What is masochism

Sexual masochism disorder are intended to apply to individuals who freely admit to having such paraphilic interests. Such individuals openly acknowledge intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors ¹. If these individuals also report psychosocial difficulties because of their sexual attractions or preferences for being humiliated, beaten, bound, or otherwise made to suffer, they may be diagnosed with sexual masochism disorder. In contrast, if they declare no distress, exemplified by anxiety, obsessions,
guilt, or shame, about these paraphilic impulses, and are not hampered by them in pursuing other personal goals, they could be ascertained as having masochistic sexual interest but should not be diagnosed with sexual masochism disorder. The extensive use of pornography involving the act of being humiliated, beaten, bound, or otherwise made to suffer is sometimes an associated feature of sexual masochism disorder. Disorders that occur comorbidly with sexual masochism disorder typically include other paraphilic disorders, such as transvestic fetishism.

The population prevalence of sexual masochism disorder is unknown. In Australia, it has been estimated that 2.2% of males and 1 .3% of females had been involved in bondage and discipline, sadomasochism, or dominance and submission in the past 12 months ¹. In a Canadian study, sadomasochistic sexual fantasies during sexual intercourse were reported by 10% of men and a large percentage of females (from 31 to 57%) were reported to have rape fantasies ². In a survey of sexual behavior in the US involving 2026 respondents, Hunt ³ found that 4.8% of males and 2.1% of females reported ever having obtained sexual pleasure from inflicting pain and 2.5% of males and 4.6% of females from receiving pain. A review ⁴ of the literature on women’s rape fantasies reported that 31–57% of women had fantasies in which they were forced into sex against their will and that for 9–17% these were a frequent or favorite fantasy experience.

Sexual masochism disorder diagnostic criteria

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5 Diagnostic Criteria

• A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors.
• B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

• With asphyxiophilia: If the individual engages in the practice of achieving sexual arousal related to restriction of breathing.

Specify if:

• In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in masochistic sexual behaviors are restricted.
• In full remission: There has been no distress or impairment in social, occupational, or other areas of functioning for at last 5 years while in an uncontrolled environment.

The Criterion A time frame, indicating that the signs or symptoms of sexual masochism must have persisted for at least 6 months, should be understood as a general guideline, not a strict threshold, to ensure that the sexual interest in being humiliated, beaten, bound, or otherwise made to suffer is not merely transient. However, the disorder can be diagnosed in the context of a clearly sustained but shorter time period.

Community individuals with paraphilias have reported a mean age at onset for masochism of 19.3 years, although earlier ages, including puberty and childhood, have also been reported for the onset of masochistic fantasies. Very little is known about persistence over time. Sexual masochism disorder per definition requires one or more contributing factors, which may change over time with or without treatment. These include subjective distress (e.g., guilt, shame, intense sexual frustration, loneliness), psychiatric morbidity, hypersexuality and sexual impulsivity, and psychosocial impairment. Therefore, the course of sexual masochism disorder is likely to vary with age. Advancing age is likely to have the same reducing effect on sexual preference involving sexual masochism as it has on other paraphilic or normophilic sexual behavior.

What is sexual sadism disorder

The diagnostic criteria for sexual sadism disorder are intended to apply both to individuals who freely admit to having such paraphilic interests and to those who deny any sexual interest in the physical or psychological suffering of another individual despite substantial objective evidence to the contrary ¹. The extensive use of pornography involving the infliction of pain and suffering is sometimes an associated feature of sexual sadism disorder. Individuals who openly acknowledge intense sexual interest in the physical or psychological suffering of others are referred to as ” admitting individuals.” If these individuals also report psychosocial difficulties because of their sexual attractions or preferences for the physical or psychological suffering of another individual, they may be diagnosed with sexual sadism disorder. In contrast, if admitting individuals declare no distress, exemplified by anxiety, obsessions, guilt, or shame, about these paraphilic impulses, and are not hampered by them in pursuing other goals, and their self-reported, psychiatric, or legal histories indicate that they do not act on them, then they could be ascertained as having sadistic sexual interest but they would not meet criteria for sexual sadism disorder.

Examples of individuals who deny any interest in the physical or psychological suffering of another individual include individuals known to have inflicted pain or suffering on multiple victims on separate occasions but who deny any urges or fantasies about such sexual behavior and who may further claim that known episodes of sexual assault were either unintentional or nonsexual. Others may admit past episodes of sexual behavior involving the infliction of pain or suffering on a nonconsenting individual but do not report any significant or sustained sexual interest in the physical or psychological suffering of another individual. Since these individuals deny having urges or fantasies involving sexual arousal to pain and suffering, it follows that they would also deny feeling subjectively distressed or socially impaired by such impulses. Such individuals may be diagnosed with sexual sadism disorder despite their negative self-report. Their recurrent behavior constitutes clinical support for the presence of the paraphilia of sexual sadism (by satisfying Criterion A – see below) and simultaneously demonstrates that their paraphilically motivated behavior is causing clinically significant distress, harm, or risk of harm to others (satisfying Criterion B – see below).

“Recurrent” sexual sadism involving nonconsenting others (i.e., multiple victims, each on a separate occasion) may, as general rule, be interpreted as three or more victims on separate occasions. Fewer victims can be interpreted as satisfying this criterion, if there are multiple instances of infliction of pain and suffering to the same victim, or if there is corroborating evidence of a strong or preferential interest in pain and suffering involving multiple victims. Note that multiple victims, as suggested earlier, are a sufficient but not a necessary condition for diagnosis, as the criteria may be met if the individual acknowledges intense sadistic sexual interest.

The Criterion A time frame, indicating that the signs or symptoms of sexual sadism must have persisted for at least 6 months, should also be understood as a general guideline, not a strict threshold, to ensure that the sexual interest in inflicting pain and suffering on nonconsenting victims is not merely transient. However, the diagnosis may be met if there is a clearly sustained but shorter period of sadistic behaviors.

Sexual sadism disorder diagnostic criteria

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5 Diagnostic Criteria

• A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.
• B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

• In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in sadistic sexual behaviors are restricted.
• In full remission: The individual has not acted on the urges with a nonconsenting person and there has been no distress or impairment in social,  occupational or other areas of functioning, for at least 5 years while in an uncontrolled environment.

The population prevalence of sexual sadism disorder is unknown and is largely based on individuals in forensic settings. Depending on the criteria for sexual sadism, prevalence varies widely, from 2% to 30%. Among civilly committed sexual offenders in the United States, less than 10% have sexual sadism. Among individuals who have committed sexually motivated homicides, rates of sexual sadism disorder range from 37% to 75%.

Individuals with sexual sadism in forensic samples are almost exclusively male, but a representative sample of the population in Australia reported that 2.2% of men and 1 .3% of women said they had been involved in bondage and discipline, “sadomasochism,” or dominance and submission in the previous year. Information on the development and course of sexual sadism disorder is extremely limited. One study reported that females became aware of their sadomasochistic orientation as young adults, and another reported that the mean age at onset of sadism in a group of males was 19.4 years. Whereas sexual  sadism per se is probably a lifelong characteristic, sexual sadism disorder may fluctuate according to the individual’s subjective distress or his or her propensity to harm nonconsenting others. Advancing age is likely to have the same reducing effect on this disorder as it has on other paraphilic or normophilic sexual behavior.

Known comorbidities with sexual sadism disorder are largely based on individuals (almost all males) convicted for criminal acts involving sadistic acts against nonconsenting victims. Hence, these comorbidities might not apply to all individuals who never engaged in sadistic activity with a nonconsenting victim but who qualify for a diagnosis of sexual sadism disorder based on subjective distress over their sexual interest. Disorders that are commonly comorbid with sexual sadism disorder include other paraphilic disorders.

What is sadism and masochism

The originator of the concepts of both masochism and sadism, Richard von Kraft-Ebing was an Austro-German psychiatrist in the 19th century best known for his work on human sexuality. Kraft-Ebing termed the concept “masochism” after the German noble Sacher-Masoch, who in his novels described men who gained sexual pleasure from domineering women. The term “sadist” was also coined by Kraft-Ebing and is derived from another 19th century noble Marquis de Sade ⁵.

Like Kraft-Ebing, Sigmund Freud ⁶ used masochism to refer to sexual peculiarity. In Beyond the Pleasure Principle, Freud contended that sadism and masochism go hand-in-hand: the masochist directs the death wish (thanatos) towards the self, while the sadist directs it towards others. Thus, he argued that the sadist is always a masochist in disguise ⁶.

It wasn’t until the 1930s and 1940s that psychoanalysts like Horney, Fromm, Reik, Berliner, Menaker, and Ferenczi broadened the concept of masochism beyond its original sexual meaning. These analysts and others developed the concept of “moral masochism” to explain individuals who seem generally—not just sexually—to derive pleasure from pain, failure, and self-defeat. Perhaps the most influential of these theorists was Wilhelm Reich, who understood masochism as arising from a sexual instinct but manifesting more broadly in repeated self-defeating behavior ⁵.

DSM-III, published in 1980 and chaired by Robert Spitzer, added Masochistic Personality Disorder to the chapter on conditions for further study. The diagnostic criteria for the disorder were:

• A) A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which they will suffer, and prevent others from helping them, as indicated by at least five of the following:
  1. chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available
  2. rejects or renders ineffective the attempts of others to help them
  3. following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)
  4. incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)
  5. rejects opportunities for pleasure, or is reluctant to acknowledge enjoying themselves (despite having adequate social skills and the capacity for pleasure)
  6. fails to accomplish tasks crucial to their personal objectives despite having demonstrated ability to do so (e.g., helps fellow students write papers, but is unable to write their own)
  7. is uninterested in or rejects people who consistently treat them well
  8. engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice
• B) The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.
• C) The behaviors in A do not occur only when the person is depressed.

Masochistic Personality Disorder was never fully added to the main text of DSM, and it was removed entirely from DSM-IV, chaired by Allen Frances, in 1994. By that time, the diagnosis had become politically controversial. Since masochism has historically been associated with female submissiveness, some began to argue that the diagnosis applied to women who repeatedly found themselves in domestic violence situations.

In part due to this controversy, and in part due to the disorder’s subjective criteria set and difficulty distinguishing this behavior from that observed in clinical depression, DSM decision makers decided to scrap Masochistic Personality Disorder from the manual.

Still, many psychiatric thinkers—chiefly psychoanalysts and those inclined to an analytic approach—believe that the concept of masochistic personality deserves continued attention and warrants additional research for possible inclusion in DSM. Nancy McWilliams ⁷, the well-known psychoanalyst and author of several popular books, has applied this concept throughout her work.

While the DSM has moved more and more towards a descriptive, behavioral approach to psychiatric diagnosis, Masochistic Personality Disorder is no more subjective of a diagnosis than is Narcissistic Personality Disorder or Borderline Personality Disorder, both well-established and validated forms of characterological pathology.

References

1. American Psychiatric Association, DSM-5 Task Force. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. American Psychiatric Association: Arlington, VA; 2013.
2. Krueger R. B. The DSM diagnostic criteria for sexual masochism. Archives of Sexual Behavior. 2010;39(2):346–356. doi: 10.1007/s10508-010-9613-4
3. Hunt M. Sexual Behavior in the 1970s. Chicago, Ill, USA: Playboy Press; 1974
4. Shields L. B. E., Hunsaker D. M., Hunsaker J. C., III Autoerotic asphyxia—part I. American Journal of Forensic Medicine and Pathology. 2005;26(1):45–52. doi: 10.1097/01.paf.0000153998.44996.fd
5. Fuller, K. (1986). Masochistic personality disorder: A diagnosis under consideration. Jefferson Journal of Psychiatry, 4(2), 7-20
6. Freud, S., & Jones, E. (Ed.). (1922). International psychoanalytical library: Vol. 4. Beyond the pleasure principle (C. J. M. Hubback, Trans.). London, England: The International Psycho-Analytical Press.
7. McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guilford Press