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Sexual Sadism Disorder

By

George R. Brown

, MD, East Tennessee State University

Reviewed/Revised Jul 2023
View PATIENT EDUCATION

Sexual sadism is infliction of physical or psychological suffering (eg, humiliation, terror) on another person to stimulate sexual excitement and orgasm. Sexual sadism disorder is sexual sadism that causes clinically significant distress or functional impairment or is acted on with a nonconsenting person.

People with sexual sadism disorder have either acted on the intense urges or have debilitating or distressing fantasies with sexually sadistic themes that they have not acted upon. The condition must also have been present for 6 months.

Sexual sadism is a form of paraphilia Overview of Paraphilias and Paraphilic Disorders Paraphilic disorders are recurrent, intense, sexually arousing fantasies, urges, or behaviors that are distressing or disabling and that involve inanimate objects, children or nonconsenting... read more , but mild sadistic sexual behavior is a common sexual practice between consenting adults that is usually limited in scope, is practiced in a way that does not cause harm, and does not meet the clinical criteria for a paraphilic disorder. However, in some people, the behaviors escalate to the point of harm. Determining when sadism becomes pathologic is a matter of degree.

Most sexual sadists have persistent fantasies in which sexual excitement results from suffering inflicted on the partner, consenting or not. When practiced with nonconsenting partners, sexual sadism constitutes criminal activity and is likely to continue until the sadist is apprehended. However, sexual sadism is not synonymous with rape Medical Examination of the Rape Victim Sexual assault is any type of sexual activity or contact that a person does not consent to. Sexual assault, including rape, may cause physical injury or illness or psychologic trauma. Survivors... read more , it is a complex amalgam of coerced sex and power exerted over the victim. Sexual sadism is diagnosed in < 10% of rapists but is present in 37 to 75% of people who have committed sexually motivated homicides.

General references

  • 1. Jones S, Chan HCO: The psychopathic–sexually sadistic offender. In Routledge International Handbook of Psychopathy and Crime Routledge/Taylor & Francis Group, 2018, pp. 398-412.

  • 2. Meloy JR: The psychology of wickedness: Psychopathy and sadism. Psychiatric Annals 27(9):630-633, 1997. https://doi.org/10.3928/0048-5713-19970901-10

  • 3. DeClue G: Paraphilia NOS (nonconsenting) and antisocial personality disorder. J Psychiatry Law 34(4):495-514, 2006. https://doi.org/10.1177/009318530603400404

Diagnosis of Sexual Sadism Disorder

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria

  • Patients derive recurrent and intense sexual arousal from the physical or psychological suffering of another person; arousal is expressed in fantasies, intense urges, or behaviors.

  • Patients have acted on their urges with a nonconsenting person, or these fantasies or urges cause clinically significant distress or impair functioning at work, in social situations, or other important areas of their lives.

  • The condition has been present for 6 months.

The clinician must specify whether the patient is living in a controlled environment (eg, prison, institution) or in full remission (ie, has not acted on the urges with a nonconsenting partner, and there has been no distress/impairment in social, occupational, or other areas of functioning for at least 5 years in an uncontrolled environment).

Sexual sadism disorder may be diagnosed in patients who deny that they have fantasies or urges related to sexual arousal triggered by the pain or suffering of others, especially if these patients report multiple sexual episodes of inflicting pain or suffering on a nonconsenting person.

Diagnosis reference

  • 1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC.

Treatment of Sexual Sadism Disorder

  • Sometimes cognitive-behavioral therapy (group or individual)

  • Sometimes antiandrogen medications

Treatment of sexual sadism is not necessary if the interests, fantasies, and behaviors do not involve nonconsenting persons and there is an absence of clinically significant distress or impairment. For those whose sexual sadism rises to the level of sexual sadism disorder, treatments applied to other paraphilias (see, for example, Treatment: Exhibitionistic Disorder Treatment Exhibitionism is characterized by achievement of sexual excitement through genital exposure, usually to an unsuspecting stranger. It may also refer to a strong desire to be observed by other... read more ) are most commonly employed, including group or individual cognitive-behavioral therapy with or without the use of antiandrogen agents.

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