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The DSM Diagnostic Criteria for Sexual Sadism

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Abstract

I reviewed the empirical literature for 1900–2008 on the paraphilia of Sexual Sadism for the Sexual and Gender Identity Disorders Workgroup for the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The results of this review were tabulated into a general summary of the criticisms relevant to the DSM diagnosis of Sexual Sadism, the assessment of Sexual Sadism utilizing the DSM in samples drawn from forensic populations, and the assessment of Sexual Sadism using the DSM in non-forensic populations. I conclude that the diagnosis of Sexual Sadism should be retained, that minimal modifications of the wording of this diagnosis are warranted, and that there is a need for the development of dimensional and structured diagnostic instruments.

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Acknowledgments

This article was prepared with the assistance of Dr. Meg Kaplan. The author is a member of the DSM-V Workgroup on Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker, Ph.D.). I wish to acknowledge the valuable input I received from members of my Paraphilias subworkgroup (Ray Blanchard, Marty Kafka, and Niklas Långström) and Kenneth J. Zucker. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.

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  1. Sexual Behavior Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 45, New York, NY, 10032, USA

    Richard B. Krueger

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Correspondence to Richard B. Krueger.

Appendices

Appendix 1: Sexual Sadism

Diagnostic Criteria for Sexual Sadism from DSM-I to DSM-IV-TR

DSM-I (American Psychiatric Association, 1952)

The only mention of sexual sadism occurs under the categorization of Sociopathic Personality Disturbance (000-x60):

Sexual Deviation. This diagnosis is reserved for deviant sexuality which is not symptomatic of more extensive syndromes, such as schizophrenic and obsessional reactions. The term includes most of the cases formerly classed as “psychopathic personality with pathologic sexuality.” The diagnosis will specify the type of the pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism and sexual sadism (including rape, sexual assault, mutilation). (pp. 38–39)

DSM-II (American Psychiatric Association, 1968)

Sadism is classified as one of the Sexual Deviations (302.6):

Sexual Deviations. This category is for individuals whose sexual interests are directed primarily towards objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in necrophilia, pedophilia, sexual sadism, and fetishism. Even though many find their practices distasteful, they remain unable to substitute normal sexual behavior for them. This diagnosis is not appropriate for individuals who perform deviant sexual acts because normal sexual objects are not available to them. (p. 44)

DSM-III (American Psychiatric Association, 1980)

Sexual sadism is classified as one of the paraphilias, with one of the following criteria necessary for the diagnosis:

  1. (1)

    on a nonconsenting partner, the individual has repeatedly intentionally inflicted psychological or physical suffering in order to produce sexual excitement

  2. (2)

    with a consenting partner, the repeatedly preferred or exclusive mode of achieving sexual excitement combines humiliation with simulated or mildly injurious bodily suffering

  3. (3)

    on a consenting partner, bodily injury that is extensive, permanent, or possibly mortal is inflicted in order to achieve sexual excitement.

DSM-III-R (American Psychiatric Association, 1987)

The diagnostic criteria for sexual sadism were revised as follows:

  1. A.

    Over a period of at least six months, recurrent intense sexual urges and sexually arousing fantasies involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

  2. B.

    The person has acted on these urges, or is markedly distressed by them.

DSM-IV (American Psychiatric Association, 1994)

The diagnostic criteria for sexual sadism were:

  1. A.

    Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

  2. B.

    The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM-IV-TR (American Psychiatric Association, 2000)

The change in the B. criterion from DSM-IV to DSM-IV-TR represents one of the few changes in criteria from DSM-IV to DSM-IV-TR. This change was made to all of the paraphilias which involved a victim, to remove any ambiguity about whether acting out sexual urges with others was sufficient for a diagnosis; some had argued that an individual with a paraphilia who was not distressed about his or her behavior could not be diagnosed with a paraphilia, and this new wording allowed for a diagnosis to be made in such a circumstance.

The diagnostic criteria for sexual sadism were revised from DSM-IV:

  1. A.

    Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

  2. B.

    The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

Suggested Criteria Following Literature Review for DSM-V

These criteria reflect my initial suggestions. Subsequently, interactions with other members of the workgroup and advisors have resulted in a modification of these initial suggestions.

  1. A.

    Over a period of at least 6 months, recurrent, intense sexually arousing fantasies or sexual urges involving acts in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

  2. B.

    The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

Appendix 2: Sexual Sadism

The ICD-9 and ICD-10 Criteria for Sexual Sadism and Sexual Masochism and the ICD-10 Diagnostic Criteria for Research for Sadomasochism

The ICD-9-CM Diagnostic Criteria for Sadism and Masochism (World Health Organization, 1989) (p. 229) are:

  • 302.8 Other specified psychosexual disorders

    • 302.83 Sexual masochism

    • 302.84 Sexual sadism

The ICD-10 International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (World Health Organization, 1992) (p. 367) criteria are:

  • Disorders of sexual preference

  • Includes: paraphilias

  • F65.5 Sadomasochism

  • A preference for sexual activity which involves the infliction of pain or humiliation, or bondage. If the subject prefers to be the recipient of such stimulation this is called masochism; if the provider, sadism. Often an individual obtains sexual excitement from both sadistic and masochistic activities.

    • Masochism

    • Sadism

The ICD-10 Classification of Mental and Behavior Disorders Diagnostic criteria for research (World Health Organization, 1993) are:

  • F65.5 Sadomasochism (p. 137)

    1. A.

      The general criteria for disorders of sexual preference (F65) must be met.

    2. B.

      There is preference for sexual activity, as recipient (masochism) or provider (sadism), or both, which involves at least one of the following:

      1. (1)

        pain;

      2. (2)

        humiliation;

      3. (3)

        bondage.

    3. C.

      The sadomasochistic activity is the most important source of stimulation or is necessary for sexual gratification.

  • F65 Disorders of sexual preference (p. 135)

    1. G1.

      The individual experiences recurrent intense sexual urges and fantasies involving unusual objects of activities.

    2. G2.

      The individual either acts on the urges or is markedly distressed by them.

    3. G3.

      The preference has been present for at least 6 months.

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Krueger, R.B. The DSM Diagnostic Criteria for Sexual Sadism. Arch Sex Behav 39, 325–345 (2010). https://doi.org/10.1007/s10508-009-9586-3

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