COMMENTARY

Should Psychiatry Categorize 'Substance-Induced Paraphilia'?

Jason Compton, MD, and Nicolas Badre, MD

January 11, 2022

The dopamine receptors of the brain get their fair share amid the didactics we receive in residency. From discussions of antipsychotics and schizophrenia to stimulants and ADHD, dopamine plays a key role. Depending on the program and interest of faculty, methamphetamine may get its own lecture or be mixed in with other stimulants of abuse. During that discussion, a comment might be made in passing on the impact of methamphetamine on sexual desire and activity.

Experiences in the emergency department caring for patients who are intoxicated from methamphetamine then effectively make up for any gaps in trainees' knowledge base. From patients engaging in self-pleasing pursuits in the emergency room to unfiltered reports of sexual exploits and desires, the impact of methamphetamine on sexual behavior quickly becomes apparent. Those experiences are later reinforced when residents are exposed to more long-term rehabilitation programs and have more in-depth conversations with patients about the sex-culture surrounding methamphetamine.

It is common to hear that, under the influence of methamphetamine, any available body will become an acceptable sexual partner – at times resulting in significant regrets, dangerous sexual activity, and complicated questions surrounding consent. Some early studies have found up to 72% increase in risky sexual behavior in methamphetamine users.1 This is particularly problematic as society has recently taken on the difficult and important work to re-examine the role and nature of consent in sexual activities. This falls within the larger #MeToo movement and has led to advocating for harsher sentencing of sexual offenders.

Yet simultaneously, society has also reconsidered its approach to apportioning blame on drug users.2 This shift to a more compassionate stance has resulted in a desire to treat and care for a disorder, rather than punish and condemn a poor choice. As forensic psychiatrists, we have noted this significant change. Where substance use disorders were once considered a risk factor for recidivism, they are now considered a disability that not only warrants treatment but can also diminish the share of blame one may be responsible for.

The convergence of those two societal movements often plays out in the courtroom, and in our experience when faced with those two opposing viewpoints, triers of fact (judges and juries) often favor punishing sexual offense over empathizing with an addictive disorder. While certainly not implying methamphetamine use condones sexual offense, we do posit the particular relationship between methamphetamine use and sexual activity should be explained to those entrusted with deciding guilt.

Examples of such problems are extremely common. A routine case involves IK,3 a 48-year-old male without significant history of legal problems, arrested for indecent exposure. His history of mental illness is closely intertwined with a history of substance use, leading to many psychiatric hospitalizations for methamphetamine-induced psychosis. After many hospitalizations he was placed in an assertive community treatment (ACT) team.

One day, IK is approached by an industrious drug dealer who frequents multiple board-and-cares in search for customers interested in relapsing. IK uses methamphetamine and within hours finds himself having walked miles away, naked, in the middle of an RV park. He subsequently describes the experience of unrelenting sexual desire, accompanied by ideas of reference involving billboards encouraging him to demonstrate his sexual prowess, as well as auditory hallucinations of women cheering him on. This leads to him pleasing himself publicly and his subsequent arrest.

Interviewing IK, 3 months later, he is embarrassed and apologetic. He is cognizant of the inappropriate nature of the incident and the foolishness of his actions. However, when asked whether he considers himself a sexual offender, he protests that he would never act in such a manner if not under the influence of methamphetamine. He points to his lack of significant sexual urges when sober, his lack of prior sexual offense, his lack of sexually violent offense, and his lack of unusual sexual interests.

It is unclear to us how society will or should adjudicate on such a case. It is not under the purview of forensic psychiatry to become a trier of fact. However, psychiatry should have a better working framework of how to discuss and conceptualize such situations, especially considering the dire consequences for those involved.

While any criminal conviction already has the potential to destroy a person's life, sexual crimes bring particularly serious consequences. Entry into the national sex offender registry, in addition to carrying an unshakable stigma, comes with additional degrees of lost freedom. These individuals are prohibited from living or working in areas that have children in proximity, subjecting them to the outskirts of society and greatly restricting any chance of economic escape from poverty. Parks, libraries, and shopping malls can become off limits. Privacy for these individuals is nonexistent; from websites they visit to where they travel physically can be monitored. Even where they live and a detailed physical description are often easily accessible by members of their community.

When should it be permissible to consider sex offender status for someone on the grounds of a mental illness? A patient with obsessive-compulsive disorder might have sadistic obsessions and compulsions to commit violent sexual acts, which, along with being repugnant to society, are entirely ego-dystonic to the suffering patient. Psychosis is often characterized as involving a loss of insight and impaired reality testing. If society accepts insanity as grounds to mitigate sentencing, then why not permit it for grounds to wave the designation of sex offender to those with certain disorders, including substance use disorder? Wherever we come down on this issue, it is a sad fact that in practically no other medical field can a person be sentenced for having a disease.

Should IK have to register as a sex offender? Regardless of the circumstances, he did publicly masturbate. Society has determined that public sexual displays are a crime worth carrying the pariah status of sex offender – why should an exception be made for methamphetamine use? On the other hand, it is difficult to claim that IK's behavior was entirely of his own free will. Most triers of fact will have never experienced that amount of dopamine reward. They can't attest to the remaining free will after experiencing more pleasurable salience and positive reinforcement than ever naturally possible.

How we deal with the behavioral consequences, and other sequelae, of methamphetamine use is a growing problem. Access to and use of methamphetamine is no longer reserved for soldiers patrolling the jungles of Vietnam. Once thought to be a scourge of the West Coast, methamphetamine is now widely available throughout the United States.4 The use of methamphetamine is likely to continue to expand as society keeps pursuing the decriminalizing of drug use. Psychiatrists practicing in areas heavily affected by methamphetamine see firsthand the burden it places on community resources in the form of increased psychosis, emergency room utilization, medical resource strain, and encounters with police.5

The presence of mental illness is tied to a small but statistically significant risk of violence. However, substance use is a well-established risk factor for violence.6 What is often missed is that many sexual offenders have not committed a violent offense. However, like IK, they have been charged with indecent exposure or other nonviolent sexual offenses, such as prostitution and solicitation. Those nonviolent offenses are driven by poor judgment and impulsivity, the trademarks of substance use. The answer cannot be to incarcerate, and eventually add to the sex offender registry, the growing number of these individuals.

Yet, as psychiatrists, we seem at a loss for how to treat these patients. The prescription of allowing them to spend a night in the ED with a complementary sandwich garnished with olanzapine often feels like enabling. Substance use treatment programs are too limited, and the wait list is rarely shorter than the time it takes our patient to purchase their next hit.

There are no effective pharmacologic treatments for methamphetamine use disorder.7 The recommendations of cognitive-behavioral therapy, family and group therapy, contingency management, and a 12-step program may be sufficient for the most motivated and well-supported patients but are inadequate for the vast majority.8 As much as we want to laud the merits of community psychiatry and the ACT [assertive community treatment] model of care, it is hard to carry that banner while confronted with the reality these patients face on a day-to-day basis during any shift in the emergency room. Eventually the countless encounters with homeless, helplessly meth-addicted patients ending in discharge back to the streets begins to tarnish the bright rhetoric surrounding community care, which starts to sound more and more like abandonment of patients to suffer in futility.9

It is not up to forensic psychiatrists, or even psychiatry as a whole, to fix the myriad of inadequacies surrounding how society handles those suffering from methamphetamine addiction. However, it is essential for psychiatry to study and educate society on the interaction of methamphetamine use and sexual behavior. There has been some exploration into other risk factors for paraphilic behavior while under the influence of substances, but there is a dearth of information on this topic. Establishing a nomenclature called "substance-induced paraphilia" might be a way to bring clarity to such instances in both a forensic and general psychiatric setting.

Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Compton has no conflicts of interest. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Psychol Addict Behav. 2016;30(2)147-57.

2. Monitor Psychol. 2019;50(6).

3. IK's case has been modified in certain ways to maintain confidentiality.

4. J Psychoactive Drugs. 2000;(2):137-41.

5. Acad Emerg Med. 2020 Nov;27(11):1116-25.

6. Swanson JW. Mental disorder, substance abuse, and community violence: An epidemiological approach, in: Monahan J and Steadman HJ, eds. "Violence and Mental Disorder: Developments in Risk Assessment" (Chicago: University of Chicago Press, 1994, pp. 101-36).

7. Addiction. 2004 Jun;99(6)708-17.

8. Am Fam Physician. 2007 Oct 15;76(8):1169-74.

9. Perspect Biol Med. 2021;64(1)70-81.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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