Many of the conditions that could be differential diagnoses for sexual sadism disorder (e.g., antisocial personality disorder, sexual masochism disorder, hypersexuality, sub— stance use disorders) sometimes occur also as comorbid diagnoses. Therefore, it is neces- sary to carefully evaluate the evidence for sexual sadism disorder, keeping the possibility of other paraphilias or mental disorders as part of the differential diagnosis. The majority of individuals who are active in community networks that practice sadistic and masoch- istic behaviors do not express any dissatisfaction with their sexual interests, and their be- havior would not meet DSM-5 criteria for sexual sadism disorder. Sadistic interest, but not the disorder, may be considered in the differential diagnosis.
Known comorbidities with sexual sadism disorder are largely based on individuals (al-
Victims. Hence, these comorbidities might not apply to all individuals who never engaged in sadistic activity with a nonconsenting victim but who qualify for a diagnosis of sexual sadism disorder based on subjective distress over their sexual interest. Disorders that are commonly comorbid with sexual sadism disorder include other paraphilic disorders.
Diagnostic Criteria 302.2 (F65.4)
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sex- ual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger).
B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
C. The individual is at least age 16 years and at least 5 years older than the child or chil- dren in Criterion A.
Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.
Specify whether:
Exclusive type (attracted only to children)
Specify if:
Sexually attracted to males
Sexually attracted to females
Sexually attracted to both
Specify if:
Limited to incest
The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who freely disclose this paraphilia and to individuals who deny any sexual attraction to prepuber- tal children (generally age 13 years or younger), despite substantial objective evidence to the contrary. Examples of disclosing this paraphilia include candidly acknowledging an intense sexual interest in children and indicating that sexual interest in children is greater than or equal to sexual interest in physically mature individuals. If individuals also complain that their sex- ual attractions or preferences for children are causing psychosocial difficulties, they may be di- agnosed with pedophilic disorder. However, if they report an absence of feelings of guilt, shame, or anxiety about these impulses and are not functionally limited by their paraphilic im- pulses (according to self-report, objective assessment, or both), and their self-reported and le- gally recorded histories indicate that they have never acted on their impulses, then these individuals have a pedophilic sexual orientation but not pedophilic disorder.
Examples of individuals who deny attraction to children include individuals who are known to have sexually approached multiple children on separate occasions but who deny any urges or fantasies about sexual behavior involving children, and who may further claim that the known episodes of physical contact were all unintentional and nonsexual. Other indi- viduals may acknowledge past episodes of sexual behavior involving children but deny any significant or sustained sexual interest in children. Since these individuals may deny experi- ences impulses or fantasies involving children, they may also deny feeling subjectively dis— tressed. Such individuals may still be diagnosed with pedophilic disorder despite the absence of self-reported distress, provided that there is evidence of recurrent behaviors persisting for 6 months (Criterion A) and evidence that the individual has acted on sexual urges or experi- enced interpersonal difficulties as a consequence of the disorder (Criterion B).
Presence of multiple Victims, as discussed above, is sufficient but not necessary for di- agnosis; that is, the individual can still meet Criterion A by merely acknowledging intense or preferential sexual interest in children.