Monday, October 26, 2009

Unusual Changes in Sexuality: Case Studies in Neurology

Fig. 1 (Currier et al., 1971). Scalp EEG showing sharp wave activity from left anterior temporal region.

In the last post we learned a bit about hypergraphia, a compulsion to write that sometimes occurs in those with temporal lobe epilepsy (TLE). According to the late behavioral neurologist Norman Geschwind (reprinted in 2009; also see Devinsky & Schachter, 2009), hypergraphia is one in a cluster of interictal [between seizure] personality traits in some TLE patients1 which can also include religiosity, hypermorality, aggressiveness, clinginess, increased emotionality, and sexual changes (mostly hyposexuality but also other alterations):

Hyposexuality is the most common, but other kinds of sexual changes do occur. ... In England, Davies and Morgenstern went out and found, among the temporal lobe epileptics, several other patients who were transvestites. ... I’m sure that the great majority of transvestites don’t have temporal lobe epilepsy, but it’s interesting that for whatever reason it can cause this. Although I’ve seen many women with temporal lobe epilepsy, someone called to my attention a phenomenon that I hadn’t observed before. The last four women I have seen have all been bisexual, which again is a rather striking finding.
Sexual behavior preceding (auras) or during (automatisms) seizures is another story. The EEG traces in Fig. 1 above are from an epilepsy patient who experienced "sexual seizures" during which she engaged in somewhat purposeless "pseudointercourse" behavior, with no memory for the event afterward. Although the general consensus is that sexual automatisms are usually associated with seizure foci in the temporal lobes (Mascia et al., 2005), an influential earlier paper insisted the origin of "sexual seizures" was in the frontal lobes (Spencer et al., 1983).

Changes in sexuality can also occur after strokes or due to brain tumors. Neurophilosopher Patricia Churchland drew attention to one of these case reports in a New Scientist article on free will and criminal responsibility:

In 2003, the Archives of Neurology carried a startling clinical report [Burns & Swerdlow, 2003]. A middle-aged Virginian man with no history of any misdemeanour began to stash child pornography and sexually molest his 8-year-old stepdaughter. Placed in the court system, his sexual behaviour became increasingly compulsive. Eventually, after repeatedly complaining of headaches and vertigo, he was sent for a brain scan. It showed a large but benign tumour in the frontal area of his brain, invading the septum and hypothalmus - regions known to regulate sexual behaviour.

After removal of the tumour, his sexual interests returned to normal. Months later, his sexual focus on young girls rekindled, and a new scan revealed that bits of tissue missed in the surgery had grown into a sizeable tumour. Surgery once again restored his behavioural profile to "normal".

Figure 1 (Burns & Swerdlow, 2003). MRI scans at the time of initial neurologic evaluation: T1 sagittal (A), contrast-enhanced coronal (B), and contrast-enhanced axial (C) views. In A and B, the tumor mass extends superiorly from the olfactory groove, displacing the right orbitofrontal cortex and distorting the dorsolateral prefrontal cortex.

This case raises the issues of diminished capacity and criminal responsibility. The man knew what he was doing was wrong -- intact capacity and moral knowledge -- but he could not inhibit his inappropriate sexual behavior. It's hard to argue against the finding of diminished responsibility when staring at a gigantic brain tumor. But many other examples of impulsive sexual offenses (Langevin, 2006) aren't nearly as obvious (e.g. after head injuries when the damage might not be visible on an MRI scan). How does society deal with them?

A key factor is a change in behavior...

Multidirectional disorders of sexual drive in a case of brain tumour

The next report is from Poland (Lesniak et al., 1972 -- before the days of MRI or even CT scans). This case history is even more disturbing and involves greater criminal offenses than the patient of Burns and Swerdlow (2003).

A description and analysis of various disorders of sexual impulse are presented. They occurred gradually between the ages of 56 and 60 years in a man previously in good health. The disorders were as follows: harlotry, incestuous intercourse with his under-age daughter [used physical violence and threatened to kill her if she told], sodomy, hetero- and homosexual pedophilia, masochism [he demanded that his wife beat him with a club] with some symptoms of sadism, coprolalia and exhibitionism. [Also bestiality with cows and calves.] Pedophilia and exhibitionism [he fancied wearing a red ribbon around his exposed penis] were the counts of the man’s indictment. After twice-repeated forensic and psychiatric examination and observation, sexual psychopathy and male climacteric were also recognized; and the defendant was acknowledged to be responsible. In the course of further examination, the psychoorganic syndrome with symptoms of moria was recognized clinically. Further specialist examinations, especially by X-ray (pneumoencephalography) showed the presence of neoplasm (probably benign glioma or meningioma) situated at the basal paracentral part of the right forehead lobe [right orbitofrontal cortex again]. Its presence being acknowledged, the defendant was found irresponsible; due precautions and eventual neurosurgical treatment were proposed. It has been stressed that the appearance of the above disorders, especially in view of the age of the subject, must lead one to suspect an organic origin.
During the trial (reminiscent of the proceedings against serial child killer and cannibal Albert Fish), expert witnesses for the prosecution found nothing organically wrong, and declared the defendant “at the moment of committing the criminal acts he was charged with, had retained the ability to recognize the significance of these acts, whereas his ability to control his acts had been slightly restricted”. The defendant was found guilty, the defense appealed and a retrial was granted. He was placed under observation for 2 months at the Psychiatric Clinic in Cracow, when the authors became involved in his case:

The neurological examination revealed a considerable bilateral impairment of smell [a tell-tale sign of bilateral orbitofrontal damage] and a marked inequality of the reflexes of the lower extremities: the knee jerks and ankle jerks were weaker on the right. The EEG tracings showed a marked generalized flattening with scattered low-voltage theta waves. After stroboscopy the number of delta waves in the frontal and anterior temporal regions increased bilaterally.

...The pneumoencephalogram revealed ... a filling defect in the frontal horn of the right lateral ventricle which was, moreover, shifted dorsally... The radiological conclusion was that a tumour was present in the parabaso-central portions of the right frontal lobe.
The authors concluded their article with a fascinating discussion of sexual psychopathy, organic brain injury, and the question of legal responsibility. Thirty years before neuroethics and neurolaw emerged as recognized fields of study. And without the benefit of MRI.

A case of hair fetishism, transvestitism, and organic cerebral disorder

An unusual noncriminal case from Australia was reported by Dr. Ball (1968). The paper includes the author's regressive views of women and a Freudian explanation for hair fetishism:

Early in 1965 a forty six year old man suffering from severe anxiety was admitted to hospital. He had married after a short engagement, one month prior to admission, despite evasion and procrastination on his part. The marriage followed a brief courtship conducted with great ferocity by a childless widow in her early forties. Between the marriage and hospitalisation the patient became increasingly agitated, running away four times. The agitation had increased as his wife’s sexual demands stimulated his life-long hair fetishism and triggered fantasies of transvestitism which had been absent for some years.

When aged four, he became acutely upset on the day that his mother was about to have her long hair bobbed. As a result of his screaming and violent rage, the mother’s hair was not cut... Thereafter, the patient became increasingly preoccupied with long female hair. ... At about ten years of age he also began to transvest in his sister’s clothing. The transvestitism continued sporadically until his late thirties. ... He attempted intercourse very rarely and then with little success and less satisfaction.
Dr. Ball went on to state that "Hair fetishism can be the product of complex symbolisation." He also speculated that the boy's "aggressive outburst, associated with his mother’s hair, could have resulted in sexual stimulation." Yeah, OK, so where's the organic cerebral disorder? As a boy, the patient was delayed in walking and talking, was clumsy, and showed poor motor coordination. Doctors at the time (in the 1920s) could find nothing physically wrong with him. Back to the present day (1965), his demanding and ferocious wife had witnessed several nighttime grand mal seizures. And the guy's hair fetish was getting worse. When admitted to hospital the patient had abnormalities in his right hand and arm. He was diagnosed with:

invasive tumour affecting the left temporal region. [The tumor was causing the seizures.] It was felt that surgery was not indicated. He has since been maintained on an anticonvulsant, (Phenytoin Sodium), antiparkinsonian agents, (Benzhexol HCL [a muscarinic antagonist, not a dopamine drug]), and a phenothiazine, (Thioridazine [antipsychotic]). The phenothiazine was recently discontinued without ill effect. His epilepsy is less frequent, the abnormality of his right arm has not progressed and his fetishism is only occasionally troublesome. His sexual potency is much reduced, but his wife though despondent, copes well.
Or so the story goes.

Stroke turns Gay Man Straight!

A 57-year-old gay man, comfortable with his identity and aware of his sexual orientation since his early teens, came to the attention of Jawad et al. (2009) after suffering a stroke in the distribution of the left middle cerebral artery. He had experienced an earlier stroke 12 years before, a minor one in his right hemisphere but recovered completely. However...
The patient started complaining of his changed personality and heterosexual orientation 6 months after his second stroke. At the same time he complained of excessive mood swings and changed interests. He became preoccupied with photography and had a successful photographic exhibition a year after his second stroke. His sexual orientation remained heterosexual 4 years following the second stroke, and he preferred to describe himself as bisexual because of his previous homosexual orientation.

The authors did not present neuroimaging findings or results from neurological examination, which seems peculiar for a paper published in 2009. There was no mention of language or motor disturbances, but one is left to wonder. The middle cerebral artery is the blood supply for a rather large swath of cortex, so it's unclear exactly where the lesion was located. However, the authors do raise the obvious point that a change in sexual orientation is very unusual. Hyposexuality most often occurs after stroke (Tamam et al., 2008) and sometimes hypersexuality can be seen after brain injury (Miller et al., 1986). The Neurological Correlates blog describes two new cases of the latter in Manic Monday (late edition): Sudden hypersexuality.

Human sexuality is such a complex and multi-determined phenomenon that it's impossible to draw generalizations from the mix of case studies in the neurological literature. And it's important to avoid extrapolation from the few to the many. Very few people with temporal lobe epilepsy are transvestites or bisexuals, and the vast majority of transvestites and bisexuals do not have TLE. And all you fundamentalist reparative therapy advocates, take note: There is only one report in the literature of a "stroke turning a gay man straight." !! Nonetheless, it is informative to gather information about changes in sexuality and to relate them to lesions in specific brain areas, most often the frontal lobes (orbitofrontal cortex in particular) and the anterior and medial temporal lobes.


1 However, the specificity of the "TLE personality" classification is disputed by others (e.g. Mungus, 1982) who maintain that a substantial portion of the variance can be accounted for by psychiatric illness.


Ball, J. (1968). A CASE OF HAIR FETISHISM, TRANSVESTITISM, AND ORGANIC CEREBRAL DISORDER. Acta Psychiatrica Scandinavica, 44 (3), 249-254. DOI: 10.1111/j.1600-0447.1968.tb07511.x

Burns JM, Swerdlow RH. (2003). Right orbitofrontal tumor with pedophilia symptom and constructional apraxia sign. Arch Neurol. 60:437-40.

Currier RD, Little SC, Suess JF, Andy OJ. (1971). Sexual seizures. Arch Neurol. 25:260-4.

Jawad, S., Sidebothams, C., Sequira, R., & Jamil, N. (2009). Altered Sexual Orientation Following Dominant Hemisphere Infract [sic]. Journal of Neuropsychiatry, 21 (3), 353-354. PMID: 19776328

Langevin R. (2006). Sexual offenses and traumatic brain injury. Brain Cogn. 60:206-7.

Lesniak, R., Szymusik, A., & Chrzanowski, R. (1972). Multidirectional disorders of sexual drive in a case of brain tumour. Forensic Science, 1 (3), 333-338. DOI: 10.1016/0300-9432(72)90031-3

Mascia A, Di Gennaro G, Esposito V, Grammaldo LG, Meldolesi GN, Giampà T, Sebastiano F, Falco C, Onorati P, Manfredi M, Cantore G, Quarato PP. (2005). Genital and sexual manifestations in drug-resistant partial epilepsy. Seizure 14:133-8.

Miller BL, Cummings JL, McIntyre H, Ebers G, Grode M. (1986). Hypersexuality or altered sexual preference following brain injury. J Neurol Neurosurg Psychiatry 49:867-73.

Spencer SS, Spencer DD, Williamson PD, Mattson RH. (1983). Sexual automatisms in complex partial seizures. Neurology 33:527-33.

Tamam Y, Tamam L, Akil E, Yasan A, Tamam B. (2008). Post-stroke sexual functioning in first stroke patients. Eur J Neurol. 15:660-6.

Medellin's famous transvestite's debut on the silver screen

A group of Canadian filmmakers are releasing a movie on La Dany, the Medellin transvestite street artist that makes Andy Warhol look like a boring heterosexual. The film will see its first screening in Colombia's second largest city on Tuesday.

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At October 26, 2009 9:22 AM, Anonymous Anonymous said...

Very interesting posts! I wonder if there was organic damage in the famous Schreber case. This case has fascinated me since I first read the original Freud report.

"Schreber was a successful and highly respected judge until middle age when the onset of his psychosis occurred. He woke up one morning with the thought that it would be pleasant to "succumb" to sexual intercourse as a woman. He was alarmed and felt that this thought had come from somewhere else, not from himself. He even hypothesized that the thought had come from a doctor who had experimented with hypnosis on him; he thought that the doctor had telepathically invaded his mind.

As his psychosis progressed, he believed that God was turning him into a woman..."

At October 26, 2009 3:28 PM, Blogger The Neurocritic said...

Famous though it is, I hadn't heard of the Schreber case before. I don't know the literature on this type of delusion in schizophrenia and how (un)common it is. I suppose he could've had frank brain damage as well...

At October 26, 2009 4:09 PM, Anonymous Anonymous said...

NC - the reason that I read your blog came from way back when. Your long post about spindle neurons. If you will read up on them again, and on results of their dysfunction, you may find that some of this fits there.

At October 27, 2009 3:51 PM, Blogger The Neurocritic said...

Given the sheer amount of brain tissue affected in these cases, I'm not sure how you can say anything about spindle neurons being involved in these sexuality changes. My old post on Spindle Neurons and Frontotemporal Dementia noted the work of Seely et al., demonstrating that spindle neurons (aka von Economo neurons) in anterior cingulate and frontoinsular cortices showed extensive degeneration. Yes, some FTP patients are hypersexual, but a greater percentage are hyposexual (Miller et al. 1995).

We don't have a clear idea of where the brain injury is located in most of the patients described here. The formerly gay man had a stroke in the MCA territory which could have affected insula, but not anterior cingulate. And some of the patients had damage restricted to the temporal lobes. To my knowledge, there are no spindle neurons located there.

At October 27, 2009 4:01 PM, Blogger The Neurocritic said...

That's not to say that spindle neurons don't have a role in social behavior (which includes sexuality). They likely do. I've been wanting to do an update on the topic, given they've been found in elephants too:

"The VEN morphology appears to have arisen independently in hominids, cetaceans, and elephants, and may reflect a specialization for the rapid transmission of crucial social information in very large brains."


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