Sexual Masochism Disorder DSM-5 302.83(F65.51)

This Article Is Part of A Series For Paraphilic Disorders

DSM-5 Category Paraphilic Disorders

Introduction

The DSM-5 explains that sexual masochism disorder is diagnosed in individuals who experience sexual arousal in response to extreme pain, humiliation, bondage, or torture.  The masochist will have unrelenting fantasies with urges to be beaten, bound or humiliated during sex (American Psychiatric Association, 2013).  Although behaviors associated with sexual masochism disorder are very prevalent, diagnostic criteria requires that the patient experience distress, such as shame, guilt or anxiety related to sexual fantasy, urges or sexual experiences. Milder forms of masochism between consenting adults, sometimes also referred to as "BDSM" or dominant and submissive, are not classified as disorders by the DSM-5.  Diagnosis occurs when certain criteria are met.

Diagnostic Criteria for Sexual Masochism Disorder

Symptoms of Sexual Masochism Disorder

Sexual Masochism Disorder is characterized by a pattern of sexual arousal for being made to suffer through physical violence or humiliation. According to changes in the DSM-5, common manifestations include being beaten, bound, or verbally abused. In some cases, asphyxiation is used to achieve sexual desire and patients often enjoy pornography or erotic literature involving masochism. To be diagnosed, the symptoms must cause impairment or distress. If the patient is not experiencing anxiety, guilt, shame or other negative feelings related to masochistic sexual desires, it I considered a sexual interest, not a disorder. In all diagnosed cases, the patient must admit to having these fantasies and urges (American Psychiatric Association, 2013).

Onset of Sexual Masochism Disorder

The average age for onset of sexual masochism disorder is 19.3 years. The DSM-5 explains that in some patients, sexual desires related to violence or humiliation may develop earlier, as young as 12 years old (American Psychiatric Association, 2013).

Sexual Masochism and Subculture

All patients who present with sexual masochism disorder have an erotic interest in a significant power discrepancy between partners. The common term for these relationships is Bondage discipline sadism and masochism (BDSM). Although most patients with sexual masochism disorder prefer to play a submissive role in sexual encounters, many assume both roles at different times with different partners (Shindel and Moser, 2011). In general, the BDSM community is strongly marginalized, and experiences stigma. Many who engage in BDSM within consensual relationships and do not experience guilt, shame or other negative emotions view the behavior as a subculture or alternative lifestyle choice, not a sexual deviance (Stiles and Clark, 2011).

BDSM subculture is so prominent that professionals, called a dominatrix, are hired to physically and verbally abuse paying male clients with sexual masochistic fantasies and desires. These women rarely, if ever, engage in sexual intercourse with clients, but instead use control and humiliation to foster sexual fantasy. When using these services, men with sexual masochistic fantasies and desires tend to experience a therapeutic response. One study reported that clients experience a psychological revitalization through shame, develop control over past trauma, and find alternatives to sexual repression (Lindemann, 2011).

Prevalence of Sexual Masochism Disorder

Although the DSM-5 explains that the prevalence of adults who meet diagnostic criteria of sexual masochism disorder are unknown (American Psychiatric Association, 2013), fantasies related to sexual masochism are fairly common. 12% of women and nearly a quarter of men respond sexual to erotic stories with masochistic themes. About 5% of women and 12% of men engage in fantasy in fantasy with masochistic themes, such as being beaten, whipped, spanked or tied up. As many as 50% of sexually active adults enjoy being bitten or scratched during consensual sexual activity. Prevalence of masochistic sexual behavior is even higher among lesbian and bisexual women (Shindel and Moser, 2011).

Distress related to masochistic behavior, such as anxiety, guilt or shame is a diagnostic criterion for sexual masochistic disorder. Although is is estimated that 16% of men consult a therapist to discuss sexual masochistic behavior or fantasy, only about 6% wishes to stop. Most patients who see sex therapists for sexual masochistic disorder usually name a different presenting problem. Besides distress, there is no clinical measure to differentiate pathological masochistic fantasy from non-pathological masochistic fantasy (Shindel and Moser, 2011). Because of stigma, many members of the BDSM community handle their sexual masochistic fantasies with concealment and secrecy. This often means that those who are troubled by any aspect of their behavior are less likely to seek help (Stiles and Clark, 2011).

Morbidity and Mortality Associated with Sexual Masochism Disorder

The most common risk associated with sexual masochism disorder is injury related to beating or binding. Autoerotic asphyxia is a specific type of sexual masochism that involves oxygen deprivation by means of neck compression during sexual activity. The most common manifestations of autoerotic asphyxia are hanging, ligature or plastic bags. Autoerotic asphyxia can be done with a partner or during masturbation. In some cases, patients use alcohol, drugs or chemical substances in conjunction with limiting oxygen to enhance sexual pleasure. Autoerotic asphyxia is the leading cause of death directly related to sexual masochistic disorder. Due to the self-inflicted nature or such deaths, it is something difficult to determine whether death was accidental or the result of suicide (Solarino, et al. 2011).

Treatment of Sexual Masochism Disorder

Because not all sexually masochistic behaviors are of clinical significance, treatment is reserved for patients who complain of distress related to their sexual behavior. Patients whose sexual desires put them in danger are also recommended for treatment. For example, if a man sustains burns or other injuries, he could severe more serious injuries or death without changes to his sexual behavior. Due to the complicated nature and inherent danger of sexual masochism disorder, an integrative approach to treatment is usually recommended. Although medication alone cannot resolve sexual masochism disorder, it can reduce some symptoms, such as hypersexual desires and anxiety that may impede treatment. Depot antiandrogen injections, for example reduce libido, thereby reducing masturbation, erections and sexual fantasies. This is not a long-term solution but works particularly well in inpatient situations. Medication should top at the patient’s request, when out-of-control sexual masochism has been resolved (Shiwach and Prosser, 2008).

The next course of treatment is for the patient to keep a diary of sexual fantasy, arousal and masturbation. The patient can discuss the contents of his journal with his therapist during frequent visits. The focus of therapy is to enhance sexual education and social skills. Insight-focused therapy can also help the patient examine his own needs within and outside his sexuality. Behavioral therapy is also helpful for the patient to develop new ways of behavior (Shiwach and Prosser, 2008)

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Lindemann, D. (2011) BDSM as therapy? Sexualities, 14(2): 151-172

Raj S. Shiwach & John Prosser (2008) Treatment of an unusual case of masochism, Journal of Sex & Marital Therapy, 24:4, 303-307

Shindel, A.W. & Moser, C.A. (2011). Why are the paraphilias mental disorders? The Journal of Sexual Medicine, 8 (3): 927-929

Solarino, B., Leonardi, S., Grattagliano, I., Tattoli, L. & Vella, G.D. (2011) An unusual death of a masochist: Accident or suicide? Forensic Science International, 204 (1): e16-e19

Stiles, B. & Clark, R. (2011). BDSM: A Subcultural Analysis of Sacrifices and Delights. Deviant Behavior, 32( 2): 158-189

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