Sexual Sadism Disorder

What Causes Sexual Sadism Disorder?

The cause of sexual sadism disorder is unknown, but different factors likely trigger it in different cases. Scientists believe that physical, medical, and psychological factors may all play a role in producing the disorder’s behavior.

Studies have suggested some factors that appear to be associated with SSD, but it is unclear whether these factors cause the disorder. Some factors are not consistently associated with the disorder, and some may be a symptom of the disorder rather than a cause. Some of these factors include:

• A desire for feelings of power, especially in those who feel powerless in their daily lives
• High testosterone levels
• Consumption of sadistic pornography
• Other mental health-related issues (e.g., antisocial personality disorder)

Is Sexual Sadism Disorder Hereditary?

Some studies have attempted to explain why sexual disorders such as sexual sadism disorder sometimes seem to cluster in individual families. While these studies suggest that a genetic component could play a role in the development of the disorders, no specific link between genes and SSD has been found.

How Is Sexual Sadism Disorder Detected?

Warning signs of sexual sadism disorder can include:

• Unusual preoccupation with sex during childhood
• Sexual fantasies that cause distress or impairment
• Only being aroused by sadistic fantasies or acts
• Interest or participation in activities that could cause severe physical harm or death

How Is Sexual Sadism Disorder Diagnosed?

Diagnosis of sexual sadism disorder begins by ruling out medical problems that may be causing symptoms. After these exams, if the doctor suspects that sexual sadism disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment.

Diagnostic steps may include:

• A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history.

After medical causes are ruled out, medical professionals can consider whether the patient meets the diagnostic criteria for sexual masochism disorder. These criteria include:

• The patient is consistently aroused by fantasies, urges, or acts that involve inflicting or witnessing extreme pain, torture, or humiliation for sexual arousal.
• The symptoms cause significant impairment in social situations, at work, or elsewhere.
• The person acts on the urges with a non-consenting person.
• The symptoms have been present for at least six months.

It is important to note that being aroused by mild sadistic acts with consenting partners is not a sign of the disorder. Doctors will consider the diagnosis only if the urges or acts cause distress or are acted upon with non-consenting people. A person can be diagnosed with the disorder even if they deny having the urges or that the urges cause them distress if there is evidence to the contrary.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Sexual Sadism Disorder Treated?

People with sexual sadism disorder typically will not seek out treatment on their own, and they will often deny that they are experiencing symptoms of the disorder. In many cases, treatment does not begin until a person has illegally acted on their urges and has been arrested.

Treatment of sexual sadism behavior may include both psychotherapy and medications. Common treatment options include:

• Cognitive-behavioral therapy teaches a person to recognize the situations that trigger their masochistic urges and develop new, healthy ways to cope with those situations.
• Group therapy or support groups
• Relaxation therapy
• Antidepressant medications, typically serotonin reuptake inhibitors (SSRIs)
• Antiandrogen drugs, such as gonadotropin-releasing hormone (GnRH) agonists and depot medroxyprogesterone acetate, work to lower testosterone levels and decrease sexual urges

How Does Sexual Sadism Disorder Progress?

Even with treatment, sexual sadism disorder has a high rate of recurrence, and the symptoms can cause significant problems over the long term. The disorder is often resistant to treatment, especially when it co-exists with antisocial personality disorder. In some cases, the person may engage in dangerous activities that put others at risk of injury or death.

In addition to the disorder’s impact on the targets of the behavior, it can also result in long-term complications for the person living with the disorder, including:

• Arrest and incarceration
• Depression or other mental health-related issues
• Loss of healthy interpersonal relationships

How Is Sexual Sadism Disorder Prevented?

There is no known way to prevent sexual sadism disorder.

Sexual Sadism Disorder Caregiver Tips

Some people with sexual sadism disorder also suffer from other brain and mental health-related issues, a situation called co-morbidity. Here are a few of the issues commonly associated with the disorder:

• Some people with the disorder also suffer from depression.
• Some people with the disorder have a co-existing anxiety disorder.
• Antisocial personality disorder is sometimes associated with sexual sadism disorder.

Sexual Sadism Disorder Brain Science

A study of violent sexual offenders found that those diagnosed with SSD showed greater than normal activity in their amygdala, a part of the brain associated with sexual arousal, when shown images depicting pain. They also exhibited increased activity in the anterior insula, a part of the brain that processes pain sensations.

Sexual sadism disorder is classified as a paraphilic disorder. These disorders involve sexual arousal induced by unusual situations, objects, or targets of arousal. Common paraphilias include:

• Fetishes (e.g., sexual arousal triggered by specific objects or situations)
• Voyeurism
• Exhibitionism
• Pedophilia

Paraphilias are not inherently considered to be disorders. Some people have sexual interests or urges others may regard as unusual but don’t cause distress or harm. Factors that make a paraphilic interest elevate to a disorder include:

• The urges or acts are illegal (e.g., pedophilia).
• The urges or acts involve non-consenting targets (either children or non-consenting adults).
• The urges or acts have the potential to cause harm.
• The urges or acts cause significant distress or impairment to the person experiencing them.

Sexual Sadism Disorder Research

Title: Lupron Sex Offender Therapy

Stage: Completed

Principal Investigator: Justine M. Schober, MD

Hamot Medical Center

Erie, PA 

This study compared cognitive-behavioral psychotherapy with leuprolide acetate (LA) to cognitive-behavioral psychotherapy with saline injections for 12 months. Five white male pedophiles (M age, 50 years; range, 36-58) volunteered for a two-year study. LA was administered by Depo injection (7 mg initially, then 22.5 mg every three mos) for 12 months, followed by a saline placebo. Effects of LA on testosterone levels, sexual interest preference by visual reaction time (Abel Assessment), penile tumescence (Monarch PPG), as well as strong urges, and masturbatory frequency to children (polygraph), were measured every three months. Subjects were treated with weekly cognitive-behavioral psychotherapy. On LA, testosterone decreased to castrate levels. Because of the suppression of testosterone, physiologic arousal response as measured by penile plethysmography (penile tumescence) was significantly suppressed compared with baseline. However, sufficient response remained to detect pedophilic interest. This pedophilic interest was also detected by visual reaction times. All subjects self-reported a decrease in strong pedophilic urges and masturbation. When asked about having pedophilic urges and masturbating to thoughts of children, polygraph responses indicated subjects were not deceptive when they reported decreases. On a placebo, testosterone and physiologic arousal eventually rose to baseline levels. At baseline and on placebo, subjects were consistently deceptive regarding increased pedophilic urges and masturbatory frequency, as noted by the polygraph. Interest preference, as measured by Abel Assessment and Monarch PPG, was generally unchanged throughout the study. Cognitive-behavioral psychotherapy augmented with LA significantly reduced pedophilic fantasies, urges, and masturbation but did not change pedophilic interest during one year of therapy. Deceptive responses by polygraph suggested that self-report was unreliable. Follow-up utilizing objective measures is essential for monitoring treatment efficacy in pedophilia. Our study supports the supposition that modification of pedophilic behavior is possible. LA may augment cognitive-behavioral psychotherapy and help break the sequence leading to a reoffense.

Title: Descriptive Epidemiology Study for Patients With Paraphilia Sex Offenders and Receiving Androgen Antagonists (EPIPARA)

Stage: Completed

Principal investigator: Florence Thibaut, MD/PhD

University Hospital

Rouen, France 

The study’s main objective is to describe the French population of individuals with paraphilia who have committed a sexual offense for whom androgen antagonists were prescribed. The secondary objectives are the description of social demographic profiles, personal and family histories, psychiatric co-morbidities, and the side effects of androgen antagonists treatment. This study, the first of its kind in France, may allow us to understand better the social demographic and clinical profile of sexual offenders with paraphilias treated with androgen antagonists.

To be included, the subject must have committed a sexual offense and must present a diagnosis of paraphilia with an indication of treatment with androgen antagonists. Paraphilia is defined by the Diagnostic and Statistical Manual as a sexual behavior disorder characterized by “sexually arousing fantasies, needs or recurrent and intense sexual behaviors generally involving (1) of non-human objects, (2) the suffering or humiliation of oneself or partner, (3) children or other persons without their consent, occurring during a period of at least six months “(Criterion A). This disorder is responsible for sexual behavior which is “clinically significant disturbances in social, occupational or other important areas of functioning” (Criterion B).

The inclusion of approximately 200 subjects is expected in this study. The inclusion period will last for 12 months.

Data will be codified, and only a few investigators will have access to these data. The statistical analysis will use the usual descriptive parameters: mean, standard deviation, median, interquartile range, range for quantitative variables, frequencies, and cumulative frequencies (if applicable) for qualitative variables.

Title: Study of Maintenance of the Efficiency and Adverse Effects of Pharmacological Treatments in Sex Offenders With Paraphilia (ESPARA)

Stage: Not Yet Recruiting

Study Chair: Florence Thibaut, MD/PhD

Hospital Cochin

Paris, France 

This research concerns the evaluation of the maintenance of the efficiency and incidence of adverse effects of pharmacological treatments in sex offenders with paraphilia.

Despite the increasing use of pharmacological treatments in these indications, few data indicate which sex offender populations benefit from which pharmacological treatments and which adverse events are observed, particularly with anti-androgens or antidepressant treatments that are widely used in these subjects. A recent Cochrane study showed that psychodynamic treatment is less effective in terms of sexual delinquency compared to probation alone and has not demonstrated significant efficacy of cognitive-behavioral therapy (CBT) compared to the lack of treatment, except for a study in which anti-androgen therapy was associated with CBT. Another recent study concluded that the tolerance, even of anti-androgenic drugs, was uncertain, as all studies were small and of limited duration; new research is needed in the future. Further research demonstrating the efficacy of SSRIs in treating paraphilic disorders is still needed, and long-term studies are lacking. Their use for this indication is still off-label.

As far as we know, this cohort should be the largest population of paraphilic sex offenders studied for the longest time to date in a field where research is insufficient. This large sample receiving routine care and followed for three years should allow for analyzing the maintenance of the effectiveness of the pharmacological treatments received (SSRIs or anti-androgens) and their tolerance. In addition, this analysis of clinical practices should be crucial to improve the knowledge of the indications for these treatments, which could be reviewed concerning their effectiveness and tolerance, especially in the most serious cases of paraphilic sex offenders.