Secondary masochism, in other words, is the relatively casual version, more akin to a charade, and most commentators are quick to point out its contrivedness.Rejection is not desired by a primary masochist in quite the same sense as the feigned rejection occurring within a mutually consensual relationship—or even where the masochist happens to be the one having actual initiative power. In Things Hidden Since the Foundation of the World, René Girard attempts to resuscitate and reinterpret Freuds distinction of primary and secondary masochism, in connection with his own philosophy.Both Krafft-Ebing and Freud assumed that sadism in men resulted from the distortion of the aggressive component of the male sexual instinct. Masochism in men, however, was seen as a more significant aberration, contrary to the nature of male sexuality. Freud doubted that masochism in men was ever a primary tendency, and speculated that it may exist only as a transformation of sadism. Sadomasochism in women received comparatively little discussion, as it was believed that it occurred primarily in men. Both also assumed that masochism was so inherent to female sexuality that it would be difficult to distinguish as a separate inclination. Havelock Ellis, in Studies in the Psychology of Sex, argued that there is no clear distinction between the aspects of sadism and masochism, and that they may be regarded as complementary emotional states. He also made the important point that sadomasochism is concerned only with pain in regard to sexual pleasure, and not in regard to cruelty, as Freud had suggested.
It is poorly understood, though, what ultimately connects these emotional experiences to sexual gratification, or how that connection initially forms. Dr. Joseph Merlino, author and psychiatry adviser to the New York Daily News, said in an interview that a sadomasochistic relationship, as long as it is consensual, is not a psychological problem:

Its a problem only if it is getting that individual into difficulties, if he or she is not happy with it, or its causing problems in their personal or professional lives. If its not, Im not seeing that as a problem. But assuming that it did, what I would wonder about is what is his or her biology that would cause a tendency toward a problem, and dynamically, what were the experiences this individual had that led him or her toward one of the ends of the spectrum. It is usually agreed on by psychologists that experiences during early sexual development can have a profound effect on the character of sexuality later in life. Sadomasochistic desires, however, seem to form at a variety of ages. Some individuals report having had them before puberty, while others do not discover them until well into adulthood. According to one study, the majority of male sadomasochists (53%) developed their interest before the age of 15, while the majority of females (78%) developed their interest afterwards (Breslow, Evans, and Langley 1985). The prevalence of sadomasochism within the general population is unknown.