Hyperactive sexual desire in Klinefelter Syndrome: Treatment with sertraline

KLINEFELTER SYNDROME (KS) is the commonest sex chromosome disorder and 47,XXY is the commonest karyotype.1 Hypoactive sexual desire due to hypogonadism is frequent in KS patients.1,2 We report a KS patient who, despite hypogonadism, had hyperactive sexual desire which markedly interfered with social and academic functioning. The sexually adverse effect of sertraline was successfully recruited in his management. The patient gave the authors written informed consent to publish this letter. M., a 22-year-old man, reported poor academic performance. He had earlier been diagnosed with 47,XXY KS. His phenotype was classical: he was tall, with narrow shoulders, broad hips, gynecomastia, and micro-orchidism. Enquiry elicited progressively increasing sexual desire from puberty, manifesting as sexual fantasizing and watching pornography for several hours a day, masturbating 1–5 times a day, and visiting prostitutes 3–4 times a week. He enjoyed these sexual activities, did not consider them abnormal and could not abstain for even a day; although he admitted that they were excessive. The phenomena were not resisted, and did not meet criteria for obsessive–compulsive symptomatology. The time-consuming sexual behaviors interfered with his studies, and he was expelled from his university. He had heterosexual orientation. There was no history of childhood sexual abuse or environmental triggers for the sexual preoccupations. There was no anxiety or mood disturbance, neither depression nor hypomania–mania. There was no history of substance use, including tobacco and alcohol. His IQ was 114. His language and social development were adequate. In non-academic matters, he was independent and self-reliant. Two years earlier, he had been evaluated in Canada for his gynecomastia and micro-orchidism, then diagnosed as having KS and had been advised intramuscular testosterone (200 mg every 2 weeks) to prevent hormonal complications of hypogonadism. Treatment partially reduced gynecomastia but had no other benefit. He fulfilled Kafka criteria for hypersexual disorder.3 With his consent, he was started on sertraline (100 mg/day) as decreased libido is a known adverse effect of serotonin reuptake inhibitors (SRI);4 testosterone was continued because, despite testosterone replacement, the peak and trough testosterone levels were low normal (300 and 200 ng/dL, respectively). Four weeks later, he reported decreased sexual desire, fantasies, masturbation, and use of pornography; and his concentration on studies had improved. Sertraline was uptitrated to 150 mg/day and, 6 months later, he reported substantial reduction in sexual preoccupation, and improved academic grades. KS is unusual here because, despite hypogonadism requiring testosterone replacement, our patient had puberty-onset hyperactive sexual desire causing clinical impairment. We cannot say with confirmation that KS is responsible for hypersexuality in this case, but we could not find other possible causes in the form of obsessive–compulsive disorder, addiction, autism or mood disorder, and the condition started well before testosterone replacement. We recruited a known SRI adverse effect (decreased sexual drive) to reduce sexual preoccupations and behaviors and thereby improve his ability to focus on studies, an issue for which he had sought clinical assistance. Sertraline, at 150 mg/day, was effective and well accepted.

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