Sexual masochism disorder is when an individual experiences persistent sexual excitement stemming from fantasies, urges, or behavior related to experiencing physical or psychological harm during sexual activity. A pattern of sexual excitement does not qualify as a mental disorder unless accompanied by significant personal distress, impairment, or grievous harm to self or others.
What Is Sexual Masochism Disorder?
Sexual masochism disorder is a subcategory of paraphilic disorders. A paraphilia is an intense, persistent sexual interest in atypical sexual targets or activities; a paraphilic disorder is a paraphilia that causes significant distress, functional impairment, and/or harm to self or others. Most people who have masochistic sexual interests or who are affected by other paraphilias don’t experience significant distress or harm and wouldn’t be classified as having a mental disorder.
A person with masochistic interests fantasizes about or engages in sexual activity which involves being humiliated, beaten, bound, or otherwise made to suffer. Consenting sexual play involving the experience of humiliation or pain doesn’t classify as sexual masochism disorder; however, it is important to assess whether adequate safety measures are in place.
Sexual masochism falls under the umbrella term BDSM (Bondage, Discipline, Dominance, Submission, Sadism & Masochism), which encompasses an exploration of power dynamics and pain as an erotic element during sexual activity. BDSM practices are widespread and BDSM fantasies or urges are a normative expression of sexual excitation.
Asphyxiophilia
Of particular concern when assessing sexually masochistic interests is whether asphyxiophilia, or an interest in the restriction of breathing, is present. Choking, strangling, or otherwise preventing breath to move freely is a risky sexual behavior and can lead to serious injury or death without the intention of causing grievous harm. Protection of the trachea is especially important when engaging in consensual breath play. Direct pressure should never be applied to the front of the throat, as this can lead to a damaged windpipe and suffocation.
Symptoms of Sexual Masochism Disorder
The main criterion for sexual masochism disorder is a recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer. This desire can be manifested by fantasies, urges, or behaviors. A person with sexual masochism disorder is often only able to achieve arousal when pain or suffering is present and they may lack control over their fantasies, urges, or behaviors.2
Sexually active adults may engage in consenting “rough sex” or be aroused by sexual acts involving the experience of humiliation or pain; however, in the absence of fixation, mental distress, or non-consenting activities, this arousal would not be classified as a mental disorder.
In order to meet the diagnostic criteria for sexual masochism disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are specific criteria that must be met.
To be diagnosed, symptoms of sexual masochism disorder must:
- Be present for at least 6 months
- Involve 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
- Involve sexual urges or fantasies that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Causes & Triggers of 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; however, there is no conclusive evidence regarding what causes or triggers sexual masochism disorder.4 Also, while other psychiatric disorders may be diagnosed along with sexual masochism disorder, this does not demonstrate causation.
Sexual masochism disorder typically develops in young adulthood. The average age of onset reported by diagnosed individuals is 19.3 years. However, it is not unusual for diagnosed individuals to have experienced sexually masochistic fantasies in puberty or childhood. Advancing age is likely to have the same reducing effect on this disorder as it has on other paraphilic disorders.3
There is no increased prevalence of having experienced childhood sexual abuse among those who are diagnosed with sexual masochism disorder.5 Evidence also shows that more men than women are aroused by masochistic fantasies.6
How Is Sexual Masochism Disorder Diagnosed?
Sexual masochism disorder is typically diagnosed through self-report of distressing urges, fantasies, or behavior to a mental health clinician. Due to the atypical nature of masochistic desires, confusion or shame may accompany the experience of masochistic sexual urges, whether or not these urges fit the criteria for a mental health disorder.
Many individuals who experience sexual excitation from humiliation or pain do not experience distress due to these urges. For those that do experience distress as a result of masochistic desires, a mental health clinician can help assess distressingly harmful behavior and implement safety precautions. During the course of treatment, a therapist may find that criteria have been met to classify these urges as a mental health disorder.
Treatment of Sexual Masochism Disorder
Sexually masochistic interests do not require treatment unless causing significant impairment or distress. For individuals who do experience distress or impairment as a result of their sexual interests, psychotherapy is the most common treatment approach. A therapist certified by the American Association of Sexuality Educators Counselors and Therapists (AASECT) can help assess distressing or harmful behavior, implement safety precautions, and help explore shame or any conflicting emotions.
Some medications have also been shown to be effective in reducing the compulsive behavior associated with sexual masochism disorder when utilized in conjunction with therapy.
Sex Therapy
Counseling with an AASECT-certified sex therapist that specializes in paraphilias will ensure a knowledgeable and non-judgmental approach to psychotherapy. A sex therapist will take a detailed sexual and psychosocial history to assess for factors that contribute to a masochistic interest and its expression through urges, fantasies, and behaviors. The therapist will explore the onset and context of the symptoms being experienced, especially any changes in situations or cues that have escalated masochistic thoughts or urges.
The therapist may also assess and focus on:
- Safety planning and harm reduction to employ when engaging in BDSM activities
- Skills for navigating urges as they arise and mindfulness exercises or self-soothing techniques for reducing distress
- Co-occurring psychological conditions, such as mood disorders or hypersexuality
Medication
Antidepressants*
Selective Serotonin Reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) can help with co-occurring mood disorders, such as depression or anxiety, while simultaneously lowering sex drive. A lowered sex drive can help with the impulsivity associated with masochistic thoughts and behaviors, however it does not directly address masochistic urges.
Antiandrogens*
Medroxyprogesterone acetate and cyproterone acetate are members of a class of drugs which can be used to lower testosterone levels temporarily in order to reduce sex drive and allow for more effective therapy. These drugs help reduce the levels of circulating testosterone and may lower sexual impulsivity or compulsive behavior.
*All medications carry risks for side effects. A therapist and doctor will help to assess if medication would be helpful.
How to Get Help for Sexual Masochism Disorder
If you or your partner has sexually masochistic urges, fantasies, or behaviors that cause significant distress or impairment, seeking psychological help with a knowledgeable and nonjudgmental professional is an important first step. Your treatment provider can assess what healthy outlets may be possible for these sexual interests and work with you on minimizing the negative impact these impulses have on you and/or your partner’s well-being.
When consulting a therapist for the psychological treatment of sexual issues, make sure that your mental health practitioner is AASECT-certified. “Sex therapist” and “sex therapy” are not protected terms, meaning anyone can call themselves a sex therapist in their marketing. Additionally, most mental health licensure requirements contain little or no instruction in human sexuality. AASECT-certified providers receive an additional 18-24 months of training and a minimum of 300 additional hours of supervision in sex specific psychological issues.
Typical rates for an AASECT-certified sex therapist are on the upper end of private pay therapy rates. Most sex therapists see individual clients for 45-60-minute sessions at rates between $120-$180. They generally see couples for 75-90 minute sessions at rates between $190-$310. These rates may vary widely based on the availability of certified sex therapists in your area and general mental health costs in your state.
Coping With Sexual Masochism Disorder
Remember that, like most mental health conditions, sexual masochism disorder is more effectively treated the sooner it is addressed. If you experience sexually masochistic urges make sure to talk honestly with your partner(s) about your sexual urges and fantasies. Partners are more likely to be supportive and understanding when your behavior isn’t secretive or dishonest.
Consult with an AASECT-certified sex therapist to explore your options for reducing compulsive behaviors, implementing safety planning, and treating co-occurring mental health conditions. You might also seek a community of people who experience masochistic urges or engage in BDSM activities and have been successful in channeling their urges, fantasies, and behaviors into a non-distressing sexual forum.
Sexual Masochism Disorder vs. Sexual Masochism (BDSM)
BDSM incorporates a variety of erotic practices, sexual preferences, and behaviors, including bondage, unequal power relationships, and/or the exploration of pain as an erotic element. Individuals who self-identify as BDSM practitioners or sexual masochists but do not report distress, impairment, or non-consensual harm to self or others are not classified as having a mental disorder.
Evolution of Sexual Masochism Disorder as a Mental Health Diagnosis
Sexual masochism has been included in the DSM since its inception in 1952. Paraphilic diagnoses, particularly sexual sadism and sexual masochism, have been criticized as an attempt to control deviant behavior. In some cases, paraphilia diagnoses have been used to pathologize, stigmatize, and discriminate against those who engage in alternative sexual practices.7
Throughout subsequent editions of the DSM, discernment was made between consensual sexual practices that do not cause distress as compared to harmful urges, fantasies, or behaviors that constitute a psychological disorder requiring treatment. Due to this narrower definition of sexual masochism disorder, prevalence of this diagnosis has dropped significantly.
Sexual masochism disorder, as defined in DSM-5 published in 2013, stipulates that this disorder only be diagnosed in instances of self-report for distress or psychosocial difficulties stemming from masochistic urges.
