Troublesome bedroom behavior posed by sexual sleep disorders can damage relationships and present serious problems for patients and bed partners.
By Carlos H. Schenck, MD
Sleep-related abnormal sexual behaviors, also called “sleepsex,” “sexsomnia,” and “atypical sexual behavior during sleep,” are gaining more attention through increased research and legitimate recognition among the medical community.1-3 While such behaviors are not nearly as prevalent as disorders such as OSA, the immediate need to identify and treat these cases should not be overlooked. Treatment is urgent seeing that there is the potential of sexual assault on an adult or minor during sleep, which could have tragic consequences for both the victim and the perpetrator. In the following case, a 32-year-old married man, with a chief complaint of “fondling my wife during sleep,” presented to our sleep center with his wife of 10 years; she had urged him to seek help for his sleep problem that had begun 4 years earlier, when he commenced to snore and also grope and fondle his wife sexually while being sound asleep.
The recently revised second edition of the International Classification of Sleep Disorders (ICSD-2) has defined parasomnias as “undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousals from sleep.4 Furthermore, the ICSD-2 recognizes that instinctual behaviors, also known as “basic drive states,” commonly emerge with the parasomnias, as exemplified by locomotion (eg, sleepwalking [SW], REM sleep behavior disorder [RBD]), feeding (eg, sleep-related eating disorder), aggression (SW, RBD), and sex. The latter set of behaviors, when pathologically intertwined with sleep (itself an instinctual behavior), has been classified in the ICSD-2 within the group of parasomnias named “disorders of arousal (from NREM sleep),” with the designation of “sleep-related abnormal sexual behaviors” being a variant of confusional arousals (and SW). A recent review has provided the first classification of all reported abnormal sexual behaviors associated with sleep disorders, including the sexual parasomnias.5
When the patient came to our laboratory, he stated that the reported fondling simultaneously commenced with the onset of heavy snoring. His snoring became progressively louder over time, his wife reported. She was also shocked to observe her husband engage in a full repertoire of sexual behavior with her while he was clearly asleep, 4 nights weekly over a period of years—and what further irked her was that he never remembered these events in the morning, so there was nothing for him to discuss with her. Nonsexual sleeptalking also appeared for the first time when he started to snore and had persisted. His wife felt aggravated by her husband’s sleepsex, which she found to be quite offensive, and it also disrupted her sleep. She doubted whether she could continue to sleep with her husband much longer and wondered whether she could remain married to him indefinitely if the sleepsex persisted.
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 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. In general, his sexual repertoire during sleepsex mimicked the sexual repertoire during their waking lives.
Beyond the sleepsex, the patient and his wife deny any underlying marital problems, both presently or in the past. However, the sleepsex eventually placed a growing strain on their marriage. They endorsed having a normal sexual life and could not identify any psychosocial triggering factor for the emergence of sleepsex 4 years previously, such as sexual problems, sexual deprivation, or some other stress. The patient had felt sheepish about what he does in his sleep, as told to him by his wife, and he was perplexed by how he cannot recall any of the sexual activity that his wife describes.
Regarding the man’s sleep routine, he generally falls asleep rapidly and sleeps (subjectively well) for about 7 hours until 6 am when he is awakens by one alarm clock and gets ready for a 12-hour work shift at a printing facility. Although the patient denies any excessive daytime sleepiness, he does complain of persistent daytime fatigue and tiredness.
The evaluation further showed that there was no history of prior sleep disorder, and specifically no childhood or subsequent history of parasomnia, such as sleepwalking, sleep terrors, confusional arousals, sleep-related eating, sleeptalking, restless legs, or rhythmic movements. There was no history of periodic hypersomnia. He also denied any family history of parasomnia or other sleep disorder. There is no history of medical, neurologic, or psychiatric disorder, nor any loss of consciousness or seizure-like spells. There was no history of paraphilia or criminal sexual misconduct, and he denied having problems with compulsive masturbation, or excessive/inappropriate sexual fantasies or preoccupations. He denied any history of having been sexually molested during childhood or subsequently. There was no history of alcohol or substance abuse, or excessive caffeine use; he smokes a pack of cigarettes daily. He had a 10th grade education, and had been employed continuously since leaving school. He lives with his wife and their daughter.
An alert, healthy-appearing, white male in no distress. He had a normal neurological and musculoskeletal exam. Oropharynx was clear, without redundant tissue, and he had a normal neck circumference. There was no cyanosis, clubbing, or edema of the extremities. No skin rash was present. Blood pressure was 100/58, weight 93.5 kg, height 178 cm.
Unremarkable, apart from some dysphoria over the longstanding, involuntary sleepsex with his wife, of which he had no memory.
A hospital-based, sleep technologist-attended, split-night PSG study documented clinically significant OSA, but no other sleep disorder or abnormal PSG finding. Neither sleeptalking, sleep moaning (sexual, nonsexual), sexual movements/behaviors (or any other parasomnia behaviors), rhythmic movements, PLMs, precipitous arousals from slow-wave sleep, loss of REM sleep atonia, increased REM sleep phasic activity, nor EEG epileptiform activity was present during either part of the split-night PSG study. The first part of the study lasted 283 minutes with 77% sleep efficiency, 23 minute sleep latency, 101 minute REM sleep latency, 11.6% stage 1, 53.2% stage 2, 11.8% stage 3/4, 23.4% REM. Obstructive apnea index = 19/hour, with nadir oxygen desaturation of 78%, compared to waking baseline SaO2 of 97%. The average apnea duration was 22.7 seconds; longest duration: 52.8 seconds.
The second part of the split-night PSG study lasted 183 minutes with 86% sleep efficiency. Administration of nasal CPAP 10 cm H2O pressure completely eliminated the sleep-disordered breathing noted on the baseline portion of the study, which resulted in normalization of sleep continuity and hemoglobin oxygen saturation. A full seizure montage was employed during both parts of the PSG study with no electrical or clinical seizure activity observed. The patient was found to be pleasant and interacted appropriately with the sleep technologists throughout all aspects of his PSG study, including the 1-hour setup time, and did not make sexual comments or act in any sexual manner.
During the post-PSG interview with the patient and his wife, they were pleasant and friendly, with the husband being a very open, mild-mannered man who interacted in a mutually considerate manner with his wife. They were each very interested in hearing the results of the PSG study and how those results related to their primary sleep complaint of sexual behaviors. The following positive and negative findings from the clinical history and PSG study were explained to the patient and his wife.
His sexual behaviors (and sleeptalking) began with the onset of snoring 4 years previously, and he was now documented to have clinically significant OSA that required effective therapy. Therefore, the sleepsex appeared to be associated with sleep-disordered breathing, most likely emerging during OSA-induced confusional arousals. The reason why sexual behaviors were the sole manifestation of his confusional arousals was unknown, since confusional arousals (spontaneous or OSA-triggered) can manifest with a variety of behaviors.
There was no prior personal history of any type of parasomnia, and no family history of parasomnia, which greatly lessened the probability that he had a primary form of confusional arousals, and supported the working diagnosis of OSA-triggered confusional arousals with sexsomnia. The distribution of sleep stages manifesting confusional arousals is probably different for OSA cases compared to spontaneous (familial) cases, with the latter being mainly from slow-wave sleep, and the former more often from REM sleep and light non-REM sleep.
There was no other history of inappropriate sexual behavior, and no other possible cause or contributing factor to the sexsomnia that could be identified. Therefore, the most likely scenario is OSA-induced confusional arousals from which emerged his sleepsex. The working diagnosis was confusional arousals (OSA-triggered) with sexsomnia variant. In the ICSD-2, “sleep-related abnormal sexual behaviors” is an identified variant of confusional arousals (and SW).
One atypical feature of his case is the reported dreaming (sexual, involving his wife) during some of his awakenings from a sexsomnia episode. This has not been reported previously among the 31 cases in the published literature5—even among the (few) patients diagnosed with RBD as the cause of the sexsomnia, but without any firm evidence supporting RBD as the cause of sleepsex. RBD is characterized by dream enactment, and so it would be unusual for true sexual RBD not to have associated dreaming. In our patient’s case, the sexual dreaming may have emerged during OSA-induced arousals from REM sleep, rather than from non-REM sleep.
At 1-month and 3-month follow-up, the patient’s wife reported that the sexsomnia had mainly disappeared since the initiation of nCPAP therapy, and only when the mask did not stay on his face sufficiently on a given night was he prone to fondling or mildly groping her. The patient reported feeling less tired and fatigued during the day, and was more rested when he got out of bed in the morning. The wife was quite pleased with the response to this sleep therapy, and was optimistic about the future of their marriage. Nevertheless, the possibility of referral to a marriage counselor for short-term intervention was being considered in order to allow this couple the opportunity to work through any lingering issues pertaining to the sexsomnia.
This case illustrates a subtype of sexsomnia that has been reported in the literature, consisting of OSA-triggering confusional arousals with abnormal sexual behaviors during sleep, with subsequent nCPAP therapy controlling both the OSA and the associated sexsomnia. Therefore, clinicians should question patients with snoring or documented OSA (or some other form of sleep-disordered breathing), along with their spouses/bed partners, about any associated abnormal sleep behaviors, including sexual behaviors during sleep. Conversely, clinicians should question patients presenting with a complaint of sexsomnia about snoring and other symptoms suggestive of sleep-disordered breathing. Most reported cases of sexsomnia have involved male patients with histories of non-REM sleep parasomnia (confusional arousals, SW, sleep terrors), with the sexual behaviors emerging after the parasomnias had been well established, often beginning in childhood.
Most forms of sexual behavior have been reported to occur with sexsomnia, including sexual vocalizations, masturbation, fondling another person, and sexual intercourse (with or without climax). PSG studies documented the non-REM sleep parasomnias in many of these cases, although sexual behaviors were rarely documented. Also, seven published cases of sexual behaviors during sleep were documented to have resulted from sleep-related seizures (involving sexual hyperarousal, ictal orgasm, and ictal sexual automatisms) in patients with epilepsy. Therefore, abnormal sexual behaviors during sleep almost always are a manifestation of either a non-REM sleep parasomnia, OSA, or sleep-related seizures. (Whether RBD with sexual behaviors exists is still open to question.) Fortunately, in the vast majority of published cases, therapy of the sexsomnia has been effective, such as clonazepam for non-REM parasomnias (and presumed RBD with sexual behaviors), nCPAP for OSA, and anticonvulsant medications for sleep-related sexual seizures. Consultation with a psychiatrist or psychologist always should be considered in the overall management of these cases, either to deal with personal or interpersonal/marital issues promoting or aggravating the sexsomnia, and/or to deal with any adverse personal or interpersonal consequences from the sexsomnia. It also should be noted that the SW variant of sexsomnia can manifest as an elaborate form of “pseudo-paraphilia” that could have forensic and adverse psychosocial consequences.6
Finally, a chapter entitled “Abnormal Sleepsex: Unknowing, Cruel Intimacy” is contained in a recently published book on sleep disorders for the general public,7 which is a resource of information for those afflicted with this condition, and their bed partners.
Carlos H. Schenck, MD, is an associate professor at the University of Minnesota Medical School, Minneapolis. Schenck is also a senior staff psychiatrist at the Minnesota Regional Sleep Disorders Center and Hennepin County Medical Center. He recently wrote and published Sleep: The Mysteries, the Problems, and the Solutions.
- Rosenfeld DS, Elhajjar AJ. Sleepsex: a variant of sleepwalking. Arch Sex Behav. 1998;27:269-278.
- Shapiro CM, Trajanovic N, Fedoroff JP. Sexsomnia—a new parasomnia? Can J Psychiatry. 2003;48:311-317.
- Guilleminault C, Moscovitch A, Yuen K, Poyares D. Atypical sexual behavior during sleep. Psychosom Med. 2002;64:328-336.
- International Classification of Sleep Disorders (Diagnostic & Coding Manual). 2nd ed. Westchester, Ill: American Academy of Sleep Medicine; 2005.
- Schenck CH, Arnulf I, Mahowald MW. Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences. Sleep. 2007;30:683-702.
- Schenck CH. Paradox Lost: Midnight in the Battleground of Sleep and Dreams. Minneapolis: Extreme-Nights, LLC; 2005. www.parasomnias-rbd.com.
- Schenck CH. Sleep: The Mysteries, the Problems, and the Solutions. New York: Penguin/Avery Press; 2007.