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HEAD INJURY AND SEXUALITY:
A LITERATURE
REVIEW
ABSTRACT
THEORETICAL
CONSTRUCTS
CLINICAL EXPERIENCE
EMPIRICAL
DATA
DYADIC RESEARCH
LOCALISATION OF LESIONS
OTHER SOFT PATHOPHYSIOLOGICAL
DATA
TREATMENT CONSIDERATIONS
CONCLUSION
REFERENCES
ABSTRACT:
Empirical data on head injury and human sexuality was mainly limited
to small series or few parameters until 1988. In the last 4 years, substantive
studies have documented the high prevalence and common patterns of disturbance
to sexual behaviour following closed and penetrating head injuries of varying
severity. Further light has been shed on the anatomical localisation of our polymorphous
perversity, and studies of nontraumatic brain injury have illuminated atypical
changes in sexual behaviour after penetrating head injury. Published principles
of state of the art management are summarised.
Head injury comprises traumatic damage to the skull and its contents, from penetration or acceleration/deceleration forces. Clinically, it implies evidence of raised intracranial pressure, loss of consciousness, post-traumatic amnesia, neurological signs of impaired brain function, and/or skull fracture. According to US statistics, for every million of the population, 4000 head injuries will occur each year, adding annually a further one hundred survivors of serious injury (Garden et al., 1990.)
Consequential disturbance of sexual functioning is the rule rather than the exception (Blackerby, 1987.)
As 85% of all head injuries' occur before age 25, there is often arrested development of sexual self-concept (Blackerby, 1987.)
The author classifies some altered sexual behaviours following head injury as transitory and normative; most as the sexual content of acting out behaviours, sometimes impulsive; many as dysfunctions, arising from cognitive and physical deficits; and a few as the results of sexual identity confusion.
The brain damage itself, social environmental response, and pre-injury social skills and experiences all affect subsequent sexual behaviour. Brain trauma may lead to poor judgement, egocentricity or insensitivity to the partner, inability to tolerate delayed gratification, poor memory, distractibility, impaired motor functions and side effects of medications.
Social environmental responses include social isolation, depression or anxiety, altered body image and self-concept, and role changes on the part of the spouse or partner.
Premorbid factors comprise general knowledge concerning sexuality, social skills in interacting with others, experiences with friendships, dating, marriage and sex.
Blackerby (1987) proposes that sexual drive, subserved by deep structures, is rarely disturbed by nonpenetrating head-injury; that it is motivation and initiation which are damaged, by blunt frontal lobe trauma.
Sexual arousal may also be reduced by loss of touch sensations, impaired sense of smell, or loss of capacity for visual imagery (Hayden and Hart, 1986.)
Early, middle and late stages of recovery from more than mild head injury are characterised by changing and overlapping patterns of disturbance of sexual behaviour (Blackerby, 1987.) Initially, there is often exhibitionistic exposure and masturbation. Sexual delusions may be evident. Confabulation extends into the middle stage, which is characterised by inappropriate verbal allusions, joking and approaches. Approaches may be physical, accompanying increased sexual drive. Later "re-entry" behaviours are more influenced by (i)nsensitivity to others, distractibility, poor judgment, memory disturbance, spouse or family role change, depression, social isolation, anxiety, medication effects, altered body image and self-concept.
Incomplete control of any seizures, and the medications prescribed, may be accompanied by diminished libido.
Lezak (1978) largely attributes spousal sexual and affectional frustration to patients' reduced interpersonal sensitivity and ability to empathise, and the mismatch between desire and performance. Many patients make incessant demands, whether or not those demands can be satisfied. Sexual sharing is often one-sided - taking by the patient, giving by the partner. The patient frequently blames the partner for any sexual dysfunction.
The patient and the relationship may be so altered that some wives feel as if they are being "unfaithful" during sexual relating after head-injury (Hayden and Hart, 1986.)
Early studies of head-injured populations established the high prevalence of sexual behaviour disturbance, and attempted to correlate some of the clinical variables.
Bond (1976) assessed the psychosocial outcome of severe head injury, using neurophysical, mental and social scales. In his study of 57 patients, length of post-traumatic amnesia and levels of physical disability or cognitive impairment did not predict the occurrence or severity of sexual disturbance.
Kosteljanetz et al. (1981) studied a sample of 19 males who were unconscious for less than 15 minutes and who had post-concussive symptoms lasting a minimum of 6 months. 10 (53%) reported reduced libido, 8 (42%) erectile dysfunction. In his study, sexual dysfunction was more common in the intellectually impaired patients.
Dreaming was not reduced overall following head injury, but the two-thirds of patients who were initially in coma reported a significant decrease in sexual content (Benyakar et al., 1988.) Whether or not there was initial unconsciousness, dreams of threatening content increased.
As impaired self-perception is usual following traumatic brain injury, a number of authors have attempted to validate the responses of patients by questioning their sexual partners independently.
A series of 50 adults with a minimum of 24 hours post-traumatic amnesia included 12 married patients (Oddy et al., 1978.) 6 months after the injury they reported no persistent sexual problems, and increases as often as decreases in coital frequency. 6 months later still (Oddy and Humphrey, 1980), three of 7 spouses felt less affectionate towards their injured mates but still reported no significant change in sexual behaviour. The only exception was a patient who had developed "partial impotence": his wife felt both partners were experiencing less satisfaction even when sex was technically satisfactory.
Rosenbaum and Najenson (1976) interviewed the wives of 10 severely brain-injured and 6 spinal-cord injured soldiers 1 year after the event. Sexual activity was better maintained by the brain-injured, and patients' distress about changes in sexual functioning was less, but their wives reported the greater mood disturbances. The authors partially attributed these wives' greater dislike of physical intimacy to the brain-injured men's "being more self-oriented and exhibiting more childlike dependency" (including less involvement in childrearing and family finances.)
47% of mothers and wives reported that brain-damaged patients, half of them traumatically head-injured, developed sexual preoccupation or lack of interest(Mauss-Clum and Ryan, 1981.) In contrast with the Oddy et al. series, patients' inflexibility (20%), inappropriate public behaviour (40%), self-centredness (43%) and decreased self-control (47%) mitigated against sexual re-adjustment. A quarter of the wives had been verbally abused, one in five threatened with physical violence and criticised by their spouses for providing poor care. A third felt they were married to a stranger, nearly a half that they were "married but don't have a husband." Roughly three-quarters of the wives responded with frustration, irritability, depression and anger.
Peters et al. (1990) of Winnipeg found that wives of severely head-injured men reported they received significantly less expression of affection than those of mildly or moderately injured patients.
Kreutzer and Zasler (1989) attempted to assess more comprehensively and specifically changes in sexual functioning following traumatic brain injury. Their Psychosexual Assessment Questionnaire (PAQ), addresses behaviour, affect, self-esteem and qualitative attributes of relationships. The authors have so far reported its use only in 21 male outpatients.
Garden et al. (1990) undertook a similar study of 11 male and 4 female patients and their spouses, using questionnaires adapted from the American Medical Association's Self-Evaluation of Sexual Behaviour and Gratification.
Rather more than half (57%) of the Kreutzer and Zasler (1989) sample reported decreases in sex drive, 14% increased libido. All the Garden et al. (1990) female patients commented that after injury they rarely or only occasionally desired intercourse when their spouses did not. Only 1 male had more frequent than spousal coital desire. Spousal answers were generally in agreement.
Sexual arousability and orgasmic release were commonly impaired in both patients and partners. 57% of the Kreutzer and Zasler (1989) patients reported decreases in ability to maintain an erection, 1 patient an increase. Ease of orgasm (ejaculation) was unchanged in about half, decreased in a third, and improved in the remaining one-sixth of the Kreutzer and Zasler (1989) series. The corresponding Garden et al. (1990) figure for erectile and ejaculatory difficulties was 36% of patients, and 1 out of 4 spouses. Spousal anorgasmia increased from 27% to 64% after the injury, and 1 out of the 3 previously orgasmic female patients developed difficulty.
Time spent in noncoital sexual activity changed significantly, but this was not necessarily a problem. 57% of the Kreutzer and Zasler (1989) patients reported changes in time spent in precoital sex play. A third of the Garden et al. (1990) partners did not have consensus on this question, but 60% of the remaining couples reported change. However, dissatisfaction of all spouses about length of foreplay fell from 27% to 13% after the injury.
The majority of couples reduced frequency of sexual intercourse after head injury. Nearly two-thirds (62%) of the Kreutzer and Zasler (1989) patients, 55% of the Garden et al. (1990) male and 75% of their female patients, reported diminished coital frequency, only one male patient in each series an increase. In the latter series, 47% were dissatisfied, 40% indicated no change, and 13% were happier with this change.
More than half the Kreutzer and Zasler (1989) patients reported decreased self-confidence (67%) and sex appeal (52%), and increased depression (71%), the opposite changes occuring in 14%, 0% and 10% respectively. In contrast, only 1 Garden et al. (1990) male patient, and the spouse of another, found that their partners lost attractiveness after the injury.
Effects on stable relationships were variable. Though 6 of the 16 Kreutzer and Zasler (1989) married patients described their relationships as good or very good compared to before the injury, the same proportion rated communication as worse. None of the 5 single patients had a steady heterosexual relationship. Conversely, 8 out of 15 Garden et al. (1990) spouses reported overall satisfaction with marital sexual adjustment and 6 rated their partners' satisfaction similarly.
O'Carroll et al. (1991) in St. John's, Newfoundland, investigated with the Golombok Rust Inventory of Sexual Satisfaction (GRISS) the psychosexual dysfunction profiles of 21 male patients and 14 partners, years after hospitalisation for closed head-injury. 50% of the patients and 9% of the partners had profiles outside the normal range. For neither group did severity of the head-injury predict the degree of distress. In addition to the expected correlation between psychosexual dysfunction and advancing age, the more recent the head-injury the greater were problems with premature ejaculation and male sexual avoidance, whereas male dissatisfaction increased with time since injury.
As well as a positive correlation between age of female sexual partner and Nonsensuality, there was evidence of increasing sexual Noncommunication with time since the injury. Scores on the General Health Questionnaire (GHQ), a self-report measure of general psychiatric symptomatology, correlated very highly with GRISS Total Score, and significantly with Infrequency, Female Dissatisfaction and Vaginismus. The Hospital Anxiety and Depression Scale (HAD) Dep and Anx subscores also correlated with GRISS Total Score, Infrequency and Female Dissatisfaction. HAD Anx was also related to Vaginismus. Thus, communication appeared to deteriorate progressively, and partners' emotional distress was reflected in a variety of psychosexual complaints.
Clark et al. (1988), studied 33 patients who had a period of unconsciousness followed by at least 24 hours' post-traumatic amnesia. They demonstrated a fall in testosterone during the first three days after head injury, apparently due to damage to the hypothalamus. This hypogonadism effect, which correlated positively with severity of injury, persisted at 3-6 months in 5 out of the 21 patients retested.
Study of disturbances in sexuality after focal brain injury may give clues about areas of brain involved in normal sexual response.
Sabhesan and Natarajan (1989) attempted to correlate evidence of persistent neurological damage with disturbances of sexual functioning still evident in 21 out of 34 East Indian patients a year after head injury. Sexually-inappropriate behaviour (purposeful use of lewd language, frotteurism, exhibitionism, sadism and rape) occuring for the first time following the head-injury, was consistently associated with other evidence of frontal lobe damage. In the other three out of eight patients with frontal lobe syndrome (constricted emotional expression, reduced inhibition, impaired foresight, personality change, usually intellectual impairment) , there was total loss of libido as part of global amotivation.
Patients with continuing sexual disturbances (sexually-inappropriate behaviour and dysfunctions) were distinguishable from the recovered controls in having significant prevalence of delusional disorder, depression and other neurotic features. In this East Indian population, diminished coital frequency following head trauma was exaggerated by a voluntary restriction of intercourse to conserve health and strength. This effect arose from the widespread myth that semen (= Sakthi = vitality) is drawn from all parts of the body and is the recreator of the self.
Hypersexual behaviour is much less common than hyposexuality following brain injury. Miller et al. (1986) attempted to correlate the development of hypersexual states with the site of the lesion in 4 patients with nontraumatic brain injury. Two of the patients had basal frontal lesions, whereas a third developed injury to the thalamic and periventricular regions of the right hemisphere, accompanied by a sexual preoccupation in the context of a manic syndrome.
The fourth Miller et al. patient, who had temporal lobe damage, developed interictal hyposexuality punctuated by hypersexual arousal after seizures. Similar hypersexuality has been documented following temporal lobectomy for epilepsy (notably Blumer, 1970). The Kluver-Bucy Syndrome (visual agnosia, placidity, altered sexual activity, irresistable impulse to touch, hyperorality and altered dietary habits), was first described in rhesus monkeys. Including a striking increase in the amount and diversity of sexual manifestations, it has similarly been described (Isern, 1987) after a gunshot wound to the temporal lobe.
Temporal lobe structures also appear to mediate sexual preference. The Kluver-Bucy Syndrome in humans, both atraumatic and following head injury, is usually associated with aphasia, amnesia, dementia and sometimes seizures. It has involved changes in sexual preference more commonly than hypersexuality (Lilly et al., 1983.) These case-reports echo that of Mitchell et al. (1954) whose patient's temporal lobe epilepsy was invariably triggered by viewing of a fetish object (safety-pin): not only the epilepsy, but also the fetish itself, was abolished by temporal lobectomy.
Miller et al. described 4 further patients who developed a change from what was previously a stable and established pattern of sexual behaviour. 3 of them had nontraumatic lesions in or near the limbic system. 2 previously heterosexual men developed pedophilia and uncharacteristic voyeurism respectively, and a heterosexual woman developed homosexual orientation. Limbic encephalitis, characteristic of rabies, is associated with acute sexual disinhibition; a similar picture was seen chronically in a young woman who suffered young childhood encephalitis (lethargica?) (Poeck and Pilleri, 1965). Erotomania (de Clerambault's syndrome) in which there is central delusion of "amorous (nonverbal) communication" with someone who initiated but will not acknowledge the love pact, has occured after head trauma (Signer and Cummings, 1987).
Miller et al.'s fourth patient developed penile mutilation in response to levodopa-carbidopa treatment of Parkinsonism, a disease affecting the basal ganglia. Approximately half of Parkinson's patients respond to levodopa with an activation of sexual behaviour.
OTHER SOFT PATHOPHYSIOLOGICAL DATA
Pandita-Gunawardena (1990) described a case of periodic paraphilic infantilism arising after recovery from six months' coma following a closed head injury at age 6 years. The patient presented at age 80 after he was arrested for indecent exposure. The sister, with whom he had lived for 60 years, had been hospitalised and was therefore no longer able to indulge his fetish by diapering and bottle-feeding him and taking him out in a pram (stroller.)
As a matter of more common clinical interest, Henn et al. (1976) found that, of 111 offenders arrested for child molestation, 14.4% were suffering from acquired organic brain disease (no further clinical details given), besides the 13.5% who were mentally retarded.
Of the roughly 10,000 brain-injured Finn veterans of the Second World War, Achte et al. (1991) reported on the 2907 suffering from psychiatric disturbance. Delusional psychosis was the most common (28%) main diagnosis of the 762 identified as suffering from psychotic illnesses. Jealousy, or fear of being sexually betrayed, was the most prominent individual content of their delusions. Recurring themes were belief that "anxiety-provoking masturbatory fantasies" were known to other people, and "thirst for seemingly righteous revenge", accompanied by outbursts of violent behaviour. Commonly 15-19 years elapsed between injury and onset of the delusional psychosis, a significantly longer latency than that of the paranoid schizophrenic and schizophreniform psychoses seen in other veterans. The authors saw heavy use of alcohol and drugs by brain-damaged veterans suffering from associated sexual disorders as probably contributing to the dominance of sexual jealousy in their delusions.
Hough (1989) surveyed 32 professional staff, mainly clinical, of an urban rehabilitation program for head-injured adults. 94% anticipated sexual adjustment problems and potential difficulties with self-esteem might develop if no information on sexuality was provided, but the majority did not introduce the topic proactively. Where only 6% thought sexual adjustment somewhat important for only a few clients, 19% feared that inclusion of sexual information might interfere with more important aspects of rehabilitation by distracting the client's attention or motivation.
The staff, 59% of whom had not attended a course or workshop on sexuality within the preceding 5 years, included the following training suggestions: related sexual dysfunctions and behaviours, approaches to spousal education and realistic couple sexual adjustment, effect of cognitive deficits on abilities to practice safer sex, clients' perceptions of sexuality, dating resources, and gay and lesbian issues.
Blackerby (1987) proposes that the self-stimulation characteristic of the early stage of recovery is part of the "normal adaptive awakening process", functional stimulation which assists the lightening of consciousness. Patients who are capable can be redirected to keep the self-stimulation socially appropriate; those who are not capable must be afforded sufficient privacy to minimise public discomfort or violation.
For the direct effects of brain injury on sexual functioning, seen in the early stages of recovery, he uses a combination of cognitive restructuring, specific suggestions in the form of alternative strategies, sex aids, and traditional behavioural sex therapy techniques.
Middle-stage social environmental factors require the addition of education and counselling, individual, family and group. Butler and Satz (1988) emphasise the importance of distinguishing and addressing specific ("it's like being with a child", "...just no longer the same") as well as more global (depression, other reactive symptomatology) causes of hypoactive desire states in the partner.
More hard-core are the premorbid factors, which, according to Blackerby (1987), can be modified to a lesser degree by including social skills training. Situationally-inappropriate late recovery conduct has been amenable to behaviour modification if sufficient cognitive functioning is retained.
Zencius et al. (1990) illustrate the effectiveness of behaviour modification techniques in a variety of hypersexual states. A young woman's sexual approach to men was largely abolished by giving half-hourly, reducing to twice-weekly, verbal feedback about the appropriateness of her behaviour. Exhibitionism in a man in his 30s was successfully addressed by self-monitoring (journalling), directed masturbation with guided imagery, and dating-skills training. Inappropriate touching by another, younger, man was largely abolished by giving him the opportunity to undertake massage in regular, scheduled, relaxation sessions.
The previously scant literature on the sexual consequences of head injury is growing rapidly. A proliferation of clinical population studies in the last 4 years has fleshed out the common clinical syndromes of sexual behaviour disturbance following traumatic brain injury. There is a somewhat fuller understanding of the anatomical basis of diverse rarer disturbances, usually following penetrating head trauma. A number of authors during the last 5 years have shared their experiences in helping patients and their partners deal with the often distressing sexual repercussions of head injury.
Achte K., Jarho L., Kyykka T., & Vesterinen E. (1991). Paranoid disorders following war brain damage. Preliminary report. Psychopathology 24(5), 309-15
Benyakar, M., Tadir, M., Groswasser, Z., & Stern, M.J. (1988). Dreams in head-injured patients. Brain Injury 2(4), 351-6
Blackerby, W. (1987). Disruption of sexuality following a head injury. National Head Injury Foundation News, 7,8.
Blumer, D. (1970). Hypersexual episodes in temporal lobe epilepsy. American Journal of Psychiatry, 126(8), 1099-1106.
Bond, M.R. (1976). Assessment of the psychosocial outcome of severe head injury. Acta Neurochirugia (Wien) 34(1-4), 57-70
Butler, R.W. & Satz, P. (1988). Individual psychotherapy with head-injured adults: Clinical notes for the practitioner. Professional Psychology Research and Practice, 19(5), 536-541.
Clark, J.D.A., Raggatt, P.R. & Edwards, O.M. (1988). Hypothalamic hypogonadism following major head injury. Clinical Endocrinology, 29, 153-165.
Garden, F.H., Bontke, C.F. & Hoffman, M. (1990). Sexual functioning and marital adjustment after traumatic brain injury. Journal of Head Trauma Rehabilitation, 5(2), 52-59.
Hayden, M.E. & Hart, T. (1986). Rehabilitation of cognitive and behavioral dysfunction in head injury. Advances in Psychosomatic Medicine, 16, 194-229.
Henn, F.A., Herjanic, M. & Vanderpearl, R.H. (1976). Forensic psychiatry: Profiles of two types of sex offenders. American Journal of Psychiatry, 133(6), 694-696.
Hough, S. (1989). Sexuality within the head-injury rehabilitation setting: a staff's perspective. Psychological Reports, 65(3 Pt 1), 745-6
Isern, R.D. (1987) Family violence and the Kluver-Bucy syndrome. Southern Medical Journal, 80(3), 373-7
Kosteljanetz, M., Jensen, T., Norgard, B., Lunde, I., Jensen, P., & Johnsen, S. (1981). Sexual and hypothalamic dysfunction in the post-concussional syndrome. Acta Neurologica Scandinavica, 63, 169-80.
Kreutzer, J.S. & Zasler, N.D. (1989). Psychosexual consequences of traumatic brain injury: methodology and preliminary findings. Brain Injury, 3(2), 177-86
Lezak, M. (1978). Living with the characterologically altered brain injured patient. Journal of Clinical Psychiatry, 39, 592-598.
Lilly, R., Cummings, J.L., Benson, F. & Frankel, M. (1983). The Human Kluver-Bucy syndrome. Neurology, 33, 1141-1145.
Mauss-Clum, N. & Ryan, M. (1981). Brain Injury and the Family. Journal of Neurosurgical Nursing, 13(4), 165-169.
Miller, B., Cummings, J., McIntyre, H. & Ebers, G. (1986). Hypersexuality or altered sexual preference following brain injury. Journal of Neurology, Neurosurgery and Psychiatry, 49, 867-873.
Mitchell, W., Falconer, M.A. & Hill, D. (1954). Epilepsy with fetishism relieved by temporal lobectomy. Lancet, 1954(2), 626-630.
O'Carroll, R.E., Woodrow, J. & Maroun, F. (1991). Psychosexual and psychosocial sequelae of closed head injury. Brain Injury, 5(3), 303-13
Oddy, M., Humphrey, M. & Uttley, D. (1978). Subjective impairment and social recovery after closed head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 41, 611-616.
Oddy, M. & Humphrey, M. (1980). Social recovery during the year following severe head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 43, 798-802.
Pandita-Gunawardena, R. (1990). Paraphilic infantilism: A rare case of fetishistic behaviour. British Journal of Psychiatry, 157, 767-770.
Peters, L., Stambrook, M., Moore, A. & Esses, L. (1990). Psychosocial sequelae of closed head injury: effects on the marital relationship. Brain Injury, 4, 39-47.
Poeck, K. & Pilleri, G. (1965). Release of hypersexual behaviour due to lesion in the limbic system. Acta Neurologica Scandinavica, 41, 233-244.
Rosenbaum, M. & Najenson, T. (1976). Changes in life patterns and symptoms of low mood as reported by wives of severly brain-injured soldiers. Journal of Consulting and Clinical Psychology, 44(6), 881-888.
Sabhesan, S. & Natarajan, M. (1989). Sexual behavior after head injury in Indian men and women. Archives of Sexual Behavior, 18(4), 349-356.
Signer, S.F. & Cummings, J.L. (1987). De Clerambault's syndrome in organic affective disorder. Two cases. British Journal of Psychiatry, 151, 404-7.
Zencius,
A., Wesolowski, M.D., Burke, W.H. & Hough, S. (1990). Managing hypersexual
disorders in brain-injured clients. Brain Injury, 4(2), 175-181
ABSTRACT
THEORETICAL
CONSTRUCTS
CLINICAL EXPERIENCE
EMPIRICAL DATA
DYADIC RESEARCH
LOCALISATION OF LESIONS
OTHER SOFT PATHOPHYSIOLOGICAL DATA
TREATMENT CONSIDERATIONS
CONCLUSION
REFERENCES
