The essential feature of sexual masochism is the feeling of sexual arousal or excitement resulting from receiving pain, suffering, or humiliation. The pain, suffering, or humiliation is real and not imagined and can be physical or psychological in nature. A person with a diagnosis of sexual masochism is sometimes called a masochist.
The Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM, is used by mental health professionals to diagnose specific mental disorders. In the 2000 edition of this manual (the Fourth Edition Text Revision also known as DSM-IV-TR) sexual masochism is one of several paraphilias. Paraphilias are intense and recurrent sexually arousing urges, fantasies, or behaviors.
In addition to the sexual pleasure or excitement derived from receiving pain and humiliation, an individual with sexual masochism often experiences significant impairment or distress in functioning due to masochistic behaviors or fantasies.
With regard to actual masochistic behavior, the person may be receiving the pain, suffering, or humiliation at the hands of another person. This partner may have a diagnosis of sexual sadism but this is not necessarily the case. Such behavior involving a partner is sometimes referred to as sadomasochism.
Masochistic acts include being physically restrained through the use of handcuffs, cages, chains, and ropes. Other acts and fantasies related to sexual masochism include receiving punishment or pain by means of paddling, spanking, whipping, burning, beating, electrical shocks, cutting, rape, and mutilation. Psychological humiliation and degradation can also be involved.
Masochistic behavior can also occur in the context of a role-playing fantasy. For example, a sadist can play the role of teacher or master and a masochist can play the role of student or slave.
The person with sexual masochism may also be inflicting the pain or suffering on himself or herself. This can be done through self-mutilation, cutting, or burning.
The masochistic acts experienced or fantasized by the person sometimes reflect a sexual or psychological submission on the part of the masochist. These acts can range from relatively safe behaviors to very physically and psychologically dangerous behavior.
The DSM lists one particularly dangerous and deadly form of sexual masochism called hypoxyphilia. People with hypoxyphilia experience sexual arousal by being deprived of oxygen. The deprivation can be caused by chest compression, noose, plastic bag, mask, or other means and can be administered by another person or be self-inflicted.
There is no universally accepted cause or theory explaining the origin of sexual masochism, or sadomasochism in general. However, there are some theories that attempt to explain the presence of sexual paraphilias in general. One theory is based on learning theory that paraphilias originate because inappropriate sexual fantasies are suppressed. Because they are not acted upon initially, the urge to carry out the fantasies increases and when they are finally acted upon, a person is in a state of considerable distress and/or arousal. In the case of sexual masochism, masochistic behavior becomes associated with and inextricably linked to sexual behavior.
There is also a belief that masochistic individuals truly want to be in the dominating role. This causes them to become conflicted and thus submissive to others.
Another theory suggests that people seek out sadomasochistic behavior as a means of escape. They get to act out fantasies and become new and different people.
Individuals with sexual masochism experience sexual excitement from physically or psychologically receiving pain, suffering, and/or humiliation. They may be receiving the pain, suffering, or humiliation at the hands of another person, who may or may not be a sadist, or they may be administering the pain, suffering, or humiliation themselves.
They experience distressed or impaired functioning because of the masochistic behaviors, urges, and fantasies. This distress or impairment can impact functioning in social, occupational, or other contexts.
Although masochistic sexual fantasies often begin in childhood, the onset of sexual masochism typically occurs during early adulthood. When actual masochistic behavior begins, it will often continue on a chronic course for people with this disorder, especially when no treatment is sought.
Sadomasochism involving consenting partners is not considered rare or unusual in the United States. It often occurs outside of the realm of a mental disorder. More people consider themselves masochistic than sadistic.
Sexual masochism is slightly more prevalent in males than in females.
Death due to hypoxyphilia is a relatively rare phenomenon. Data indicate that less than two people per million in the United States and other countries die from hypoxyphilia.
The DSM criteria for sexual masochism include recurrent intense sexual fantasies, urges, or behaviors involving real acts in which the individual with the disorder is receiving psychological or physical suffering, pain, and humiliation. The suffering, pain, and humiliation cause the person with sexual masochism to be sexually aroused. The fantasies, urges, or behaviors must be present for at least six months.
The diagnostic criteria also require that the person has experienced significant distress or impairment because of these behaviors, urges, or fantasies. The distress and impairment can be present in social, occupational, or other functioning.
Sexual masochism must be differentiated from normal sexual arousal, behavior, and experimentation. It should also be differentiated from sadomasochistic behavior involving mild pain and/or the simulation of more dangerous pain. When this is the case, a diagnosis of sexual masochism is not necessarily warranted.
Sexual masochism must also be differentiated from self-defeating or self-mutilating behavior that is performed for reasons other than sexual arousal.
Behavior therapy is often used to treat paraphilias. This can include management and conditioning of arousal patterns and masturbation. Therapies involving cognitive restructuring and social skills training are also utilized.
Medication is also used to reduce fantasies and behavior relating to paraphilias. This is especially true of people who exhibit severely dangerous masochistic behaviors.
Treatment can also be complicated by health problems relating to sexual behavior. Sexually transmitted diseases and other medical problems, especially when the sadomasochistic behavior involves the release of blood, can be present. Also, people participating in hypoxyphilia and other dangerous behaviors can suffer extreme pain and even death.
Because of the chronic course of sexual masochism and the uncertainty of its causes, treatment is often difficult. The fact that many masochistic fantasies are socially unacceptable or unusual leads some people who may have the disorder not to seek or continue treatment.
Treating a paraphilia is often a sensitive subject for many mental health professionals. Severe or difficult cases of sexual masochism should be referred to professionals who have experience treating such cases.
Because it is sometimes unclear whether sadomasochistic behavior is within the realm of normal experimentation or indicative of a diagnosis of sexual masochism, prevention is a tricky issue. Often, prevention refers to managing sadomasochistic behavior so it primarily involves only the simulation of severe pain and it always involves consenting partners familiar with each other's limitations.
Also, because fantasies and urges originating in childhood or adolescence may form the basis for sadomasochistic behavior in adulthood, prevention is made difficult. People may be very unwilling to divulge their urges and discuss their sadistic fantasies as part of treatment.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.
Andreasen, Nancy C., M.D., Ph.D., and Donald W. Black, M.D. Introductory Textbook of Psychiatry. Third edition. Washington, DC: American Psychiatric Publishing, Inc.,2000.
Baxter, Lewis R., Jr., M.D. and Robert O. Friedel, M.D., eds. Current Psychiatric Diagnosis & Treatment. Philadelphia: Current Medicine, 1999.
Ebert, Michael H., Peter T. Loosen, and Barry Nurcombe, eds. Current Diagnosis & Treatment in Psychiatry. New York: Lange Medical Books, 2000.
Ali Fahmy, Ph.D.