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Klüver–Bucy syndrome, hypersexuality, and the

law
a b a
Julie Devinsky , Oliver Sacks & Orrin Devinsky
a
New York University Langone School of Medicine, New York, USA
b
Departments of Neurology and Psychiatry, Columbia University School of Medicine,
New York, USA
Published online: 18 Nov 2009.

To cite this article: Julie Devinsky , Oliver Sacks & Orrin Devinsky (2010) Klüver–Bucy syndrome, hypersexuality, and
the law, Neurocase: The Neural Basis of Cognition, 16:2, 140-145, DOI: 10.1080/13554790903329182

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 NEUROCASE
2010, 16 (2), 140–145

Klüver–Bucy syndrome, hypersexuality, and the law

NNCS

Julie Devinsky,1 Oliver Sacks,2 and Orrin Devinsky1

Klüver–Bucy Syndrome, Hypersexuality, and the Law

1
New York University Langone School of Medicine, New York, USA
2
Departments of Neurology and Psychiatry, Columbia University School of Medicine,
New York, USA

A 51-year-old right-handed man developed hypersexuality after a second right temporal lobectomy to treat epi-
Downloaded by [University of Chicago Library] at 06:31 15 September 2013

lepsy. His hypersexuality started with increased marital intercourse and masturbation but he later downloaded
child pornography. Hyperphagia and distractibility, other features of the Klüver–Bucy syndrome, also developed.
Resection of the amygdala and/or temporal lobe neocortical areas that inhibit other limbic areas may contribute
to the pathogenesis of hypersexuality. Neurological factors mitigate the criminal responsibility for hypersexual
activity in patients with Klüver–Bucy syndrome. Most previously reported patients were never charged with a
crime despite uninvited physical contact in some instances. Our patient was convicted and imprisoned.

Keywords: Hypersexuality; Klüver–Bucy syndrome; Temporal lobectomy; Medical-legal.

INTRODUCTION anterior temporal lobectomy in male rhesus mon-

In 1888, Sanger Brown and E. A. Schaefer, two
British experimental physiologists, described a
variety of behavioral transformations after remov-
ing both temporal lobes in monkeys (Brown &
Schaefer, 1888).
He no longer clearly understands the meaning of
the sounds, sights, and other impressions that
reach him. His food is devoured greedily, the head
being dipped into the dish, instead of the food
being conveyed to the mouth by the hands. He
reacts to all kinds of noises, even slight ones – such
as the rustling of a piece of paper – but shows no
consequent evidence of alarm or agitation and dis-
plays tyrannizing proclivities towards his mate.
(Brown & Schaefer, 1888)
Half a century later, Heinrich Klüver, a German-
American experimental psychologist, and Paul
Bucy, an American neuropathologist and neuro-
surgeon, described the behavioral effects of bilateral
keys (Bucy & Klüver, 1955; Klüver & Bucy, 1939).
The Klüver–Bucy syndrome (KBS) is character-
ized by excessive orality and hyperphagia,
distractibility (especially for visual stimuli), hyper-
sexuality and change in sexual preference, visual
agnosia and loss of aggressive and fearful
responses (Bucy & Kluver, 1955; Weiskrantz,
1956).
In humans, partial KBS was first reported in 1955
after bilateral temporal lobectomy for epilepsy con-
trol (Terzian & Ore, 1955). A complete human KBS
case after encephalitis was reported in 1975 (Mar-
lowe, Mancall, & Thomas, 1975). KBS symptoms
may be caused by diverse disorders affecting the tem-
poral lobe, including head trauma, anoxia,
Alzheimer’s disease and other dementias, adrenoleu-
kodystrophy, unilateral temporal lobectomy, and the
postictal state (Devinsky & D’Esposito, 2003). Most
patients have only one or two features, since human
diseases often incompletely destroy anterior temporal
regions. Also, some diseases cause neuronal loss as

There were no sponsors of this study. There are no financial disclosures.

Address correspondence to Julie Devinsky, 97 Westview Road, Short Hills, NJ 07078, USA. (E-mail: julierach@comcast.net).

© 2009 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurocase DOI: 10.1080/13554790903329182
 KLÜVER–BUCY SYNDROME, HYPERSEXUALITY, AND THE LAW
well as hyperexcitability, which can cause irritability,
aggressiveness and paranoia (Cummings & Duchen,
1981; Hooshmand, Sepdham, & Vries, 1974; Lilly,
Cummings, Benson, & Frankel, 1983; Pilleri, 1966)
rather than the loss of aggressive and fear responses.
We report KBS-related hypersexuality in a man
with medically uncontrolled seizures whose behav-
ior changed after an extension of a prior right tem-
poral lobectomy. His hypersexuality started with
increased marital intercourse and masturbation
but expanded to the viewing and downloading of
child and adult internet pornography for which he
was convicted and imprisoned. The literature on
Downloaded by [University of Chicago Library] at 06:31 15 September 2013
hypersexuality associated with temporal lobe
lesions is reviewed, and medical and legal implica-
tions of these disorders are discussed.
CASE REPORT
This 51-year-old man first suffered attacks of déjà
vu at age 19. They became much more frequent –as
many as 20 attacks a day – and much more com-
plex, the déjà vu now being followed by ‘a cascade’
of other symptoms: sharp pains in the chest and
sensations of breathlessness; alterations of hearing;
occasional musical hallucinations – he would
always hear a particular song ‘as clearly as if it
were being played in the next room’; and in the
severest attacks, olfactory and gustatory hallucina-
tions (‘a pungent smell and a taste corresponding
to the smell’) followed by vomiting. There were
occasional ‘out of body’ experiences too. In Christ-
mas of 1976 he had a tonic-clonic seizure.
A work-up at this time showed a seizure focus in
the right temporal lobe. Antiepileptic drugs were
started, but it was never possible to achieve good
seizure control. He started to develop certain insid-
ious personality changes – he became (in his own
words) ‘more spiritual’, ‘more creative’ (he started
to write a great deal), and, specifically, ‘more
musical’ –strumming his guitar ‘obsessively . . . for
hours and hours’ – though plucking the strings, he
found, could induce a seizure. But he maintained an
unbroken work record – he was trusted and well-
liked by his colleagues and loved by his wife. He was
‘a good husband’, his wife told us, not given to any
inordinate or perverse sexual practices, and always
sensitive and responsive to her needs and feelings.
On evaluation at age 33, his MRI showed a right
mesial temporal lesion and videoEEG revealed right
temporal seizure onsets. An intracarotid amobarbi-
tal test revealed left hemisphere language dominance
141
with impaired right hemisphere memory (1/6 items)
and preserved left memory (6/6). A one-stage right
temporal lobectomy was performed after mapping
the ‘musical areas’ in the cortex to avoid damage to
these. Pathology showed a ganglioglioma. Following
surgery, he was seizure free for 9 months, until he
self-tapered off phenobarbital and had a convulsion.
Complex partial seizures became refractory to ther-
apy and began with a ringing sound, foul smell, and
a ‘feeling of thickness in my tongue’. Despite seizures
and medication side effects, he continued to work
full-time as a pharmaceutical researcher and volun-
teered to provide support at programs and fundraise
for the local Epilepsy Foundation.
At age 39, repeat videoEEG monitoring showed
a right posterior temporal seizure focus. A two-
stage subdural grid/strip electrode surgery was per-
formed, with a posterior temporal resection. He
was seizure free for more than 4 years, but then par-
tial seizures recurred. However, approximately a
month after surgery, behavioral changes of irrita-
bility, hyperphagia and hypersexuality (including
coprophilia) developed. He became more sexually
active with his wife and masturbated more often.
Compulsively, he began to watch adult porno-
graphic images and videos on the internet when his
wife slept. Some websites solicited him to view and
purchase child pornography. He became obsessed
with this and eventually purchased and down-
loaded pornographic images of prepubescent
females engaged in sexual activities from the inter-
net. He was ashamed and secretive about these
activities, not discussing the pornography or mas-
turbation with his wife or with anyone else. In 2006,
he was arrested by federal authorities for down-
loading child pornography. He was charged with
knowingly and willfully possess[ing] material
which contained at least three images of child por-
nography, as defined in 18 U.S.C. § 2256, which
were shipped and transported in interstate and
foreign commerce, including by computer, and
were produced using materials that were shipped
and transported in interstate and foreign com-
merce, including by computer.
Following his arrest, he was treated by a psychia-
trist with quetiapine and sertraline and his obses-
sive sexual thoughts abated. His wife confirmed
that his incessant demands for sexual relations
stopped and he became hyposexual.
The patient described his own behavioral
changes as follows:
 142 DEVINSKY, SACKS, DEVINSKY
my appetite for food and sex increased dramati-
cally. I had greater mood swings. I wanted sex
constantly. Every day. I was very easily stimulated
and began to touch myself regularly. I began to
request sex daily from my wife. If I wasn’t having
sex with my wife, I masturbated. This behavior
increased over time. I became more emotionally
labile, obsessive–compulsive, but on the other
extreme became disinterested or unable to initiate
things I needed or was supposed to do.
I raged for hours at inappropriate things at home
(no socks, no rye bread, perceived criticisms).
Driving home from work a driver ‘squeezed me’
on a merge. I accelerated and cut him off. I rolled
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my window down, gave him the finger and began
screaming at him, and threw a metal coffee mug
and hit his car. He called police from his cell. I was
pulled over and ticketed.
I become distracted so easily that I can’t get any-
thing started or done.
His wife’s account tallies with this:
He started to gain weight and his pants changed 3
sizes within 6 months. His appetite was out of con-
trol. He would get up in the middle of the night
and eat an entire bag of cookies or a block of
cheese with a large box of crackers. He asked that
I serve the same foods every day. He also had to
wear the same sets of clothing. I always had to do
laundry every night so his two favorite shirts and
two favorite pants were in a closet with 25 other
sets that he not would wear.
He wanted to have sex all the time. He went from
being a very compassionate and warm partner to
just going through the motions. He didn’t
remember having just been intimate. He said it
didn’t seem like a current memory or emotion.
He wanted sex constantly after his surgery until
the day the officers showed up, at least 5 to 6 times
a day. He also gave up on foreplay. He would
always want to get right to it. [He] was constantly
grasping with his hands, coming up behind me and
pressing himself against me while I was doing
chores or talking on the phone. If [he] came to bed
in the middle of the night, he would ply me for sex.
Two years ago, after his arrest, he was given
Zoloft and Seroquel and became much warmer
and loving but the medications shut off his libido.
As with much of his obsessions and activities that
were ‘all or nothing’, sex became non-existent. His
emotions to me, however, have reverted back to
loving and compassionate and his outburst of
anger and rage have disappeared. It is as if a faulty
switch was turned off.
LEGAL PROCEEDINGS
The patient was arrested at his home and his com-
puters were confiscated. He pleaded guilty to pos-
sessing at least three images of child pornography
that were transported in interstate or foreign com-
merce. He was sentenced in the US District Court.
The treating physician (OD) summarized the
patient’s neurological history and the KBS, focus-
ing on hypersexuality after temporal lobe damage.
Several cases from the literature were cited to
exemplify the range of behaviors in KBS: an eld-
erly patient with frontotemporal dementia who
sexually approached minors (Mendez, Chow,
Ringman, Twitchell, & Hinkin, 2000) and a 14-
year-old girl who masturbated in public after a
temporal lobectomy (Ozmen, Erdogan, Duvenci,
Ozyurt, & Ozkara, 2004).
It was argued that KBS caused or was the major
contributing factor to the patient’s hypersexuality
and viewing of child pornography. Hypersexuality
almost immediately followed his second surgery; it
was a sudden and dramatic behavioral change and
associated with other KBS symptoms of hyper-
phagia and distractibility. The prosecutor asked
how, since there are only rare cases of pedophilia
reported in relation to KBS, a relation could be
established with medical certainty? The response
was that there is a wide range of hypersexual behav-
iors in KBS, from marked increase in heterosexual
intercourse and excessive masturbation to fetishism,
homosexuality, pedophilia, zoophilia, coprophilia,
and other changes in sexual appetite that were never
previously evident. These changes in sexual behav-
ior could occur separately or clustered in a so-called
polymorphous perversity. The temporal relation to
surgery and reports from the patient and wife were
typical of KBS hypersexuality.
The prosecutor argued that the patient’s hyper-
sexual behavior in some situations but not others
was evidence for volitionally controlled criminal
behavior; that it was incompatible with a neurolog-
ical cause. For example, he downloaded and
viewed child pornography at home but not at
work. We responded that patients with neurologi-
cal disorders may restrain their urges when in
socially inappropriate places and only give vent to
them in selected settings. For example, a Parkin-
son’s patient in a hyperdopaminergic state may
compulsively masturbate in his bedroom but not in
public. Neurological disease often changes the
threshold for abnormal behavior, but does not
make behavior indiscriminate.
 KLÜVER–BUCY SYNDROME, HYPERSEXUALITY, AND THE LAW
The defense attorney presented the opinion of
Judge Mansmann in US v. McBroome: ‘an indi-
vidual’s average or above average mental capacity
in one aspect of his or her affairs is not necessarily
relevant to a determination about the individual’s
mental capacity in another aspect’ (USA vs. McB-
roome). The defense then quoted from a letter
from OS: ‘. . . a man of superior intelligence and of
real moral delicacy and sensibility, who at one
point was driven to act out of character under the
spur of an irresistible physiological compulsion
resulting from his brain injury. A recurrence of
such behavior is extremely unlikely given his char-
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acter and insight. It is important to note that even
when his Klüver–Bucy syndrome was at its worst,
[he] never acted, never had any actual inappropri-
ate contact with children or anyone else. He is
strictly monogamous’.
The patient faced up to a 20-year maximum
prison sentence with a 5-year minimum term.
Despite the reports and testimony of physicians,
the prosecutors sought the maximum sentence
allowable by law because they saw the patient as a
pedophile with an unrelated neurological disorder.
The judge found that KBS was a mitigating factor
and he received the shortest sentence allowable: 26
months in prison, 25 months of home confinement,
and then a 5-year period of supervision.
DISCUSSION
Hypersexuality after unilateral temporal lobec-
tomy (Baird, Wilson, Bladin, Saling, & Reutens,
2002; Blumer, 1970; Anson & Kuhlman, 1993;
Christianson, Silfvenius, Saisa, & Nilsson, 1995;
Cogen, Antunes, & Correll, 1979) can occur as an
isolated symptom of KBS or, as in our patient, can
be accompanied by increased appetite and distract-
ibility. Hypersexuality after temporal lobectomy
occurs in both sexes, often with a latency averaging
1–6 months (Blumer, 1970; Cogen et al., 1979).
Hypersexuality can involve ideation and fantasy,
use of obscene language, demands for sexual activ-
ity by a spouse, frequency and duration (up to 2 h)
of erections, masturbatory behavior, changes in
sexual preference (from heterosexual to homosex-
ual, etc.), and unprecedented interest in sexual
activity with children (Anson & Kuhlman, 1993;
Blumer, 1970; Christianson et al., 1995; Cogen
et al., 1979) Hypersexuality after temporal lobec-
tomy lasts from several months to more than 5
years (Anson & Kuhlman, 1993; Baird et al., 2002;
143
Blumer, 1970; Christianson et al., 1995; Cogen
et al., 1979).
The pathological qualities of our patient’s sexu-
ality – its all-or-noneness and its insatiability –
developed only after the second lobectomy. ‘All-
or-none’ or ‘on/off’ reactions are characteristic of
impaired central control systems; they occur for
example, in parkinsonian patients maintained on
L-Dopa (Sacks, 1990). Normal control systems
have a middle ground and respond in a modulated
fashion. The patient’s wife also observed that he
wanted more sexual activity within seconds of
orgasm – that there were only fleeting moments of
satiety before he was again overtaken by sexual
urges. Normally, when one has eaten enough or
climaxed sexually, there follows a peaceful period
of consummatory fulfillment. Our patients’ sexual
and hunger appetitive systems were continually on
‘GO’; there was never any sense of satisfaction,
only the drive for more and more.
The role of amygdala lesions in causing hyper-
sexuality remains uncertain. In monkeys, the amy-
gdala is activated during sexual and aggressive
social interaction (Kling, Steklis, & Deutsch, 1979).
In humans, amygdala stimulation can elicit sexual
experiences (Gloor, 1990) and functional imaging
reveals amygdala activation during sexual arousal
(Karama et al., 2002). In monkeys, bilateral amy-
gdala lesions cause some features of KBS behaviors
(decreased fear and aggressive responses, hyperoral
behavior) but they do not alter sexual behavior
(Aggleton & Passingham, 1981; Spies et al., 1976;
Weiskrantz, 1956). Similarly, in humans, bilateral
amygdalotomy for behavioral disorders transiently
alters sexual behavior, causing either hypo- and
hypersexuality, in less than 5% of patients (Baird,
Wilson, Bladin, Saling, & Reutens, 2007).
The paradoxical role of amygdala lesions in
hypersexuality probably reflects intersecting effects
of temporal regions that are resected, preserved,
and irritated. In monkeys, hypersexuality with KBS
requires bilateral amygdala and neocortical resec-
tions. In our patient, the first temporal lobectomy,
in which the amygdala and anterior temporal neo-
cortex was resected, did not result in hypersexual-
ity. This suggests that resection of additional
posterior neocortical temporal regions was critical.
Other patients developed hypersexuality after either
limbic or neocortical temporal lesions (Ozmen
et al., 2004). Patients who become hypersexual after
temporal lobectomy have larger contralateral
amygdala than those without changes in sexual
behavior (Baird, Wilson, Bladin, Saling, & Reutens,
 144 DEVINSKY, SACKS, DEVINSKY
2004). The volume of the contralateral amygdala cor-
related with the degree of postoperative hypersexual-
ity. Amygdala dysfunction may impair sexual
arousal; removal of the diseased amygdala can
improve libido if the contralateral amygdala func-
tions normally (Ellison, 1982). Humans with KBS
hypersexuality often have irritative lesions such as
encephalitis and tumor that cause seizures. Hypersex-
uality after temporal lobectomy is not usually corre-
lated with seizure activity (Baird et al., 2002), as in our
patient. Rarely, hypersexuality abated immediately
after the first postoperative seizure (Blumer, 1970).
Functional imaging studies in normal subjects
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and clinical observations in epilepsy patients sug-
gest that the right hemisphere dominates the per-
ception, activation and regulation of sexual
behavior (Fisher, Aron, & Brown, 2005; Janszky
et al., 2002; Ozkara et al., 2006; Remillard et al.,
1983; Tiihonen et al., 1994). Visual sexual stimuli
selectively activate right temporal regions on func-
tional imaging studies (Fisher et al., 2005). During
male orgasm, there is a larger increase in blood
flow in the right frontal regions (Tiihonen et al.,
1994). Ictal sexual automatisms, ictal orgasm, and
orgasm-induced seizures are more frequent with
right temporal seizure foci (Janszky et al., 2002;
Ozkara et al., 2006; Remillard et al., 1983).
Unilateral lesions, usually involving the tempo-
ral lobes, can cause hypersexuality or hyposexuality.
Increased libido is more frequent after right than left
hemisphere strokes (Baird et al., 2002; Kalliomaki,
Markkanen, & Mustonen, 1961). Another group
found hyposexuality significantly more often with
left hemisphere lesions and hypersexuality with right
hemisphere lesions (Braun, Dumont, Duval, Hamel,
& Godbout, 2003). These observations suggest that
the right hemisphere inhibits sexual thoughts and
impulses. Although hypersexuality occurs equally
after right and left temporal lobectomy, other fac-
tors such as contralateral amygdala size may influ-
ence symptoms (Baird et al., 2004).
Pedophilia and other changes in sexual prefer-
ence can follow brain damage. A 41-year-old man
developed hypersexuality 5 weeks after a right tem-
poral lobectomy (Blumer, 1970). In addition to
obscene language at work, he desired homosexual
relations with his 15-year-old nephew. Pedophilia
developed in one man with frontotemporal demen-
tia and another with bilateral hippocampal sclero-
sis; both patients had prominent right anterior
temporal hypometabolism on PET (Mendez et al.,
2000). Among 34 cases with pedophilia after neu-
rological injury, causes included postencephalitic
parkinsonism, anoxia, multiple sclerosis, post-
neurosurgical and head trauma (Mendez et al.,
2000). These lesions predominantly affected the
right frontal and temporal regions.
Hypersexuality and pedophilia from brain disor-
ders often conflict with social rules and laws. Our
case highlights the complex medical-legal issues
regarding responsibility for behavior in the setting
of KBS. Many patients focused their sexual inter-
ests and activities on their spouses, leading some
patients to request that their spouses have temporal
lobe surgery and occasionally leading spouses to
request the operation themselves, in order to ‘keep
up’ (Baird et al., 2002). Other postsurgical patients
have violated criminal statutes. One woman, fol-
lowing a left temporal lobectomy, had postictal
voracious eating, masturbating in public and solic-
iting family and neighbors for sex (Anson & Kuhl-
man, 1993). After one seizure she was brought to an
emergency room and after 30 min was found per-
forming fellatio on an elderly cardiac patient
(Anson & Kuhlman, 1993). This case and others
involved actual physical contact or an expressed
desire to engage in sexual relations with another
individual as a result of KBS, but none was crimi-
nally charged (Anson & Kuhlman, 1993; Blumer,
1970; Mendez et al., 2000). Among more than 35
cases of pedophilia associated with neurological
disorders, an arrest was only reported in two cases.
One man with a right frontal arteriovenous malfor-
mation extending into the septum had sex with a
juvenile (Fisher et al., 2005). Another man with
bilateral hippocampal sclerosis, (Mendez et al.,
2000) (see above) molested a 5-year-old boy (Miller
& Cummings, 1991). In contrast, our patient was
prosecuted by federal authorities and now serves a
19-month prison sentence for downloading porno-
graphic images of children. The KBS was a critical
factor in driving his hyersexuality. In light of this
mitigating factor, was he criminally responsible?
Did his behavioral actions warrant imprisonment?
We believe the answer is no to both questions.
Original manuscript received 1 August 2009
Revised manuscript accepted 8 September 2009
First published online 18 November 2009
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