BRAIN INJURY, 1998, VOL. 12, NO .

8, 703± 707

Ca se stud y

Medroxyprogesterone in the treatment of

K EN NET H R . BR IT TO N
Physical Medicine and Rehabilitation, The University of Minnesota, USA

(Received 2 December 1997; accepted 14 January 1998 )

Sexual function is among the many areas affected by traumatic brain injury. The most common change
is decreased sexual performance and satisfaction, for the brain injured person and the sexual partner.
Hypersexuality, especially inappropriate sexual comments and gestures, is also a common result of
traumatic brain injury. A case of hypersexuality in a severely disabled brain injured man is presented.
He was successfully treated with medroxyprogesterone acetate after failure of multiple other treatment
strategies. The literature is reviewed. An evaluation and treatment strategy for sexual dysfunction post
traumatic brain injury is presented.

Introd uctio n
The effects of traumatic brain injury on human sexuality remain poorly understood.
The medical literature describes both hyposexuality and hypersexuality as possible
outcomes. Inappropriate sexual comments and behaviour is a frequently encoun-
tered problem in brain injured patients. Failure to adequately address inappropriate
or hypersexual behaviour results in increased difficulty with community reentry and
additional stress on the family relationships for the brain injured patient. Failure to
recognize and treat hyposexuality, while less of a problem for the rehabilitation
team, adds to the burden on the relationship between the brain injured patient and
their spouse or sexual partner.
This paper reports the case of a severely disabled brain injured man. The suc-
cessful treatment of his hypersexual behaviour averted his expulsion from the only
facility in his home community that could provide for his care.

Ca s e s tud y
RD is a 36 year-old brain injured male who presented to the Physical Medicine and
Rehabilitation Service of the Minneapolis Veterans Administration Medical Center.
His current treatment programme failed to control his sexually inappropriate and
aggressive behaviours. The Director of Nurses in the nursing facility in which he
resided, his attending physician, and his family requested that he be evaluated and a
new treatment plan developed. The problematic behaviours included touching or

Correspondence to: Kenneth R. Britton, DO, Physical Medicine and Rehabilitation, The
University of Minnesota, Minneapolis Veterans Administration Medical Center, 701 Park Avenue,
Minneapolis, MN 55415-1829, USA.
0269± 9052/98 $12 ´ 00 Ñ 1998 Taylor & Francis Ltd.
704 K. R. Britton

grabbing the breast, buttocks, and genital region of female staff, residents, and
visitors, `constant’ masturbation when he lay down, and hitting, kicking, and occa-
sionally, choking male staff, residents and visitors. The nursing facility would not
continue to provide for his care unless these behaviours were controlled.
RD was initially injured at the age of 21, during a high speed motorcycle
accident. He was ultimately transferred to a nursing home in a persistent vegetative
state.
Six years post injury he was able to visually track, reliably nod his head yes or no
in response to questions, and move his extremities purposefully, although with poor
control. Aggressive behaviour towards male residents began 8 years post injury.
Behavioural management techniques such as time out, verbal reprimands, and
verbal feedback from the staff and the psychologist were ineffective. He was also
treated with trazodone, alprazolam, phenytoin, carbamazepine, and lithium. These
treatments failed to control his aggressive behaviour. Over time his behaviour
progressed and included the combination of inappropriate sexual touch, excessive
masturbation, and aggression toward males. These behaviours steadily increased up
to the time of his admission.
A functional assessment at the time of admission found that he could feed
himself with adaptive equipment and set up. His major nutrition was via a gastro-
stomy tube. He could push his wheelchair backwards for short distances, but not
forwards. Transfers and mobility were dependent. A Foley catheter provided blad-
der management and he was on a bowel programme with good control. He
responded to simple commands and directions. He would speak some words, but
his vocabulary was limited and he was dysarthric. Thumb up or thumb down was
used with fair reliability for yes/no responses.
Laboratory studies were normal. Magnetic Resonance Imaging of the brain
revealed symmetrically increased signal in the periventricular white matter indicative
of previous trauma, and diffuse moderate cerebral atrophy. The EEG was normal.
A psychiatric consultation was obtained. The psychiatrist’ s impression was that
RD showed severe cortical disease with behaviours that were a combination of
organic pathology and a compulsive disorder.
While RD was hospitalized (total stay of 10 days), a behaviour modification
program me was instituted. This was an operant conditioning program me without a
cognitive training component. This program me showed promise, with the inap-
propriate sexual touch decreasing from four to five episodes per day to one to two
episodes per day at the time of discharge.
During this hospitalization, occasional masturbation was noted, but not nearly to
the extent reported by the nursing home. No episodes of aggression towards males
were noted.
RD was discharged back to the nursing home with valproic acid and the behav-
ioural management programme. One month later he was seen for follow-up. All of
his problematic behaviours had recurred. His valproic acid level was therapeutic.
The staff of the nursing home admitted that they had been unable to follow through
with the behavioural program me. The behavioural managem ent programme and
the valproic acid were discontinued.
Medroxyprogesterone acetate 300 mg as a weekly intramuscular injection was
ordered with the approval of his mother, who is also his legal guardian and con-
servator. Follow-up was initiated at one and two months of therapy. The prob-
lematic behaviours were better within 10 days and adequately controlled by 3 weeks
Treatment for hypersexual behaviour 705

of therapy. Presently he has four to five episodes per week of inappropriate touch
and occasional, but not prolonged, masturbation. He continues to react violently
toward men `that he doesn’t like’ . Overall, his aggressive behaviour is much
improved. He is noted to be calmer and to interact more with the staff, including
increased speech. Follow-up completed blood count (CBC) and metabolic studies
remain normal. No negative effects have been noted.
Follow-up visits were held at monthly, then quarterly, intervals. This treatment
remained effective in controlling his sexually aggressive behaviour. Telephone fol-
low-up revealed that his local physician was now prescribing the medroxyproges-
terone at the original 300 mg per week dosage. The nursing facility continues to
provide care and the nursing staff and his mother are quite pleased with the out-
come.

D is cu s s io n a nd c onclu s io ns
The topic of sexuality in the brain injured patient has received increased attention in
the past few years. The available literature suggests that sexual dysfunction is a
frequent complication of traumatic brain injury [1± 3]. Kreutzer and Zasler [1]
found that 57% of the patients in their study reported a decrease in sex drive,
compared to 14% with increased and 28% with unchanged sex drive relative to
their pre-injury function. The incidence of reduced sexual drive increased to71% in
severe head injury [3].
Although reduced sexual drive is the most common form of sexual dysfunction
post brain injury, the literature also reports multiple cases of hypersexuality [4, 5].
Hypersexuality can include promiscuity, seductiveness, excessive or public mastur-
bation, exhibitionism, rape, or voyeurism. Penile mutilation has also been reported
[5]. Sexual activities of this type can cause significant legal difficulties including
potential incarceration.
Hypersexuality may be due to anatomic lesions or epilepsy of the temporal lobe
or limbic system [6± 8]. Hypersexuality with an organic aetiology may be amenable
to treatment with anticonvulsants such as carbamazepine or valproic acid.
The most common form of hypersexuality, however, is inappropriate sexual
comments and gestures [7± 10]. These actions frequently are manifested in the
early post injury period [11]. A progression of sexual interest is often noted as the
patient advances through the levels of brain injury recovery [12]. Inappropriate
sexual remarks and gestures most commonly represent disinhibition rather than
hypersexuality. The psychosocial impairments of the brain injured person impact
on their ability to interact appropriately, including in their sexual relationships.
Whyte [8] states, `Contrary to popular belief, hypersexuality is not common, but
a high incidence of impulsivity or inappropriate sexual remarks may be seen in
disinhibited patients with frontal lobe injury’ .
Hyposexuality, similarly, may have an organic basis, or may be secondary to the
psychosocial complications of brain injury. These secondary causes may include
increased interpersonal tension, depression, loneliness, loss of feelings of attractive-
ness or self-esteem [11]. These changes may be present in either the brain injured
person or in their sexual partner.
Evaluating sexuality in the brain injured patient begins with taking historical
information from the patient, and if possible, the sexual partner. Of primary import-
ance is the current, compared to the premorbid, sexual function and interest. If
706 K. R. Britton

sexual dysfunction is noted, an initial search for underlying treatable causes should
be undertaken. A careful review of medications, with attention to those which may
affect sexual function, must be performed. An MRI of the brain and EEG will
evaluate for anatomic lesions or epilepsy. Laboratory studies can include CBC,
metabolic profile, thyroid profile, urinalysis, and serum follicle stimulating hormone
and oestrogen or testosterone levels. An evaluation for depression is indicated in
hyposexuality. Standard medical treatment for any observed underlying medical
condition should be instituted.
If no organic cause for the sexual dysfunction is found, then empiric treatment is
indicated. Hyposexuality may respond to sexual counselling for the couple with a
sex therapist. Hypersexuality may be treated with behavioural management tech-
niques or by medication. Medications that may be useful include carbamazepine,
phenytoin, valproic acid, and medroxyprogesterone acetate. Medroxyprogesterone
acetate is especially helpful, in men, in cases where hypersexual behaviour is unre-
sponsive to other therapies, or where rapid control of the behaviour is necessary
[13± 15]. Side effects reported with the use of medroxyprogesterone acetate in
demented or psychiatric patients have been negligible. It has been well tolerated
and rapidly effective. Discontinuation of the drug may be possible after 1 year of
therapy without recurrence of the hypersexual behaviour.
For all patients, but especially those who will reenter the community, brain
injury treatment must include sexuality evaluation and treatment of dysfunction.
Vital aspects of this treatment include self-care and groom ing and communication
skills. It is common for brain injured persons to have difficulty appropriately initiat-
ing or continuing conversation with a potential sexual partner. Much of human
sexuality involves communication and intimacy without coitus. The impaired psy-
chosocial skills of the brain injured person in these areas must be addressed before a
sustained sexual relationship can be maintained. Likewise, the egocentricity, impul-
sivity, and impaired insight common to many brain injured patients, create barriers
to mutually satisfying sexual relationships. Cognitive training and/or behaviour
modification programmes can be very helpful in addressing these problems. In
the long term these types of treatment will likely prove more effective than drug
therapy in most patients. Many programmes of this type are in use currently [3, 7,
9± 12, 16± 19].

S um m a ry
The case presented in this paper is interesting from the aspect of the late onset of
hypersexual behaviour and the social problem of the impending expulsion from the
nursing facility. In a rural environment, such as Minnesota, there may be limited
availability of facilities or services in the home community capable of providing the
care needed by the brain injured person. Socially unacceptable sexual behaviour
may prevent them from receiving the needed services. In cases like this, a treatment
such as medroxyprogesterone acetate may be indicated to preserve the ability of the
patient to remain in his community and benefit from the interaction with family and
friends. Alternative treatment such as behavioural management may also be effective.
This case also demonstrates a significant management problem. An appropriate
behavioural programme was shown to be effective, however, the care facility staff
were unwilling to follow this plan. The staff, as well as the patient’s mother, were
Treatment for hypersexual behaviour 707

unwilling to alter their approach. They were also unwilling to attempt a trial of
reduction of the medroxyprogesterone.
Medroxyprogesterone appears to be an effective and safe treatment for aggressive
hypersexual behaviour in the brain injured male. It is likely that the dosage can be
reduced and eventually discontinued. Further trials and reports in the literature
would be helpful in determining the role of this treatment.

Referenc es
1. K REUTZER, J. and ZA SLER, N. : Psychosexual consequences of traumatic brain injury: methodology
and preliminary findings. Brain Injury, 3: 177± 186, 1989.
2. ZENCIUS, A., WESOLOW SKI , M., B URKE, W. et al.: Managing hypersexual disorders in brain-
injured clients. Brain Injury, 4: 175± 181, 1990.
3. B LA CKENBY , W. and PORTER, S. : Psychosocial aspects of sexual dysfunction in head injury. In
Traumatic brain injury. State of the art reviews. Physical Medicine and Rehabilitation, 3: 1989.
4. GRABER, B., HA RTMANN, K., COFFMAN, J. et al.: Brain damage among mentally disordered sex
offenders. Journal of Forensic Sciences, 27: 125± 134, 1982.
5. M ILLER, B., C UMMINGS , J., M C INTYRE, H. et al.: Hypersexuality or altered sexual preferences
following brain injury. Journal of Neurology, Neurosurgery, and Psychiatry, 49: 867± 873, 1986.
6. WOOD, R. (editor): Neurobehavioral Sequelae of Traumatic Brain Injury (Taylor & Francis, Bristol,
PA), 1990.
7. WEHMAN, P. and K REUTZER, J. (editors): Vocational Rehabilitation for Persons with Traumatic Brain
Injury (Aspen, Rockville, MD), 1990.
8. WHYTE, J. and R OSENTHAL, M.: Rehabilitation of the patient with traumatic brain injury. In
J. DeLisa and B. Gans (editors) Rehabilitation Medicine Principles and Practice, 2nd edn ( J. B.
Lippincott, Philadelphia), pp. 849± 850, 1993.
9. R OSENTHAL , M., GRIFFITH, E., B OND , M. et al.: Rehabilitation of the Adult and Child with
Traumatic Brain Injury, 2nd edn (F. A. Davis, Philadelphia), 1983.
10. S A CHS, P.: Treating Families of Brain-injury Survivors (Guilford Press, New York), 1988.
11. O’ HA RA , C. and HARRELL , M. : Rehabilitation with Brain Injury Survivors: An empowerment approach
(Aspen, Gaithersburg, MD), 1991.
12. COLE, T. and COLE, S. : Rehabilitation of problems of sexuality in physical disability. In F. Kottke
and J. Lehman (editors) Krusen’s Handbook of Physical Medicine and Rehabilitation, 4th edn (W. B.
Saunders, Philadelphia), p. 1000, 1990.
13. B ERLIN, F.: Treating sexual disorders with medroxyprogesterone acetate. Currents in Affective
Illness, 6: 5015, 1987.
14. COOPER, A. : Medroxyprogesterone acetate (MPA) treatment of sexual acting out in men suffering
from dementia. Journal of Clinical Psychiatry, 48: 368± 370, 1987.
15. JENIKE, M. : Geriatric Psychiatry and Psychopharmacology: A clinical approach (Yearbook Medical
Publishers, Chicago), 1989.
16. A NGLE, D. and B UXTON, J.: Community Living Skills Workbook for the Head Injured Adult
(Aspen, Gaithersburg, MD), 1991.
17. WOOD , R. : Management of behavior disorders in a day treatment setting. Journal of Head Trauma
Rehabilitation , 3: 53± 61, 1988.
18. VA LENTICH, M. and GRIPTON, J.: Facilitating the sexual integration of the head-injured person in
the community. Sexuality and Disability, 7: 28± 42, 1986.
19. D EB OSKY, D., HECHT, J. and CA LUB , C. : Educating Families of the Head Injured: a Guide to Medical
Cognitive, and Social Issues (Aspen, Gaithersburg, MD), 1991.