DSM-IV on Masochism

Sexual masochism

Diagnosis and Prognosis

Definition: Sexual masochism denotes sexually arousing fantasies, sexual urges or sexual behaviors that involve the real act (not a simulated act) of being humiliated, beaten, bound or made to suffer in some other way.

Diagnostic criteria

The DSM-IV criteria for the diagnosis of sexual masochism state that: there must be 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; these fantasies, urges or behaviors must have a duration of at least 6 months; the fantasies, urges or behaviors must cause significant distress or functional impairment.

ICD-10 gives diagnostic criteria for a single diagnosis of sadomasochism.

Symptoms and signs

By definition, sexual masochism involves sexual excitement derived from pain, humiliation or suffering; the fantasies, urges or behavior must have been present for at least 6 months; and they must cause distress or functional impairment.

Some patients may report masochistic fantasies, typically during sexual intercourse or masturbation, that are not acted upon. The most commonly reported fantasy is of being raped while tied down or restrained by others so that escape is impossible.

Other patients may report that they act on these behaviors by themselves, such as: tying themselves up; sticking pins into themselves or otherwise inflicting physical pain; giving themselves electrical shocks; hypoxyphilia (acts of sexual arousal involving oxygen deprivation); acts of self-mutilation.

Still other patients may report masochistic acts with a partner, such as: physical restraint ('bondage'); blindfolding ('sensory bondage'); smacking, whipping or beating; electrical shocks; hypoxyphilia (acts of sexual arousal involving oxygen deprivation); physically humiliation (e.g. by being defecated on or being forced to adopt humiliating behaviors); forced cross-dressing, verbal abuse or humiliation.

Typically, sexual masochists repeat the same fantasy or act. In many cases, the potential injuriousness of the masochistic behavior does not increase over time, although this is not always so, especially during periods of stress.

Most patients with sexual masochism enjoy the masochistic fantasies or behaviors but are not reliant on them for sexual satisfaction. However, some patients are incapable of sexual satisfaction without masochistic rituals.

Most patients can trace masochistic fantasies back to their childhood, and many sexual masochists also have fetishism, transvestic fetishism or sexual sadism, and most sexual masochists have begun to engage in masochistic acts by early adulthood.

Investigations

The diagnosis is a clinical one based on the patient's history. No laboratory investigations are indicated.

Psychological testing may identify additional psychiatric disorders and paraphilias that are contributing to the severity of the sexual masochism.

Penile plethysmography may offer additional information to establish arousal associated with masochistic behavior and assess the patient for arousal associated with other paraphilias; however, the reliability of this measure is questionable and may result in false-negative information.

Complications

Complications of sexual masochism include: legal implications of the masochistic behavior - some patients with sexual masochism may become sexual offenders and commit sex crimes, especially if further paraphilias develop as masochism loses its novelty; impaired social or sexual functioning; infection and other medical problems, including death, that may arise from the masochistic activities, including sexual violence, exposure to fecal matter and hypoxyphilic behavior (such as autoerotic asphyxiation).

Paraphilias that frequently coexist with sexual masochism include urophilia and coprophilia.

Differential diagnosis

The differential diagnosis of sexual masochism includes: mild degrees of consensual masochistic stimulation that is used to enhance otherwise normal sexual activity and that does not fulfill the criteria for sexual masochism; other self-mutilating or cruel behavior that is not connected with sexual arousal.

Prognosis

Sexual masochism is usually chronic, and without treatment, it tends to remain a preference in sexual behavior, fantasies and urges.

With appropriate treatment it is often possible to reduce the frequency and intensity of masochistic behavior, fantasies and urges and to decrease the dangerousness of the activities.

Treatment and Outcome

The ethical implications of 'treating' someone for masochism have been heavily debated. It is generally agreed, however, that if the patient is uncomfortable with their pattern of sexual arousal, or if the patient is engaging in dangerous activities and risk-taking behavior, treatment is appropriate. Unfortunately, the effectiveness of treatment is questionable.

Treatment aims

The aim of treatment is to reduce masochistic behavior, particularly dangerous masochistic behavior.

Pharmacological treatment

Antidepressant medication

Most antidepressant medications given for paraphilias, including sexual masochism, are thought to work by treating the 'obsessional' nature of the disorder and by taking advantage of the sexual side-effect profile of these medications.

Selective serotonin reuptake inhibitors (e.g. fluoxetine**, fluvoxamine**, paroxetine**) generally have fewer side effects than the tricyclic antidepressants (e.g. clomipramine**, imipramine**) and may be considered first-line agents, especially for patients on few or no other medications.

Appropriate dosages have not been determined, but it is generally accepted that medications should be prescribed in doses similar to those given in the treatment of obsessive-compulsive disorder or depression. Doses can be adjusted until symptoms are controlled or side-effects become intolerable.

** off-label use

Standard dosage

Standard doses are: fluoxetine: 20mg/day (maximum dose 60mg/day); fluvoxamine: 100mg/day initially (maximum dose 300mg/day); paroxetine: 20mg/day (maximum dose 50mg/day); clomipramine: 30-150mg/day; imipramine: 75mg/day initially, then up to 150-200mg/day.

Contraindications

Fluoxetine, fluvoxamine and paroxetine are contraindicated in mania and should be used with caution in: patients with a history of mania; seizure disorder; cardiac disease; bleeding disorders; hepatic impairment; renal impairment.

Clomipramine and imipramine are contraindicated in: recent myocardial infarction; mania; severe liver disease.

Clomipramine and imipramine should be used with caution in: heart disease; seizure disorder; liver disease; pheochromocytoma; patients with a history of mania; psychosis; closed-angle glaucoma.

Main side effects

The side effects of fluoxetine, fluvoxamine and paroxetine include: gastrointestinal reactions (nausea, vomiting, indigestion, abdominal pain, diarrhea, constipation), which are the most common side effects and are dose-related; cardiac problems; antimuscarinic effects (e.g. dry mouth, constipation, urinary retention); sexual side effects (e.g. anorgasmia); a withdrawal syndrome, seen in up to 60% of patients in whom the drug (especially paroxetine) is stopped suddenly, which can cause dizziness, anxiety, agitation, confusion, tremor, paresthesiae, nausea and sweating.

The side effects of clomipramine and imipramine include: heart block and other arrhythmias; postural hypotension; convulsions; drowsiness; dry mouth; blurred vision; constipation; urinary retention; neuroleptic malignant syndrome (rare).

In longer-term use, they can cause severely decreased reaction times and psychomotor retardation. They can precipitate a manic episode in bipolar patients.

Main drug interactions

Fluoxetine, fluvoxamine and paroxetine must not be used within 2 weeks of stopping of a monoamine oxidase inhibitor.

Similarly, clomipramine and imipramine should not be used within 2 weeks of a monoamine oxidase inhibitor. They should not be used concomitantly with drugs that prolong the QT interval because of an increased risk of ventricular arrhythmias; the most significant interaction is with amiodarone, and the combination should be avoided.

Hormonal agents

Hormonal agents been shown to be effective in suppressing sexual urges, including masochistic urges, but they may truncate the individual's sexual life and result in decreased compliance with medication. Agents that have been used include: medroxyprogesterone acetate**, which lowers testosterone levels and has demonstrated efficacy for decreasing sexual urges, fantasies and behaviors; leuprolide**, which inhibits gonadotropin secretion by blocking gonadotropin releasing hormone receptors in the pituitary gland.

** off-label use

Standard dosage

Standard doses are: medroxyprogesterone acetate: 80mg/day by mouth or 500mg/week by intramuscular injection; leuprolide: 1mg/day by subcutaneous injection or 7.5mg/month by intramuscular injection.

Contraindications

Medroxyprogesterone is contraindicated in: hepatic impairment; severe arterial disease, porphyria.

It should be used with caution in diabetes mellitus, hypertension and renal impairment.

Leuprolide is contraindicated in patients with undiagnosed vaginal bleeding.

It should be used with caution in: vascular disease (coronary artery disease, cerebrovascular disease, thromboembolic disease); seizure disorders; hypertension; diabetes mellitus; edema.

Main side effects

The side effects of medroxyprogesterone acetate include: acne; fluid retention; gastrointestinal disturbances.

The main side effects of leuprolide include: weight gain; hypertension; lethargy; hot flashes; mood lability (especially early during treatment); phlebitis (rare); gynecomastia (rare).

Cognitive-behavioral therapy is sometimes useful and may include: behavioral therapy to reduce inappropriate sexual arousal and increase appropriate sexual arousal; challenging distorted thinking and beliefs, especially those concerning justification for the masochistic behavior; social skills training, assertiveness training and communication skills training; relapse prevention by helping the patient to identify vulnerable thoughts and situations and to intervene to prevent or stop the behavior by using various cognitive and behavioral skills.

Follow-up and management

Patients may need counseling to improve their skills in relating to sexual partners in a non-masochistic manner. It is important to assess patients for their wish or need for counseling for other paraphilias or other psychopathology. Some patients should be monitored to assess their likelihood of engaging in sexual offenses or sex crimes. Antiandrogen medication, serotonin uptake inhibitor, and psychodynamic psychotherapy along with sexual education and social-skills training and aversive behavior therapy should all tried over a period of 9 months. The combination therapy with antiandrogens and aversive behavior therapies may be the most effective treatment.

Scientific Background

Etiology

No single theory is accepted to explain the etiology of sexual masochism. Theories that have been put forward include: behavioral theories, which suggest that masochistic behavior is paired with sexual arousal (classic conditioning), which is inherently positive (operant conditioning); the masochistic behavior is further reinforced by masturbatory fantasies and may be associated with increased autonomic nervous system arousal (as a result of danger and risk); escape theories, which suggest that patients with sexual masochism are drawn to masochistic behavior to escape their identity and to act out a new (and sometimes opposite) persona; opponent-process theories, which suggest that fear, discomforting and painful experiences initiate an opponent process of pleasure (analogous, for example, to dangerous activities such as skydiving or rock climbing); psychodynamic theories, which suggest that the patient wants to dominate but is psychologically conflicted and therefore submits to be dominated.

Epidemiology

Sadomasochism between consenting partners is not considered rare and is possibly common, and more people describe themselves as masochistic than sadistic.

The incidence of sexual masochism that fulfills the diagnostic criteria is, however, not known.

The age of onset of masochistic behaviors is typically early adulthood, but most people with sexual masochism can trace masochistic fantasies back to their childhood.

Sexual masochism seems to be slightly more common in men than in women.

Comorbidity with other paraphilias or sexual dysfunctions is reasonably common.

The reported annual death rate from hypoxyphilic behaviors is 1-2 per 1,000,000 of the population.

References

Blanchard R, Hucker S Age, transvestism, bondage, and concurrent paraphilic activities in 117 fatal cases of autoerotic asphyxia. Br J Psychiatry 1991; 371-377.

Diagnostic and Statistical Manual of Mental Disorders, 4th ed Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association; 2000; 572-573.

Laws DR, O'Donohue W Sexual Deviance New York: Guilford Press 1997;

Levitt EE The prevalence and some attributes of females in the sadomasochistic subculture: a second report. Arch Sex Behav 1994; 465-473.

Shiwach RS, Prosser J Treatment of an unusual case of masochism. J Sex Marital Ther 1998; 303-307.

The ICD-10 Classification of Mental and Behavioral Disorders: clinical descriptions and diagnostic guidelines (ICD-10). Geneva: World Health Organization 1992;