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Sleep sex can be pleasurable but often has negative consequences.

"Dr. Christian Troy, famous Los Angeles plastic surgeon, had sex with Dr. Liz Cruz, his colleague and ‘outspoken lesbian anesthesiologist' while allegedly asleep."

This imaginary tabloid headline was inspired by the show Nip/Tuck. During a recent episode, Dr. Troy was dealing with the side effects of chemotherapy for male breast cancer. Despite his reputation for going it alone and not needing help from anyone, he turned to his colleague and co-worker, Dr. Liz Cruz. She is one of the better-adjusted characters on the show and was willing to help out with Dr. Troy's care, despite his often thoughtless and crass behavior.

After helping him through a very difficult evening of nausea, she was preparing to leave when he asked her to stay for support. She does and this being Nip/Tuck, she ends up sleeping in his bed. During the night, while apparently asleep, he rolls on top of her and they proceed to have intercourse. This is unsettling to her as she struggles with issues of her own sexuality but she seems to accept that he was indeed asleep. But was he? Really? This is, of course, fiction—but what about reality? Is it possible for people to engage in sexual behavior while asleep?

It is indeed. Well-known and frequently documented behaviors that have long been recognized by researchers as a normal part of sexual activity include nocturnal emissions ("wet dreams") in men and sexual dreams and sleep orgasms in women. These were reported in the famous surveys of sexual behavior reported by Kinsey in the 1940s and 1950s. (The Hite Reports published in the 1970s and 1980s, however, did not address the issue of sexual behavior in sleep at all.)

Recently, it has been recognized that more complex sexual behaviors may occur during sleep and in 2007, in the journal Sleep, Carlos Schenck, Isabelle Arnulf, and Mark Mahowald reported on numerous sleep-related sexual behaviors. Their search of the literature revealed a wide range of sleep-related sexual behaviors that includes masturbation, fondling, sexual intercourse with climax, and sexual assault/rape. These behaviors are collectively known as "sexsomnia." They found that these behaviors most often had unpleasant consequences, although there are some reports of pleasurable effects, similar to what Dr. Cruz, at least initially, experienced in her encounter with Dr. Troy.

These unusual and potentially disturbing sexual behaviors most often occur as a result of confusional arousals during which complex behaviors may occur when a sleeping person is suddenly aroused out of deep sleep.

Confusional arousals usually happen without the sleeping person coming to consciousness and the person is usually amnesic for the event. When sexsomnia occurs, women typically exhibit sexual vocalizations and masturbation. Men were found to more often engage in fondling and intercourse with females, although same-sex behavior is reported.

These behaviors seem to most often occur in people with other significant sleep-related problems such as driving and eating while asleep. In addition to co-existing sleep disorders, other factors that may increase the risk of sexsomnia include the use of alcohol, sleep disruption such as caused by obstructive sleep apnea and sleep deprivation. Another cause of sexsomnia is sleep-related epilepsy that can result in sexual arousal, pelvic thrusting, and orgasms. Unlike sexsomnia associated with confusional arousals, the person with sleep-related epilepsy often remembers the event.

Most episodes of sexsomnia are reported after the fact. There is, however, a case of sexsomnia with intercourse that was documented with nocturnal polysomnography. Interestingly, a review of the video of the study showed that the patient's wife initiated foreplay while her husband was asleep and this led to sexual intercourse without his waking up. (During polysomnography it is possible to verify that the person was sleeping based on EEG and other data).

Reported cases of sexsomnia include histories such as a woman in her 20s who would, while asleep, suddenly tear off her clothes and violently masturbate during the first half of the night. If she were interrupted by her husband, the behavior could occur once or twice again later in the night. If awakened, she would refuse offers of intercourse and would deny that the behavior had occurred.

One exceptional case involved a man in his 20s frequently performing cunnilingus on his wife — while both were asleep. There are a number of examples of men having intercourse with their partners while asleep. Usually, the woman describes the man as being "glassy-eyed" and vacant. The behavior stops if he is awakened. At least one woman, however, described her boyfriend as being a better lover with more effective technique when asleep than awake.

Some episodes of sexsomnia have resulted in criminal prosecutions. Arrests were more likely when the behavior involved minors. Sexsomnia has been successfully used as a criminal defense.

Sexsomnia can be successfully treated. Treatment involves medication (bedtime benzodiazepines) for sexual behavior associated with confusional arousals, CPAP to treat obstructive sleep apnea that is causing sleep disruption leading to confusional arousals and thus to sexsomnia, and anticonvulsant therapy for behavior related to seizure activity.

As for how Drs. Troy and Cruz are working out their issues? According to the previews, it seems that Dr. Troy has purchased a diamond ring. Will Dr. Cruz accept it? Only some quality time spent together while awake—and the next episode—will tell.

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