Homicidal Act Commited by an Elderly Person with Sexual Dysfunction-Case Report

6 Transilvania University of Brasov, Faculty of Medicine, 56 Nicolae Balcescu Street, Brasov-500019, Romania Abstract: Sexual dysfunctions (SDs) are highly prevalent with aging. Studies reported an interactive correlation between psychiatric morbidity and SD. Also, SDs have significant influence on patients` self-esteem, body image, interpersonal relationships, and physical health in general. The aim of the present research is to present an intimate partner homicide case and to discuss a possible correlation between SDs of elderly patients and their inclination towards aggressive behavior from intimate partner violence (IPV). A forensic psychiatric assessment was performed on a married male patient, aged 61. He was diagnosed and treated for BPH and he could no longer have sexual intercourse. Using a knife, he provoked over 20 stab wounds to his wife, who died following the attack. He admitted that he was jealous, due to his wife having an affair. The psychiatric forensic expertise found that the killing was committed with discernment. Psychological states found in IPV perpetrators are partly like those met in SDs patients. The relation between SDs in older adults and aggressive behavior, especially IPV, requires further research. In the case discussed, a complex of negative emotions and aggressiveness could be determined equally by infidelity of the spouse or by the perpetrator’s SD, but we can assume that SD played a relevant role in the causal chain.


Introduction
Romantic relationships are a significant part of our lives. Longer relationships have more support, but also have higher levels of negative interactions, control and jealousy and can become a source of great sorrow and distress (Lantagne & Furman 2017). Rejection is a risk involved in the establishment of all interpersonal relationships and can lead to disrupted psychological functioning (Cano, & O'Leary, 1997;Murphy & Russell 2018). Jealousy is defined as a complex mental state caused by a real change or false imaginary change in the way people perceive a threat consisting of ending a valued partnership in favor of a real or imaginary rival (Cynkier, 2018).
Although low urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are common in the elderly, they are underreported (Taha et al., 2020). BPH reduces the patient's quality of life, with negative physical and psychological effects . BPH and its specific medication can further determine a deterioration of sexual function (Corona et al., 2017). Sexual and urinary dysfunctions are associated with many social and psychological losses, with worsened quality of life. Erectile dysfunction (ED) is defined as the persistent inability to attain and/or maintain a penile erection adequate to initiate and complete a sexual intercourse (Drogo, 2019). Prevalence of ED is increasing with age, from 1-10% at people aged 40, to 20-40% in those aged 60-69, and 5-100% in those aged over 70. Despite all ED's treatment possibilities, treatment ineffectiveness, side effects, the quality of one's intimate relationship as well as the cost of the treatment are reported as common barriers to treatment adherence (Williams et al., 2019).
The well-being of the elderly has its own importance (Breaz, 2019), and health care systems goals should be to support methods of improving psychological states of the elderly (Racoare et al., 2020), besides their illness and disability (Steptoe et al., 2014). Research into psychological condition, well-being, and health elderly males with erectile dysfunction is at an early stage. Sexual health is known to be linked with general health, and is conditioned by cultural, social, relational, intrapsychic, and biomedical aspects, being coordinated by the neurological, endocrine and vascular systems (Mollaioli et al., 2020). Risk factors of sexual dysfunctions are physical factors like obesity, smoking, alcohol and substance abuse, and psychosocial factors like stress, anxiety, depression, income, experiences, and personality Ciubara et al., 2016). The impairment of sexual functioning also determines a psychological problem, because of the influence on self-esteem, body image, interpersonal relationships, and physical health in general (Mollaioli et al., 2020). Latest research suggests that ED has a strong connection with depression. According to Mallis et al.,63,1% of 103 patients with ED received a psychiatric diagnosis, out of whom 25,2% presented depressive disorders. One out of four patients with ED, who was free of previous symptoms, was diagnosed with a psychiatric condition (Mallis et al., 2005). Until now, numerous studies have explored the association between LUTS, BPH and sexual dysfunctions. However, there are many studies which indicate a bidirectional relation between sexual dysfunctions and psychological state. The aim of the present research is to present an intimate partner homicide case and to discuss a possible relation between sexual dysfunctions in elderly patients and their psychological influence, especially if it can determine an aggressive behavior, and additionally intimate partner violence .

Case report
A forensic psychiatric assessment was performed for a male patient aged 61, to establish his mental capacity in relation to a criminal act of intimate partner homicide. The result of the psychiatric forensic expertise was based on multiple examinations, with the patient being continuously hospitalized in a psychiatric medical institution.
He was married for 40 years, retired from workplace, father of two adult children, coming from urban environment, with secondary school education, with no personal or family psychiatric history, who states that he has been yearly psychologically examined before retiring, examination required at the workplace. He was diagnosed with benign prostatic hyperplasia and he was following a medical prescription and because of that he no longer could have sexual intercourse. He declared sexual intercourse monthly or twice a month, and no erectile dysfunctions before starting the treatment. No help for erectile dysfunction was sought. He was a smoker and he declared casual alcohol, benefic in low doses (Ciubara et al., 2018), consumption, but no drugs. He denied any criminal records, claimed that he was a nonviolent person, but from time to time he had disagreements with his wife. The wife was 51 years old and she was a kindergarten teacher.
From the report of the judicial investigation, it is revealed that one day, while at home, the suspect applied over 20 knife stabs to his wife. After the attack, the victim deceased. Also, it is reported that the crime was committed on a basis of jealousy from the suspect.
During the psychiatric examination, the patient admitted the crime and described with details the committed act, he regretted, and he was aware of its consequences. He also admitted that he was jealous, and he claimed that he was triggered by his wife's extramarital affair. He related that he was stalking her every day and that he had seen her many times next to the same man. His wife told him she was in love with the other man and had been laughing about his inability to have sexual interactions.
Regarding the day of the crime, he declared that while he was preparing food, his wife's phone rang, a spontaneous conflict appeared, he stabbed her 3-4 times, after which she fell on the floor. He declared that he did not consume alcohol that day. After the homicide, he called the Emergency Service 112 and his daughter, he stated the committed act and then he tried to commit suicide by repeatedly stabbing himself, resulting in 5 superficial wounds on the left anterior hemithorax area. He also claimed that he did not have other suicide attempts before.
The interview and the psychological observation revealed depressive mood, easy crying, reduced communication, demoralizing somber ideation, guilt, mnesic and prosexic deficit, Hamilton Depression Rating Scale-34 points, indicating a severe depression, depressive profile situational-related. EEG examination revealed spontaneous activity within normal limits. The psychiatric forensic expertise report's conclusions were that the suspect presented reactive-situational depressive episode; and it had at the time of committing the offense the psychic ability to critically assess the content and the social-legal consequences of its deeds.

Discussion
Jealousy transforms itself into a disease process when it grows into an obsession or a fixed belief, the border between obsession and delusion being often blurred (Da C. Stravogiannis et al., 2018;Seeman, 2016). The chronic threat of losing a partner is caused by previous experiences of infidelity, which can determine cognitive, emotional and behavioral reactions (Cynkier, 2018). The jealous person, in time, brings up anger, guilt, shame, social anxiety, loneliness and embarrassment, which can lead to a broad spectrum of behaviors (Cynkier 2018;Mathes &Verstraete 1993;Rodriguez et al., 2015). In the present case, the jealousy feelings of the aggressor were provoked by a real extramarital relationship of the spouse of which he was aware and which he accepted subconsciously because of his sexual dysfunction. The criminal act was not determined by pathological jealousy, the forensic psychiatric examinations did not reveal any signs for this BRAIN. Broad Research in December, 2020 Artificial Intelligence and Neuroscience Volume 11, Issue 3, Supplementary 1 12 pathology. Jealousy feelings associated with negative emotions involved in the management of social acceptance and rejection feelings gathered over time, coupled with a spontaneous conflict, all the above conducted to intimate partner homicide. Intimate partner violence (IPV) continues to be a pervasive problem of paramount societal, public health, and economic importance. Over a lifetime, more than 1 of 3 women (35.6%) and more than 1 of 4 men (28.5%) will have experienced physical violence, rape, and/or stalking by an intimate partner (Birkley & Eckhardt 2015;Tharp et al., 2013). Malik et al. (2020) studied knife-related injuries and observed that female knife-injured patients were more likely to be injured in domestic violence circumstances (64.9% cases), and 16.2% of them were pregnant at the time of injury (Malik et al., 2020). Recent research has shown that repeated incidents of IPV had been registered by the police and/or by the health-and social care services before an intimate partner homicide case occurred. This raises a signal for both the police and health-and social services for coordinated approach to prevent recurrent family violence (Nesset et al., 2020).
The reasons behind relationship problems can be grouped into three major areas, related to emotions, sexuality, and communication. The results of a study indicated that 70% of the people who got involved in extramarital relationships reported that their act was triggered by marital problems (Thompson, 1984). The reactions to a partner's extramarital relationship can suffer great variability (Charny & Parnass, 1995). Distrust is an important determinant in experiencing and expressing jealousy. Reactive jealousy appears with the partner's awareness of an extramarital relationship as it was in the present research.
Oftentimes patients are embarrassed to discuss about sexual concerns and consider their problem as an inevitable part of aging or illness, being unaware of the treatment possibilities Vik & Brekke 2017;Williams et al., 2019). Studies report a percentage range from 10% to 30% for those who sought help, where the most common type of help sought was consulting a general practitioner (Vik & Brekke 2017). In a study, out of 1117 consultations performed by several general practitioners (GPs), 47 (4,2%) involved a wide variety of concerns about sexual health (Vik & Brekke 2017). Neither did the patient in our case seek medical advice for his ED.
ED has a major influence on the patient and his sex partner's quality of life and emotional well-being. Many older adults consider sexuality as an important part of life and a mark of successful aging (Lindau et al., 2007;Steptoe et al., 2014). Regarding the intimate partner's thoughts on ED patient, there are reported feelings of frustration, missing intimacy and sexual activity, and sadness. A lack of communication within the partnership could worsen existing conflicts rather than resolve the problem (Hinchliff et al., 2018). All these support the idea of the partner's influence on a patient's psychological state and willingness to seek treatment, and the importance of the partner's involvement in ED management which can be beneficial (Mallis et al., 2005). In the case discussed, it seems like sexual dysfunction of the husband had a negative influence on the marriage, and instead of support, communication and seeking help, we see conflict, feelings of inferiority, frustration, intimacy deficits and low self-esteem. Therefore, we can assume that problems in sexual functioning could play a relevant role in the etiology of aggressiveness.
The impairment in sexual function has an adverse effect on selfesteem, body image, interpersonal relationships, and physical health in general. There are many studies which indicate bidirectional relation between sexual dysfunction and psychiatric symptoms and/or conditions. In Lu's study, carried on 1267 men, the incidence of anxiety and depression in men with sexual dysfunction was 75,84% (339/447) and 68,46% (306/447) respectively, significantly higher than in the group of patients with no sexual dysfunction reported. Also, they reported worsened life quality and life satisfaction, negative emotions, and emotional status. Participants under 60 presented significantly worse negative emotions, life quality and life satisfaction, which can be explained by a decreased sexual desire with age, and less impactful effects on older people (Ciobotea et al, 2016;Lu et al., 2020;Valcea et al., 2016). In this sense, Yang et al. reported that 63,1% of ED patients developed psychiatric symptoms, and for depression, a significant positive association was found. However, the correlation between depression and erectile dysfunction is interactive because depression can cause sexual dysfunction and a dissatisfying sexual life can determine depressive symptoms with various intensity (Bolos et al., 2012). Various anxiety disorders are also reported to have an interactive correlation. They also presented a positive correlation between ED severity duration and incidence and progression of psychological disorders (Yang et al., 2019). Correspondingly, Mallis et al. reported a percentage of 63,1% with psychiatric conditions out of 103 ED patients. Frequent psychiatric diagnoses were depressive disorders in 25,2%, anxiety disorders 11,7% and personality disorders in 5,8% of the cases. Of the 64 patients with psychiatric morbidity, 24 were newly diagnosed (Mallis et al., 2005). This means that physicians should be aware that ED is a stressor leading to psychiatric morbidity, especially in men with a positive psychiatric anamnesis. Rettenberger et al. (2013) studied 163 sexual homicide perpetrators in order to assess the presence of genital abnormalities like phimosis and cryptorchidism in childhood, because they have considered that sequelae may last into adolescence and adulthood and can affect sexual functioning, fertility and psychosexual development and well-being, thinking of sadistic impulses as well as sexually aggressive behavior. They affirmed that sexual dysfunction could determine feelings of inferiority, frustration, and aggressiveness, which can trigger violent behavior against the intimate partner. Also, intimacy deficits, sexual anxiety or problems with self-esteem are considered possible explanations for the relationship between sexual dysfunction and sexual offending (Rettenberger et al., 2013). These psychopathological states described by Rettenberger et al. are partly like those met for IPV perpetrators.

Conclusions
After a survey of available research, we found that there is an interactive correlation between ED and psychiatric morbidity. Still, the correlation between sexual dysfunctions in older adults and aggressive behavior, especially intimate partner violence, is yet to be discovered. Considering these, this paper recommends further research direction to clarify this suggested underlying correlation.
In our case of intimate partner homicide, a complex of negative emotions, such as feelings of inferiority, jealousy, rejection, and threat of losing the intimate partner, and aggressiveness, could be determined equally by the infidelity of the spouse or by the perpetrator's sexual dysfunction, but we can assume that SD played a relevant role in the causal chain.