Sexual sadism is the infliction of physical or psychological suffering (eg, humiliation, terror) on another person to stimulate sexual excitement and orgasm. Sexual sadism disorder refers to sexual sadism that causes clinically significant distress or functional impairment, or is acted on with a nonconsenting person.
People with sexual sadism disorder have either acted on the intense urges or have debilitating or distressing fantasies with sexually sadistic themes that they have not acted on. The condition must also have been present for ≥ 6 months.
Sexual sadism is a form of paraphilia, but mild sadistic sexual behavior is a common sexual practice between consenting adults that is usually limited in scope, is practiced in a way that does not cause harm, and does not meet the clinical criteria for a paraphilic disorder. Sadism exists along a spectrum, and its identification as pathological is contingent on its severity. However, in extreme cases, sexual sadism can rarely lead to sexual homicide (1).
Most sexual sadists have persistent fantasies in which sexual excitement derives from suffering inflicted on a partner, regardless of whether that person consents. When practiced with nonconsenting partners, sexual sadism constitutes criminal activity and is likely to continue until the sadist is apprehended. However, studies based on data arising from crime scene investigations suggest that, while sexual sadism is not synonymous with rape, it is characterized by a complex amalgam of coerced sex and power exerted over the victim, sometimes leading to rape and homicide (2). Sexual sadism is diagnosed in < 10% of rapists but is reported to be present in 35% of people who have committed sexual homicides (3, 4).
Sexual sadism is particularly dangerous when associated with antisocial personality disorder. This combination of disorders may culminate in criminal sadism involving kidnapping or abduction of unwilling parties who may be harmed or killed (5). Individuals with both conditions are considered particularly recalcitrant to psychiatric treatment (6). Such individuals, when apprehended and convicted, are sometimes civilly committed as sexually violent predators for decades due to the lack of effective treatment options (7).
General references
1. Ploeg OHJ, Grace RC, Cording JR. Sexual homicide: a descriptive analysis of demographics, behaviour, and body disposal in New Zealand. J Sexual Aggression. 2024;1–17. https://doi.org/10.1080/13552600.2024.2374084
2. Healey J, Lussier P, Beauregard E. Sexual sadism in the context of rape and sexual homicide: an examination of crime scene indicators. Int J Offender Ther Comp Criminol. 2013;57(4):402-424. doi:10.1177/0306624X12437536
3. Frances A, Wollert R. Sexual sadism: avoiding its misuse in sexually violent predator evaluations. J Am Acad Psychiatry Law. 2012;40(3):409-416.
4. Chopin J, Beauregard E, Bitzer S. Factors influencing the use of forensic awareness strategies in sexual homicide. J Crim Justice. 2020(71):1-9. 10.1016/j.jcrimjus.2020101709
5. Jones S, Chan HCO. The psychopathic–sexually sadistic offender. In Routledge International Handbook of Psychopathy and Crime. Routledge/Taylor & Francis Group; 2018:398-412.
6. Meloy JR.The psychology of wickedness: Psychopathy and sadism. Psychiatric Annals. 27(9):630-633, 1997. https://doi.org/10.3928/0048-5713-19970901-10
7. DeClue G. Paraphilia NOS (nonconsenting) and antisocial personality disorder. J Psychiatry Law. 34(4):495-514, 2006. https://doi.org/10.1177/009318530603400404
Diagnosis of Sexual Sadism Disorder
Psychiatric assessment
Clinical criteria for the diagnosis of sexual sadism disorder from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) include the following (1):
Patients derive recurrent and intense sexual arousal from the physical or psychological suffering of another person; arousal is expressed in fantasies, intense urges, or behaviors.
Patients have acted on their urges with a nonconsenting person, or these fantasies or urges cause clinically significant distress or impair functioning at work, in social situations, or other important areas of their lives.
The condition has been present for ≥ 6 months.
When making the diagnosis using DSM-5-TR criteria, the clinician must specify whether the patient is living in a controlled environment (eg, prison, institution) or in full remission (ie, has not acted on the urges with a nonconsenting partner, and there has been no distress/impairment in social, occupational, or other areas of functioning for at least 5 years in an uncontrolled environment).
Sexual sadism disorder may also be diagnosed in patients who deny that they have fantasies or urges related to sexual arousal triggered by the pain or suffering of others, especially if these patients report multiple sexual episodes of inflicting pain or suffering on a nonconsenting person.
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:790-792.
Treatment of Sexual Sadism Disorder
Sometimes cognitive-behavioral therapy (group or individual)
Sometimes antiandrogen medications
Treatment of sexual sadism is not necessary if the interests, fantasies, and behaviors do not involve nonconsenting persons and there is an absence of clinically significant distress or functional impairment. For those whose sexual sadism rises to the level of sexual sadism disorder, treatments applied to other paraphilias (see, for example, Treatment: Exhibitionistic Disorder) are most commonly employed, including group or individual cognitive-behavioral therapy with or without the use of antiandrogen agents.
If antisocial personality disorder is also present, treatments have not been shown to be particularly effective. Most individuals with this combination of disorders do not present for treatment voluntarily and are likely to make up the majority of those with sexual sadism who are imprisoned (1).
Treatment reference
1. Healey J, Lussier P, Beauregard E. Sexual sadism in the context of rape and sexual homicide: an examination of crime scene indicators. Int J Offender Ther Comp Criminol. 2013;57(4):402-424. doi:10.1177/0306624X12437536
