Sexual Masochism Disorder: Definition, Symptoms & Treatment Options

What Is Sexual Masochism Disorder?

Sexual masochism disorder is a subcategory of paraphilic disorders involving an intense, persistent sexual interest in experiencing pain or humiliation as part of sexual activity, causing significant distress, functional impairment, and/or harm to self or others. Most people who have masochistic sexual interests don’t experience significant distress or harm and wouldn’t be classified as having a mental disorder.

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.

Masochism & Autoerotic Asphyxiation (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.

What Is Sadomasochism?

Sadomasochism refers to either giving or receiving pleasure from sexually painful or humiliating acts. Sadomasochists seek out consensual pain within sex, love, and intimate contexts. However, they don’t necessarily desire it elsewhere, and they aren’t aggressive without consent. A person with sadomasochistic tendencies may alternate situations of inflicting and receiving pain from others.

Sexual Masochism Disorder Vs. Masochistic Behavior & BDSM

A person with masochistic interests fantasizes about or engages in sexual activity that 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.

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. People who 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 disorder.

Is Sexual Masochism Dangerous?

Sexual masochism can potentially be dangerous, particularly if asphyxiophilia is involved. Any form of inflicted pain carries some degree of risk. Everyone should be aware of their own physical health and the boundaries established within the sexual relationship. With that, it’s important to note that sexual masochism can certainly also be practiced consensually and safely, and it does not need to be stigmatized.

Sexual Masochism Examples

Sexual masochism refers to deriving sexual pleasure from receiving pain or humiliation. Sexual masochism is intentional, voluntary, and consensual, and most people (but not all) with this specific paraphilia will share their desires with sexual partners. Sexual masochism behaviors fall on a wide spectrum—some people may prefer one specific type of behavior, whereas others are more fluid.

Common forms of sexual masochistic behavior involve:

• Violent role-play
• Gagging
• Physical restriction via bondage or handcuffs
• Verbal humiliation
• Using whips or electric shocks
• Physical pain via spanking or slapping

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.¹

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 six 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

Why Do People Engage in Sexual Masochism?

While there is no conclusive evidence regarding what causes or triggers 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.¹ Also, while other psychiatric disorders may be diagnosed along with sexual masochism disorder, this does not prove a direct 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 reduce symptoms of the disorder.¹

There is no increased prevalence of having experienced childhood sexual abuse among those who are diagnosed with sexual masochism disorder.²

Are Men or Women More Likely to Engage in Sexual Masochism?

It’s estimated that sexual masochism disorder impacts 1-5% of the general population, but exact studies on the prevalence of sexual masochism among men and women are difficult to find. One study found that 4.8% of men and 2.1% of women obtained sexual pleasure from inflicting pain, whereas 2.5% of men and 4.6% of women obtained pleasure from receiving pain.⁴

However, masochistic behaviors are far more prevalent than sexual masochism disorder. Research shows that upwards of 40-70% of adult men and women have BDSM-related fantasies, and about 20% indicate engaging in BDSM.⁵ In addition, one Australian study found that BDSM behavior is more common in the LGBTQ+ population.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 sexual shame may accompany the experience of masochistic sexual urges, whether or not these urges fit the criteria for a mental health disorder.

Many people 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 their 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 they cause significant impairment or distress. For people 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 who 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

Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) may be beneficial for people wishing to reduce or eliminate certain sexual behaviors. CBT highlights the interconnected relationship between thoughts, feelings, and behaviors. By learning how to change unwanted or intrusive thoughts, people can feel more empowered in how they choose to respond. Over time, this can lead to profound change.

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.

The Importance of an AASECT-Certified Sex Therapist

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.

Cost of Sex Therapy

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.

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.