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CC BY-NC-ND 4.0 · Sleep Sci
DOI: 10.1055/s-0045-1809927
Case Report

Abnormal Sexual Behavior During Sleep in an Adolescent: Sexsomnia and Defecation

Oya Güleşen Kapan 
1   Department of Child and Adolescent Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
,
Zeynep Ihtiyar Aydilek
2   Department of Child and Adolescent Psychiatry, Van Erciş Şehit Rıdvan Çevik Devlet Hastanesi, Van, Turkey
,
Mustafa Kapan 
3   Department of Child and Adolescent Psychiatry, Gülhane Training and Research Hospital, Ankara, Turkey
,
Mehmet Baştemur
4   Department of Pediatric Neurology, Gülhane Training and Research Hospital, Ankara, Turkey
,
Güray Koç
5   Department of Neurology, Ankara Bilkent City Hospital, Ankara, Turkey
,
Şahin Bodur
3   Department of Child and Adolescent Psychiatry, Gülhane Training and Research Hospital, Ankara, Turkey
,
Sinan Yetkin
6   Department of Psychiatry, Gülhane Training and Research Hospital, Ankara, Turkey
,
Mehmet Ayhan Cöngöloğlu 
3   Department of Child and Adolescent Psychiatry, Gülhane Training and Research Hospital, Ankara, Turkey
› Institutsangaben

Funding Source The author(s) received no financial support for the research.
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Abstract

Sexsomnia is characterized by sexual behaviors ranging from masturbation, sexual sounds, and verbalizations, to touching and full sexual intercourse during NREM sleep, with subsequent amnesia. Autonomic activation occurs with sexual arousal. Sexsomnia has been described mostly in adult males and is still an underrecognized condition. Treatment is often effective but without current consensus.

In a case now reported of an adolescent male with sexsomnia, which is rarely reported in the literature, a novel feature that is now first reported is defecation accompanying sexsomnia as a co-occurring autonomic disturbance during sleep.


 

Keywords

adolescent - defecation - parasomnias - sexual behavior - sexsomnia

Introduction

Parasomnias comprise the behavioral, emotional, and autonomic disturbances occurring during NREM or REM sleep or during sleep-wake transitions.[1] Sexsomnia is classified as a subtype of Confusional Arousals from NREM sleep, with the designation of “sleep-related abnormal sexual behaviors”[2].

Reported cases of sexsomnia encompass sexual behaviors ranging across masturbation, sexual sounds, and verbalizations, touching and full sexual intercourse during NREM sleep, with subsequent amnesia.[3] Autonomic activation occurs with sexual arousal.[4] There is subsequent amnesia for sexual behaviors. It is male-predominant and preferentially occurs in early and mid-adulthood.[5] As in other parasomnias, predisposing factors in sexsomnia include psychosocial stressors, alcohol substance and drug use, fatigue and sleep deprivation, and irregular sleep-wake schedule.[6] Polysomnography is the most appropriate diagnostic test. Information provided by the bed partners or other observers is critical.

The case reported herein is a rare adolescent case that is the first reported case in which defecation accompanies sexsomnia behavior.


 

Case

A 17-year-old male patient was brought by his family with complaints of putting his finger to the anal area during sleep and contaminating the clothes and sheets with stool.

It was stated that his complaints had been present for about 11 months, occurred almost every night, and recurred 3-4 times in the same night. The patient described that he had itching in the anal region in the hours before going to bed in the evening, did not remember the actions, and realized that the action had taken place when he noticed stool contamination if he woke up after the action. Although the patient did not describe ejaculation, his mother stated that there was semen in the patient's underwear after the action along with pink-yellowish discharge from the anal area, and that it was smeared on the clothes and sheets. For this reason, the patient had previously been started on clonezapam 2 mg/day in another hospital, but after using it for about 4 days, he discontinued the drug himself because he did not see any benefit.

According to the information obtained from the patient's parents regarding his history, he had bedwetting at night until he was 14 years old. It was observed that at the age of 11, he would scream at night and jump out of bed in fear (sleep terror), sometimes get out of bed and look around with blank eyes (confusional awakening), and the patient did not recall these episodes. This happened 3-4 times at 2-month intervals and each lasted 5-10 minutes. This process continued for about 1 year. In the examinations performed by neurology during this period, it was not evaluated as an epileptic seizure or pathology.

In the patient's history, there was no history of consanguinity in either mother or father. He was born at term, via cesarean section, and weighed 2800 grams. There was a history of incubation for 12 hours after birth. No disruption was described in the developmental stages. There was no history of daytime encopresis described in the past or present. He was evaluated as having normal intelligence in the clinical examination and IQ tests. The patient and his mother described frequent arguments but reported no impairment in daily functioning. School success and peer relationships were good. The patient did not have any accompanying personality disorder.

The patient's uncle had a history of bipolar disorder. His mother was using levothyroxine sodium due to hypothyroidism. There was no family history of sleep disorders or parasomnia.

In the patient's examinations, there was a B12 deficiency due to malnutrition, so B12 treatment was given. Consultation was requested from neurology and gastroenterology outpatient clinics. No pathology was detected in the neurological examination. However, tests were requested to evaluate epilepsy history and sleep epilepsy-related pathologies. Brain MRI and spinal MRI were evaluated as normal.

The polysomnography study was taken one night. The sleep structure was within normal limits. However, the event was not observed. Then, video EEG monitoring (VEM) was performed to evaluate whether there was an epileptic seizure. Electrooculogram (EOG) and chin electromyogram were added to VEM recordings and were performed for three nights. The event was observed on the first and second nights of the examination. On the first night in VEM, in N2 sleep for the first half of the night, after approximately 3 seconds of K arousal (without behavior), the action was started and lasted approximately 10 seconds. The patient took his hand to the anal area and then smelled his finger, sleep continued with N2 sleep after the action. In the second night recording, the event occurred at midnight, 3 hours after going to bed, in N3 sleep. The behavior is arousal and lasts about 30 seconds. Then sleep continues with N2 sleep. Likewise, there was the behavior of the patient taking his hand to the anal area and then smelling his hand. No ictal EEG findings were observed.

In the gastroenterological examination of the patient, anal fissure and skin tag were detected at the 6 o'clock position. Perianal dermatitis findings were present. The stool parasite test was negative.

The patient was evaluated with the diagnosis of “Sexsomnia” according to the presence of ejaculation and defecation after possible anal stimulation during sleep, the accompaniment of autonomic findings, the patient's not remembering what happened in the morning, and sleep EEG. Clonazepam 2 mg/day treatment was rearranged and followed up. The patient did not comply with the treatment and did not use it regularly. Due to the lack of follow-up, we could not obtain information about the final status of the patient.

Written informed consent was obtained from the patient and his parents for publication of this case report.


 

Discussion

Sexsomnia was first described in 1986 in Singapore in a male case who masturbated in his sleep.[7] In 2003, Shapiro et al. coined the term “sexsomnia” for the first time in a case series of 11 people who engaged in sexual behaviors while asleep.[6]

Sexsomnia is a rare parasomnia and its exact frequency in the general population is unknown.[8] Cases of sexsomnia reported in the literature are generally predominant in the male gender. The reason for this is currently unknown.[3] Although sexomnia is generally reported in young adult males, it has also been reported in very few adolescents in the literature. Recent reported adolescent cases include a 16-year-old male adolescent and a female adolescent with co-occurring Chron's disease and depressive symptoms.[5] [9] This presented case is rare and is the first case seen with defecation. This case is one of the rare cases reported as sexsomnia in adolescence.

Patients' sexsomnia behavior can often include masturbatory behavior, touching, and attempted sexual intercourse. There may be behavioral problems that lead to injury. This case is the first in the literature because it is accompanied by defecation. According to the patient's anamnesis and the information received from his parents, this situation appeared after itching the anal area, but exactly how the itching behavior occurred could not be described. Considering the presence of itching, case reports in the literature about scratching during sleep are increasing. This condition has been described as primary and secondary. While it is primarily referred to as itching that occurs without any other condition, it is secondarily defined as an increase in the symptoms of dermatological diseases during sleep.[10] In this patient, the itching behavior was not fully described and was not considered parasomnia due to the accompanying ejaculation and defecation. It was thought that what was meant by itching was anal stimulation with the patient's finger, as well as sexual stimulation.

The diagnosis of sexsomnia requires a comprehensive clinical history and sleep history. In addition, a complete EEG to capture nocturnal sexual behaviors and a nocturnal sleep study with video monitoring can also be used in the diagnosis.[6] Consistent with the sleep EEG of this case, fast and slow EEG activities accompanying N3 awakenings in half of patients with sexsomnia can support the diagnosis. Video-polysomnography for diagnosis is not a mandatory criterion among ICSD-3 (International Classification of Sleep Disorders) criteria to confirm arousal disorders. Video-polysomnography may have importance in ruling out differential diagnoses such as REM sleep behavior disorders and epilepsy, or in determining whether some N3 arousals are triggered by treatable respiratory events or periodic leg movements.[11]

Affected individuals often have a history of NREM sleep parasomnias (e.g., sleepwalking and sleep terrors) from childhood.[8] In this case, sleep terror was defined by the family at the age of 11.

Clonezepam has been studied the most in the literature in the treatment of patients with sexsomnia due to its association with confusional arousals and mixed results have been obtained.[3] [12] Other drugs used with limited success include trimipramine, lamotrigine, olanzapine, carbamazepine, clomipramine, fluoxetine, escitalopram, duloxetine, and paroxetine.[11] [13] In the presence of obstructive sleep apnea, CPAP and supportive devices have also been shown to be beneficial.[13] Clonezepam treatments have been tried so far in this patient, but no effective improvement has been achieved. Other options tried in the literature may be beneficial in the treatment of the patient.

Trauma-related sleep disorder, REM sleep behavior disorder, and nightmare disorder may be considered in the differential diagnosis of patients with sexsomnia. However, the history and sleep EEG of this case did not reveal any findings suggestive of these disorders. The patient did not describe any nightmares and EEG findings were detected in the N-REM stage of sleep. In these patients, information should be obtained to differentiate potentially mimicking confusional arousals such as chronic pain, mood disorders, or drug/substance use (e.g. antidepressants, sedative-hypnotics, anxiolytics, alcohol, opioids).[14] Neurologically, causes such as focal epileptic seizures, nocturnal frontal lobe epilepsy, and sleep-related epilepsy should also be considered in the differential diagnosis.[12] [15] In some seizures affecting the parietal and insular region, non-specific somatosensory sensations may occur in the genital organs. When differentiating epilepsy and sexsomnia, the occurrence of events in the awake state at the same time, the accompaniment of additional non-sexual behaviors, sexual behavior as a part of a wide emotional and motor automatism, inability to be awakened during the event, and lack of consciousness are in favor of epilepsy findings.[16]


 

Conclusion

Sexsomnia is a disorder that is little known in clinical practice, and it has challenges in diagnosis and treatment. These challenges are magnified in the novel case reported herein of defecation accompanying masturbation and ejaculation during sleep in an adolescent male. According to the available data, it has been reported very rarely in adolescents. Further studies are needed to better understand and treat the disorder and its complex presentations.


 

 

Conflicts of Interest

We have no conflicts of interest to disclose.


Address for correspondence

Oya Güleşen Kapan, MD

Publikationsverlauf

Eingereicht: 22. Februar 2025

Angenommen: 05. Juni 2025

Artikel online veröffentlicht:
15. Juli 2025

© 2025. Brazilian Sleep Academy. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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