An uncommon case of hypersexual behaviour with frotteurism

Introduction

Humans show a wide array of sexual preferences and behaviours. By their very nature, disorders of sexual preference ¹ or paraphilia ² are bizarre patterns of sexual behaviour that have diverse manifestations and are of complicated sexual orientation. Masturbation refers to sexual stimulation of a person's genitals, often to the point of orgasm. ³ The stimulation can be performed manually, by other types of bodily contact (short of sexual intercourse), by use of objects or tools, or by some combination of these methods. Frotteurism is an aberrant behaviour wherein the person has recurrent and intense sexual fantasies, sexual urges or sexual behaviours involving touching or rubbing against a non-consenting person. This occurs over a period of at least six months. The person is distressed or impaired by these attractions or has sought sexual stimulation from touching and rubbing against a non-consenting person on separate occasions. ⁴ A person who practices frotteurism is known as a frotteur. The majority of frotteurs are male and the majority of victims are female, ⁴ although female on male, female on female and male on male frotteurs exist. Adult on child frotteurism can be an early stage in child sexual abuse. ⁵ This activity is often done in circumstances where the victim cannot easily respond, in a public place such as a crowded train or concert. Usually, such non-consensual sexual contact is viewed as a criminal offence and a form of sexual assault albeit often classified as a misdemeanor with minor legal penalties. It is also not easy to prosecute frotteurs as intent to touch is difficult to prove. In their defence statements, the accused often claim that the contact was accidental. Conviction may result in a sentence or psychiatric treatment. ⁶ There is a paucity of literature on frotteurism. We describe a girl with hypersexual behaviour presenting in the form of masturbation with features of frotteurism involving her younger brother.

Case report

Ms N, an 11-year-old girl, was brought to the psychiatry outpatient department by her mother with complaints of excessively rubbing her genitalia for 15–20 minutes and also against the bed many times a day. On being scolded, she started spending more time in the toilet. This behaviour had become worse when she started rubbing her genitalia many times a day for 10–20 minutes against her younger brother, seven years old, who reported it to the mother. The girl reported to the mother that she had developed this behaviour for the last nine months. She tried to control the behaviour but failed. There were no identifiable triggers for her behaviour. Due to this behaviour, the girl could not concentrate on her studies and was distressed. She developed sadness of mood, sleeplessness, heaviness in the head, loss of interest, decreased appetite, feelings of guilt, worthlessness, hopelessness and loss of concentration for the last six months. There was no history of any other psychiatric disorder, chronic physical illness or drug dependence. There was no family history of any psychiatric illness. Her academic performance had been reported to be satisfactory. Physical examination was normal. The investigations, which included haemogram, urine examination and culture, blood urea and sugar, EEG, ultrasonography of abdomen and CT scan of the head, were all normal. On mental state examination, her speech had decreased pitch tone and volume. She showed irritability and sadness of mood. There were ideas of guilt for her sexual behaviour. There was no formal thought disorder or perceptual abnormality. Higher mental functions were normal. She fulfilled the criteria of hypersexual behaviour with frotteuristic disorder with co-morbid unipolar depression and was started on fluoxetine 20 mg in the morning and clonazepam 0.5 mg at night daily. There was a gradual decline in her hypersexual behaviour along with improvement in symptoms of depression. The dose of fluoxetine was increased to 40 mg daily. The patient showed complete remission of symptoms within six weeks. This patient has been followed up for the last four months and has not developed any similar symptoms.

Discussion

There is no scientific consensus concerning the cause of frotteurism. Most experts attribute the behaviour to an initially random or accidental touching of another's genitals that the person finds sexually exciting. Successive repetitions of the act tend to reinforce and perpetuate the behaviour.

The exact prevalence of hypersexual behaviour in girls is not known. The majority of frotteurs are male and the majority of victims are female. Most acts of frottage are performed by those between 15 and 25 years of age. After the age of 25, the acts decline. ⁵ But the present frotteur was an 11-year-old girl. Frotteurism has been described in bipolar disorder, child abuse and temporal lobe epilepsy. ⁷ Children with pervasive developmental disorders, schizophrenia or tic disorders display behaviours such as rubbing their genital areas (self-stimulation) or using sexual words – actions that are usually neither flirtatious nor amusing. ⁸ The authors could find no report of hypersexual behaviour with co-morbid depression. The present case was atypical because, firstly, she had developed the habit of masturbation with frotteurism involving her brother. Secondly, frotteurism typically occurs in crowded and public places but in the present case, it occurred secretly. Thirdly, the behaviour occurred with co-morbid unipolar depression, i.e. depressive symptoms appeared after the development of frotteurism. Fourthly, there was a guilt feeling associated with it. Lastly, there was complete remission of hypersexual behaviour and frotteurism along with symptoms of depression with the administration of fluoxetine. Selective serotonin re-uptake inhibitors have been used in the treatment of paraphilia, even without depression, ⁹ but this patient improved with the improvement of depression. If hypersexual behaviour occurs as a part of psychosis or due to drug use, ¹⁰ then treatment with antipsychotics or stoppage of the offending drug is required, but in the present case there was nothing suggestive of psychosis and the patient was not taking any medication. Treatment typically involves psychotherapy aimed at uncovering and working through the underlying cause of the behaviour. Behaviour therapy is commonly used to try and treat frotteurism. The frotteur must learn to control the impulse to touch non-consenting victims. The present case responded to drug treatment only.

Future studies are warranted on hypersexual behaviour and frotteurism. One should consider depression in the differential diagnosis of hypersexual behaviour and vice versa.