Sex In The Brain: How Seizures, Strokes, Dementia, Tumors, and Trauma Can Change Your Sex Life

BLAME IT ON MY BRAIN

Imagine you have a tumour growing in your frontal lobe. You become hypersexual, and begin to demand more sex from your long-term partner. Perhaps this reignites the passion you both felt in the first few months of your relationship and it brings you closer together. Alternatively, your mismatched libidos may frustrate and exhaust your partner, causing resentment and eventually leading to the relationship breaking down altogether.

In this scenario, whichever way it goes, your hypersexual behaviour is only directed towards your partner. It is contained to your bedroom, and its consequences are personal and specific to your relationship. Those consequences may be disastrous consequences, but they are restricted to you and your partner and do not directly impact others in your life. In contrast, consider the case of Gary (see Chapter 7). His right frontal lobe brain tumour resulted in hypersexuality that impacted dramatically on others. It led to him downloading child pornography and making sexual advances towards his stepdaughter – both of which are criminal offences. From his case report, we know he was ordered to complete a treatment program for ‘sexual addiction’, but there are no other comments about any legal proceedings.

We know that there have been rare cases of people who have committed sexual offences as a result of hypersexuality brought on by a neurological disorder or treatment. These people have faced the criminal justice system. But what happens when these people are charged with a sexual offence or assault? Do they blame their brains and, if so, how does the law respond? Are they deemed to be ‘responsible’ for their hypersexual behaviour? Are they punished?

The case of Isaac, a man with dementia who I met in my clinical practice, shows that there are no easy answers to these questions. Isaac was depressed. He was in his eighties, and he was lonely and tired. He missed his wife, who had died ten years before, and he missed working. He had loved being a high-school teacher, watching the kids in his class soak up the information he offered. He had been respected in his community and even served as president of a cultural organisation. Now he felt old and useless. He had so many medical issues, and took so many medications that didn’t seem to help. He had been living with one of his sons, but when he started leaving pots burning on the stove and getting lost on his way home from the local shops, his family felt it was too hard to look after him. He moved into an aged care facility.

He had been living there for two years when his son contacted me, asking for an urgent neuropsychological assessment for his father. Isaac had been charged with an alleged sexual assault on his neighbour at the facility, a woman with severe dementia; he had been found by a staff member with his hands in her underpants. He had been taken to the police station and fingerprinted. His son had accompanied him and requested the police cease the interview when he realised his father’s responses were confused and often incorrect. Isaac was charged with sexual assault, an apprehended violence order (AVO) was issued against him, and a request for a DNA sample was made.

Isaac had seen a geriatrician the week before his appointment with me, and the question of whether he had some type of dementia had been raised. In my assessment, he had a lot of trouble doing the ‘frontal’ executive tasks that I gave him, particularly those that required him to control his responses. For example, if I said a sentence with the last word missing and asked him to complete it with a word that did not fit, he just could not resist saying the word that did fit. He couldn’t stop this automatic response. From the history of his cognitive decline that I got from his son, and the way he behaved with me – making comments such as, ‘You are a naughty girl. You are teasing me. I am being silly’ – it was clear that Isaac’s frontal lobes were no longer doing their job of putting on the brakes in social situations. Documents from the aged care facility showed that staff had made increasingly frequent complaints about his sexually disinhibited behaviour; they had reported comments and demands that he had made, such as ‘Give me a kiss’.

In my report, I advised that Isaac had probable vascular or behavioural-variant frontotemporal dementia. His sons were relieved, but also sad and worried. They gave my report to the legal aid solicitor who was helping them. Isaac effectively became a prisoner in his room due to the AVO: because his alleged victim was his neighbour, if Isaac left his room he was in breach of the AVO. He developed bedsores and became even more depressed. He felt that other residents and staff had ostracised him. Eventually he was moved into the dementia unit at the same facility, and life became a little easier for him – he could safely leave his room with no legal ramifications. But Isaac’s case shows how complex this issue is for everyone involved: the aged care staff, the police, the family of the victim, Isaac’s family, and Isaac himself.

The aged care staff are trying to manage a challenging situation. They are bound by a duty of care (to both Isaac and other residents), and by laws that require them to report any incidents of ‘unlawful sexual contact’ or any sexual contact with a resident without consent. Would another staff member witnessing the incident have reported it, or would they have just shooed Isaac out of his neighbour’s room and back to his own? How did the witness know if the neighbour had given consent or not? How is the idea of consent treated in residential homes where people have dementia? Staff did not know Isaac had dementia at the time of the alleged offence. If they had known, would they have handled the situation differently?

The police, faced with someone who has potentially committed a serious crime, are following the steps they are obliged to take in such incidents. But when the alleged perpetrator is an 80-year-old man with multiple medical conditions who is clearly confused, are there any alternatives to these standard practices? Do the police have any guidelines on how to manage elderly offenders with dementia? I’m not aware of any, but I know that in New South Wales, where I live, the government has allocated $10 million for a Justice Advocacy Service to help people with cognitive impairment navigate the criminal justice system, and to provide guidance to police, legal aid and the courts in responding to people with cognitive impairment such as dementia.

The family of Isaac’s alleged victim, already living with the sad reality of her dementia, is now faced with the news that she was allegedly assaulted in a place where they thought she was safe. They are no doubt reeling, and must surely feel that someone should be brought to account or punished.

Isaac’s sons are trying to reconcile their memories of their highly respected father with who he is now: a man with dementia, in the final stage of his life, who is now facing criminal charges. The myriad emotions they are dealing with must be exhausting.

And of course there is Isaac, a man with a brain that has no brakes due to a dementia that had started years before he walked into his neighbour’s room, but wasn’t diagnosed until after the alleged incident. Should he be considered responsible for his behaviour, and should he be punished? And, if so, how?

I met Isaac’s son at the courthouse a year after we had first met at Isaac’s neuropsychological assessment. He introduced me to the solicitor who was running Isaac’s case. ‘I think it’s a lay-down misère,’ she said, meaning that she felt the outcome was certain. She explained that she would be arguing that Isaac was ‘unfit to plead’, and that she couldn’t see the point of proceeding to court at all in cases such as Isaac’s. ‘He couldn’t respond to any questions about the alleged incident,’ she said. ‘There is no purpose of punishment for a person with dementia. They really should be diverted out of the criminal justice system.’ I nodded in agreement. Nevertheless, she admitted that she was unsure of the arguments the prosecution was going to present. She told us the process could take a few hours, as there were several other matters to be dealt with first, and that the actual hearing ‘could take one minute or an hour’. I decided to stay and hear the outcome of Isaac’s court case firsthand.

There’s a lot of waiting that goes on in courts. The foyer was full of people nervously huddled in corners, talking softly with friends and family, staring blankly into their mobile phones or anxiously listening to their immaculately dressed lawyers. No doubt everyone was wondering when it would be their turn to face the magistrate who would decide their fate. I watched the magistrate as he deliberated over several other cases. He often spent time reading through documents while everyone in the court watched him in complete silence. I marvelled at his composure, the incredible level of responsibility he had, and his ability to process so much material on the spot and make life-changing decisions about people he had only just laid eyes on. He spoke eloquently and succinctly – not an ‘um’ to be heard. I wondered how much experience he’d had with people with dementia, and how this might influence his decision in Isaac’s case.

There was no need for Isaac to be in court. His son was relieved that they had shielded him from all the worry and uncertainty over the previous year. ‘He has no idea about any of this,’ he said to me. ‘I’m glad he doesn’t have to sit here. He was a pillar of society, a well-respected teacher. Surely this can’t be the legacy of his life?’ He proudly showed me some recent video footage of Isaac on his phone. He looked relaxed as he stared directly into the camera and spoke in his native language. Isaac’s son agreed that Isaac was much happier in the dementia unit, noting that the staff were ‘much more kind, flexible and forgiving’. Isaac was still disinhibited, but there had been no further complaints about his behaviour since he moved to the dementia unit.

I asked Isaac’s son if his father’s disinhibition was still sexual in nature, and he nodded and gave me two examples of incidents that had occurred during his recent visits. On one occasion a movie was playing in the communal lounge and there was a scene of a couple kissing. Isaac leaped out of his seat and announced to the room, ‘They are kissing! Look, they are kissing!’, raising his hands above his head and clapping. His son was shocked at how excited he became. Another time Isaac pointed to his two slippers that were on the floor of his cupboard, one placed on top of the other. He remarked, ‘Look, they are humping, like rabbits!’ The son laughed and shook his head. ‘For him to interpret two slippers in that way? Wow. I just couldn’t believe it.’ Isaac really did have sex on the brain.

In the end, a year of worry and four hours of waiting in court were resolved in a one-minute judgment. The magistrate said the evidence from the reports about Isaac was ‘overwhelming with respect to his lack of mental capacity’ and that ‘the only conclusion to reach is that he is not fit to be tried’. He dismissed the case of sexual assault, and then the prosecution raised the issue of the AVO. Isaac’s lawyer spoke for ten seconds. ‘If it’s to anyone’s comfort he is now in a dementia unit, Your Honour, essentially under lock and key’ – nowhere near his former neighbour in the facility. The magistrate paused, then replied, ‘I suppose it’s the same conclusion. There is no prospect of him understanding or complying with such an order. Dismissed.’

I nodded to Isaac’s son across the aisle as we stood up and headed for the door. The solicitor bowed to the magistrate and darted out behind us.

‘Is that it, then?’ Isaac’s son asked.

‘Yes,’ she answered. ‘As I said – a lay-down misère.’

As we walked to the court’s car park, Isaac’s son seemed tired but very relieved. ‘So much worry, and what for?’ he asked. ‘It should never have got to this.’ We shook hands, and on my way home I wondered how many other cases like Isaac’s were going through the criminal courts right now, causing angst for all the families involved.

SOME OF THE PATIENTS I HAVE ALREADY DISCUSSED IN Chapter 7 were charged, as Isaac was, but were then imprisoned for their criminal behaviour despite evidence of their neurological condition being presented to the court. Debbie, who had multiple sclerosis (MS) and developed a range of paraphilias, ended up dying in her jail cell. Her case report by Neil Ortego and colleagues stated that:

A possible relationship between the patient’s MS and her bizarre behavior was ignored. She was thought to be cognitively intact with a ‘normal IQ,’ and thus in full awareness and control of her actions. Based on this line of reasoning, she was given the maximum sentence and died in the jail cell. Her neurological tragedy was unnecessarily exaggerated by the disregard for the relationship between her MS and her altered behavior.

Todd, who had part of his right temporal lobe removed to treat his temporal lobe epilepsy (see Chapter 7), also ended up in prison for his child pornography offence. The authors of his case study argued strongly that he should not have been charged or imprisoned:

Among more than 35 cases of pedophilia associated with neurological disorders, an arrest was only reported in two cases…In contrast, our patient was prosecuted by federal authorities and now serves a 19-month prison sentence for downloading pornographic images of children. The KBS [Klüver-Bucy syndrome] was a critical factor in driving his hypersexuality. In light of this mitigating factor, was he criminally responsible? Did his behavioral actions warrant imprisonment? We believe the answer is no to both questions.

We learn more about Todd’s court case and sentencing from Oliver Sacks’ posthumously published book. Sacks states that the judge agreed that he ‘could not be held accountable for having Klüver-Bucy syndrome’, but argued that he was culpable ‘for not speaking sooner about the problem to his doctors, who could have helped, and for persisting for many years in behavior that was injurious to others’. Todd’s crime, the judge said, ‘was not a victimless one’.

In the case of Gary, also discussed in Chapter 7, there was a clear association between his tumour and hypersexual behaviour: the behaviour stopped when the tumour was removed, and started again when the tumour grew back. This is evidence of causality. We know from abundant neuropsychological and neuroimaging research that the orbitofrontal region, where Gary’s tumour was located, is crucial in regulating social behaviour. If this brain region is damaged during childhood, it can cause difficulties in learning and understanding social norms and rules. Symptoms of orbitofrontal damage include poor social judgment, lack of empathy and remorse, reduced impulse control, and difficulty interpreting people’s emotions and mental states. If you injure this brain region as an adult, you can manifest what has been termed ‘acquired sociopathy’. Famous patients such as ‘EVR’ and Phineas Gage have highlighted how this type of brain damage can have a devastating impact on a person’s ability to function in the social world, resulting in unemployment and family breakdown. In some people with orbitofrontal brain damage there can be a dissociation between ‘knowing’ and ‘doing’, in that people can know what they are doing is wrong, but are unable to stop themselves acting in certain ways. In other words, their ‘moral knowledge’ is intact, but they have a loss of impulse control, or a failure of their brakes. The authors of Gary’s case study, neurologists Jeffrey Burns and Russell Swerdlow, stated that:

The orbitofrontal disruption likely exacerbated a preexisting interest in pornography, manifesting as sexual deviancy and pedophilia. To our knowledge, this is the first description of pedophilia as a specific manifestation of orbitofrontal syndrome…Our patient could not refrain from acting on his pedophilia despite the awareness that this behavior was inappropriate.

In other words, Gary knew what he was doing was wrong, but he could not stop himself.

The authors of Debbie’s, Todd’s and Gary’s published case studies all argued that their patients should not have been held responsible for their sexual offences. They felt that the law disregarded the causal link between brain conditions and criminal sexual behaviour and that this crucial factor should have been considered. No one can be considered ‘responsible’ for developing multiple sclerosis or temporal lobe epilepsy, or for growing a brain tumour. These people have already suffered a ‘neurological tragedy’, and the symptoms of hypersexuality only compound this. Isn’t that punishment enough?

But there were victims, too, in these cases, and in all cases those victims were children. Isn’t there a risk that people like Debbie, Gary and Todd will commit more offences? Surely their crimes are too significant for us to let these people off with a warning? And where do we draw the line? Of course ‘your brain made you do it’ – our brains make us do everything! If charges are dropped because paedophilia occurred in the context of a brain tumour, couldn’t all paedophiles just claim that their brains are wired differently and therefore they are not responsible for their crimes? Doesn’t this raise the question of whether ‘free will’ actually exists? Is there a risk that anyone committing a sexual offence could just blame their brain? As you can see, these cases of hypersexuality arising from brain disorders raise some very complex issues.

In the case of the criminal justice system, the two obvious and interrelated questions are: (1) are they responsible for their criminal behaviour; and (2) should they be punished – and if so, how? Legal, ethical and philosophical scholars have spent entire careers researching such issues, so it is far beyond the scope of this chapter to adequately address them, but I will highlight some relevant cases that show how legal systems in Australia and other countries are dealing with this. Specifically, I will describe what happened to two men with Parkinson’s disease who were charged with sexual offences that they committed while taking prescribed medications for their condition – medications that were directly responsible for their hypersexuality.

IF YOU DEVELOPED PARKINSON’S DISEASE, YOU WOULD no doubt be desperate for some relief from your motor symptoms. You would gladly take any medications that your doctor prescribed if they stopped you from shaking, shuffling and freezing while you walked. Just as Steven (see Chapter 2) and Ray (see Chapter 4) were, you would be thrilled if those drugs were effective and you could walk freely again. Nevertheless, the joy you felt might be tainted if you developed a known side effect of the medication: hypersexuality.

If your prescribed medication caused hypersexuality that led to criminal behaviour, should you be punished? Not according to the judges of two such cases, from the United Kingdom and Australia. ‘Parkinson’s caused teacher’s child porn habit, judge rules’ was the headline of a 2008 story in one UK newspaper. Philip Carmichael, a 58-yearold retired school principal, had been prescribed dopamine replacement therapy to relieve symptoms of his Parkinson’s. During the period in which he took the medication, he downloaded 8000 child pornography images. Police also found one image on his computer that Carmichael had downloaded before starting this medication; Carmichael claimed he did not know where it came from. The existence of this single ‘pre-medication’ image raises the question of whether the medication unmasked a latent or pre-existing tendency. The judge in Carmichael’s case disregarded this notion as this image was entirely separate from the bulk of the downloaded images. Judge Mary-Jane Mowat stated that:

This is a very distressing case. To say that he was to blame would be a complete denial of the reality of the evidence that I see. He was not only an ill man at the time, but a man whose medication can be described as ultimately responsible for the committal of these offences.

Judge Mowat noted that Carmichael was now under medical supervision and had a loyal social support network; she considered it unlikely that he would reoffend. It was not deemed necessary to ban him from working with children.

A critical question raised by these two cases is: did these men know that their medications could induce hypersexuality and, if so, how long did they know of this link before their illegal behaviours began? Did they continue to take their medications even while they knew about the side effects? Maybe they had been warned by their doctors and knew of the possible link, but had no reason to suspect that it would cause them to engage in criminal behaviour. Should they have foreseen those consequences? There is plenty of evidence that dopamine replacement treatments can cause hypersexuality, but it is not clear if they specifically cause paedophilic interest. The question of whether these medications can unmask a previously unexpressed sexual desire has also been raised, and a case reported in The Journal of Sexual Medicine suggests that this is possible.

Norman was 67 years old and had been diagnosed with Parkinson’s disease seven years earlier. His doctors had tried a few different medications to ease his motor symptoms and juggled the doses over the years. After increasing the dose of one of his medications (Pramipexole), his wife rang his doctor’s office in tears. She described a profound change in Norman’s sexual behaviour. He had been shy and reserved, and they had previously had sex approximately once a week, but since his medication increase he wanted sex daily. It wasn’t just the ramping up of the frequency, though. His wife reported a change in how he wanted it and what he said during it: he had developed an extreme preference for anal sex, and would vocalise ‘unusual obscenities’ during it. He had never expressed this desire or requested this type of sex in over 40 years of marriage.

The doctor scheduled an appointment. Norman initially denied any changes, but when his wife confronted him, he said that he assumed his requests were ‘unusual compared with his previous sexual experiences with her’, but according to the case report, he said that ‘these were practices that he secretly desired when he was younger’, and that ‘now he felt somehow less ashamed to put his desire into practice’.

The Pramipexole was ceased, and after 30 days his sexual behaviour returned to its usual pattern. When asked about his change in sexual behaviour at a subsequent review, he showed insight into how his drug-induced hypersexuality now seemed to him ‘inadequate and unacceptable’ in the context of his marriage.