176 Sexual Sadism (302.84)

DSM-IV-TR criteria

• Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.
• The person has acted on these sexual urges with non consenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
• Sexual Sadism is severe and is associated with Antisocial Personality Disorder. The sexually sadistic individual may either seriously injure or kill the victim or partner.

Associated features

• The paraphilic focus of Sexual Sadism involves acts in which the individual derives sexual excitement from psychological or physical suffering (including humiliation) of the non-consenting victim. It is the suffering of the victim that is sexually arousing. Sadistic fantasies or acts may involve activities that indicate the dominance of the person, such as forcing the victim to crawl or keeping the victim confined. Such fantasies may also involve restraint, blindfolding, paddling, spanking, whipping, pinching, beating, burning, electrical shocks, rape, cutting, stabbing, strangulation, torture, mutilation, or killing. Some individuals with this Paraphilia feel empowered by their sadistic fantasies; this feeling may be invoked during sexual activity but not otherwise acted upon. Some individuals with SS may engage in sexual acts for many years without the need to increase the potential for inflicting serious physical damage; however, usually the severity of their sadistic acts increases over time. When SS is severe, or when it is associated with Antisocial Personality Disorder, the individual with SS may seriously injure or kill the victim.
• The urges must have been recurrent for at least six months for a diagnosis to be made or attempted. Achieving sexual excitation or orgasm is dependent on the other individual’s being humiliated or receiving pain. Some individuals are bothered by these fantasies, which may occur during the sexual excitation and activity but are otherwise not carried out; thus, they remain fantasies. The partner (victim) may very well be terrified of the anticipated act, especially if the behavior involves total control or domination. In other instances, the sexual sadist will have a partner who willingly acts with him or her; she or he may suffer from sexual masochism. Some individuals with SS may act out their fantasies on unwilling partners or victims. Typical sadistic fantasies involve dominance over the partner/victim, and the fantasies were most likely present during the individual’s childhood.
• Sexual Sadism is often linked with Sexual Masochism.

Child vs. adult presentation

Sadistic sexual fantasies are likely to have been present during childhood and it is likely that individuals with SS were abused as children, both sexually and physically. Adult presentation is usually expressed in early adulthood about the time that the sexually sadistic activities appear, and the disorder is usually chronic in its course. Generally the sadistic acts increase in severity over the sufferer’s lifespan.

Gender and cultural differences in presentation

Sexual Sadism presents itself in males in over 95% of known cases researched worldwide. Sexual Sadism will present itself in much the same manner throughout different cultures. Although this disorder can be obtained by males or females, it is more common for males to behave with more non-consenting partners even if it is considered rare.

Epidemiology

• Sexual Sadism is found in only 1 to 2% of the population in the United States.
• Age of onset varies greatly, but it typically has developed by early adulthood.

Etiology

There is no universally accepted cause or theory explaining the origin of Sexual Sadism. Some researchers explain it as the result of biological factors. Evidence for this theory comes from abnormal findings from neuropsychological and neurological tests from offenders. Others believe it is caused from brain injury or mental disorders such as Schizophrenia.

Empirically supported treatments

• Behavior therapy is often used to treat Sexual Sadism. This psychological treatment includes management and conditioning of arousal patterns and masturbation as well as cognitive restructuring and social skills training.
• Medication is especially recommended for individuals with SS who exhibit behaviors dangerous to others. The medications that are used are female hormones, which speed up the clearance of testosterone from the bloodstream, and Antiandrogen medications, which block the body’s uptake of testosterone. SSRIs may also be used.

Prognosis

Because of the chronic course of sexual sadism and the uncertainty of its causes, treatment is often difficult. The fact that many sadistic fantasies are socially unacceptable or unusual leads many people who may have the disorder to avoid or drop out of treatment. Treating a paraphilia is often a sensitive subject for many mental health professionals. Severe or difficult cases of sexual sadism should be referred to a specialized clinic for the treatment of sexual disorders or to professionals with experience in treating such cases.