Sexual behaviour in sleep: an internet survey

Understanding Sexual Parasomnias: A Review of the Current Literature on Their Nature, Diagnosis, Impacts, and Management

Sexual behavior during sleep, known as sexual parasomnias, has captured the interest of researchers and clinicians. These parasomnias involve various sexual activities that occur unconsciously during sleep. Although relatively rare, they can profoundly affect well-being and relationships and can carry legal consequences. Understanding their nature, prevalence, and causes is crucial for advancing knowledge in this field. This article revisits the topic of sexsomnia, presenting new data and discussing cases published from 2007 to 2023. By analyzing these cases, we aim to enhance recognition, diagnosis, and management of sexsomnia, reducing stigma and providing better support for affected individuals.

A case-control study of sexualised behaviour in sleep: A strong association with psychiatric comorbidity and relationship difficulties

Sexualised behaviour in sleep (SBS) is a relatively rare parasomnia consisting of instinctive behaviours of a sexual nature occurring during non-rapid-eye movement (NREM) sleep. Little information exists at present regarding the clinical features and onset of this condition as well as its link to psychiatric comorbidity, other sleep disorders and history of adverse early life experience. Aims were to typify the condition further and compare features of SBS patients to those with other NREM parasomnias.

METHODS

Details of 335 consecutive patients presenting to a single tertiary sleep centre with non-rapid eye movement (NREM)-parasomnias over a 15-year period (2005-2020) were examined. Data were collated by reviewing case-notes for anthropometric data, past medical history, clinical findings, and video polysomnography. SBS patients were compared to a cohort of 270 non-SBS, NREM-sleep disorder patients (case-control) to ascertain whether they had any distinguishing features from other parasomnias classified in this group.

RESULTS

Sixty-five patients with SBS were identified: 58 males, 7 females (comprising 19.4% of the cohort overall). Mean age at presentation was 33(±9.5) years. Onset of behaviours was commoner in adulthood in the SBS cohort, whereas non-SBS, NREM-parasomnia onset (n = 270) was commoner in childhood: 61.1% and 52.9% respectively (p = 0.007). An association was identified between the presence of psychiatric diagnoses and onset of SBS (p = 0.028). Significant triggers for SBS behaviours included alcohol consumption (p < 0.001), intimate relationship difficulties (p = 0.009) and sleep deprivation (p = 0.028). Patients with SBS were significantly more likely to report sleepwalking as an additional NREM behaviour (p < 0.001). Males were more likely to present at clinic together with their bedpartner and females presented alone. A history of SBS appeared to be more common in those working in the armed forces or the police compared to those presenting with non-SBS, NREM-parasomnias (p = 0.004).

CONCLUSIONS

SBS is more common in clinical practice than previously described and presents with some distinguishing features within the NREM disorder category. This study is the first to identify that onset in childhood or lack of amnesia does not preclude the condition and that patterns of presentation differ between men and women. Sleepwalkers particularly should be asked about SBS. Comorbid psychiatric conditions, profession and intimate partner difficulties are strong determinants of the presentation.

Sexual Behaviors and Sexual Health of Sexsomnia Individuals Aged 18-58

Objective: The objective of this study was to address the relationships between demographics and sexsomnia episodes, and sexual health issues in affected individuals. This study is the first sexsomnia survey conducted in Turkey. Sexsomnia comprises involuntary, unconscious sexual behavior during sleep, observed by a bed partner. Method:To reach people with and without sexsomnia, an online survey method was used. Among 274 participants, 42 of them reported having sexsomnia. Results: Women who do not have sexsomnia have more sexual problems than women who have sexsomnia episodes. The sexsomnia experiences of men and women also differed. Additionally, there were gender differences with difficulties caused by the sexsomnia. Conclusions: There is a need for further studies on sexsomnia that address socio-cultural, gender, and biological factors (including sleep disorders).

Sleep and Sex: A Review of the Interrelationship of Sleep and Sexuality Disorders in the Female Population, Through the Lens of Sleeping Beauty Syndrome

INTRODUCTION

For many, sleep and sex are crucial for physical, emotional, and mental well-being. Poor sleep quality is linked to a myriad of ailments from coronary artery disease to major depressive disorder. Likewise, a decrease in the frequency of sexual activity is associated with a decrease in self-rated health status. Kleine-Levin syndrome (KLS) is a rare sleep disorder that provides a unique lens to examine the intricate interplay between sleep and sex as it is one of the few sleep disorders defined by concomitant sexual dysfunction.

OBJECTIVES

This study reviews the literature on links between sleep disorders and sexuality with a focus on women's health followed by a case study of unusual patient with KLS with persistent genital arousal disorder.

METHODS

Literature searches were conducted for English language publications, including foreign language publications with English abstracts with ninety-five articles reviewed. The literature review is followed by a case report.

RESULTS

We review the known literature linking sleep and women's sexual health with a focus on insomnia, circadian rhythm sleep disorder, obstructive sleep apnea, restless leg syndrome, sexsomnia, and KLS. We then present a case of KLS-associated persistent genital arousal disorder, which was amenable to treatment with a multimodal approach aimed at symptomatic relief with intravaginal diazepam suppositories, topical clitoral lidocaine, and duloxetine.

CONCLUSION

This case highlights that hypersexuality and persistent arousal cannot effectively be treated in isolation but rather must be contextualized within a patient's broader medical history and diagnoses. Specifically, sleep quality and potential sleep disorders should be assessed for those presenting with sexual health complaints (and vice versa). Zwerling B, Keymeulen S, Krychman ML. Sleep and Sex: A Review of the Interrelationship of Sleep and Sexuality Disorders in the Female Population, Through the Lens of Sleeping Beauty Syndrome. Sex Med Rev 2021;9:221-229.

Alcohol and Parasomnias: The Statistical Evaluation of the Parasomnia Defense in Sexual Assault, Where Alcohol is Involved

Sleep sex may be a defense for alleged sexual assault. The International Classification of Sleep Disorders (ICSD3) states: "Disorders of arousal should not be diagnosed in the presence of alcohol intoxication… The former [alcohol blackouts] are exponentially more prevalent." A panel member of ICSD3, quoting ICSD3 asserts: "alcohol intoxication should rule out a sleep-walking defense". This implies extremely strong support for a prosecution hypothesis (H_p ) over a defense hypothesis (H_d ). I use Bayesian methodology to evaluate the evidential probity of alcohol intoxication. The likelihood ratio, LR, measures the amplification of prior odds of guilt, LR = Posterior odds of guilt after considering alcohol intoxication /Prior odds of guilt before considering alcohol intoxication . By Bayes' theorem, LR = p ( alcohol intoxication, given H p ) / p ( alcohol intoxication, given H d ) . I use data from cross-sectional studies of sexual assault and prevalence of alcohol use, in college students, with data from longitudinal studies, and data from the epidemiology of parasomnias to evaluate LR (alcohol). LR ~1.5 or 5, depending whether alcohol does, or does not, increase the risk of parasomnias. The proposition of extremely strong support for H_p implies a LR ~1,000,000, so the proposition in ICSD3 is not supported by formal analysis. The statistical reasoning in ICSD3 is unclear. There appears to be inversion of the Bayesian conditional (confusing intoxication given assault, and assault given intoxication) and failure to evaluate alcohol intoxication in H_d . Similar statistical errors in R. v Sally Clark are discussed. The American Academy of Sleep Medicine should review the statistical methodology in ICSD3.

Sexsomnia in an Adolescent

ABSTRACT

Sexsomnia has been reported and is well described in 115 prior cases in the literature. There have been associations with other sleep disorders serving as triggers for confusional arousals, thereby worsening sexsomnia episodes. We present a case of an adolescent boy with a history of resected and treated pineoblastoma who later developed sexsomnia marked by multiple episodes of masturbatory events per night. He had additional suspicions of obstructive sleep apnea. Polysomnography confirmed severe obstructive sleep apnea and captured multiple episodes of sexsomnia from both REM and NREM sleep. The patient also had daytime symptoms of severe anxiety and hypersomnia that required pharmacological intervention, cognitive behavioral techniques, and hypnosis. The patient showed improvement with hypnosis along with a multimodal approach to the treatment of sexsomnia.

Sexsomnia: parasomnia associated with sexual behaviour during sleep

INTRODUCTION

The purpose of our study is to describe 4 cases of sexsomnia, a form of parasomnia characterised by sexual behaviour during sleep.

METHODS

Clinical history and video-polysomnography recordings from patients diagnosed with sexsomnia in the Multidisciplinary Sleep Unit at Hospital Clínic in Barcelona.

RESULTS

Three men and one woman between 28 and 43 years of age reported sexual behaviours during sleep with progression times ranging from 9 months to 7 years. Episodes consisted of masturbation without seeking the participation of a sleeping partner (2 cases) and attempts at sexual intercourse with inappropriate and uncharacteristic vocalizations and behaviours (3 cases). The frequency of the episodes ranged from 4 isolated episodes to 2-3 per week. Patients were amnestic of these events and surprised by their partners' accounts of their behaviour. Medical histories revealed that 1 patient was a somnambulist, 2 had confusional arousals, and 1 experienced somniloquy. Video-polysomnography did not disclose sexual behaviours during sleep but revealed sleep apnoea in 2 cases and periodic leg movements in sleep in another. The only patient treated with clonazepam reported decreased frequency of both confusional arousals and sexsomnia episodes.

CONCLUSIONS

Sexsomnia occurs in young adults and is characterised by masturbation and inappropriate attempts at achieving sexual intercourse followed by total amnesia of the events. It 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 use of online methodologies in studying paraphilias - A review

Aims The paper outlines the advantages, disadvantages, and other implications of using the Internet to collect data from those people displaying sexually paraphilic behavior. Method Using empirical and clinical studies published in the paraphilia literature, the main issues concerning online paraphilic data collection are reviewed and discussed. Results The specific online data collection methods examined included the collection of paraphilic data via (i) online questionnaires, (ii) online forums, (iii) online interviews, and (iv) online participant observation. Conclusions It is concluded that there are many useful and practical advantages of using online research methodologies to examine sexually paraphilic behavior.

Abnormal sexual behavior during sleep in temporal lobe epilepsy: a case report

Herein, we describe a case who presented with abnormal sexual behaviour during sleep. Video-electroencephalography monitoring during sleep revealed an abnormality suggesting an epileptic basis. The patient was successfully treated with carbamazepin. The psychiatric symptoms that were thought to be related to abnormal sexual behaviours were controlled with antipsychotic treatment. Our findings strongly emphasize the fact that efforts should be spent to increase awareness of seizure activity at night, which can be misinterpreted as benign parasomnias. Such a misinterpretation may have serious consequences, such as insufficient seizure control, progressive personality changes, and cognitive impairment.

Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences

STUDY OBJECTIVES

To formulate the first classification of sleep related disorders and abnormal sexual behaviors and experiences.

DESIGN

A computerized literature search was conducted, and other sources, such as textbooks, were searched.

RESULTS

Many categories of sleep related disorders were represented in the classification: parasomnias (confusional arousals/sleepwalking, with or without obstructive sleep apnea; REM sleep behavior disorder); sleep related seizures; Kleine-Levin syndrome (KLS); severe chronic insomnia; restless legs syndrome; narcolepsy; sleep exacerbation of persistent sexual arousal syndrome; sleep related painful erections; sleep related dissociative disorders; nocturnal psychotic disorders; miscellaneous states. Kleine-Levin syndrome (78 cases) and parasomnias (31 cases) were most frequently reported. Parasomnias and sleep related seizures had overlapping and divergent clinical features. Thirty-one cases of parasomnias (25 males; mean age, 32 years) and 7 cases of sleep related seizures (4 males; mean age, 38 years) were identified. A full range of sleep related sexual behaviors with self and/or bed partners or others were reported, including masturbation, sexual vocalizations, fondling, sexual intercourse with climax, sexual assault/rape, ictal sexual hyperarousal, ictal orgasm, and ictal automatism. Adverse physical and/or psychosocial effects from the sleepsex were present in all parasomnia and sleep related seizure cases, but pleasurable effects were reported by 5 bed partners and by 3 patients with sleep related seizures. Forensic consequences were common, occurring in 35.5% (11/31) of parasomnia cases, with most (9/11) involving minors. All parasomnias cases reported amnesia for the sleep-sex, in contrast to 28.6% (2/7) of sleep related seizure cases. Polysomnography (without penile tumescence monitoring), performed in 26 of 31 parasomnia cases, documented sexual moaning from slow wave sleep in 3 cases and sexual intercourse during stage 1 sleep/wakefulness in one case (with sex provoked by the bed partner). Confusional arousals (CAs) were diagnosed as the cause of "sleepsex" ("sexsomnia") in 26 cases (with obstructive sleep apnea [OSA] comorbidity in 4 cases), and sleepwalking in 2 cases, totaling 90.3% (28/31) of cases being NREM sleep parasomnias. REM behavior disorder was the presumed cause in the other 3 cases. Bedtime clonazepam therapy was effective in 90% (9/10) of treated parasomnia cases; nasal continuous positive airway pressure therapy was effective in controlling comorbid OSA and CAs in both treated cases. All five treated patients with sleep related sexual seizures responded to anticonvulsant therapy. The hypersexuality in KLS, which was twice as common in males compared to females, had no reported effective therapy.

CONCLUSIONS

A broad range of sleep related disorders associated with abnormal sexual behaviors and experiences exists, with major clinical and forensic consequences.