Sexual Sadism Disorder: Symptoms, Causes, & Treatment Options

What Is Sexual Sadism Disorder?

Sexual sadism disorder is a subcategory of paraphilic disorders, an intense and persistent sexual interest in atypical sexual targets or activities. Most people who have sadistic sexual interests or who are affected by other paraphilias do not experience significant distress or cause harm, and would therefore not be classified as having a mental disorder. Sexual sadism disorder is typically diagnosed when sexual assault involving the infliction of pain has occurred with three or more victims or in multiple episodes involving a single victim.

Rape, or sexual assault without the deliberate infliction of pain, is not linked with sexual sadistic disorder, unless pain experienced by the victim is related to the perpetrator’s level of sexual arousal. Among civilly committed sex offenders in the United States, less than 10% have been diagnosed with sexual sadism disorder.¹ However, among individuals who have committed sexually motivated homicides, rates of sexual sadism disorder range from 37% to 75%.¹

Consenting Sadistic Acts Vs. Sexual Sadism Disorder

Consenting sexual play involving the infliction of pain does not classify as sexual sadism disorder. Sexually active adults may engage in consenting “rough sex” or be aroused by sexual acts involving the infliction of pain. In the absence of fixation, mental distress, or the non-consenting infliction of pain on another person, this arousal would not be classified as sexual sadism disorder.

Symptoms of Sexual Sadism Disorder

The main criterion for sexual sadism disorder is a recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, sexually intrusive thoughts, urges, or behaviors. A person with sexual sadism disorder is often only able to achieve arousal when the infliction of suffering is present and they may lack control over their fantasies, urges, or behaviors.⁴

Individuals who openly acknowledge an intense sexual interest in sadistic sexual activities are referred to as “admitting individuals.” These people are only diagnosed with a mental disorder if they report psychosocial difficulties or distress in relation to their sexual interests or have a legal record to indicate that they have acted on these impulses. Those who deny sadistic sexual interests yet have a history of inflicting pain or suffering on multiple non-consenting persons may be diagnosed with sexual sadism disorder despite their negative report.

In order to meet the diagnostic criteria for sexual sadism disorder, the sexually sadistic focus must have:¹

• Been present for at least six months.
• Involved recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.
• Included the individual acting on these urges with a non-consenting person.
• AND/OR: The sexual urges or fantasies have caused clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Other Specifiers of Sexual Sadistic Disorder

Sexual sadistic disorder may be specified as:

• In a controlled environment, when an individual lives in an institution or other setting where opportunities to engage in sadistic sexual behaviors are restricted.
• In full remission, when the individual has not acted on urges with a non-consenting person, and there has been no distress or impairment in social, occupational or other areas of functioning for at least five years while in an uncontrolled environment.

Causes & Triggers of Sexual Sadism Disorder

Sexual sadism disorder typically develops in young adulthood. The average age of onset in one study of sadistic males was 19.4 years.¹ Advancing age is likely to have the same reducing effect on this disorder as it has on other paraphilic disorders.

Some studies show that temporal lobe abnormalities may be implicated in sexual sadism, but more information is needed before any strong conclusions can be made.² There is no conclusive evidence regarding what causes or triggers sexual sadism disorder. While other psychiatric disorders may be diagnosed along with sexual sadism disorder, this does not demonstrate causation.

How Is Sexual Sadism Disorder Diagnosed?

Sexual sadism disorder is most often diagnosed through mandated psychological treatment following the perpetration of assault on a non-consenting person or people. Sexual sadism disorder may also be identified through self-report of distressing urges, fantasies, or behavior to a mental health clinician.

Many people who experience sexual excitement from the psychological or physical infliction of suffering on another person do not experience distress due to this excitement or act on their urges with unwilling participants. For those who do experience distress at the source of their arousal, a mental health clinician may find that criteria have been met to classify these urges as a psychological disorder.¹

Treatment of Sexual Sadism Disorder

Sexually sadistic interests do not require treatment unless causing significant impairment or distress, or harm to self or another has occurred. For individuals who do experience distress or impairment as a result of their sexual fantasies, urges or behavior, psychotherapy is the most common treatment approach.

Some medications have been shown to be effective in reducing the compulsive behavior associated with sexual sadism disorder when utilized in conjunction with therapy.

Sex Therapy

Sex therapy with a certified sex therapist who specializes in paraphilias will ensure a knowledgeable and non-judgmental approach to therapy. A sex therapist will take a detailed sexual and psychosocial history to assess for factors that contribute to the sadistic interest and its expression through urges, fantasies, and behaviors.²

The therapist will explore the onset and context of the symptoms being experienced, especially any changes in the situations or cues that have escalated sadistic thoughts or urges. The therapist may teach skills for navigating urges as they arise and employ cognitive-behavioral therapy (CBT) techniques. Co-occurring psychological conditions, such as mood disorders or hypersexuality, will also be assessed and treated.

Cognitive Behavioral Therapy (CBT)

Sex therapists with CBT training will employ cognitive restructuring techniques to identify and change thoughts and behaviors. They may utilize aversion therapy or guided imagery to reduce interest in sadistic fantasies and change masturbatory habits. Studies have shown CBT to be an effective treatment for sexual sadism disorder, particularly when utilized in conjunction with drug therapy.²

Antidepressants

Selective Serotonin Reuptake inhibitors (SSRIs) such as Prozaccan 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 sadistic thoughts and behaviors, however it will not directly address the sadistic urges without therapy.²

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 prime the recipient for cognitive restructuring therapy techniques.²

How to Get Help for Sexual Sadism Disorder

People who suffer from sexual sadism disorder may not seek treatment due to denial, embarrassment, or fear of judgment. If you or your partner has sexually sadistic urges, fantasies, or behaviors which 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 (American Association of Sexuality Educators Counselors and Therapists). “Sex therapist” and “sex therapy” are not protected terms, meaning that 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.⁶

Cost of Sex Therapy

Typical rates for an AASECT certified sex therapist are on the upper end of private pay therapy rates in your area. Most sex therapists see individual clients for 45-60 minute sessions at rates between $120-$180 and 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 on general mental health costs in your state.

Sexual Sadism Statistics

Consider the following statistics about sexual sadism disorder:^1,2,3,4

• Sexually sadistic interests (NOT classified as a mental disorder) occur in approximately 1-2% of the population in the United States.
• Sexually sadistic interests (NOT classified as a mental disorder) occur at approximately twice the rate in men as compared to women. One study hypothesized that this increased prevalence is due to male socialization that emphasizes sexual aggression and experimentation.
• Among civilly committed sex offenders in the United States, less than 10% have been diagnosed with sexual sadism disorder.
• Among individuals who have committed sexually motivated homicides, rates of sexual sadism disorder range from 37% to 75%.
• Sexual sadism disorder frequently co-occurs with other paraphilic disorders.
• Sexual sadism disorder typically develops with early adulthood.
• While the onset of sexual sadism disorder usually occurs early, symptoms may come and go throughout the lifespan of an individual, typically waning over time.

Living With Sexual Sadism Disorder

If you are suffering from sexually sadistic 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 is not secretive or dishonest.
• Consult with a certified sex therapist to explore your options for reducing compulsive behaviors and co-occurring mental health conditions.
• Seek a community of other individuals who experience sadistic urges and who have been successful in channeling their urges, fantasies and behaviors into a non-distressing sexual forum.
• Remember that, like most mental health conditions, sexual sadism disorder is more effectively treated the sooner it is addressed.

Sexual Sadism Disorder Vs. BDSM

BDSM (bondage, discipline, dominance and submission) incorporates a variety of erotic practices, sexual preferences and behaviors. BDSM can include bondage, unequal power relationships and/or the exploration of pain as an erotic element. Individuals who self-identify as BDSM practitioners or sexual sadists but do not report distress, impairment or non-consensual harm to self/others are not classified as having a mental disorder.

Evolution of Sexual Sadism Disorder as a Mental Health Diagnosis

Sexual sadism has been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) since its inception in 1952. Paraphilic diagnoses, particularly sexual sadism and sexual masochism, have been criticized as an attempt to control deviant behavior and arguably do not meet the criteria for true mental health diagnoses. Paraphilia diagnoses have been used to pathologize, stigmatize and discriminate against those who engage in alternative sexual practices.⁶

Throughout subsequent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) discernment was slowly made between consensual sexual practices which do not cause distress as compared to harmful urges, fantasies or behaviors which would constitute a psychological disorder requiring treatment.

Due to this narrower definition of pathological sexual sadism, prevalence of diagnosis has dropped significantly. Sexual sadism disorder as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) published in 2013 is rarely found in the general population outside of those diagnosed following sexually motivated crimes.⁶