Community individuals with paraphilias have reported a mean age at onset for masoch- ism of 19.3 years, although earlier ages, including puberty and childhood, have also been reported for the onset of masochistic fantasies. Very little is known about persistence over time. Sexual masochism disorder per definition requires one or more contributing factors, which may change over time with or without treatment. These include subjective distress (e.g., guilt, shame, intense sexual frustration, loneliness), psychiatric morbidity, hypersex- uality and sexual impulsivity, and psychosocial impairment. Therefore, the course of sex- ual masochism disorder is likely to vary with age. Advancing age is likely to have the same reducing effect on sexual preference involving sexual masochism as it has on other para- philic or normophilic sexual behavior.
Functional Consequences of Sexual Masochism Disorder
The functional consequences of sexual masochism disorder are unknown. However, mas- ochists are at risk of accidental death while practicing asphyxiophilia or other autoerotic procedures.
Many of the conditions that could be differential diagnoses for sexual masochism disorder (e.g., transvestic fetishism, sexual sadism disorder, hypersexuality, alcohol and substance use disorders) sometimes occur also as comorbid diagnoses. Therefore, it is necessary to carefully evaluate the evidence for sexual masochism disorder, keeping the possibility of other paraphilias or other mental disorders as part of the differential diagnosis. Sexual masochism in the absence of distress (i.e., no disorder) is also included in the differential, as individuals who conduct the behaviors may be satisfied with their masochistic orienta- tion.
Known comorbidities with sexual masochism disorder are largely based on individuals in treatment. Disorders that occur comorbidly with sexual masochism disorder typically in- clude other paraphilic disorders, such as transvestic fetishism.
Diagnostic Criteria 302.84 (F6552)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the phys- ical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational. or other important areas of functioning.
Specify it:
In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in sadistic sexual behav- iors are restricted.
In full remission: The individual has not acted on the urges with a nonconsenting per- son, and there has been no distress or impairment in social, occupational, or other ar- eas of functioning, for at least 5 years while in an uncontrolled environment.
The diagnostic criteria for sexual sadism disorder are intended to apply both to individuals who freely admit to having such paraphilic interests and to those who deny any sexual interest in the physical or psychological suffering of another individual despite substantial objective evidence to the contrary. Individuals who openly acknowledge intense sexual interest in the physical or psychological suffering of others are referred to as ”admitting individuals.” If these individuals also report psychosocial difficulties because of their sexual attractions or prefer— ences for the physical or psychological suffering of another individual, they may be diagnosed with sexual sadism disorder. In contrast, if admitting individuals declare no distress, exempli- fied by anxiety, obsessions, guilt, or shame, about these paraphilic impulses, and are not ham- pered by them in pursuing other goals, and their self-reported, psychiatric, or legal histories indicate that they do not act on them, then they could be ascertained as having sadistic sexual interest but they would not meet criteria for sexual sadism disorder.