Sexual Sadism Disorder DSM-5 302.84 (F65.52)
This Article Is Part of A Series For Paraphilic Disorders
DSM-5 Category: Paraphilic Disorders
Introduction
When an individual exhibits a propensity to engage in courtship or sexual behaviors considered extremely deviant of the norm, they may qualify for diagnosis of a paraphilic disorder. There is no universal agreement on the line between what is considered sexually deviant vs. atypical but normal sexual behavior, but the DSM-5 provides clear criteria for diagnosing sexual disorders. The Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5, The American Psychiatric Association, 2013) subdivides paraphilic disorders based on the nature of the sexual abnormality. These abnormal sexual preferences must involve a significant risk of physical harm, as well as causing psychological distress, in order to be diagnosed as a paraphilic disorder (The American Psychiatric Association, 2013).
Algolagnic disorders are a class of paraphilic disorders wherein sexual arousal is dependent on pain and suffering. Sexual sadism disorder is a specific algolagnic disorder wherein sexual arousal occurs from the physical or psychological suffering of another individual (The American Psychiatric Association, 2013).
Symptoms of Sexual Sadism Disorder
Sexual sadism disorder is hallmarked by intense feelings of sexual excitement when fantasizing about or witnessing another individual undergoing physical or psychological pain. Acts of sexual sadism may occur with a consenting partner, or as assault on a nonconsenting individual (The American Psychiatric Association, 2013).
Diagnosis of Sexual Sadism Disorder
If an individual experiences recurrent and intense sexual arousal from fantasies regarding or behaviors resulting in the physical or psychological harm of others for at least six months, along with either significant distress or impairment in functioning, or having acted upon these urges with a nonconsenting person, then diagnosis of sexual sadism disorder is appropriate. The diagnosis should indicate whether the individual is in a controlled environment preventing contact with others or if symptoms have been in remission for a minimum of 5 years without psychological distress (The American Psychiatric Association, 2013). In addition to the use of patient report and criminal records, the Severe Sexual Sadism Scale (SSSS), shows strong criterion validity for the diagnosis of sexual sadism disorder (Mokros, Schilling, Eher, & Nitschke, 2012).
A diagnosis of sexual sadism applies to both individuals who admit to their urges, with or without distress, and to those who deny sadistic sexual urges despite significant evidence otherwise. Often, those who deny possessing symptoms of sexual sadism disorder claim that episodes of sexual assault were unintentional, or may admit to past episodes but deny ongoing interest in sexual sadism. In both of these cases, it is likely that the individual will deny significant impairment or distress, but will still qualify for diagnosis of sexual sadism disorder (The American Psychiatric Association, 2013).
When diagnosing sexual sadism disorder in individuals who have committed sexual crimes, it is important to carefully differentiate between behaviors consistent with sexual sadism and those associated with nonsadistic sexual assault (McLawsen, Jackson, Vannoy, Gagliardi, & Scalora, 2008). It has been demonstrated through use of phallometric testing that individuals diagnosed with sexual sadism disorder or who demonstrate preference for sadism without qualifying for the disorder demonstrate sexual arousal to violence or injury in a sexual context, while those with other disorders or no diagnoses that commit sexual crimes respond to resistance or nonconsent (Seto, Lalumiere, Harris, & Chivers, 2012).
When diagnosis sexual sadism disorder, it is also important to note that mild forms of pain, including scratching or spanking, between consenting adults is considered within the normal range of human sexual experimentation. As long as the intent of the behavior is for mutual attraction and all parties are consenting, acts of sadism may not qualify for diagnosis of sexual sadism disorder.
Co-morbidity of Sexual Sadism Disorder
Sexual sadism disorder is commonly comorbid with other paraphilic disorders, with no clear evidence that any particular sexual disorder is more commonly co-diagnosed than others. Our current knowledge of comorbidity with regards to sexual sadism disorder comes primarily from data regarding primarily male individuals convicted of criminal acts of sadism against nonconsenting victims, and as such this data may not apply to those diagnosed with sexual sadism disorder based on distress without nonconsenting acts (The American Psychiatric Association, 2013).
There is some evidence that impaired emotional recognition and deficits in emotional processing are commonly seen in those diagnosed as psychopaths, and that these same reduced levels of empathy and increased aggression levels may occur in individuals diagnosed with sexual sadism disorder as well (Kirsch & Becker, 2007).
Prevalence of Sexual Sadism Disorder
Prevalence rates of sexual sadism disorder vary from less than 10% of convicted sexual offenders in the United States, to anywhere from 37-75% of individuals who have committed sexually motivated homicide (The American Psychiatric Association, 2013).
Treatment of Sexual Sadism Disorder
Treatment of paraphallic disorders typically seek to reduce sexual urges and behaviors via behavioral therapy, used to identify the triggers that lead to undesirable behaviors and redirect those behavior in socially appropriate ways, and through the use of psychopharmaceutical intervention (The American Psychiatric Association, 2013).
Studies have demonstrated a significant improvement in the symptoms and urges associated with sexual sadism disorder through the use of psychopharmaceuticals. In particular, the use of serotonin reuptake inhibitors, a class of antidepressants, have been linked to the repression of sexual impulses and the overall improvement of sexual impulse disorders. Similarly, the use of antiandrogens, including medroxyprogestrone and cyproterone, along with antipsychotics reduce the physical reactions and psychological symptoms related to sexual sadism disorder (Kafka, 1995).
Outcomes for Sexual Sadism Disorder
Statistical analysis indicates that while psychiatric diagnosis of sexual sadism disorder is not directly related to recidivism in male sexual offenders, sexual arousal to violence indicated by penile erection was. The author of this study argues that diagnostic criteria for sexual sadism disorder should include phallometric indicators as a means of predicting future violent offenses (Kingston, Seto, Firestone & Bradfor, 2010).
Since acting upon the sexual urges consistent with sexual sadism disorder upon a nonconsenting individual is likely to lead to arrest, prosecution, and incarceration, it is critical for patients to do everything in their power to refrain from acting upon these urges. When also considering that these urges put others at considerable risk of harm, these patients should remain under the close supervision of a psychologist who is intimately familiar with the treatment of paraphilic disorders. In addition, if the treatment plan involves the use of antipsychotics, antidepressants, or antiandrogens, treatment should also be monitored by psychiatrists and medical personnel capable of regulating the reactions and interactions of these drugs in the human body.
References
American Psychiatric Association, The (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Kafka, M.P. (1995). Current concepts in the drug-treatment of paraphilias and paraphilia-related disorders. CNS Drugs, 3(1), 9-21.
Kingston, D.A., Seto, M.C., Firestone, P., & Bradford, J.M. (2010). Comparing indicators of sexual sadism as predictors of recidivism among adult male sexual offenders. Journal of Consulting and Clinical Psychology, 78(4), 574-584.
Kirsch, L.G., & Becker, J.V. (2007). Emotional deficits in psychopathy and sexual sadism: Implications for violent and sadistic behavior. Clinical Psychology Review, 27(8), 904-922.
Mokros, A., Schilling, F., Eher, R. * Nitschke, J. (2012). The severe sexual sadism scale: Cross-validation and scale properties. Psychological Assessment, 24(3), 764-769.
McLawsen, J.E., Jackson, R.L., Vannoy, S.D., Gagliardi, G.J., & Scalora, M.J. (2008). Professional perspectives on sexual sadism. Sexual Abuse – A Journal of Research and Treatment, 20(3), 272-304.
Seto, M.C., Lalumiere, M.L., Harris, G.T., & Chivers, M.L. (2012). The sexual responses of sexual sadists. Journal of Abnormal Psychology, 121(3), 739-753.
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