Sexual Masochism Disorder and Consensual BDSM: Where Is the Line?

In the clinic's older content, someone asked whether it was abnormal to want another person to shave their head roughly and to want to feel controlled. My answer was that this kind of feeling belongs to the group of interests called submissive or masochistic, which are part of BDSM, and that it is not abnormal as long as it happens between adults who genuinely consent.

This article expands on that from an academic angle: when this interest becomes a condition worth addressing, and what you really need to be careful about. It is part of the Paraphilic Disorders series.

What is BDSM, and why is it not a disorder?

BDSM stands for Bondage, Discipline, Dominance, Submission, Sadism and Masochism. It refers to sexual activities that play with power roles, control or certain sensations, which everyone involved has agreed to in advance.

Research does not support the belief that people who enjoy BDSM have psychological problems. A study in the Netherlands (Wismeijer & van Assen, 2013) found that BDSM practitioners scored no worse, and in several areas better, than a comparison group on a range of psychological characteristics. A Canadian survey (Joyal & Carpentier, 2017) found that about 1 in 4 adults had experienced masochistic desires, slightly more often in women than in men.

For these reasons, the World Health Organization's ICD-11 removed sadomasochism practised with consenting partners from its list of disorders. Code 6D36 is used only when there is marked distress or a significant risk of serious injury or death.

Sexual masochism disorder in DSM-5-TR

DSM-5-TR (2022) diagnoses it when:

1. There is intense, recurrent sexual arousal from being humiliated, beaten, bound or otherwise made to suffer, lasting at least 6 months.
2. The interest causes clinically significant distress or impairment in daily life.

Note that this disorder has no criterion about "acting on a non-consenting person", because the person on the receiving end is oneself. Clinicians may also add the specifier "with asphyxiophilia", meaning arousal from having one's breathing restricted, which is a high-danger sign.

A preference vs a condition that needs treatment

Distress caused only by society or other people not accepting you does not mean you are ill. It is still something you can talk through with a professional to feel more at ease.

Not a condition needing treatment

• Adults agree beforehand, with clear limits
• Can stop any time with an agreed signal
• No injury needing treatment
• Feel good about yourself

Should be assessed

• Pressured, or afraid of being left if you refuse
• No stop signal, or the partner doesn't listen
• Repeated injury, loss of consciousness, risk to life
• Distress affecting work and relationships

vs

ICD-11 removed consensual sadomasochism from its list of disorders.

Consent: the heart of safe BDSM

Principles widely used by the community and by professionals include:

• Negotiate first. Talk about what is allowed, what is off-limits, and each person's physical and emotional boundaries.
• Ongoing consent. Consent can be withdrawn at any moment, even after it has been agreed.
• A safe word or safe signal that everyone understands and respects immediately.
• Full awareness. Do not play while drunk or high, because it distorts judgment about risk and consent. Read more in What is chemsex and how to reduce harm.
• Aftercare. Look after each other afterwards, both physically and emotionally.
• Know the risks. Common frameworks are SSC (Safe, Sane, Consensual) and RACK (Risk-Aware Consensual Kink).

Talking about this with a partner may not be easy. The article Sexual fantasies: are they normal and how to talk with your partner has practical ways to start.

Consent

Agree first

• What is OK, what is off-limits
• Physical and emotional limits

Ongoing consent

• Can be withdrawn at any time

Stop signal

• Understood by everyone
• Respected immediately

Clear-headed

• No play while drunk or on substances

Care afterwards

• Aftercare, physical and emotional

Know the risks

• SSC / RACK
• Restricting breathing has no safe method

Asphyxiophilia: a risk that cannot be made safe

I want to be direct on this point. There is no safe technique for restricting breathing or blood flow to the brain for sexual arousal. The brain can run short of oxygen and you can lose consciousness very quickly, and once unconscious you cannot help yourself. The risk is highest when doing it alone. A review of forensic reports (Sauvageau & Racette, 2006) collected 408 deaths during solitary sexual activity, most of them from accidental asphyxia. Even with a partner, it can damage the brain, blood vessels or heart.

If you have this desire, or have ever lost consciousness during sexual activity, please talk to a doctor. Not to be judged, but to find safer options and prevent a tragedy.

Assessment and care

For people who are distressed or at risk, care starts with a non-judgmental conversation to understand where the distress comes from, such as guilt from the values you grew up with, an unequal relationship, or behaviour that is becoming riskier over time.

• Psychotherapy and sex therapy help with self-acceptance, communicating with a partner and setting safe limits.
• CBT when there is risky behaviour you cannot stop, or when it occurs alongside depression, anxiety or substance use.
• Screening for relationship violence, because being forced is not BDSM. It is abuse.
• Medication is rarely needed for this condition. If it is, it is under a psychiatrist's care.

The counterpart of this condition is sexual sadism disorder, where the question of consent is even more important. Interests tied to particular materials or objects are covered in Fetishes and fetishistic disorder.

Where to get help

• Talk confidentially with a clinical sexologist. See When to see a clinical sexologist.
• 1323, Thailand's free mental-health hotline (Thai language; ask for English support), if you are distressed or have thoughts of harming yourself.
• 1669 for medical emergencies, and 191 (police) if you are being forced or hurt.

Dr. Kris Clinic offers sex-positive, non-judgmental clinical sexology consultations at the clinic and online, including in English, with referral to a psychiatrist when needed.