Medical Therapy for Inappropriate Sexual Behaviors in a ...

1 Medical Therapy for Inappropriate Sexual Behaviors in a Teen With Autism Spectrum Disorder Loyal Coshway, MD,a Julia Broussard, MD,b Kruti Acharya, MD,c Karen Fried, PsyD,d Michael E Msall, MD,e John D. Lantos, MD,b Leena Nahata, MDa Teens with autism spectrum disorder often exhibit Sexual Behaviors in abstract public that are disturbing to parents, teachers, and peers. Some have proposed that such Behaviors can be curtailed with hormonal suppression. There is information on the Internet suggesting that such medications work, and some reports in the peer-reviewed Medical literature support these claims. Such medications can have serious side effects. In this paper, we present a case in which parents requested such treatment of their teenage son with autism spectrum disorder. Teens with autism spectrum disorder directions. His parents are now aDivision of Endocrinology, Nationwide Children's Hospital, (ASD) often exhibit Sexual Behaviors afraid to leave him unattended with Columbus, Ohio; bChildren's Mercy Hospital Kansas City, in public that are disturbing to younger children because of his Sexual Kansas City, Missouri; cDepartment of Disability and Human Development, University of Illinois at Chicago, Chicago, parents, teachers, and peers.

2 Some Behaviors . Illinois; dAdvocate Health Care System, Chicago, Illinois; and have proposed that such Behaviors eUniversity of Chicago, Chicago, Illinois Brad sees a psychiatrist who has can be curtailed with hormonal tried behavioral Therapy as well Accepted for publication Dec 1, 2015. suppression. In this month's Ethics as medication (olanzapine and Drs Coshway, Nahata, Acharya, Lantos, Broussard, Rounds, we present a case in which fluoxetine). These have been Msall, and Fried contributed to the design of this parents request such treatment paper, the drafting of the manuscript, and the ineffective in reducing Brad's Sexual from a pediatric endocrinologist. review of the manuscript; and all authors approved Behaviors . His parents have done We then asked experts in pediatric the nal version. research on the Internet and found endocrinology and developmental DOI: reports that hormonal Therapy to pediatrics to comment on the Address correspondence to John D.

3 Lantos, MD, suppress luteinizing hormone (LH). appropriate response to such a Children's Mercy Hospital, 2401 Gillham Road, and testosterone levels can decrease request. Kansas City, MO 64108. E-mail: Inappropriate Sexual Behaviors in cognitively impaired teens. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). THE CASE On examination, he is in mid-puberty. Copyright 2016 by the American Academy of Gonadotropins and testosterone Pediatrics The mother of a 12-year-old male, level show evidence of central FINANCIAL DISCLOSURE: The authors have Brad, makes an appointment in the puberty and are consistent with this indicated they have no nancial relationships pediatric endocrinology department exam. Bone age is 1 year greater relevant to this article to disclose. because her son has been exhibiting than chronological age but within FUNDING: No external funding.

4 Inappropriate Sexual Behaviors normal limits. Therefore, although POTENTIAL CONFLICT OF INTEREST: The authors (public exposure, masturbation, his pubertal onset was earlier than have indicated they have no potential con icts of and Inappropriate touching of his average, there is no evidence of interest to disclose. younger siblings). Brad has been endocrine pathology. diagnosed with ASD. He has cognitive impairment and is currently in The parents are concerned that, unless To cite: Coshway L, Broussard J, Acharya K, et school at the kindergarten grade effective treatment can be found, Brad al. Medical Therapy for Inappropriate Sexual Behaviors in a Teen With Autism Spectrum level. He cannot read. He is able to may cause harm to the other children Disorder. Pediatrics. 2016;137(4):e20154366. communicate and follow simple in the house or at school. Brad himself Downloaded from by guest on October 7, 2019.

5 PEDIATRICS Volume 137, number 4, April 2016:e20154366 ETHICS ROUNDS. is unable to consent due to cognitive In terms of potential benefits, LHRH a survey of 100 parents of children limitations. Would it be appropriate agonists induce hypogonadism (ie, age 9 to 38 years with autism, to try hormonal Therapy as a means lower testosterone levels) and may Inappropriate Sexual Behaviors to reduce or eliminate Brad's therefore suppress hypersexual were frequent; 65% touched Inappropriate Sexual behavior? Behaviors . Treatment of hypersexual their private parts in public, 23%. Behaviors with these agents has masturbated in public, 18% touched mainly been reported in adults the opposite sex inappropriately, and Loyal Coshway, MD, and who have committed Sexual crimes, 14% masturbated with an unusual Leena Nahata, MD, Pediatric including pedophilia, exhibitionism, Other problem Behaviors Endocrinologists, Comment sadism, rape, and voyeurism.

6 Based include undressing or touching on review of 13 studies, Briken et body parts in public and Sexual In this case, a question has been al1 concluded that LHRH agonists Increased masturbation raised about using luteinizing offer a reasonable treatment option in autism may be a self-stimulatory hormone releasing hormone (LHRH) for adult paraphilia; however, behavior and related to sensory agonists to reduce Sexual behavior. conclusions were weakened due to Such Behaviors can LHRH agonists are typically used the lack of randomized controlled be challenging for parents, teachers, for the suppression of centrally trials, differing methodology, and the and other caregivers, leading to mediated precocious puberty, use of patient self-report as opposed curtailment of routine activities. defined as puberty occurring before to objective measures of behavior. 9 years of age in a male.

7 They are The authors ultimately advised that For individuals with autism, administered via monthly or 3 LHRH agonist use could be justified underlying problems are lack monthly injections and are also if the individual poses a danger to of social competence and poor available as a 1 year depot implant. others, but that patients should give communication. Because of an LHRH agonists, such as leuprolide informed consent because of the risk inability to pick up on social cues, and triptorelin injections, have been of side moderate and severely autistic used for the court-ordered treatment patients may be unaware that public of adult paraphilia (off-label There are increased risks of exposure or masturbation is indication).1,2 Use of leuprolide in an using LHRH agonists in a growing Koller9 writes that Sexual desire is adult autistic male living in a group child, as pubertal suppression a natural part of human behavior, home was reportedly successful in interrupts several natural processes.

8 And that appropriate expression is reducing Inappropriate Behaviors Testosterone is required for pubertal enabled by age and developmentally and allowing him to continue to growth spurt, increase in lean muscle, appropriate education on pubertal live in the Treatment decrease in fat, and increase in bone development, Sexual desires, measures, including Sexual education density. In the case of someone pregnancy, and sexually transmitted and the antiandrogen flutamide, with chronic mental disability, it diseases. Newer literature suggests had been ineffective, resulting in is unclear when such treatment that high-functioning autistic temporary police custody for public could be successfully discontinued, individuals have fairly typical Sexual Sexual Behaviors toward other and side effects of longstanding experiences as adults. However, Despite these reports, it is hypogonadism include osteoporosis individuals with autism were far unclear if pubertal suppression for and higher incidence of less likely to receive education Inappropriate Sexual Behaviors in Short term side effects include about sexuality, contraception, and injection site pain, abscess or local this young autistic child is ethically sexually transmitted diseases from reaction, and growth suppression sound.

9 There is minimal evidence their parents or teachers; instead, from loss of testosterone-mediated supporting the use of LHRH agonist higher-functioning individuals Of note, most families Therapy for pediatric hypersexual with autism obtained information cannot afford leuprolide without behavior. In addition, there are from media such as insurance approval due to the high possible side effects, and this patient Parents of low-functioning autistic cost (single injections range from would be unable to consent to children often failed to teach even $1413 to $8481 depending on the Therapy because of age and cognitive basic Sexual education: puberty, dose and duration). limitations. Thus, the decision to reproduction, reporting Sexual use this treatment would need to be Additionally, it is important to victimization, and that it is wrong made carefully after ensuring that acknowledge the difference between to coerce Sexual Koller benefits outweigh possible harm adults with sex addictions/criminal outlines specific protocols for and acknowledging that the efficacy behavior and children with autism excessive public masturbation, would be uncertain.

10 And hypersexual behavior. Based on including interrupting the behavior, Downloaded from by guest on October 7, 2019. 2 COSHWAY et al reminding the person of appropriate benefit from the SSRI may be difficult, additional legal protections. The time and place, redirection, and this seems to be the most optimal United Nations Convention of allowing masturbation in private approach for the patient. the Human Rights of People with because it may be the only type of Disabilities recognizes fertility as an Sexual satisfaction available to that Kruti Acharya, MD, Michael E. inherent human person in their lifetime. Specialists Msall, MD, and Karen Fried, PsyD. (Developmental Pediatrics and Child Brad is a preadolescent with ASD. do caution that adult Sexual Psychology) Comment and cognitive impairment. He clearly relationships involving a person with lacks capacity to consent to Medical autism should be viewed with great The scenario presented is not treatment.