What is sexsomnia

Sexsomnia also called “sleep sex” or “atypical sexual behavior during sleep” or “somnambulistic sexual behavior”, refers to sexual acts that are carried out by a person who is sleeping ¹⁾. Sexsomnia occurs in young adults and is characterized by masturbation and inappropriate attempts at achieving sexual intercourse followed by total amnesia of the events ²⁾. Sexsomnia can be associated with other parasomnias such as sleepwalking and confusional arousals. Other sleep disorders, including sleep apnoea and periodic leg movement disorder, may trigger episodes of sexsomnia.

The International Classification of Sleep Disorders Second Edition (ICSD-2) recognized sexsomnia as a NREM (non-rapid eye movement) parasomnia (as a clinical subtype of disorders of arousal from NREM sleep—primarily confusional arousals or less commonly sleepwalking), but it has also been described in relation to REM (rapid eye movement) parasomnias ³⁾, ⁴⁾.

Recent studies have described sexsomnia (sleep sex), a parasomnia in which specific motor activation produces inappropriate and involuntary sexual behavior ⁵⁾. After falling asleep, patients with sexsomnia engage or attempt to engage in sexual intercourse or sexual behavior in inappropriate and inhabitual ways. They are not conscious of this behavior and cannot recall what happened the next day. Behavior may include masturbation, attempting sexual activity with a partner sleeping in the same bed, or even attempting sex with a non-partner with whom the patient does not share a bed or a room. Sexsomnia may lead to marital repercussions, or even legal repercussions in very serious cases or those involving minor children ⁶⁾. Prevalence of sexsomnia
is unknown since it is rare and probably underdiagnosed due to patients’ and doctors’ lack of awareness and reluctance to describe it ⁷⁾.

Medical literature on sexsomnia is very scarce. Fewer than 50 cases had been described prior to October 2012 ⁸⁾ and clinical symptoms may be mistaken for those of other entities such as epilepsy. Most (80%) of the published cases are of men; average age at initial consultation is between 30 and 32 years, with about a 10-year history of symptoms. Average age at onset in women is 14 years, compared to 27 years in men. All patients experienced total amnesia of the episodes, which were described by the people who witnessed them masturbating or with whom they attempted intercourse.

Sexsomnia is not associated with erotic dreams; this being the case, the subject does not seem to be acting out a dream, as seen in other types of parasomnia such as sleepwalking, confusional arousal, and REM sleep behavior disorder. Masturbation and sexual vocalizations are the most typical sexsomnia behaviors in women, whereas men more commonly touch and fondle a bed partner’s breasts and genitals or attempt to complete coitus. The latency between sexual arousal and sexual readiness is short; patients easily achieve erection or vaginal lubrication. Sexual interests during sexsomnia episodes do not reflect the patient’s waking preferences. Cases of homosexual sexsomnia have been described in subjects who are heterosexual when awake; there are also cases of fathers touching the genitals of their daughters or daughters’ friends. Sexual behavior during sexsomnia episodes also differs from waking behavior. Some patients are more gentle and affectionate with their partners, whereas others are more direct and abrupt, or even aggressive and violent. They may strike or insult their partners or even attempt sex acts not contemplated in their normal practice, such as anal penetration. A few partners prefer the patient’s sexual approach during sexsomnia episodes to the waking approach; the patient may be either more gentle or more direct than normal. However, most partners refuse to engage in sex play and coitus after realizing that the patient’s actions are not voluntary. In other cases, sexsomnia episodes have erroneously been considered rape due to being interpreted as non-consensual sex acts committed by a person in an alert and conscious state ⁹⁾.

Sexsomnia episodes are especially common during the first half of the night. Frequencies vary between patients, ranging from one-time occurrences to several episodes weekly. Trigger factors tend to be physical contact with the bed partner, sleep deprivation, periods of stress, fatigue, and abuse of such substances as alcohol and marijuana on the night of the episode. Sleep masturbation may be violent; the literature includes a case of vaginal tearing and a fractured digit. Typically, the bed partner is surprised upon waking up to find the patient masturbating and uttering moans and sexual vocalizations. Such vocalizations may present as moaning, provocative remarks intended to initiate sex, lewd and sexual remarks, or sexual insults. Sex play includes attempts at removing the partner’s clothes, touching his or her genitals, and initiating fellatio or cunnilingus. Sexsomniacs may attempt vaginal, or more rarely anal, penetration; if coitus is completed, it may or may not be followed by ejaculation or orgasm. Various postures are possible if permitted by the patient’s partner ¹⁰⁾.

Sexsomnia is often associated with a history of isolated sleepwalking and sleep talking incidents. It has also been described in 4 patients with REM sleep  behavior disorder. Patients with waking sexsomnia have a normal sex life with no history of sexual abuse, sexual trauma, paraphilia, or psychiatric alterations. Some cases have been associated with obstructive sleep apnoea syndrome and the use of zolpidem and selective serotonin reuptake inhibitor antidepressants ¹¹⁾.

Very few episodes of sexsomnia have been described using polysomnography with audio-visual recording. Three patients were heard to utter sexual moans during deep N3 stage sleep ¹²⁾. One patient with sexsomnia completed coitus with his partner (who provoked him sexually while they were sleeping together in the laboratory). He was between wakefulness and light N1 stage sleep, and was unable to recall the episode later ¹³⁾. A video-polysomnography study of a 60-year-old woman revealed a masturbation
episode lasting a few minutes and beginning in deep N3-stage sleep. During the episode, the EEG trace showed a mixture of alpha activity and persistent delta waves indicating deep N3 sleep. When the technicians roused the patient, she could not recall touching herself or having been dreaming ¹⁴⁾.

Sexsomnia key findings ¹⁵⁾:

• Predominant in males (3 men, 1 woman).
• Affects younger adults (patients’ ages at time of examination ranged from 28 to 43 years).
• History of isolated sleep talking or non-REM sleep parasomnia.
• No history of neurological diseases such as epilepsy.
• No psychiatric disorders and no history of sex-related diagnoses such as paraphilias.
• Sexual activity with intention to complete coitus or masturbate.
• Inappropriate or atypical attitude to sex compared to waking sexual behavior, characterized by lewdness and vulgarity, or more rarely, forcefulness or aggressiveness.
• Variable frequency (from 4 single episodes to 2-3 episodes weekly).
• Not associated with dreams.
• Total amnesia of the episodes.
• Polysomnography recordings do not typically detect episodes of sexsomnia, but they may identify other sleep disorders, including sleep apnea or periodic leg movements.
• Research shows that treatment with clonazepam may reduce the frequency of sexual behaviors during sleep ¹⁶⁾.

What causes sexsomnia

As with all other types of non-REM sleep parasomnia, the cause of sexsomnia is unknown, but it is likely related to disordered sleep-wake regulation mechanisms ¹⁷⁾. Another type of parasomnia, sleep eating, in which motor activity consists of consuming foods in unusual ways instead of presenting as the sexual behavior seen in sexsomnia ¹⁸⁾.

Sexsomnia triggers

Sexsomnia episodes may possibly be triggered by circumstances leading to broken sleep, such as sleep apnea, periodic leg movements or changes in the sleep-wake cycle (changing work shifts). It is possible that treating these trigger factors may decrease the frequency and intensity of sexsomnia episodes.

Trigger factors tend to be physical contact with the bed partner, sleep deprivation, periods of stress, fatigue, and abuse of such substances as alcohol and marijuana on the night of the episode.

Sexsomnia symptoms

Sexsomnia episodes are especially common during the first half of the night. Frequencies vary between patients, ranging from one-time occurrences to several episodes weekly. Masturbation and sexual vocalizations are the most typical sexsomnia behaviors in women, whereas men more commonly touch and fondle a bed partner’s breasts and genitals or attempt to complete coitus. The latency between sexual arousal and sexual readiness is short; patients easily achieve erection or vaginal lubrication. Sexual interests during sexsomnia episodes do not reflect the patient’s waking preferences. Cases of homosexual sexsomnia have been described in subjects who are heterosexual when awake; there are also cases of fathers touching the genitals of their daughters or daughters’ friends. Sexual behavior during sexsomnia episodes also differs from waking behavior. Some patients are more gentle and affectionate with their partners, whereas others are more direct and abrupt, or even aggressive and violent. They may strike or insult their partners or even attempt sex acts not contemplated in their normal practice, such as anal penetration. A few partners prefer the patient’s sexual approach during sexsomnia episodes to the waking approach; the patient may be either more gentle or more direct than normal. However, most partners refuse to engage in sex play and coitus after realizing that the patient’s actions are not voluntary. In other cases, sexsomnia episodes have erroneously been considered rape due to being interpreted as non-consensual sex acts committed by a person in an alert and conscious state ¹⁹⁾.

Sexsomnia treatment

Clonazepam is effective for reducing sexsomnia episode frequency and intensity in most patients ²⁰⁾. Antidepressants may be of use ²¹⁾, although there is a published case in which citalopram caused sexsomnia episodes ²²⁾. The patient should achieve uninterrupted sleep with no arousals or microarousals. Shift changes, apnoea, and periodic leg movements may fragment sleep, and this can lead to episodes of sexsomnia in predisposed individuals ²³⁾. On this basis, fostering good sleeping habits and treating sleep apnea and periodic limb movements may reduce the frequency of sexsomnia episodes.