Sexual Sadism DSM 5 TR:  What counts as “sexual behavior involving suffering”

Sexual Sadism DSM 5TR –As I interpret it the DSM-5TR Sadism Disorder narrative permits evaluators to infer that sexual arousal from suffering is present where there is a history of recurrent sexual behaviors involving suffering. However, this inference won’t be valid if the perpetrator is not aware at the time that he is causing suffering. Or to put it more dimensionally, how apparent was the victim’s suffering to the perpetrator at the time of the sexual behavior?

Consider the following two examples (lightly edited from real life).

Example A: Two students (a man and a woman) are friends. The man is very sexually attracted to the woman but she has repeatedly made it clear to him that she doesn’t want to have sex with him. One evening they are at a party, they both drink a lot of alcohol and are seen leaving the party holding hands. They are then later seen kissing with mutual passion and enthusiasm outside the man’s apartment. They then went in, had sex, and fell drunkenly asleep. Neither in the morning can recall the details of their sexual interaction except that it was obvious that they had had sexual
intercourse. The woman was very upset when she woke up about what had happened and complained to the university about the man’s behavior. He was eventually charged with rape because he should have known that she did not want to have sex with him and that her apparent enthusiastic consent was simply because she was drunk and did not represent her true wishes.

Example B:  A woman goes to a man seeking to buy illicit drugs. He tells her they need to travel in his car to a place where he can get them for her. As they are driving, he says he will stop at his apartment to use the bathroom. She comes into the house as well and they both use the bathroom, him first. When she comes out of the bathroom she finds him standing naked. He tells her they are going to have sex. She says No and tries to leave. He physically prevents her from leaving, knocks her to the ground,  and drags her into the bedroom by her hair. He then forcibly removes her clothes, striking her with his fist repeatedly to subdue her. Then he sexually penetrates her anally and vaginally, continuing until he orgasms.

In the first example, I would suggest that the man was likely unaware that the woman would suffer as a result of his sexual behavior: her lack of consent would likely not have been apparent to him at the time of sexual activity. I would suggest that this is not sensibly seen as “sexual behavior involving suffering” since the suffering, although real, would not have been salient to the offender and likely occurred later rather than at the time of the sexual activity.

In contrast, in the second example, victim distress and the coercive aspect of the event would have been highly salient to the perpetrator so I think it is reasonable to count the second example as “sexual behavior involving suffering”.

This distinction means that one can’t simply count adult victims or include all incidents that might be called rape. One has to more precisely identify many victims who were subject to “sexual behavior involving suffering” that was salient to the perpetrator at the time of the sexual activity.

This, of course, still leaves the empirical question of whether recurrent behavior of this kind is associated with arousal from suffering. Still, at least it means the whole matter is more nuanced than a simple victim count.

Or..on the other hand…this would be an unwarranted stretch by the diagnostician. We can blame the authors for not producing a clear text to accompany the criteria for Sexual Sadism Disorder.

Considering the formal presentations, debates, opportunities for comments, etc., for the Paraphilia section and for other sections of the DSM-5, it would be both surprising and unprofessional for the authors of the Sexual Sadism Disorder text to significantly change the boundaries for the diagnosis without presenting advanced notice and inviting comments.

I don’t believe that the core of Sexual Sadism Disorder has been changed (other than the changes involved with distinguishing a paraphilia from a paraphilic disorder).

I think that to diagnose Sexual Sadism Disorder from behavior (without self-report) would require an inference that the person derives sexual pleasure from the pain and suffering of others.

In reading DSM-5, the criteria are the criteria. The rest of the text may help us decide a particular case whether the data are sufficient to conclude that the criteria are met.

In my practice, if I can’t conclude with a reasonable degree of certainty that the person has a deviant pattern of sexual desire that involves sexual arousal to the pain and suffering of others, then I do not diagnose Sexual
Sadism Disorder. (I don’t have the manual handy.  I would insert the exact wording from the criteria if I had the manual handy.)