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Sadism
Sexual sadism denotes fantasies, urges or behaviors that involve real acts (not simulations) in which the suffering of another person is found sexually exciting.
Diagnostic criteria
The DSM-IV criteria for the diagnosis of sexual sadism state that: there must be recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving acts (real, not simulated) in which the psychological or physical suffering of the victim is sexually exciting to the person; these fantasies, urges or behaviors must have a duration of at least 6 months; the fantasies, urges or behaviors must cause significant distress or functional impairment.
ICD-10 gives diagnostic criteria for a single diagnosis of sadomasochism.
Symptoms and signs
By definition, sexual sadism involves sexual excitement derived from the physical of psychological suffering or humiliation of another person; the fantasies, urges or behavior must have been present for at least 6 months; and they must cause distress or functional impairment.
Patients with sexual sadism often come to medical attention only as a result of legal problems, although self-referral is not unknown.
Some patients may report sadistic fantasies that occur during sexual activity but that are not acted upon. The most commonly reported fantasy is of having complete control over the victim, who is terrified of the sadistic act about to be committed.
Other patients may report that they sadistic behaviors with consenting partners (who usually have sexual masochism) or with non-consenting partners.
Acts of sexual sadism include: activities that indicate the dominance of the sadist over the victim (e.g. forcing the victim to adopt humiliating postures or locking them in a cage); verbally abusing the victim; physical restraint of the victim ('bondage'); blindfolding the victim ('sensory bondage'); smacking, whipping, beating the victim or inflicting physical pain in other ways; administering electrical shocks; cutting the victim; mutilating the victim; torturing the victim;
killing the victim.Not all sexual sadists rely sadistic fantasies or behavior to achieve sexual arousal.
Some patients with sexual sadism may engaging in sadistic acts for years without any increase in the potential injuriousness of their activities; however, the severity of the acts usually increases with time.
Sexual sadists whose activities involve non-consenting partners usually continue their activities until they are apprehended.
The age of onset varies but is commonly be early adulthood. Most patients with sexual sadism can trace sadistic fantasies back to their childhood.
Investigations
The diagnosis is a clinical one based on the patient's history. No laboratory investigations are indicated.
Psychological testing may identify additional psychiatric disorders and paraphilias that are contributing to the severity of the sexual sadism.
Penile plethysmography may offer additional information to establish arousal associated with sadistic behavior and assess the patient for arousal associated with other paraphilias; however, the reliability of this measure is questionable and may result in false-negative information.
Complications
Complications of sexual sadism
Legal problems resulting from the sadistic behavior - sexual sadism may result in sadistic injury to others, rape or murder, as well as a variety of other illegal activities. impaired social or sexual functioning, especially if sexual arousal is impossible without sadistic activities or if the sadistic behavior extends beyond sexual sadism to involve other areas of life and functioning; infection and other medical problems, which may arise from the activities engaged in, such as violent sexual behavior, exposure to fecal matter, drinking blood and eating body parts or organs (as in the case of some sadistic killers).
Paraphilias that frequently coexist with sexual sadism include: urophilia; coprophilia; vampirism (sexual arousal associated with drawing or drinking blood); piqueurism (the act of stabbing the victim in the breasts or buttocks before escaping); necrophilia (sexual arousal associated with corpses or mutilating corpses, which may occur directly after a murder or may involve a victim who has been dead for some time).
Differential diagnosis
The differential diagnosis of sexual sadism includes: mild degrees of consensual sadomasochistic stimulation that is used to enhance otherwise normal sexual activity and that does not fulfill the criteria for sexual sadism; psychotic disorders that may lead to sadistic behavior for reasons other than sexual excitement.
Prognosis
Without treatment, sexual sadism tends to have a chronic course. Sadistic behaviors may decrease in old age, although fantasies may remain voyeuristic in content.
Indicators of a poor prognosis include: early age of onset; no feelings of guilt or remorse for sadistic behavior; high frequency of engaging in sadistic behavior; poor sexual and social relationships.
Treatment and Outcome
Treatment aims
The aims of treatment are: to reduce sadistic behavior; to improve the patient's sexual functioning with consenting partners; to prevent relapse.