Dear Editor,

At present, there is an increasing level of interest about abnormal sexual behavior occurring during sleep which is called sleeping sexuality or atypical sexual behavior during sleep and sexsomaina. International Classification of Sleep Disorders (ICDS-2) treats this phenomenon as a variant of confusional excitation which is included in parasomnia classification (1). This disorder may present itself as creating sexual sounds during sleep, speaking or yelling, masturbation, caressing someone else, sexual intercourse during sleep, aggressive sexual behavior, ictal orgasm, ictal automatic sexual behavior, ictal pelvic motion looking like having a sexual intercourse (1-3). Sexual behaviors during sleep and sexual behavioral disorders might not only be caused by parasomnias. Some of them may be the result of epileptic seizures. Orgasms during sleep is a very rare disorder in female population and is almost in all cases are related to dreams with sexual content. The physical and psycho-social effects of this disorder may seriously disturb the life quality of the patient (4). It may be treated effectively according to the cause which may be found after thorough clinical and polysomnographic evaluation. Medical treatments regulating sleep frequently solves the problems of the patients (1).

The case is a 69 years old female patient who is an elementary school graduate, married and housewife. She applied to our clinic on October 2013 with a complaint of having orgasm in her sleep at least once a week, at most once in two weeks interval. She applied to gynecology clinic first but no pathology was discovered after her gynecologic evaluation and thus referred to our clinic. She had her complaints for twelve years but as she felt embarrassed, she did not seek for medical help before. However recently, her orgasms got intense enough to cause sub-sclerotic haemorrhages in her eyeballs. She had no dreams of sexual content prior to orgasms and felt very disturbed about this situation as she could not recover for the next few days. She had no pathology in her psychological examination. Complete blood count (CBC), hepatic, renal and thyroid function tests, lipid profile, vitamin B12, folic acid, eustrodiol, follicul stimulating hormone, luteinasing hormone, testosterone and prolactine levels were evaluated and all were in normal ranges. MRI scan was clear and EEG showed no signs of any epileptic pathology. As she had only one polysomnographic test centre in her hometown from which she could not have an appointment in less than 6 months did not have the test. She was treated with 1mg/day clonazepam. She returned for control visit 3 months after medical treatment. She reported no orgasm during her sleep after clonazepam treatment. 

She had a history of growing up in a conservative family and married at the age of 18 with a man who was chosen by her family. She stated that she had problems with her husband since the beginning and was never happy during her marriage. In spite of these she defines herself as a person who can be happy with small things and loves life. She had been a sexually active woman during her youth and been able to have both clitoral and vaginal orgasms, mostly the first. However, due to her husband’s neurological disorder, she had not had a sexual experience for the last 15 years. She states that she feels no sexual desires and does not masturbate in normal circumstances. The orgasms she had happen only during her sleep, in any stage. She feels no pleasure but rather a very drastic quaking all around her body and vagina. She did not have any dreams of sexual intercourse prior to orgasms, instead saw herself getting down off a tree and felt her vagina to be rubbed to the body of the tree. She also stated that she had pain on all over of her body which she had to take painkillers to deal with. 

The literature reveals 3 female cases with ictal orgasms. The first case is a 31 years old lady with temporal epilepsy. She had seizures which started with vaginal enlarging and a feeling of pleasure and had her symptoms controlled with diphenilhydantoine treatment. The second case was a 41 years old lady who had had orgasm like symptoms during her sleep after her fenobarbital treatment ended. Her symptoms also disappeared after fenebarbital treatment restarted. The third case was a 55 years old lady who woke up from her sleep with strong sexual desire and had a somatosensorial seizure and hemiplegia (1). There are two female patients that have been reported to have orgasm during their sleep in the literature as far as we know and both have been reported from Turkey. The first patient was 37 years old lady with orgasms during her sleep in any stage and as her EEG and MRI tests revealed no pathology and she refused to take any treatment. The second was 48 years old pre menapousal lady and as her symptoms disappeared with 0,375mg/day clonazepam treatment she rejected to take MRI and EEG tests (4). 

Our patient seems to be the oldest case in the literature. Although our patient’s EEG was recorded as normal this does not rule out epilepsy. As clonazepam, which is both an anti-epileptic and depressive of sleep stages, was used for treatment, it is hard to differentiate the possible cause (4). Despite all these facts, our case represents a very rare problem and we believe it will support the literature.

Sincerely

1. Schenck CH, Arnulf I, Mahowald MW. Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences. Sleep 2007; 30:683-702.

2. American Academy of Sleep Medicine. The International Classification of Sleep Disorders: Diagnostic and Coding Manual, Second ed. (ICSD-2). Westchester, Illinois: American Academy of Sleep Medicine, 2005, 142-150.

3. Aksu M, Sevim S, Firat H, Ucar ZZ. Sleeping disorders study guideline. Turkish Medical Sleeping Association Edition, 2008.

4. Ozcan H, Tasın C, Tandogan M, Ozaksit G. Two women having orgasm during sleep. Düşünen Adam The Journal of Psychiatry and Neurological Sciences 2012; 25:187-188.