Zoophilia in an adolescent with high-functioning autism from Sri Lanka

Case report

SB is a 17-year-old school student living in rural Sri Lanka. SB’s paternal grandparents live close by and raise a herd of cattle on their land.

SB had deficits in social communication as a toddler with mostly isolated play at preschool, poor sustained eye contact and lack of imaginative play. Further, there were features suggestive of restricted repetitive behaviours (RRB) in the form of lining up of toys, delayed echolalia and extreme need for sameness regarding food. He had speech regression during his second year and spoke only single words at two years of age. He was diagnosed with ASD at five years of age by a psychiatrist, and he was treated with behavioural interventions. After a few years of follow-up, his parents had stopped taking him for reviews mainly due to travelling costs. Along the years, his speech, social deficits and RRBs improved, but he continued to have difficulties in establishing peer relationships.

For the preceding 12 months, the parents had observed SB to be spending more and more time at his grandparents’ cattle house. Even though this behaviour was new and unusual for him, the family decided not to intervene, as they thought he was developing warmth towards these animals, which is rarely seen in SB towards anyone. However, a neighbour had seen SB seemingly masturbating near the cattle house and had reported this to his mother. Afterwards, his father had warned SB not to engage in such behaviour publicly, but he had not thought of any connection to cattle. Things took a twist when his grandmother found him having penetrative intercourse with the heifer. She had screamed and reportedly had fainted.

The adolescent’s parents took him to a local healer in the village immediately, and he was prescribed a ‘thovil’ in order to relieve him of demonic possessions, which the healer believed to be the cause for this tabooed behaviour. The healer had demanded 40,000 rupees (AU$360) for the procedure, but the parents were unable to provide this amount. Therefore, they had taken SB to local health service the following morning, which is free of charge. Subsequently, SB was referred to a specialised youth psychiatric service. After initial denial, he later requested help to stop his urges.

SB had recurrent, intense sexual fantasies about having sexual intercourse with cattle, watching them mate and masturbating while observing them over the previous 12 months. Acting on these urges had often led SB to miss academic activities, and keeping this behaviour a secret had required considerable effort. He had never had a romantic or sexual relationship with another human in his life. He had watched pornography on the Internet involving humans, but stated he did not enjoy it compared to watching animals. SB denied any sexual interest in non-living objects, children or adult males and significantly lesser interest in adult females compared to animals.

SB avoided sustained eye contact on assessment and appeared distressed. There were no significant mood, thought, perceptual or cognitive abnormalities. Intelligence assessment using the test of non-verbal intelligence revealed average intelligence. ⁶ Perusal of academic reports and teacher’s feedback on past performance revealed average language abilities. The biochemical profile of sex hormones was found to be normal.

Zoophilia is categorised under other specified paraphilic disorder in the DSM-5. This could be applied when a clinical presentation is suggestive of a paraphilic disorder and found to cause significant distress or impairment but does not meet criteria for a specific class. SB had recurrent intense sexual fantasies, urges and behaviours related to the animal for more than six months, fulfilling criterion A. As per criterion B, SB had acted on the urges, and these had also caused him significant distress. Furthermore, it was clear that he preferred sexual fantasies and behaviours related to animals more than human sexual exposure. It was concluded that SB met DSM-5 criteria for other specified paraphilic disorder, in addition to ASD.

SB was treated as an outpatient with cognitive–behaviour therapy (CBT) by the child and adolescent psychiatrist. The main goals were to reduce inappropriate arousals using techniques such as covert sensitisation and to enhance appropriate arousals employing methods such as orgasmic reconditioning. In addition, provision of sexual education and social skills training were incorporated. Further, he was commenced on sertraline 25 mg mane initially and titrated to 50 mg after two weeks, which was continued unchanged.

At three-month follow-up, SB reported better control of his urges, and his parents had not observed any deviant sexual behaviour. The reduced psychological distress was seen by the reduction of Kessler’s psychological distress scores. ⁷

Discussion and conclusion

This case report describes an adolescent with HFA and zoophilia. To our knowledge, this is the first reported case of zoophilia in autism from the Asia-pacific region and probably the first in an individual with HFA in the world. In a recently published study on aspects of sexuality in adolescents with autism, inappropriate sexual behaviours and paraphilias were reported in a quarter of participants. ⁸

Premarital sex is tabooed in traditional Sri Lankan society. An individual with autism might be vulnerable to sexual deviances, as social difficulties may further hinder establishment of sexual partnerships. Even though the teenager was content with his RRBs, he was markedly distressed about his deviant sexual urges, indicating that his paraphilic disorder presentation was not encompassed by his autism.

According to Aggrawal’s classification, this adolescent’s behaviour could be categorised as class VII, which is termed as regular zoophile and describes a person who does not prefer intercourse with humans and instead prefers intercourse with animals. ¹

Studies have found Sri Lankan carers delay seeking help from mental-health services due to fear of their loved ones being labelled and stigmatised as mentally ill. ⁹ The delay for psychotic illnesses such as schizophrenia is found to be extremely long compared to affluent countries. ¹⁰ This could mean potential exacerbation and progression of complications. The low mental-health literacy of the parents may have contributed to seeking traditional healing in the form of thovil. Thovil is a demonic ritual, mostly exorcist in nature, which aims to chase away any malevolent spirits that are believed to induce pathological body and mind states. The ritual may last up to 12 hours during the night and is characterised by a humorous- as well as fear-inciting dialogue between the master healer and drummer who dance wearing colourful demonic masks which are selected based on the suspected illness. ¹¹

An antidepressant was combined with CBT, considering the potential social impact on the adolescent and lack of inpatient care facilities for adolescents. The total number of psychiatric beds for adolescents remains at nine for the whole country, and there are none at this adolescent’s treatment facility. ¹² Selective serotonin reuptake inhibitors have been found to be effective in the treatment of paraphilic disorders among adolescents, and the combination of pharmacotherapy with CBT has been shown to be useful. ¹³

In conclusion, reports of zoophilia worldwide are limited, and zoophilia in autism is rarer. This case report describes this unique association. Further studies in multicultural settings are required in order to explore the nature of paraphilic disorders in ASD.