Sexual Behaviors during Sleep
Christian Guilleminault, MD
Stanford University, Palo Alto
Violence, during sleep or out of sleep, related to abnormal alertness has received more attention during the past 10 years. Absence of full alertness and impairment of brain function due to associated sleep disorders has been considered as a legal defense in crimes and homicides [1,2]. Sleep Medicine experts have been requested to testify in medical legal cases. Educational efforts have been made to attract the attention of physicians about the problem, medical-legal implications, and the need to have appropriate documentation of the medical problems associated with the reported violence. A general population survey has indicated that sleep-related violence is much more common than known by physicians. Two percent of the general population reported the occurrence of sleep-related violence . However, reports and surveys have provided little information on "atypical sexual behavior" during or out of sleep, which may present as an annoying but tolerable problem to the bed partner. It may be an aggressive, harmful behavior during sleep, often called "rape" or "rape-like" behavior by the bed partner. This behavior, also called "sleep sex" by some bed partners, is therefore poorly documented. In our experience, it is also not often mentioned to physicians, due to the feelings of shame of patients and bed partners. This work presents a series of patients who exhibited different behaviors that we labeled "atypical sexual behavior during sleep". Two of these cases led to police interventions, and one of them had charges of "rape" against a teenager and was seen as a medical-legal case. The 11 case-vignettes are briefly presented to outline the range of the problems. The work-up performed, objective findings, treatment approaches, and follow-up outcome are presented. The goal is to outline some of the medical implications that may hide behind "atypical sexual behavior" from clinical information collected during sleep structured interviews, and to suggest tests and investigations that may be done to find the underlying sleep abnormalities leading to the behavior.REFERENCES
- Moldofsky H, Gilbert R, Lue FA, MacLean AW. Sleep related violence. Sleep; 1995, 18: 731- 39.
- Guilleminault C, Moscovitch A, Leger D. Forensic Sleep Medicine: Nocturnal Wandering and Violence. Sleep. 1995; 18: 740-48.
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- Guilleminault C, Moscovitch A, Yuen K. Poyares D, Atypical Sexual Behavior During Sleep, Psychosomatic Medicine 2002/64:328-336
Carlos Schenck, M.D.
University of Minnesota Medical School
Terms and Definition
- Atypical Sexual Behavior During Sleep
- Abnormal Sleep-Related Sexual Behaviors (ICSD-2)
Problematic sexual behaviors emerging during sleep.
Problems With Sexsomnia
- Disrupting the sleep of the bed partner.
- Physicial injury to the bed partner or to oneself from aggressive sexual behaviors.
- Psychological disturbance to the bed partner from offensive sleepsextalking.
- Psychological disturbance to the bed partner from:
- The inappropriate time of sex.
- The inappropriate type of sex.
- The non-consensual sexual behaviors (since the bed partner is asleep).
- Psychological disturbance to the sexsomniac: shame, guilt, confusion, experienced within the context of amnesia for the event: being told about one's objectionable actions.
- Negative marital/relationship impact
- Non-REM Parasomnia: Confusional Arousals, Sleepwalking
- Obstructive Sleep Apnea
- Nocturnal Seizures: Epileptic Sexsomnia
- REM Sleep Behavior Disorder (?)
- Medications: SSRI (one case reported), Sedative-Hypnotics (?)
[N.B. No apparent association with sexual deprivation or sexual perversion (paraphilia)]
Sexsomnia: Two Most Common Causes
- Non-REM Parasomnia: Confusional Arousals, Sleepwalking. There is usually a history of parasomnias, often childhood-onset: Sleepwalking, Sleep Terrors, Confusional Arousals, Sleep Related Eating Disorder, Sleeptalking, RMD, etc.)
- Obstructive Sleep Apnea (inducing Confusional Arousals) "Snorgasm" "Sexapnea". Typical history: onset or increase of snoring with the onset of the sexsomnia, as reported by the bed partner.
- REM Sleep Behavior Disorder (?)-not yet documented by video-polysomnography. Sixel-Döring FTE, et al. Associated factors for REM sleep behavior disorder in Parkinson disease. Neurology 2011;77:(in press).N=457 pts with vPSG: no sexual behaviors, despite 46% (n=210) with RBD/vPSG behaviors].
- Epileptic Sexsomnia (Sleep Related Sexual Seizures)
A case of alleged sexsomnia in which there is no current documented OSAS, and no past history of (observed) parasomnia should be considered with skepticism. A first-time sexsomnia episode resulting in legal consequences should be considered doubtful. Role of alcohol?
ICSD-2 (2005) PARASOMNIAS Disorders of Arousal (From delta NREM )
- Confusional Arousals--including variants:
- Severe Morning Sleep Inertia
- Abnormal Sleep-Related Sexual Behaviors
- Sleep Terrors
- Schenck CH, Arnulf I, Mahowald MW, "Sleep and Sex: What Can Go Wrong? A Review Of The Literature On Sleep Disorders and Abnormal Sexual Behaviors and Experiences" , Sleep 2007; 30: 683-702.
Sexsomnia: Parasomnia & Sleepsex (31 published cases)
- Males: 80.6% (n=25)
- Females: 19.4% (n=6)
- Age: 31.9 +8.0 yrs
- Duration: 9.5 +6.1 yrs (n=8)
- (n=8: 1 episode)
- (n=14: unknown)
- Masturbation: 22.6% (n=7)
- Sexual vocal/verbal: 19.3% (n=6)
- Fondling: 45.2% (n=14)
- Sexual intercourse: 41.9% (n=13)
- Amnesia for sleepsex: 100% (31)
- Assaultive sleepsex behaviours: 45.2% (14)
- Sleepsex with minors: 29.0% (9)
- Legal repercussions: 35.5% (11)
- Polysomnography, performed: 83.9% (26)
- Total #, parasomnias: 71
- Mean #, parasomnias/pt: 2.2 +1.0 (range: 1-4)
Cicolin A, et al. "Sexual Behaviors During Sleep Associated With Polysomno- graphically Confirmed Parasomnia Overlap Disorder" [2 cases], Sleep Medicine 2011;12: 523-528
[5 NREM/REM Motor Parasomnias: each patient!]
"Sexsomnia: An Uncommon Variety of Parasomnia", Clinical Neurology and Neurosurgery 2009; doi:10.1016/j.clineuro.2009.08.026
(Bejot Y, et al.) University of Lyon
- 36 year-old married woman
- 40 year-old married woman
Clinical and Polysomnography Findings:
- Both patients: traumatic and sexual psychological stress during childhood.
- Both patients: amnestic sexsomnia, with sexual moaning, "dirty talk", masturbation, sexual assault of the male bed partner, and sexual intercourse.
Both patients had multiple, abrupt, spontaneous arousals from SWS, without associated behaviors: very suggestive of a Non-REM sleep parasomnia, such as Confusional Arousals or Sleepwalking.
Therapy: SSRI (Escitalopram, 10 mg/day)-
both patients (n=1 depression; n=1 no dep.).
Response: complete control of sexsomnia, at 9 month and 2 year follow-up, respectively.
(No rationale given for the SSRI therapy of the sexsomnia).
Krol DGH "Sexsomnia during treatment with a selective serotonin reuptake blocker", J of Psychiatry (Netherlands) 2008; 50 (11): 735-9
30 y.o.man without parasomnia history, developed de novo Sexsomnia on a nightly basis for 3 weeks upon starting Escitalopram, 10 mg/day, as therapy of Major Depression.
Sexsomnia: full intercourse with bed partner.
Sexsomnia immediately ceased with discontinuation of escitalopram.
No recurrence of Sexsomnia with duloxetine therapy (serotonin-norepinephrine reuptake inhibitor).
Sexsomnia: Treatment Efficacy
- Parasomnia: clonazepam: 83% (10/12)
- Parasomnia: SSRI: 100% (2/2)
- OSA: nCPAP: 100% (5/5)
- Epileptic Sexsomnia: 100% (5/5) (anticonvulsant therapy) [Need to identify all target symptoms when starting Rx and assessing its efficacy.]
Treatment of Abnormal Sleepsex Besides pharmacotherapy, consider referral (of patient and spouse/significant other) to a psychologist or psychiatrist for one of two reasons (or both):
- Explore marital/interpersonal relationship as a contributing factor to the sexual parasomnia.
- Deal with the adverse consequences (personal and interpersonal) of the sexual parasomnia.
Case Report: OSA and Sexsomnia
32 Year Old Married Man
(concurrent emergence and control of both sleep disorders with nCPAP) Somnology 2008; 12: 38-49
- Chief complaint: sexually groping and fondling his wife during sleep-for 4 years.
- Began at the same time as snoring began, which became progressively louder-and his wife complained that over time "he tried to hump me while he was asleep."
- Sexsomnia frequency: 4 nights/week.
- Full amnesia for sexsomnia events.
- 10 years married: no other problems.
- "His wife reported that he was somewhat insistent with his sleepsex initiatives with her, but was never aggressive or violent, and he always responded promptly to her limit setting."
- "On some occasions he would be awakened by his wife in the midst of a sexsomnia episode, and then he would recall having a sexual dream involving the two of them."
- His sleepsex repertoire was the same as the sexual repertoire during their waking lives.
- Normal wakeful sex life: no sexual deprivation
- No stress-related trigger for sexsomnia onset.
- No psychiatric history, no paraphilia history.
- No parasomnia history.
- Negative family History.
- No history of alcohol or drug abuse.
- Employed continuously since high school.
- Lives with wife and daughter.
- Major marital stress from the sexsomnia.
- Video-Polysomnography: documented OSA
- Apnea Index: 19/hr; O2 nadir: 78%
- Nasal CPAP therapy, 10 cm H2O pressure: completely normalized sleep continuity and hemoglobin O2 saturation.
- No sexsomnia or other parasomnia behaviors were documented during polysomnography.
- 1 month and 3 month visits: wife reported complete control of sexsomnia and snoring with ongoing nCPAP therapy.
- When CPAP mask off: some mild sexual groping and fondling.
- Wife was very pleased: optimism about the marriage.
- Therefore, need to question snoring/OSA patients about sexsomnia-and vice versa.
- Sexsomnia is a medical (sleep-related) problem, and not a primary psychological or psychiatric problem, or a result of sexual deprivation.
- Question patients/spouses/other bed partners with snoring/documented OSA/SDB about Sexsomnia.
- Patients with OSA/other forms of SDB may comprise a large, vastly under-recognized group of Sexsomnia patients.