Human sexuality is a fundamental part of being human, encompassing not just physical acts but also a person's feelings, attractions, identities, and behaviors. Sexuality is often driven by a combination of biological, psychological, social, and cultural factors. As such, sexual preferences may differ between individuals, representing a diverse spectrum of what brings people sexual pleasure. 

Healthy sexual relationships involve mutual consent and respect between partners. When these factors are absent, and one derives pleasure from causing physical or psychological harm to a partner, it may be a sign of a serious condition, such as sexual sadism disorder (SSD). Below, review a more detailed explanation of SSD, including its symptoms and potential causes. In addition, find treatment options and tips for how individuals can overcome SSD to foster safety, trust, and healthy sexual relationships, and how therapy can help.

What is sexual sadism disorder (SSD)?

The American Psychiatric Association defines sexual sadism as a paraphilia that causes a person to experience sexual excitement through the intentional infliction of physical or psychological suffering on another person. Other paraphilias include (but aren’t limited to) fetishism, exhibitionism, sexual masochism, and voyeurism. Pedophilia, necrophilia, and frotteurism are also considered paraphilias. Not all paraphilias are classified as disorders. A paraphilia is considered disordered when it causes impairment or distress, or its practice harms (or risks harming) others. 

SSD vs. BDSM

Bondage, discipline (or domination), sadism, and masochism (BDSM) is a label that includes a broad spectrum of sexual practices. During these practices, consenting adults derive sexual pleasure from activities emphasizing power exchange and sensation play. The defining characteristic of BDSM is explicit, informed consent from all participants. Relationships involving BDSM can be healthy, trusting, and loving, and typically benefit all parties involved. 

The critical differences between BDSM behaviors and SSD lie in consent, intent, and how they affect daily life. People with SSD often engage in sexual behavior with nonconsenting individuals. SSD typically causes significant distress or impairment in various aspects of a person's life when they experience overwhelming shame, guilt, and anxiety. Sexual sadists may struggle with obsessive thoughts about harming others and might not be able to achieve sexual satisfaction without inflicting pain on another person. 

Key features and diagnostic criteria

Sexual sadism disorder is categorized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as one of the algolagnic disorders, which are a class of paraphilic disorders where sexual arousal depends on pain and suffering. Key diagnostic criteria for sexual sadism disorder include: 

• Recurrent and intense sexual arousal from the physical or psychological suffering of another person. This must be manifested by fantasies, urges, or behaviors lasting at least six months.
• The individual has acted on these urges with a nonconsenting person, or sadistic sexual fantasies and urges cause significant distress or impairment in critical areas of functioning.

The DSM also utilizes specifiers, such as indicating if the individual is in a controlled environment or complete remission. Consensual sadistic practices between adults, where no harm is intended, are not considered a disorder. If you feel that you may be experincing symptoms of an algolagnic disorder, consider talking to a therapist.

Sexual sadism disorder (SSD) and criminal behavior

Although not everyone with SSD demonstrates criminal behaviors, ongoing research reveals a connection between sexual sadism and sexually sadistic criminal behavior, particularly when SSD is combined with psychopathy. This combination can increase the risk of serious criminal acts, including kidnapping and abduction, often involving harm or death to the targeted individual. 

Despite the connection, some evidence suggests that sexually motivated homicides are relatively rare and are most often committed against strangers. In many cases, people who’ve committed sexually motivated homicides are motivated by a desire for power, control, and dominance. The manifestation of violent, sadistic fantasies can range in severity and action. 

Possible causes and risk factors

Psychologists introduced the concept of sexual sadism as a disorder warranting classification and study in the 19th century. Since then, many experts in sexology have explored its potential causes. Like most other paraphilic disorders, the etiology of SSD still isn’t fully understood, but researchers believe it likely involves a combination of biological, psychological, and social factors.

Biological risk factors for sadism and similar disorders

Some research suggests that sexual sadism may be linked with differences or dysfunctions in brain regions related to impulse control and sexual behavior. There's also an interest in exploring the potential role of the endocrine system and its interaction with the brain in the development of sexual sadism. Some studies indicate a familial grouping of paraphilias, suggesting a possible genetic component. However, it's prudent to note that studies on genetics and sexual sadism are ongoing, and a direct causality between the two has yet to be established. 

Psychological and environmental factors

Some theories suggest that childhood trauma, abuse, and difficulty with empathy play a role in the development of sexual and emotional dysfunction. Some individuals might learn to associate sexual pleasure with control or pain through repeated abuse. Faulty thinking patterns and beliefs about sexual arousal and pain can contribute. 

Additionally, while it may not be a cause, some people with sexual sadism may have low self-esteem and use the infliction of pain to feel powerful or in control. Finally, exposure to certain cultural norms or societal attitudes that normalize or desensitize individuals to violence could be a factor. 

Sexual sadism and personality disorders

Sadistic personality disorder (SPD) was previously included in the DSM (but not currently). SPD was characterized by a pattern of cruelty, aggression, and dominance; however, DSM criteria indicated these behaviors weren’t necessarily tied to sexual arousal or sexual intercourse. Still, the frequent overlap between SPD and sexual sadism is one of a few factors leading to SPD’s removal from, and SSD’s addition to, the DSM. 

Additionally, SPD shared a high rate of comorbidity with other personality disorders— particularly narcissistic and antisocial personality disorder (ASPD)—raising questions about whether it was a unique condition or a manifestation of other conditions.  Currently, research on the link between sexual sadism disorder and psychopathy is limited. (Psychopathy is a term referring to symptoms of ASPD, narcissism, and some other personality disorders.) However, existing studies do suggest that individuals with such disorders exhibit higher levels of sexual sadism compared to those with other personality disorders with less psychopathy. 

Other co-occurring mental conditions 

Personality disorders aren’t the only mental illnesses associated with SSD. While it may not happen in every case, individuals with SSD may be more prone to depression and anxiety connected to the distress caused by their behavior. Substance use disorders have also been linked to SSD, as individuals might use drugs and alcohol to cope with their symptoms or facilitate sadistic behaviors. 

Treatment approaches

People with psychopathy and SDD are considered particularly resistant to psychiatric treatment. Some may only receive a diagnosis when it's court-ordered as a part of sentencing for sexual offenders. In any case, mental health professionals may use the severe sexual sadism scale (SeSaS) to assess the presence and severity of sexual sadism. 

SSD and cognitive-behavioral therapy (CBT)

Cognitive-behavioral therapy is a primary treatment approach for sexual sadism disorder. Many techniques fall under the CBT umbrella, focusing on modifying thoughts and behaviors related to sexual arousal and aggression. People with SSD may receive CBT treatment in an individual setting, a group setting, or a combination of both. Individuals with SSD may also participate in social skills training as part of a treatment plan. This treatment can help them improve their social interactions, communication, and empathy, potentially reducing aggression or dominance. 

Medication

While CBT is often considered a cornerstone of treatment, medication can play a supportive role. Physicians may prescribe medications that suppress testosterone production and reduce sex drive, and certain antipsychotics may be used to manage aggression and impulsivity. Additionally, some antidepressants may be used in conjunction with other treatments for their libido-lowering side effects. Some studies also indicate opioid antagonists could show promise in adolescent cases of SSD.  

The BetterHelp platform is not intended to provide any information regarding which medication or medical treatment may be appropriate for you. The content provides generalized information that is not specific to one individual. Do not take any action without consulting a qualified medical professional.

How SSD affects relationships

In consenting, trusting relationships, sadism can be a “kink” that enhances sexual gratification healthily. When it becomes a disorder, it can significantly harm relationships in several ways. For example, when individuals with SSD engage in sexual acts that involve physical or psychological harm without the partner's consent, it can lead to trauma and potential long-term damage. Other ways sexual sadism can harm relationships include (but aren’t limited to):

• Emotional detachment: Sexual sadism is often linked to emotional deficits, including a lack of empathy, which can hinder healthy relationship functioning.
• Control and manipulation: Individuals with sadistic tendencies may use sexual acts to exert control and manipulate their partners, leading to power imbalances and unhealthy dynamics. 
• Psychological distress: Partners of individuals with SSD often experience significant psychological distress, leading to anxiety, depression, and post-traumatic stress.
• Relationship satisfaction: Even in cases of consensual sadomasochism, high levels of sadistic tendencies can reduce relationship satisfaction, particularly when there are difficulties or conflicts in other areas of the relationship. 

Cognitive behavioral therapy for survivors

As people with SSD typically require therapy to change their sexual behaviors and tendencies, sexual assault survivors often experience psychological distress that requires psychotherapy for healing. Therapy for sexual trauma may include specialized methods of CBT, such as trauma-informed CBT, psychodynamic psychotherapy, and eye movement desensitization and reprocessing therapy (EMDR). In treatment, survivors can process their experiences in a safe, comforting environment. A therapist can help individuals reduce the emotional pain and anxiety of traumatic memories, manage fear and anger, and cope with distress in daily life. 

Finding mental health support online

While not suitable for every case, previous research suggests that virtual therapy can benefit sexual assault survivors with PTSD. A PubMed pilot study examined an online, therapist-assisted CBT program for five college-aged rape survivors. After seven weeks of intervention, four no longer met PTSD criteria, and all reported reduced fears of vulnerability. Most also experienced fewer trauma-related negative thoughts.

Platforms like BetterHelp provide access to specialized care that may not be readily available to all survivors, particularly those in rural or underserved areas. Individuals can attend online therapy sessions from the comfort of their own homes, eliminating transportation barriers and potentially reducing scheduling challenges. Additionally, home-based therapy can provide a greater sense of physical and emotional safety, which may make it easier to engage in treatment.