Sexual Sadism Disorder: How BDSM Differs from Sexual Violence

The word "sadist" is used so loosely in everyday speech that it has lost its meaning. Some people call a partner who likes to tease them a sadist, and some worry they are abnormal because they like to take the lead in bed. Medically, there is a clear dividing line here: consent. Being the controlling partner in BDSM that everyone has agreed to is one kind of sexual preference. Being aroused by the pain or fear of someone who has not consented is a condition that is dangerous to others.

This article is part of the Paraphilic Disorders series and is best read together with Sexual masochism disorder and consensual BDSM.

DSM-5-TR and ICD-11 criteria

DSM-5-TR (2022) diagnoses sexual sadism disorder when:

1. There is intense, recurrent sexual arousal from the physical or psychological suffering of another person, lasting at least 6 months.
2. The person has acted on these urges with a non-consenting person, or the urges cause clinically significant distress or impairment in daily life.

Clinicians may add the specifiers "in a controlled environment" or "in full remission" (no acting on urges and no distress for at least 5 years).

ICD-11 goes further and uses the name 6D33 Coercive Sexual Sadism Disorder. It is used only when there is a pattern of sexual arousal from inflicting suffering on a non-consenting person, and the person has acted on it or is markedly distressed by it. Sadomasochism practised with consenting adults is not considered a disorder (Krueger et al., 2017).

A preference vs a condition that needs treatment

A Canadian survey (Joyal & Carpentier, 2017) found that sadistic desires were clearly less common than masochistic ones (about 7% compared with about 24%), and that most of them were fantasies or consensual play, not violence.

Consensual preference

• Limits always agreed beforehand
• Stop signals respected at once
• Cares about partner's pleasure and safety
• Aftercare, and an ordinary life

Should be treated

• Aroused by the other person's real reluctance or fear
• Wants to continue even when asked to stop
• Violence keeps escalating
• Starts planning or seeking chances with unaware people

vs

ICD-11 uses 6D33 Coercive Sexual Sadism Disorder only when it involves non-consenting people.

Without consent, it is sexual violence

Whatever name it goes by, physically or psychologically hurting another person in a sexual way without their consent is violence and a crime. "Consent" obtained through threats, emotional or financial pressure, or while the other person is drunk or unconscious is not consent. The same principle applies to touching strangers without consent and to other paraphilias involving non-consenting people. With children, there is no situation in which consent is possible.

If you are a partner who feels forced, hurt or unable to say no, that is not BDSM. It is relationship violence. You can get help from 1300 (Thailand's social assistance hotline) or call the police on 191 in an emergency.

Risk assessment

Assessment is done by an experienced doctor, and when there is a risk to others, a psychiatrist should be involved. The assessment covers:

• The nature of the fantasies, and whether they involve consenting or non-consenting people
• Whether there has been planning, seeking opportunities or acting on them
• Co-occurring issues such as alcohol or substance use, difficulty controlling anger, or personality factors
• How the person feels about other people's suffering, and their motivation to change

Nature of fantasies

• Do they involve consenting people or not

Actions

• Any planning or seeking of opportunities
• Or have they already acted

Co-existing issues

• Alcohol or substances
• Anger control

Protective factors

• Feeling for others' suffering
• Motivation to change

If risk to others is high, a psychiatrist should be involved.

Treatment

Psychotherapy is the foundation of care at every level.

• CBT to understand triggers and distorted thinking, and to practise controlling urges.
• A relapse-prevention plan and the Good Lives Model, which helps build meaningful life goals without harming anyone.
• Building empathy and skills for consensual relationships.
• Treating co-occurring conditions, especially substance use and mood problems.

Medication: the WFSBP (2020) guidelines grade treatment by severity and risk to others. Where there are intense fantasies or a high risk of sexual violence, a psychiatrist may consider testosterone-lowering medication alongside psychotherapy. This requires informed consent and close monitoring for side effects. It is not a treatment to be used outside a psychiatrist's care.

Where to get help

If you are frightened by your own thoughts, that is a good sign that you still want to protect others. Use that feeling as the push to seek help.

• Talk confidentially with a doctor or clinical sexologist. See When to see a clinical sexologist.
• 1323, Thailand's free mental-health hotline, open 24 hours (Thai language; ask for English support).
• In an emergency, 191 (police) or 1669 (medical).

Dr. Kris Clinic offers confidential initial consultations and risk assessment, at the clinic or online and in English, with referral to a psychiatrist or specialist treatment team. Consultations are confidential, except when someone else is in immediate danger. For consensual, safe preferences, read about talking with your partner in Sexual fantasies: are they normal?, and see Family therapy for couples who want to work on their relationship together.