Treatment of Sexual Masochism

As currently defined by the 'DSM-IV-TR' (American Psychiatric Association, 2000), sexual masochism is diagnosed when a person experiences "recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer" for a period of at least 6 months. For a diagnosis to be made, the fantasies, urges, or behaviors must also cause clinically significant distress or impairment in social, occupational, or other important areas of functioning for the presenting individual. Large-scale studies on sexual interests in the general populations of the United States and Australia have suggested that approximately 2 to 5% report experiencing sexual pleasure from receiving pain or involvement in bondage/dominance/sadism/masochism (BDSM) activities (Hunt, 1974; Richters, Grulich, de Visser, Smith, & Rissel, 2003). Disagreement exists over whether sexual masochism should be classified as a mental disorder, with opponents arguing that its inclusion is unnecessary and pathologizes groups that consensually engage in alternative sexual practices (see Krueger, 2010a). Indeed, a number of studies have indicated a relative lack of associated pathology in individuals who engage in sexually masochistic behaviors (e.g., Connolly, 2006; Moser & Levitt, 1987; Sandnabba, Santtila, & Nordling, 1999; Santilla, Sandnabba, Alison, & Nordling, 2002; Williams, 2006). However, it is likely to be retained in DSM-V, with arguments supporting its inclusion highlighting the potential for severe harm or even death to occur in some sexual masochists (e.g., Blanchard & Hucker, 1991; Hucker & Blanchard, 1992; Sandnabba et al., 1999), as well as the fact that the diagnostic criteria, if used correctly, would not apply to the vast majority of individuals who practice these behaviors. This distinction has important implications for the treatment of persons presenting with sexual masochism, as it will help inform treatment options and directions.