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Sexual Masochism Disorder

By George R. Brown, MD, Professor and Associate Chairman of Psychiatry;Adjunct Professor of Psychiatry, East Tennessee State University;University of North Texas

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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 sexual masochism that causes significant distress or significantly impairs functioning.

Sexual masochism is 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 mo.

Prevalence of the paraphilic form of sexual masochism disorder is unknown. However, a single report of data from a telephone survey in Australia (2001 to 2002) found that 2.2% of males and 1.3% of females reported being involved in sexual masochism and/or sadism in the previous 12 mo.

Sadomasochistic fantasies and sexual behavior between consenting adults is very common. Masochistic activity tends to be ritualized and long-standing. For most participants, the humiliation and beating are simply acted out; participants know that it is a game and carefully avoid actual humiliation or injury. However, some masochists increase the severity of their activity with time, potentially leading to serious injury or death.

Masochistic activities 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

Or they may seek out a partner who may be a sexual sadist. Activities with a partner include being

  • Bound

  • Blindfolded

  • Spanked

  • Flagellated (whipped)

  • Humiliated by being urinated or defecated on

  • Forced to cross-dress

  • Part of a simulated rape

Diagnosis of sexual masochism disorder is based on specific clinical criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):

  • Patients have been repeatedly and intensely aroused by being humiliated, beaten, bound, or otherwise abused; 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.

  • The condition has been present for ≥ 6 mo.

Treatment of sexual masochism disorder is often ineffective.

Autoerotic asphyxiation (asphyxiophilia)

Asphyxiophilia is considered a subtype of sexual masochism disorder.

In this disorder, people restrict their breathing (partial asphyxiation) at or near the time of orgasm to enhance the experience. 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.