It happened in the dark. It always did. Around three years ago, I started having dreams about a strange woman. You could say we had a physical connection. Any time this woman and I were in the same place, things instantly got hot and heavy, without words, or so much as a glance, exchanged. But these weren't just ordinary dreams: these dreams seeped into reality. I soon realized this strange woman was actually my girlfriend, lying next to me in bed.
The feeling is that of a bizarre wet dream that blends with reality just enough to make it real, but not enough to abandon the surreal—like something out of a Murakami novel. My girlfriend, to whom I'm now married, began affectionately referring to my nocturnal advances as the "Midnight Sex Pest," even though it typically happened around 1 AM. But these encounters also go by another name gaining in popularity: sexsomnia.
Early in his career, Dr. Colin Shapiro, PhD, was working as a researcher at a sleep laboratory in South Africa. It was then, around 1984, when he first stumbled across the woman that would lead him to coin the term "sexsomnia."
"I did an interview with a female reporter. And at the end of the interview she asked me if she could discuss something personal," Shapiro said.
This reporter opened up to Shapiro, recounting nights where her husband woke to find her masturbating in her sleep. The couple, at the time, had recently married. Her unrecognized sexsomnia symptoms put a strain on their relationship, leading to feelings of inadequacy for the husband and confusion for the wife.
"I have to say, when I heard this I didn’t understand," Shapiro told me. "It took seeing a few cases to realize that there was a pattern. So, eventually, when you start asking the right questions, you get an answer."
Over the next twelve years, Shapiro collected other sexsomnia cases and wrote an article about them—the first of its kind—published in 1996 and called "Sexual behaviour in sleep—a newly described parasomnia." Parasomnia, both then and now, is a broad categorization of abnormal behavior like sleepwalking, night terrors and paralysis, and most recently, sexsomnia. In 2003, Shapiro and his colleagues published an evolution of that initial report under the heading "Sexsomnia—A new parasomnia?" that presented and described the 11 cases he'd since collected in more detail.
One of the more eye-opening pieces of sexsomnia research, however, came out of an effort coordinated between the Minnesota Regional Sleep Disorders Center, the University of Minnesota, and Stanford University. Published in 2007 by Dr. Carlos Schenck, MD, Dr. Mark Mahowald, MD, and Dr. Isabelle Arnulf, MD, PhD, "Sleep and Sex: What Can Go Wrong?" shed more light on how sexsomnia is experienced differently from person to person. The study showed that sexsomnia in women typically manifests itself as self-stimulation, while men tend to incorporate the person lying next to them into their sexual behavior.
The latest study—another Shapiro was involved with, released in 2010—found that almost eight percent of patients at a sleep disorder center in Toronto had reported sexsomnia. The same study also revealed the condition is more common in men than women.
Despite Shapiro's history with the condition, sexsomnia itself is still in its clinical infancy. It was only officially published as a recognized condition in the International Classification of Sleep Disorders III (ICSD-3) in May of 2014. There’s still much we don’t know about it. We do know, however, that the full spectrum of sexsomniac behavior includes moaning, shouting profanity, masturbation, inappropriately touching the person lying next to you, pelvic thrusting, or even intercourse.
It became a pleasant surprise for us, if not a source of humor. But not all sexsomnia is that innocent.
In my case, it involved me putting the moves, with some heavy petting, on my wife. Most of the time she responded positively, albeit half-asleep, to my unconscious come-ons. There was something weirdly heightened about the experience, as though we were both different people somehow. It became a pleasant surprise for us, if not a source of humor. But not all sexsomnia is that innocent.
A quick Google search on the subject led to enough alleged cases of rape and sexual assault for me to realize I had to see a doctor. You see, along with my sexsomniac symptoms, I also have a long history of sleepwalking and night terrors, which have produced their fair share of stories: During the latest episode, I flipped over our bedroom dresser that doubles as a TV stand in my sleep. As if I didn’t need more to worry about, I became increasingly fearful about what else I might do in the Land of Nod—sexually or otherwise.
My general practitioner referred me to the Weill Center for Sleep Medicine at Cornell, located on Manhattan’s Upper East Side. I met with co-director Dr. Arthur J. Spielman, PhD, who had a field day with my initial consultation. There was little doubt he'd order me an overnight sleep study. It was just a matter of which conditions to investigate.
Parasomnias, including sexsomnia, can be triggered by any number of things. What brings on this behavior in people like me is an abrupt awakening from a deep sleep. In some cases it could be an external factor, something as simple as a noise in the middle of the night, that rouses you. Other times, it could be a medical condition like sleep apnea where snorers are partially waken after they’ve stopped breathing—another type of disturbance that can fragment sleep and, the thinking goes, trigger sexsomnia. Alcohol, another major sleep disrupter, plays a key role as well.
Given the variety of parasomnias I reported to Dr. Spielman, and the fact that I sometimes snore, my sleep study order included observation for sleep apnea and non-REM parasomnias, which includes sexsomnia, along with the classic sleepwalking and night terror behaviors. For good measure, Dr. Spielman also threw in nocturnal seizures (a subset of epilepsy) and REM-behavior disorder, involving punching and kicking in your sleep.
By the time I got fully wired up by my sleep technician on the night of the study, I was wearing 33 pieces of technology, monitoring every relevant behavior possible. This colorful assortment of instruments relied heavily on electroencephalography (EEG), measuring everything from my brain's activity to what the rest of my body was up to during sleep.
I had 15 EEG electrodes on my head to monitor my brain waves, ultimately showing what stage of sleep I was in. Normally there are nine, but in my case, the tech applied an extra six EEG electrodes to check for nocturnal seizures. Each of these electrodes on my head was applied with a conductive paste, smeared between my hair and the electrode, to help facilitate the electrical reading. The tech then applied one EEG electrode by each eye to measure optical movements and help gauge REM sleep, and three on my jaw to monitor teeth grinding. Two EEG electrodes were placed on each of my arms and legs to measure for muscle tone and limb movement associated with REM behavior disorder.
There were also two electrocardiogram (EKG) electrodes applied to my torso, one on my rib cage and the other on my upper chest, to get a reading on my heart rate. Two respiratory bands looped around my chest to determine how much my chest was rising and falling. One thermistor, a set of plastic tubing perched in front of my mouth, measured my breathing and circadian rhythms.
We were almost done. The most annoying part, however, was yet to come.
Wired for sleep. Photo courtesy the author
That would be the p-flow cannula, another set of plastic tubing, this time inserted into my nostrils to measure snoring. It tickled at first, but became easily the most aggravating part of the whole prep process. The finishing touch was the finger pulse oximeter, attached to my right index finger to measure the oxygen levels in my blood. Even with all of these pieces of hardware clinging to my body, I felt oddly comfortable after ten minutes or so. Then I was ready to sleep.
Because parasomnias like sexsomnia are triggered by an abrupt awakening from deep sleep, sleep deprivation in the days prior to an event is typically a factor in these sorts of episodes. I agreed to get two hours less sleep than I normally would the night before my study. The goal was to make the conditions as similar as possible to the nights when my episodes occur. So with that in mind, I did what I normally do during my bedtime routine: watched some TV and read afterwards until my eyes got heavy.
Falling asleep was much easier than I thought it would be, but I stirred throughout the night. At one point I woke up agitated, thrashing in bed. I couldn’t understand what I was doing. But then I figured it out: I was trying to rip the pulse oximeter off my index finger. I didn’t know why, but I was doing everything I could to tear the damn thing off.
Once I fully woke up and calmed down, I alerted the technician through the intercom system. He came in and tried to reattach the oximeter to no avail. Apparently, I broke it. So he reattached a new one. These types of episodes are uncommon under the clinical observation of a sleep study, and I felt a strange sense of pride as I fell back asleep.
Later, I learned that I may have had a little help. While it’s still unclear if this is practiced at the Weill Cornell Center for Sleep Medicine, Dr. Andrew Westwood, MD, a neurologist at the Columbia University Medical Center, shared a trade secret.
"We look to see if they’re in a deep sleep. And then any kind of noises through the intercom can be used to try to provoke one of these episodes," Westwood told me.
I was unable to confirm if this was a regular practice of Dr. Spielman, who wished not to be directly quoted during my study and follow-up, or his staff. But it might explain why I felt so groggy the next morning as I washed my hair for the third time, trying to remove the last bits of conductive paste. I was glad I did the overnight study, but I couldn’t imagine doing it again any time soon.
"Usually, people come to the sleep clinic because of someone else," said Westwood. "It’s usually not their own motivation that gets them to go, it’s when other people are concerned about them, or they’ve injured themselves and they’re starting to worry that there could be something seriously wrong."
But even in the city that never sleeps, these studies are becoming more common. For his part, Westwood said they're becoming more popular.
"You see now and again, people want to come in to have a sleep study not because anything in particular is wrong, but just to make sure everything’s okay," he said.
People want to come in to have a sleep study not because anything in particular is wrong, but just to make sure everything's okay.
A week after my overnight study, I had my follow-up with Dr. Spielman to go over the findings. There was good news: With what was observed, he was able to rule out sleep apnea, nocturnal seizures, and REM-behavior disorder.
The study showed I had large amounts of slow wave non-REM 3 sleep, or N3. During this slow wave N3 sleep, I had several abrupt awakenings paired with a rapid heart rate—the signature of non-REM parasomnia. Dr. Spielman was thus able to confirm that my sexsomnia, sleepwalking, and night terrors—even my attempt to rip off the pulse oximeter—could be linked to these patterns.
As Dr. Spielman closed out my file in his computer system, he entered in "sexsomnia" as one of the diagnoses. It's something he might not have been able to do four months ago, but now can, thanks in part to the recently published version of the ICSD-3, revised to include the condition. And while my diagnosis of sexsomnia was straightforward, what actually happens in the brain during an episode of sexsomnia is anything but.
"In sleep, the pre-frontal cortex is essentially offline," explained Dr. Michel Cramer Bornemann, MD, lead investigator at Sleep Forensics Associates, a leading group of medical and legal experts on parasomnias.
"The pre-frontal cortex is the part of the brain that legislates motivation, executive function and goal-driven behaviors," he told me. "Deep seated in the brain you have central pattern generators. And these central pattern generators handle behaviors that are necessary for survival."
These survival behaviors, regulated with programmed loops of electric current, include primal urges like our fight or flight response, eating, and of course sexual activity, said Bornemann, who added that the central pattern generators of those urges are located "very close" to parts of the brain that control sleep and waking life.
"So if you have anything that fragments sleep," like a noise in the night or a partner nudging you, "it takes just a little electrical switching error from the sleep/wake generating centers to trigger a central pattern generator," he explained. "And one of the results could be sexualized behavior."
In other words, when a switching error like this occurs, your pre-frontal cortex isn’t on the job to make sure you don’t do anything in your sleep you might regret, or otherwise would never do. This also helps explain people who eat or become violent during their sleepwalking episodes.
The neurological mechanics of sexsomnia, it seems, can be explained. The treatment, however, is still hard to decipher.
Photo courtesy the author
The treatment plan Dr. Spielman and I agreed on was a trial of Klonopin (generic Clonazepam), a benzodiazepine anti-anxiety sedative. Klonopin is known to be effective in treating non-REM parasomnias like sexsomnia over 70 percent of the time. What’s unknown is how exactly.
Klonopin essentially functions by activating gamma amino butyric acid (GABA)—your brain’s neurotransmitter in charge of calming you down. The drug locks onto the GABA-A receptor site of the brain, increasing sedation and hypnosis. The theory is that with a higher level of sedation you’re less likely to be disturbed by things that go bump in the night, and less likely to have an abrupt awakening that triggers a sexsomnia episode.
Whether Klonopin actually alters the pathways in the brain where these late night switching errors occur has yet to be seen. But even if the neurological specifics aren't fully clear, doctors have seen positive results.
"Needless to say, I think we accept that Klonopin is pretty effective across the board," Bornemann said.
According to him, Klonopin is currently the most widely prescribed treatment for sexsomnia and other non-REM parasomnias. And although the way we medicate sexsomnia is so seemingly single-minded, the way the condition affects different relationships is quite varied.
"Whether it’s severe or mild may not relate as much to your behavior," said Dr. Bornemann, "but to how your partner reacts to it. Let’s say it happens once a month. For someone who’s sensitive to it, that once a month could be really problematic."
I’m fortunate in the sense that my sexsomnia episodes are mild and non-threatening. My wife understands my condition, and accepts it. But then, there is the other end of the spectrum. As you might imagine, sexsomnia can lead to relationship problems, including divorce. Even worse, it can lead to—or at least be blamed for—incidents of sexual assault.
In neuroscience, we recognize that consciousness is on a spectrum. The legal community doesn't really account for that.
Along with medication, lifestyle adjustments can also help prevent such unfortunate events. Managing one's sleep deprivation and stress, and likewise who one chooses to share a bed with, are at the top of the list.
Even though the condition is completely unrelated to pedophilia, I'm told parents with sexsomnia would be well advised to forgo sharing beds with their kids. (I, for one, do not have children.) Tragically, some people discover this advice too late.
In the recent case of an Ottawa man accused of molesting his daughter, the defendant testified that he had a history of sexsomnia, but didn’t seek a formal diagnosis until after the alleged episode that brought about criminal charges. Every case is different in its complexity, but this one had two sleep experts—one of them being Dr. Shapiro—giving conflicting testimonies on the role alcohol plays as a trigger. A verdict is expected on November 12.
According to Dr. Bornemann, many of the criminal cases he participates in with claims of alleged sexsomnia involve parents and their children. He and his colleagues at Sleep Forensics Associates were the first group to offer sleep disorder expertise in legal cases. Even before their group was formed, Bornemann, Dr. Carlos Schenck, MD, and Dr. Mark Mahowald, MD were all sought out by the legal and law enforcement community in criminal allegations that potentially involved parasomnia.
"An attorney might go to the legal assistant and say, 'Find anything you can in medical literature related to violence and sleep.' And inevitably, it always pointed in our direction," Bornemann said.
As the lead investigator at Sleep Forensics Associates, Bornemann has investigated over 300 sleep-related criminal cases, 40 percent of which are associated with sexual assault. If you account for the cases involving both Ambien side effects and sexual assault, that percentage creeps higher.
"Now that’s not to say that I'm always working with the defense. It’s not uncommon for the prosecution to hire me because they’re concerned that the opposing counsel is attempting to use a 'Twinkie defense,'" Bornemann said, referring to a label for flimsy legal claims coined by reporters covering the trial of Dan White, who was tried for murdering Harvey Milk and San Francisco Mayor George Moscone in 1979. (White's lawyers argued that his consumption of Twinkies was a symptom of his depression and "diminished capacity" at the time of the killings. White was convicted of voluntary manslaughter, instead of first-degree murder, and spent five years in prison before being paroled in 1985.)
In his work, Bornemann does everything from looking at past medical history and screening for other sleep conditions, to examining police and eyewitness reports. He even goes so far as to reconstruct the events in 3D video.
"So based upon that we can start to construct the behavioral processes and the complexity of the behavior," he explained. "Was it a several step process? This is particularly important. Then we can begin to piece it together."
From there, Bornemann assesses the sleep forensics and whether or not it tracks with the signature of sexsomnia. After thorough investigation and analysis, he recommends to the courtroom whether sexsomnia behavior was "very likely, likely or not likely." The jury is ultimately left to make the decision.
The biggest obstacles to his work in these types of cases, Bornemann told me, are interlinked. The court’s skepticism of sexsomnia is part and parcel of pervading beliefs that oppose neurological science. With any legal case, there are two important components for a conviction to be made: mens rea, Latin legalese for motivation or intent, demonstrated by consciousness; and actus rea, which deals with the physical actions that took place.
A legal defense of sexsomnia is based on the assumption that the perpetrator could not have motivation or intent at the time of the crime due to a lack of consciousness. It’s this crucial point where law and science differ.
"Simply put, the legal community sees consciousness as a dichotomy. Either you’re fully conscious or you’re not conscious," Bornemann said. "It’s the same thing with sleep. Either you’re fully asleep or you’re awake. It’s one or the other. But in neuroscience, we recognize that consciousness is on a spectrum. And the legal community doesn’t really account for that."
One thing that has furthered sexsomnia’s case in the courtroom is its recent addition in the ICSD-3 as an official condition, a revision that, as chair of the parasomnias section of the ICSD-3, Bornemann was able to make himself. Before this classification, the sexsomnia defense could get thrown out entirely if the judge deemed it "novel."
This new development was not just an advancement in how sexsomnia episodes are viewed in the courtroom. Moving forward, it will help promote research and awareness. With the advent of electronic medical records, being able to code for a relatively uncharted condition like sexsomnia goes a long way in collecting data and developing a broader understanding of the condition.
Still, even with this hopeful step forward, there's much progress to be made. For my part, I can report only one night terror episode since my overnight study. No sexsomnia. I plan to start my Klonopin trial soon. Given my hesitancy to use prescription medication on a long-term basis, I’m hoping it’s just that—a trial. But the medication itself is only treatment, not a cure. Regardless of what we learn about sexsomnia in the future, when I turn off the lights at night, I won't expect to see everything clearly in the darkness.