main goals of research into paedophilia.
Regardless of the diagnostic term that is used, a sexual preference for children that exists as a thought or desire only is considered atypical and abhorrent, and there is no doubt that acting on it in any way is a criminal offence. A frightening fact is that there are rare cases in which this paraphilia has developed suddenly and unexpectedly in people with brain injury or disease. These cases provide the most striking evidence for the sexual neural network, particularly those cases in which (1) the treatment of the neurological condition (which in some cases involves the neurosurgical removal of the ‘offending’ brain region) results in the cessation of the paraphilia; and (2) the neurological condition returns, and the paraphilia returns with it. The extraordinary case of Gary, who developed paedophilic disorder associated with a right frontal lobe tumour, offers some insights.
Before reading Gary’s case, please be aware that the text to come may be distressing to some people. Paedophilia is a very confronting issue. There are two main reasons why it is discussed here. First, the purpose of this book is to highlight cases in which people with brain injury or disease have experienced changes in their sex lives, and there are cases in which there is a clear association between a neurological condition and paedophilia or a paedophilic disorder. Such cases offer critical evidence for the role of specific brain regions in the sexual neural network. Therefore, from a scientific perspective, these cases need to be discussed. Second, we can only understand and ultimately prevent paedophilia through research and discussion. Failing to discuss it does not help victims. The goal of research into this condition is to protect future victims by learning what triggers offending, and how that can be prevented well before it happens.
GARY WAS A HEALTHY AND HAPPILY MARRIED 40-YEAR-old schoolteacher when he developed an increasing interest in pornography. He had enjoyed browsing it since his teenage years, but this was much more intense. He began obsessively collecting porn magazines and viewing pornographic videos online. He hid the magazines in the bottom drawer of his filing cabinet, but when this became full, he had to find a new hiding spot in the garage to conceal them from his wife and stepdaughter. The other difference in his newfound obsession was that he desired child pornography, something he had never been interested in before. He was actively searching internet sites for images of children and adolescents. He knew it was wrong, but he felt that his sexual impulses were just too strong to resist.
Gary developed a habit of visiting prostitutes and attending ‘massage parlours’ regularly. He’d pretend he was going to the gym, and even sneak in visits after his teaching duties were done before his wife got home from work. But it was when he started making sexual advances towards his prepubescent stepdaughter that things took a catastrophic turn. After several weeks, the child finally told her mother. Gary’s wife was horrified. When she also discovered his porn stash and frequent access to child pornography on their family computer, she realised she had no idea who her husband was now. She was too shocked to grieve their marriage and focused on protecting her daughter. Gary was legally removed from their home and found guilty of child molestation. There’s no further information in this case study about whether he pleaded guilty or not, nor the exact nature of the charges. Cases like Gary’s raise complex questions about criminal responsibility and punishment that the legal system must grapple with; I discuss this further in Chapter 10.
During his sentencing hearing the judge told Gary that he could either go to jail or complete a 12-step inpatient rehabilitation program for sex addiction. Not surprisingly, he chose the latter option. Nevertheless, his sexual urges still were too strong for him to resist. When he began to ask staff and other clients at the rehabilitation facility for sexual favours, he was expelled from the program. The night before he was due to attend his prison sentence hearing, Gary developed a severe headache and attended a hospital emergency department. Given the timing, his headache was initially dismissed as stress-related, but when he discussed thoughts of suicide and a fear that he would rape his landlady, he was admitted to the psychiatry service. The next day, he complained of poor balance, and was referred to a neurologist. During the neurological examination he urinated on himself and showed no concern about it. He asked female doctors in the team for sex. He swaggered from side to side when instructed to walk, and had trouble writing and drawing a clock face, which is a standard cognitive test. It was more than enough evidence that something sinister was going on in his brain, and he was sent for an MRI brain scan.
The scan revealed a large tumour that was squashing his right orbitofrontal lobe. He was sent to the neurosurgical team and had the tumour removed. The tumour was found to be a particularly aggressive type called a hemangiopericytoma. After his operation, Gary’s walking and bladder control improved, and his paedophilic behaviour and excessive interest in pornography resolved. He successfully completed a rehabilitation program, and seven months later he was not considered a threat to his stepdaughter. Amazingly, the case report notes that he ‘returned home’. There is no information about the state of his relationship with his wife.
Three months later, Gary developed a persistent headache and secretly started collecting pornography again. An MRI scan showed that the tumour had regrown. It appears that this regrowth of his tumour had switched his sexual impulses back on. He underwent a second neurosurgical resection of the tumour two years after his first surgery, and after that there is no further follow-up. I emailed one of the authors of this case study to ask for more information about Gary, his wife, and what happened after his second surgery, but received no reply. The case study was published in 2003, and the media went wild when it was presented at a conference; I read online that the authors were inundated by requests from defence lawyers who wanted help defending clients charged with paedophilia-related offences. So perhaps the authors were tired of the attention, and of being associated with the ‘blame my brain for paedophilia’ phenomenon (see Chapter 10).
Paedophilia is never the sole symptom of a neurological condition. It always occurs in the midst of other cognitive or physical changes, and typically in the context of hypersexuality, as in Gary’s case. Paedophilia has long been considered a lifelong trait, a stable and unchangeable condition, and the cases in which it arises in the context of a brain injury or condition are rare. In these situations, paedophilic disorders have been discussed as behavioural manifestations of a ‘pre-existing latent paedophilic urge’ that has been ‘released’ by general impulse disinhibition. In other words, it could be considered that Gary’s tumour did not cause a specific change in his sexual preference; rather, the preference had always been there, repressed or ‘under the surface’, and his tumour just allowed him to express it, as it made him disinhibited or unable to control his behaviour in general, including his sexual behaviour. This, in addition to his heightened sex drive, may have caused him to desire and indiscriminately search for any sexual partner, young or old, stranger or family member.
Others have argued that de novo (entirely new) sexual preferences are possible in the context of brain injury or disease even when general behaviour does not become disinhibited. Without more information, we cannot know if Gary had pre-existing paedophilia, but according to his own report, these desires only surfaced after his tumour developed. There were no previous complaints against him during his work as a schoolteacher. There is no suggestion that he was disinhibited in any other ways prior to his tumour removal. The fact that his paraphilia disappeared after his tumour was removed supports the notion of causation. Does that mean a change in sexual preference can arise anew and be switched off and on in anyone who has a scar, tumour or injury affecting a specific part of the sexual neural network? No, it doesn’t – not all people with right orbitofrontal tumours develop paedophilia. Do all paedophiles have some kind of brain abnormality? I asked an expert in paedophilia this very question, and it turns out there’s no simple answer.
DR TILL AMELUNG IS A GERMAN PSYCHIATRIST WHO HAS spent nearly a decade researching paedophilia. He became involved in a treatment program for people with paedophilia after he saw an interview with a man who described an intense feeling of ‘falling in love’ with a child. Ever since then, in Till’s words, ‘the topic has not let me off the hook’.
Germany is the only place in the world where there is a treatment program for paedophilia outside of the forensic system, Till tells me – in other words, it is a program for ‘non-offending’ people who have a sexual interest in children but have not committed any sexual offence. But is it actually possible to ‘treat’ paedophilia? Experts in the field disagree on exactly what should be treated. Some argue that the aim of treatment, which involves both psychotherapy and drug treatments, should be to alter and indeed eliminate the sexual interest in children. Others argue that this is actually not possible, as it is a sexual orientation that cannot be changed; rather, they say, the aim of treatment should be controlling the sexual impulses to prevent offending. It is a debate of ‘elimination’ versus ‘control’.
Till is in the ‘control’ camp. After his treatment program, he says, those who have a sexual interest in children but have not offended report that, as a result of the treatment, their sexual interest and impulses have decreased. However there has not yet been a long-term follow-up study, so it is unclear how long the positive effects of treatment may last, and whether any of these non-offenders have ended up committing a child sexual offence. Till made a comment that I found both confronting and fascinating, and I have thought about it repeatedly since we spoke: ‘There is a struggle of people with paedophilia to have a sex life without doing harm,’ he said.
Most people with right temporal and/or frontal injuries do not develop hypersexuality or paedophilia. Those who do develop paedophilia in the context of a neurological condition typically show general behavioural ‘disinhibition’. But why do only some people with brain disorders express this in a sexual way? What is it about Gary that is different from other people who have right frontal tumours and do not develop such dramatic sexual changes? Till suggested that people like Gary may have had a sexual interest in children before their injury or the onset of their neurological disorder. They may have a predisposition of some sort, which there is still very little understanding of, and this makes them more vulnerable to develop it after an injury or the onset of disease. It might be that the disinhibition that can occur after a brain injury, disease or tumour, as in the case of Gary, means that this level of response shifts. The latent response that only existed very subtly before the tumour grew may then suddenly turn into a full-blown sexual reaction.
There are multiple pathways to developing paedophilia. Prenatal and developmental predispositions have been identified, such as the masculinisation of the brain in utero, and some evidence of peer alienation during early puberty – that is, separation from same-sex peers due to trauma or some other type of atypical feature, such as a physical or psychological difference. So, are the brains of paedophiles somehow different? There is no simple answer, as much of the research is confounded by the fact that studies are conducted with those who have already committed a sexual offence and are in prison. In this population, one common finding is reduced amygdala volume. This is fascinating given that we know that when both amygdalae are destroyed or damaged in animals or people they can experience Klüver-Bucy syndrome, and considering my own research finding of a bigger amygdala resulting in a better sexual outcome after seizure surgery (see Chapter 1). Yet again it highlights that there is no doubt that the amygdala is fundamental to our sex drives and lives.
What about those people who have paedophilic interest but have not committed any offence? It turns out that their brains are actually different from the brains of those people who have offended. Those who have offended typically have reduced brain volumes, while those who have paedophilic interest but have not offended have larger brain structure volumes, higher connectivity and ‘overcompensatory’ mechanisms – that is, stronger ‘brakes’ when doing cognitive tasks that assess control. Till explained that ‘normal’ people’s brains seem to be somewhere in between paedophilic offenders and non-offenders in terms of these specific measures – volume/size, connectivity and strength of ‘brakes’ during response control tasks. But this is all preliminary research that is still being carefully analysed.
Surely, though, it is possible that non-offenders could move into the offender group at any time; all offenders began their lives as non-offenders. So, if there are clear differences in brain structure and function between non-offenders and offenders, what causes this change? Do these brain changes occur after they have offended or just before? Research is currently underway to try to answer these questions and understand what predisposes non-offenders to offend. This is crucial research, as identifying these people and what triggers their offending is the first step in developing treatments to prevent it. Preventing offending is what is required to avoid the tragic and often life-destroying consequences of sexual abuse for victims.
I asked Till what reactions he has had from people when he tells them about his work. He said he is very cautious about discussing his area of research. Some people have told him about their own sexual abuse experiences, and he has even bumped into some of his patients by chance outside of work, so he feels that being careful with his job description is important for their privacy. What motivates him to continue working in the field? He told me that his main motivation was to address the discrepancy between the ‘disastrous consequences’ of paedophilia for everyone concerned, most particularly the children who are sexually abused, and the scarcity of knowledge about the causes of paedophilia and how to address them:
The debate on whether to treat the sexual interest in itself or rather the self-control mechanisms is a good example of how even the most renowned specialists do not agree on the most basic question. From my point of view, much of this confusion is caused by concepts that are not yet well defined, like, for example, mistaking ‘paedophilia’ as ‘child sexual abuse’ or the debate over paedophilia as a ‘sexual orientation’. This imprecision in concepts results in imprecise research and unstable results. I feel that is a major problem also for clinical work. This lack of knowledge keeps patients and victims at a risk that might be reduced with better research. That’s what I am hoping to be able to contribute to.
I understood why he had stayed in this field. There were so many unanswered questions to explore. So many lives could potentially be saved from the trauma of sexual abuse if we understood more about this condition, and how to identify and treat it before sexual offences occur.
WHILE GARY’S TUMOUR DISRUPTED HIS RIGHT FRONTAL lobe, another case that involved the right temporal lobe is frighteningly similar. Todd was 19 years old when he started to have frequent feelings of déjà vu – an overwhelming feeling of familiarity, as though he was reliving a moment he had already experienced – up to 20 times a day. This can occur when a seizure focus occurs in the hippocampus, which is a crucial memory structure (see Chapter 3). Over time, he developed other symptoms during his déjà vu attacks, including breathlessness, sharp chest pains and even occasional musical hallucinations, when he could hear a particular song ‘as if it was playing in the next room’. During some seizures he would also have gustatory (taste) and olfactory (smell) hallucinations. Despite trying various anti-seizure medications, his seizures were never well controlled, but he was still able to work in his role as a pharmaceutical researcher and also volunteered with his local epilepsy foundation. He had personality changes over time, including feeling more spiritual, creative and musical. He was well-liked by his work colleagues and loved by his wife, who had said he was a ‘good husband’, was ‘not given to any inordinate or perverse sexual practices’, and was always ‘sensitive to her needs and feelings’.
Todd was 33 years old when he had his first neurosurgical operation. The seizure detectives, in the form of an MRI brain scan and video EEG, had found the culprit – his right temporal lobe. He had a right temporal lobectomy and afterwards had nine months of seizure freedom. He decided to reduce his anti-seizure medications, but this triggered a seizure, which was followed by many more. His seizures were different after his surgery, and started with a ringing sound, a foul smell and a feeling of thickness in his tongue. Six years after his first surgery he had a second operation – a posterior right temporal resection – to get rid of the remaining bits of his right temporal lobe that were still causing seizures.
The surgery was considered a success in one way, as he had four years with no seizures, but the dramatic changes in his behaviour that started a month after the operation were far from desirable: irritability, hyperphagia (excessive eating), hypersexuality and coprophilia (an interest in faeces and defecation). His neurologists diagnosed Klüver-Bucy syndrome. His hypersexuality manifested itself with his wife and when he was alone. In his own words, as reported in his case study by the famous Oliver Sacks and co-authors Julie and Orrin Devinsky, Todd said:
My appetite for food and sex increased dramatically…I wanted sex constantly. Every day. I was very easily stimulated and began to touch myself regularly [and] request sex daily from my wife. If I wasn’t having sex with my wife, I masturbated. This behavior increased over time. I became more emotionally labile, obsessive–compulsive, but on the other extreme disinterested or unable to initiate things I needed or was supposed to do. I raged for hours at inappropriate things at home…I become distracted so easily that I can’t get anything started or done.
He started to watch pornography online while his wife slept. He became lost in a labyrinth of websites and was tempted to view and purchase child pornography. He became obsessed with it, and went on to download and purchase images of prepubescent girls. He was ashamed and secretive about it, and never discussed it with his wife or anyone else. Eventually he was arrested by US federal authorities for downloading child pornography.
Todd’s wife told his doctors, ‘He wanted to have sex all the time. He went from being a very compassionate and warm partner to just going through the motions. He didn’t remember having just been intimate. He said it didn’t seem like a current memory or emotion.’ Until the day the federal officers showed up, she said, Todd had wanted sex five to six times a day, constantly touching and grasping at her. Two years after his arrest, he was prescribed antidepressive and antipsychotic medications that made him ‘much warmer and loving’ and stopped his angry outbursts, his wife said, though they left him with no libido at all. ‘It is as if a faulty switch has been turned off,’ his wife observed.
Todd’s case is so extraordinary that Oliver Sacks writes about it in his posthumously published book, Everything In Its Place (2019), where he calls him Walter. We learn that his wife stood by him during his imprisonment and subsequent home confinement, and when he was freed they returned to their previous lives. Sacks writes that, during their last meeting, ‘Walter’ was ‘relieved that he had no more secrets to hide. He radiated an ease I had never seen in him before’. (See also Chapter 10.)
GARY’S AND TODD’S BRAIN LESIONS WERE FOCAL, impacting on specific brain regions known to be part of the sexual neural network. Their neurosurgical operations targeted these areas and seem to have switched on and off the hypersexual and paedophilic behaviours. Other neurological conditions cause more widespread lesions or damage, and if multiple lesions invade many different parts of the sexual neural network, they can cause havoc with sexual behaviour. Multiple sclerosis (MS), which means ‘many scars’, is a neurological disorder characterised by lesions that can occur throughout the central nervous system – in the brain, spinal cord and optic nerves (the nerves that connect the retinas in the back of the eyes to the brain). It is an inflammatory disorder in which white blood cells, which usually fight infection, cause injury in the nervous system. The myelin sheath which protects nerves is damaged during the inflammatory process and this means the nerves cannot conduct electricity effectively. The lesions typically occur in the brain’s white matter – the myelin of nerve cells. MS symptoms depend on where the lesions are, and can range from tingling toes and blurred vision to incontinence and slurred speech. In rare cases, like Debbie’s, a multitude of sexual changes can occur due to lesions throughout the sexual neural network.
Debbie was 26 years old when she first felt numbness in her hands and legs. After it persisted for a few months, she decided it was time to see a doctor. She had a neurological review and a lumbar puncture to check her cerebrospinal fluid, and was diagnosed with MS. She was given a hormone treatment that was very effective and the feeling in her hands and legs returned. She carried on with her work as a waitress and caring for her two boisterous sons. Even though she had no symptoms and the diagnosis felt like it might have been a dream, it still popped into her mind occasionally and kept her awake at night; she wondered if and when the brain lesions would strike again and what her future held. She knew it had struck again a year later when she had an intermittent feeling of pins and needles in her legs, feet and left hand. She tried to ignore it, but when her vision got blurry and her left leg felt like it was dragging while she walked, it was time to go back to hospital. Her CT brain scan was normal and she was given the same treatment as the previous time, but it didn’t work as well. As a single parent she had to carry on and return to work, but she was exhausted after her waitressing shifts.
Debbie’s next recorded hospital visit was a couple of years later when her sensory and motor symptoms had switched to her right side. Then there were no hospital notes for the next nine years, until 1991, when she was 39 years old, and was arrested for a variety of sexual offences. The case report, by psychiatrist Neil Ortego and colleagues, outlines that over a two-month period Debbie was alleged to have
seduced her 14-year-old son’s 17-year-old female lover; engaged in oral sex and used a vibrator during mutual masturbation with the 17-year-old girl; offered sex to her son’s 15-year-old male friend; requested that her son and his girlfriend engage in sexual intercourse while she watched; attempted to have the pet German shepherd have intercourse with her in front of her son and his girlfriend; had her pet dog lick her genitalia in front of minors.
Debbie had been heterosexual, with no prior history of any paraphilia; she had not even been sexually active in the years preceding these criminal offences. Yet here she was, 13 years after her diagnosis of MS, with a sudden onset of a myriad dramatic sexual changes: hypersexuality, incest, zoophilia (engaging in sex with animals), scoptophilia (arousal from watching others have sex), ephebophilia (sexual activities with adolescents), paedophilic disorder and exhibitionism. These changes in her sexual orientation and behaviour were prominent symptoms, and they did not appear to be caused by a general behavioural disinhibition.
The case study reported that she was seen by a psychologist during her legal proceedings. Her assessment could not be completed due to her ‘slowness and limited cooperation’. The psychologist found her to be ‘demanding and narcissistic’, and noted she was depressed. The question of whether her MS had altered her impulse control was raised by the psychologist in her report, but it was never discussed in her criminal trial; the case report doesn’t say why. The finding that Debbie essentially had ‘faulty brakes’ due to the extensive brain damage caused by her MS raises questions about her responsibility for her actions – and whether she deserved to be punished. This is discussed further in Chapter 10.
During her trial, Debbie woke one morning and was unable to get out of bed, and had lost control of her bladder and bowels. She went to the emergency department and was hospitalised, but it was suspected that she was malingering – feigning illness to avoid the repercussions of the trial. Nevertheless she was sent for an MRI brain scan, which revealed that lesions consistent with MS were scattered throughout her brain, and – crucially – were found in multiple critical areas of the sexual neural network. It showed extensive white matter lesions in her frontal, temporal and parietal regions, and a large lesion in her left thalamus and right midbrain. Essentially, there was widespread damage throughout her brain. After treatment with high-dose steroids she was able to walk with the aid of a walking frame, but the steroid treatment was discontinued after she was discharged from hospital.
Back in the courtroom, the prosecutors in Debbie’s case alleged that she had molested her older son 12 years earlier, suggesting that she was a paedophile even before the MS lesions had ravaged her brain. This was never proven; the nature of this alleged earlier incident – planned, organised and done in secret – was entirely different from her dramatically altered and exhibitionist sexual behaviour in the two months before her arrest. Without further information it is impossible to know if Debbie had a de novo onset of her paraphilias, or had acted on long-standing but repressed paraphilic preferences after the onset of her MS.
Despite the clear evidence of MS, Debbie was convicted on all counts of child molestation and given a maximum sentence of eight years in prison. The final months of her life were spent lying in her jail cell, ‘incontinent of urine and faeces’. The prison guards thought she was malingering so she was left unaided, with a mop to clean up after herself. She was described as being ‘surprisingly unconcerned by her predicament’. She died unexpectedly – and perhaps mercifully, given the tragedy of her situation – of a pulmonary embolism, a blood clot in the artery that runs from the heart to the lungs.
Despite the clear association between their neurological conditions and paraphilic disorders, Gary, Todd and Debbie were all charged and convicted of sexual offences, and two of them spent time in jail. These cases present a complex challenge for the criminal justice system, which we will discuss in Chapter 10.
The cases I have included in this chapter are rare. The vast majority of people with temporal lobe epilepsy or right frontal lobe tumours do not develop paraphilias like Harry, Gary and Todd did; very rarely do people with MS develop paraphilias like Debbie. But these intriguing cases offer a chance to gain insights into how our brains control our sex lives. We need to keep asking why and how, especially in the case of paedophilia, where the consequences for the person and their potential victims are so devastating. It is only by clarifying the nature of this condition, identifying its causes and understanding how it can lead to criminal behaviour that we will be able to prevent the immense suffering it brings.