Sexual Behavior during Sleep: Convenient Alibi or Parasomnia; 'Sexsomnia' Disrupts Sleep, Threatens Relationships, and Has Forensic Implications

Article excerpt

Jan Luedecke, a 30-year-old landscaper, got drunk during a party in 2003 at a Toronto house and fell asleep on a couch. Some time later, he approached a woman who was sleeping on an adjacent couch, put on a condom, and began sexual intercourse with her.

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At his trial in 2005, he was acquitted of sexual assault after University of Toronto psychiatry professor Dr. Colin Shapiro testified that Luedecke was experiencing "sex-somnia" and was in a dissociative state when the incident occurred.

In February 2008, a Canadian provincial appellate court upheld Luedecke's acquittal. The court did not rule on prosecutors' claim that if sexual behavior during sleep is a mental disorder, Luedecke should be declared mentally ill and required to appear before a mental health review board. (1), (2)

Sexual behavior during sleep (SBS)--or "sexsomnia" as the media called it during Luedecke's trial--is more than a sensational defense for a high-profile court case. Sleep physicians are finding that sexual behaviors during sleep are real and more common than previously thought. (3) Although SBS cases sound psychological in origin, it appears that the problem lies in the brain itself. (4)

SBS can cause great distress to its initiators and recipients but often goes unreported and untreated because of embarrassment about seeking help. Among patients who report their symptoms, many say they experienced SBS 10 to 15 years before seeking help. (5) SBS not only disrupts sleep but can damage relationships and lead to allegations of sexual assault and rape.

What is sleep sex?

Shapiro et al (6) first suggested that SBS might be a parasomnia--an unpleasant or undesirable behavioral or experiential phenomena that occurs predominantly or exclusively during sleep. (7) Parasomnias occur in approximately 2.5% of adults, and violent behaviors during sleep have been reported in 2% of adults. The prevalence of SBS is unknown. (8)

Parasomnias can be primary (disorders of the sleep states per se) or secondary (a manifestation of a medical or psychiatric disorder such as nocturnal epilepsy, posttraumatic stress disorder, or nocturnal panic disorder). They are further classified by sleep state of origin: rapid eye movement (REM) sleep or non-rapid eye movement (NREM) sleep. SBS is thought to be a NREM parasomnia, similar to sleeptalking (somniloquy), sleepwalking, and sleep-related eating disorder.

The International Classification of Sleep Disorders, 2nd edition, (ICSD-2), published in 2005 by the American Academy of Sleep Medicine, does not list SBS as a diagnosis. DSM-IV-TR recognizes 3 parasomnia types: nightmare disorder, sleep terror disorder, and sleepwalking disorder. Parasomnia not otherwise specified (NOS) includes "disturbances that are characterized by abnormal behavioral or physiological events during sleep or sleep-wake transitions, but that do not meet criteria for a more specific parasomnia." Disorders such as REM sleep behavior disorder, sleep paralysis, and presumably SBS are included in this diagnostic category. (9)

Characteristic features

Sleep and wakefulness are not mutually exclusive states. State-determining variables of wakefulness, NREM sleep, and REM sleep may occur simultaneously or oscillate rapidly. (10) The mechanism of SBS and other parasomnias is not entirely understood. Arousal disorders can be triggered by febrile illness, alcohol, sleep deprivation, emotional stress, certain medications, pregnancy, or menstruation. Primary sleep disorders such as sleep apnea and periodic limb movement disorder that are associated with arousals also can trigger NREM parasomnias.

NREM parasomnias--characterized by cortical arousal--result in dissociation, with the brain partially awake and partially in NREM sleep. In this mixed state, the brain is awake enough to perform complex and often protracted motor or verbal actions but asleep enough not to have conscious awareness of the actions. …