Sexual masochism is intentional participation in an activity that involves being humiliated, beaten, bound, or otherwise abused to experience sexual excitement. Sexual masochism disorder is diagnosed when a patient experiences recurrent, intense sexual arousal from these activities but also has clinically significant distress or impaired functioning.
Sexual masochism is a form of paraphilia, but most people who have masochistic interests do not meet clinical criteria for a paraphilic disorder, which require that the person's behavior, fantasies, or intense urges result in clinically significant distress or impairment. The condition must also have been present for ≥ 6 months.
People with sexual masochism generally openly acknowledge their interest in, or participation in, masochistic sexual activities. The term BDSM (bondage-domination-sadism-masochism) is an encompassing descriptive term that includes sexual masochists who do, or do not, meet clinical criteria for a diagnosis of sexual masochism disorder.
Prevalence of sexual masochism disorder is unknown. However, a single report of data from a telephone survey in Australia from 2001 to 2002 found that 2.2% of males and 1.3% of females reported being involved in BDSM behaviors in the previous 12 months (1).
Sadomasochistic fantasies and sexual behavior between consenting adults is very common. Masochistic activity tends to be ritualized and long-standing. For most participants (similar to most other paraphilic interests), the humiliation and beating are simply acted out; participants know that it is a game and carefully avoid actual humiliation or injury, often through the use of a prenegotiated "safe word." However, some masochists increase the severity of their activity with time and may stop using their safe word to protect themselves, which can potentially lead to serious injury or death.
For people who engage in masochistic activities, these may be the preferred or exclusive mode of producing sexual excitement. People may act out their masochistic fantasies on themselves—for example, by
Binding themselves
Piercing their skin
Applying electrical shocks
Burning themselves
Self-suffocation during masturbation (asphyxiophilia)
Or they may seek out a partner who may be a sexual sadist. Activities with a partner may include being
Bound
Blindfolded
Spanked
Flagellated (whipped)
Humiliated by being urinated or defecated on
Forced to cross-dress
Coerced into a sexual act
Partially asphyxiated, usually at the time of orgasm
Autoerotic asphyxiation (asphyxiophilia)
Asphyxiophilia is considered a subtype of sexual masochism disorder. As part of the diagnostic process, the clinician should note whether this behavior is "present" or "absent."
In this disorder, people restrict their breathing (partial asphyxiation)—or allow a partner to do so—at or near the time of orgasm to enhance the sexual experience, not as a way to harm themselves. Typically, people use articles of clothing (eg, scarves, underwear) as a ligature to choke themselves. The ligature is often suspended from an object in the room (eg, doorknob, bedpost).
Loss of consciousness can occur rapidly because obstruction of venous return from the brain impairs cerebral perfusion even before hypoxia and hypercarbia become significant. People who asphyxiate themselves in such a way that the ligature does not release if they lose consciousness can inadvertently have permanent brain damage or die.
General reference
1. Richters J, Grulich AE, de Visser RO, et al: Sex in Australia: Autoerotic, esoteric and other sexual practices engaged in by a representative sample of adults. Aust N Z J Public Health 27(2):180-190, 2003. doi: 10.1111/j.1467-842x.2003.tb00806.x
Diagnosis of Sexual Masochism Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
The specific clinical criteria follow (1):
Patients experience recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer. This arousal is expressed in fantasies, intense urges, or behaviors.
Their fantasies, intense urges, or behaviors cause significant distress or impair functioning at work, in social situations, or in other important areas of their lives.
The condition has been present for ≥ 6 months.
The clinician must specify whether
Asphyxiophilia is present
The patient is living in a controlled environment (where it would be difficult to engage in masochistic behaviors)
The patient is in full remission (ie, has experienced at least 5 years without distress/impairment in an uncontrolled environment)
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 Masochism Disorder
Cognitive-behavioral therapy
Antiandrogen therapy
Treatment of sexual masochism is not necessary if the individual does not have clinically significant distress or impairment. Although there are few large studies, for those who merit a diagnosis of sexual masochism disorder, a combination of cognitive-behavioral therapy and antiandrogen treatments appear to have the most efficacy (1).
Treatment reference
1. Lykins A, Hucker SJ: Treatment of sexual masochism. In Case Studies in Sexual Deviance: Toward Evidence-Based Practice, edited by T Downhiller, Routledge/Taylor & Francis Group, 2014, pp. 102–116.
