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, 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, 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.
Sexual sadism is particularly dangerous when associated with antisocial personality disorder. This combination of disorders may result in criminal sadism involving kidnapping or abduction of unwilling parties who may be harmed or killed (1). Individuals with both conditions are considered particularly recalcitrant to psychiatric treatment (2). Such individuals, when apprehended and convicted, are sometimes civilly committed as sexually violent predators for decades due to the lack of effective treatments (3).
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
The specific clinical criteria follow (1):
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) are most commonly employed, including group or individual cognitive-behavioral therapy with or without the use of antiandrogen agents.
If antisocial personality disorder is also present, treatments have not been shown to be particularly effective.
