KeywordsPersonality Disorder Sexual Interest Risk Assessment Instrument Paraphilic Disorder Transvestic Fetishism
The consideration of the relationship between these concepts and the specific notion of sexual sadism has been discussed by many authors (see reviews by Marshall and Kennedy 2003; Yates et al. 2008). The general conclusion of these studies is that while sexual sadism is conceptualized as distinct from these other concepts, the evidence of its uniqueness is not convincing. Each concept has various and overlapping features. In this entry we will attempt to delineate, as far as possible, the unique features of sexual sadism.
The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, APA 2013) specifies the criteria required for a person (usually but not always a male) to be diagnosed as a sexual sadist as having experienced “over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person as manifested by fantasies, urges or behaviours” (Criterion A, APA, p. 695) with the added requirement that “the individual has acted on these urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Criterion B, APA, p. 695). While these criteria may guide clinicians, researchers have challenged APA’s approach by either suggesting additional or alternative criteria or by pointing to vagueness in the DSM’s criteria (see Marshall and Kennedy 2003, for a review).
While the concept of sexual sadism has a long history dating back to the stories of the infamous Marquis de Sade, it was not recognized as a disorder until Krafft-Ebing (1886) provided a clear description of its salient features. He said it involved the experience of sexually pleasurable sensations produced by cruelty to other persons or animals and may include the desire to humiliate others. Karpman (1954) noted that sadism also included a “will to power” manifest in the sadist’s desire for absolute control over his victim. These various features said to be indicative of sexual sadism appear throughout the literature and reflect, in varying degrees, the current diagnostic criteria in both the American Psychiatric Associations (APA) Diagnostic and Statistical Manual of Mental Disorders and the World Health Organizations International Classifications of Diseases. We will outline the DSM diagnostic criteria as they appear in the latest version (DSM-5, American Psychiatric Association 2013). Although there are female sexual sadists (Pflugradt and Bradley 2011), we will restrict our focus to males since they have been the focus of almost all of the literature.
Sexual sadism disorder appears in the latest version of APA’s diagnostic manual (APA 2013, DSM-5) in the section dealing with paraphilic disorders. In the opening remarks in this section, it is noted that a paraphilia “denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners (DSM-5, Criteria A, p. 685). DSM-5 distinguishes a “paraphilic disorder” from a “paraphilia” where the former is said to be “currently causing distress or impairment to the individual or…whose satisfaction has entailed personal harm, or risk to harm to others (Criteria B, pp. 685–686). Paraphilic disorders require clinical interventions, while paraphilias may not. The proper application of the diagnosis of paraphilic disorder requires both sets of criteria to be met, whereas a paraphilia is said to occur when only Criteria A is met. Thus a person who admits to sexual interests causing pain or distress to others but who does not inflict direct suffering on others, and is not personally distressed by his desires, would not meet criteria for a diagnosis of sexual sadism. This person would be deemed to have a paraphilia involving arousal to sexually sadistic imagery.
From a treatment point of view, this distinction may be moot since it seems likely that sexually sadistic clients presenting at a clinic who meet Criteria A and B or just A (i.e., a diagnosis or not) will be offered similar if not identical treatment. However, in the case of a diagnosis of sexual sadism, the clinician might be legally required to take action to warn the authorities or particular persons who might be a target of the client. The diagnosis can be made if the client freely admits to meeting the criteria or, in the case where the client denies the interest, “despite substantial objective evidence to the contrary” (DSM-5, p. 696).
There are many concerns that can be raised regarding these criteria (both A and B), some of these issues have to do with the vagueness or arbitrariness of particular criteria. For example, why is it necessary to have the fantasies and arousal for 6 months? In some cases fantasies lasting 6 months may be transitory during periods of sexual deprivation associated with feelings of being treated badly. More particularly, what is meant by “recurrent and intense sexual arousal?” And how does the clinician determine that the client is experiencing these feelings? This is particularly relevant where, as is often the case, the client denies any such interests. The DSM-5 approach, in these cases, is problematic.
For clients who have a history of vicious rapes of adult women, sadistic motivation is only one of several possible interpretations. For example, many rapists viciously attack women as a result of feeling anger at all women or as a result of displaced anger toward one woman and even the murder of a woman during a sexual assault may be variously motivated (e.g., to silence the witness or as revenge against women) rather than being clearly an expression of sadistic desires. Furthermore, even some of the features said to be distinctive of sadism (e.g., extreme forcefulness, the exercise of power and control, and an intent to humiliate and degrade) appear quite commonly in most rapes.
As a result of concerns about the diagnosis, Marshall and Kennedy (2003) reviewed the research describing various aspects of sexual sadists. They found that almost all studies identified somewhat unique criteria for selecting sadists and almost none adhered strictly to DSM criteria. Apparently researchers (and presumably the clinical settings in which they work) employ idiosyncratic diagnostic practices making it impossible to integrate this literature in any meaningful way. Not surprisingly when Marshall et al. (2002) followed up this review by asking international renowned experts from these various settings to diagnose as sadists (or not) a group of 12 violent sexual aggressors, the experts failed to agree (kappa = 0.14) despite being provided with extensive information on each offender.
We, Marshall et al. (in press), have summarized the various approaches to the assessment of sadists that are meant to complement or replace DSM criteria in order to arrive at a diagnosis. We will restrict ourselves to a consideration of just two such approaches.
Phallometry: This assessment procedure (sometimes called “plethysmography”) involves measuring a man’s erectile responses to various sexual stimuli. The selection of stimuli that distinctly captures the features said to be diagnostic of sexual sadism is critical. Unfortunately, most studies have relied on stimuli that are known to identify rapists without adding any features unique to sadists. These unique features might include depictions of gratuitous violence, cruelty, humiliation, or torture of the victim. Indeed, the only researchers who have described an attempt to create sadist-specific stimuli are Jean Proulx and his colleagues at the University of Montreal and at the Philipe-Pinel Institute in Montreal (Proulx et al. 2006). They found that stimuli depicting violent rapes that included the humiliation of the victim produced greater responses in sadists than in other sexually aggressive offenders. Clearly, however, more research is required before a phallometric protocol, including standardized stimuli, can serve as a diagnostic tool supplementing an overall diagnostic procedure.
Crime scene data: According to Hollin (1997), “the essential elements of the act – the psychological or physical suffering and humiliation of the victim – will be evident from crime scene analysis and witness and victim statements” (p. 214). Research relying on crime scene data to identify sadists has examined features such as evidence of intercourse, the sexual positioning of the victim’s body, the degree of organization, indications of torture, and ritualistic elements. Unfortunately, many of these elements appear in nonsadistic sexual assaults so inferences about the underlying motivations (i.e., sadistic or not) of the offenders may still result in unreliable diagnoses. However, crime scene data are essential pieces of information for the diagnostician particularly where the offender denies sadistic interests. Fortunately some reports suggest that certain aspects of crime scene data can be reliably interpreted (Nitschke et al. 2009).
One particularly valuable study that examined crime scene data was reported by Proulx et al. (2005). They compared crime scene data derived from comparison groups of sexual sadists and nonsadistic sexual aggressors. Proulx et al. found that sadists more commonly employed expressive violence (90.7 %), planned their attacks (86 %), chose an unknown victim (83.8 %), explicitly humiliated the victim (53.7 %), mutilated the victim (30.2 %), and bound or otherwise enslaved the victim (16.3 %). Of those sadists who murdered their victims, 50 % strangled them and another 25 % stabbed the victim. Among these murderous sadists, 31.1 % had postmortem intercourse and 44.4 % mutilated their victim after death.
In Marshall et al.’s (2002) report mentioned earlier, they also asked the international experts to rate the importance of 17 items said by various researchers to define sadism. Contrary to the experts’ lack of agreement on a diagnosis, they displayed quite consistent ratings of the relevance of these items in arriving at a diagnosis. On the basis of this reported agreement across experts, Marshall and Hucker (2006) developed a checklist that listed each of the 17 items which future clinicians could utilize to assist them in arriving at a diagnosis. Subsequently, Nitschke et al. (2009) refined this scale by reducing it to ten items, nine of which were to be derived from crime scene data with one additional item being the offender’s responses at phallometric testing. Nitschke et al. demonstrated that their scale met a variety of psychometric properties, most importantly satisfactory test-retest reliability (r = 0.93) and strong inter-rater agreement (r = 0.86). In addition, they showed that scores on this scale significantly differentiated 50 offenders who admitted to having repetitive sadistic sexual fantasies and who committed distinctly sadistic offenses and 50 sex offenders whose offenses and self-reports revealed no indications of sadistic interests. A meta-analysis (Nitschke et al. 2012) demonstrated that the scale had both high sensitivity (the detection of sadism) and high specificity (the identification of the absence of sadism). We recommend its use as a central component in the various processes involved in arriving at a diagnosis of sexual sadism.
The most commonly associated feature of sadism, at least among nonoffenders in the community, is masochism. This is perhaps not surprising since self-identified sadomasochists alternate between the two behaviors. In addition, there is some evidence that sadists also display other paraphilias such as fetishism and transvestic fetishism (Dietz et al. 1990).
One of the most relevant studies of features associated with sexual sadism is a report by Proulx et al. (2005). They showed that sadists, relative to matched nonsadists, displayed a higher incidence of an array of personality disorders. These offenders were more likely to show evidence of schizoid, avoidant, histrionic, and schizotypal personalities. During the immediate pre-crime phase, the sadists had far more frequent conflicts with women and were in a state of considerable anger prior to and during their offense.
Sadists have also been shown to have greater interpersonal difficulties than other sex offenders. For example, sadists in the study by MacCulloch et al. (1983), all reported significant problems interacting with others particularly in sociosexual interactions. These problems, MacCulloch et al. said, contributed to the sadists’ development of a low sense of self-worth which aggravated their social isolation leading to anger at the world and anger specifically directed at women.
Finally, there is some evidence that sadists suffer from physiopathologies of the right frontal cortex (see Hucker 1997 for a review). Just what role these issues have in the etiology and maintenance of sexual sadism remains unclear, but further studies of brain functioning are clearly justified and needed. Examinations of endocrine abnormalities have not revealed anything distinct about sadists despite the common deployment of pharmacological agents in the treatment of serious sex offenders including sadists (Bradford 2000).
The incidence of sexual sadism in the non-adjudicated community was reported in the landmark study by Kinsey et al. (1953) to be between 3 % and 12 % among women and 10–20 % among men. Since sadistic themes appear to be common in mainstream pornography (Donnelly and Fraser 1998; Grubin 1994), it seems likely that many of the people attracted to these images do not act out with nonconsenting partners. In DSM-5 terms, these people would meet criteria for a “sexual sadism paraphilia” but not a “sexual sadism paraphilic disorder.” While these people constitute an interesting and potentially problematic group in terms of possible future propensities, they are not usually the focus of clinical attention. It is those who have offended who are predominantly the focus of diagnosis and treatment.
Various authors have attempted to estimate the prevalence of sexual sadism among sex offenders. In these reports the rates vary from 2 % to 5 % to as much as 50 %. In their review, Marshall and Kennedy (2003) observed that many estimates of prevalence came from centers that specialized in the assessment and treatment of sadists so that their estimates would necessarily be toward the high end of the spectrum. Nitschke et al. (2012) examined prevalence rates from three centers that select sex offenders on the basis of the seriousness of their crimes. Across these centers the average rates of sexual sadism were approximately the same (6.1 %).
Risk to Reoffend
There is now available an extensive body of evidence on the risk to reoffend of sexual offenders (Hanson et al. 2003). This research has identified features that allow appraisers to categorize offenders into low, moderate, or high risk to reoffend. According to risk assessment instruments derived from these studies, sadists will likely fall into the high-risk category. However, it is important to note that this is not the result of the unique features of sadists but rather because they typically share offense and life history features with high-risk rapists. What is needed are studies of the way in which sadistic features might predict reoffense potential as well as the potential for, and degree of, likely harm.
To date there have been only two studies of the future risk to reoffend that are specific to sexual sadists. In the more informative of these, Berner et al. (2003) identified higher reoffense rates (40 %) among sadists than was true for nonsadistic sex offenders (29 %). A report by Knight et al. (1998) indicated that the sadistic aspects of sex crimes displayed the greatest consistency over repeated offenses. It appears then that sadists are at considerable risk to reoffend although larger-scale replications are needed. Most importantly, sexual sadists who do reoffend also inflict serious harm to their victims including, in some instances, death. Unfortunately, the issue of harm to future victims or its reduction has been neglected to date. This neglect of potential harm has been true in all studies of future risk among sex offenders of all types (e.g., Hanson et al. 2003) and in all studies of treatment outcome (e.g., Hanson et al. 2002; Lösel and Schmucker 2005). This issue needs to be addressed in future research, but in the meantime clinicians must keep in mind this potential for serious harm in sadistic offenses.
Little has been written about the specific etiology of sexual sadism although there is a plethora of accounts of the general development of sexual offending (see the extensive volume edited by Ward and Beech, in press). Generally, these theories posit disturbances in attachment relationships in childhood, problems in negotiating the tumultuous years of adolescence, and the tasks involved in establishing fulfilling adult romantic and sexual relationships. It seems likely that difficulties at each of these stages will characterize the developmental course of the emergence of sadism, and some evidence already suggests this (MacCulloch et al. 1983). In the absence of more extensive evidence, it would seem wise for clinicians evaluating and treating sexual sadists to examine with their clients each of these developmental stages while we await more helpful research findings.
There have been predominantly two approaches to the treatment of sex offenders: cognitive behavior therapy (CBT) and pharmacological interventions. However, it should be noted that there do not appear to be any studies of either of these approaches that have specifically targeted sexual sadists. It is apparent among CBT approaches that, for the most parts, all sex offenders are offered the same treatment with the extent and perhaps intensity, being adjusted for those offenders judged to be at differing levels of risk to commit further crimes. Large-scale meta-analyses have shown CBT to be an effective approach to reducing reoffending rates although the reductions are not always remarkable (Hanson et al. 2002; Lösel and Schmucker 2005). However, it is impossible to determine how many sadists were in these studies and how well they fared. Nevertheless, the best course of action, in the present state of knowledge, would appear to be to offer sexual sadists a place in such a program and to energetically encourage them to accept the offer.
Bradford (2000) has been a champion of the use of pharmacological agents, particularly in severe cases of sexual offending, although he generally advocates a combination of medications and CBT. In Lösel and Schmucker’s (2005) meta-analysis, pharmacological treatments appeared to produce marginally better outcomes than CBT, but it is not clear that the studies they reported used antiandrogenic medications alone. Grubin (2008), a British psychiatrist, noted in his review that with few exceptions, the reports of pharmacological interventions “involve small numbers of subjects; they often fail to take into account subjects who drop out of treatment; and they are reliant on self-report measures of sexual activity” (p. 605). Also most of these reports note the potential for serious side effects such as feminization, depression, weight gain, and gynecomastia. Although somewhat uncommon, these side effects present a cautionary tale that clinicians must attend to in the use of these agents.
On the basis of the literature, perhaps the best course of treatment in the case of severe sexual sadists is to offer a combination of CBT and antiandrogens with the aim of eventually weaning the client off the medications.
Yates et al. (2008), in their comprehensive review, declare that “sexual sadism has proved to be an elusive concept to define and measure…the psychopathology of the disorder remains uncertain…(and even the most) recent research suggests unreliability in the diagnosis” (p. 213). Given the serious nature of this putative diagnosis, and the dreadful consequences for the victims of the individuals so affected, these observations by Yates et al. offer serious cause for concern. Unfortunately, our current summary of the knowledge bearing on the issue offers little comfort to clinicians who are given the responsibility of diagnosing and treating these offenders. While it is tempting to offer the typical call for further research such an agenda is unlikely to advance understanding until the various investigators can agree on the critical features of sadism. Unfortunately, clinicians faced with clients who engage in sadistic, or sadistic-like behaviors, do not have the luxury of waiting for studies that might clarify their tasks.
At present, the best approach to diagnosis, offered in the literature to date, would seem to be a combination of Nitschke et al.’s (2009) scale along with the results of several in-depth interviews and adherence to the DSM-5 criteria. Where it is available, phallometric test results employing the stimuli generated by Proulx et al. (2006) should significantly enhance the validity of a diagnosis. As for treatment, the most sensible approach, given current knowledge, would appear to involve a carefully monitored administration of an antiandrogen, complemented by cognitive behavior therapy aimed at overcoming what seem likely to be an array of personal and interpersonal deficits. Proulx et al.’s (2005) observations of associated personality disorders should be investigated and addressed in treatment as should MacCulloch et al.’s (1983) noted deficits in interpersonal skills. Upon discharge from a program or institutional setting, sadists need careful and extended monitoring in the community.
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