Sleep sex

Under DSM-5 criteria, there are 11 diagnostic groups that comprise sleep-wake disorders. These include insomnia disorders, hypersomnolence disorders, narcolepsy, obstructive sleep apnea hypopnea, central sleep apnea, sleep-related hypoventilation, circadian rhythm sleep-wake disorders, non–rapid eye movement (NREM) sleep arousal disorders, nightmare disorders, rapid eye movement (REM) sleep behavior disorders, restless legs syndrome (RLS), and substance-medication-induced sleep disorders. Sexsomnia is classified under NREM arousal parasomnia.[2]

Parasomnia disorders are classified into the following categories:

• arousal disorders
• sleep-wake transition disorders
• parasomnias associated with REM sleep

Sexsomnia affects individuals of all age groups and backgrounds but present as an increased risk for individuals who experience the following:

• coexisting sleep disorders
• sleep disruption secondary to obstructive sleep apnea
• sleep related epilepsy
• certain medications

Behaviors such as pelvic thrusting, sexual arousal, and orgasm are often attributed to sleep-related epilepsy disorder. In some cases, physical contact with a partner in bed has been seen to trigger sexsomia behaviors.[5][8]

Certain medications, including the sedative-hypnotic Zolpidem (commonly known by the brand name Ambien) frequently used to treat insomnia, have been seen to increase risk of sexsomnia as an adverse effect.

Like sleep-related eating disorders, sexsomnia presents more commonly in adults than children. However, these adult individuals usually have a history of parasomnia that began in childhood.

Non-Rapid Eye Movement sleep, or NREM, consists of three stages. Stage 1 is described as "drowsy sleep" or "somnolence" and is characterized by breathing rates becoming increasingly more consistent, the beginning of a decrease in muscle activity, and a decrease in heart rate.[10] The typical duration of Stage 1 is around 10 minutes and accounts for approximately 5% of an individual's total sleep. Stage 2 is characterized by a further decline in muscle activity accompanied by a fading sense of consciousness of surroundings. Brain waves during Stage 2 are seen in the theta range. Stage 2 accounts for approximately 45-50% of an individual's total sleep. Stage 3 is the final stage of NREM sleep and the most common for parasomnias to occur. Also known as slow wave sleep (SWS), Stage 3 is characterized by brain temperature, respiratory rate, heart rate, and blood pressure being measured at their lowest. Representing approximately 15-20% of an individual's total sleep, brain waves during this stage are seen in the delta range. When an individual awakes during this stage, they are likely to exhibit grogginess and require up to thirty minutes to regain normal function and consciousness.[11]

Determining factors include but are not limited to:

• a family history of somnambulism or sleepwalking
• prior episodes of somnambulism
• disorientation when awoken
• observed confusional or autonomic behavior
• amnesia of episode
• trigger factors the individual possesses
• lack of regard to conceal episode
• the nature of event compared to the individual's baseline character

Electroencephalograms, or EEG, are tests used to depict electrical activity and waves produced by the brain.[12] This test has the ability to detect abnormalities that are associated with disorders that affect brain activity. Episodes of sexsomnia occur most commonly during slow-wave-sleep, or SWS. During this stage of sleep, brain waves tend to slow down and become larger. Through the use of electroencephalography, health professionals are able to determine if the sexual behaviors are occurring during non-REM sleep or if the individual is fully conscious.

Polysomnography is a study conducted while the individual being observed is asleep. A polysomnograph (PSG) is a recording of an individual's body functions as they sleep. Specialized electrodes and monitors are connected to the individual and remain in place throughout study. Video cameras can be used to record physical behaviors that occur while the subject is asleep. Typically, the unwanted sexual behaviors do not present on film and the majority of information is taken from a sleep study.[13]

The image above depicts an individual undergoing a sleep study.

A PSG cannot determine a diagnosis every time it is performed, but can assist in determining what diagnoses should be considered or excluded. While PSG is a useful diagnostic tool, it cannot replace forensic examination. A PSG study may identify sexsomnia, but cannot determine whether it was responsible for an individual's actions or present during the time of an alleged crime. Likewise, the study may not identify sexsomnia, but that does not mean that the patient has never experienced it, so it is essential to collect information from as many sources as possible. This could include interviews with friends, family, and significant others, as well as medical records concerning the individual's sleep previous patterns.[14]

Polysomnography is also used in the diagnosis of other sleep disorders such as obstructive sleep apnea, narcolepsy, and restless leg syndrome.[13][15]

• inspiratory and expiratory air flow
• oxygen saturation in blood
• respiratory effort
• respiratory rate
• eye movements
• brain waves
• electrical activity in muscles
• position of body

Clonazepam has been prescribed as treatment for sexsomnia. This medication is classified as a benzodiazepine and works by acting on the GABA-A receptors present in the central nervous system (CNS).[17] Benzodiazepines open the chloride channels to allow chloride to enter the neuron. The most common use of this medication is for the treatment of anxiety, seizures, panic disorders, and sleep disorders. Anticonvulsant therapy is used to treat sexual behaviors that result secondary to sleep related epilepsy.[18]

Continuous positive airway pressure is commonly used as a treatment for sleep apnea. In cases where the individual has both sleep apnea, and sexual behaviors consistent with sexsomnia, the implementation of a continuous positive airway pressure resulted in complete discontinuation of unwanted behaviors.

Positive lifestyle changes are encouraged for individuals with sexsomnia. Reducing stress and anxiety triggers may reduce the likelihood of an exacerbation of the disorder. The use of open discussion and understanding between couples decrease the negative emotional feelings and stress felt and generates a support system.[9]

Articles regarding sexsomnia continue to circulate on Glamour.com, the Huffington Post, and Refinery29 among many others. Increased exposure has resulted in a conversation between those who have the disorder and those directly affected. Sexsomnia has also been featured in popular television series including House, MD, Law and Order: Special Victims Unit, and Desperate Housewives.

The number of alleged sex offenders claiming sexsomnia as the cause of their offenses is rapidly growing. The Australasian Sleep Association has urged qualified physicians to contribute in expert testimony in such cases to ensure the individual's claims are valid and not just an attempt to be released of sexual offense charges.[20]

Smith v. State of Georgia officially established a separate affirmative defense for the unconscious. According to the defense, "A person who commits an act during unconsciousness or sleep has not committed a voluntary act and is not criminally responsible for the act." In order for the assault to be considered a crime by the State of Georgia, the accused must have voluntarily committed the act and exhibited intent to carry out the act.[15]

Mikael Halvarsson was acquitted of rape in Sweden due to the sexsomnia defense. Charges were brought against Halvarsson after reports of sexual assault were filed by his girlfriend at the time. Upon investigation, Halvarsson was found still asleep in the alleged victim's bed when police arrived. During the appeal, a previous girlfriend of Halvarsson testified of similar behavior she had observed in the past, as well as his mother reporting unusual sleep behaviors beginning at a young age.[21]

In 2022, a case came to light in England, where an allegation of rape in 2017 was dropped in 2020 by the Crown Prosecution Service (CPS) due to expert opinion that the woman involved had sexsomnia, and so the male defendant may have believed that she was consenting, and was thus formally acquitted.[22] The woman involved later appealed the decision. A chief crown prosecutor separate from the department that made the decision to close the case reviewed the evidence of the case again: he concluded that the case should have gone to court; that the expert opinions on sexsomnia should have been challenged in court; and that the decision to close the case was a mistake. The reviewing chief prosecutor apologised unreservedly to the woman when concluding the review. Despite the review, the case could not be reopened because the case had been formally closed and the defendant declared not guilty.[22]