DSM-IV-TR criteria

• Over a period of at least 6 months, 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.
• The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Associated features

• Sexually masochistic behaviors are usually evident by early adulthood and often begin with masochistic or sadistic play during childhood. The masochist experiences sexual excitement from physically or psychologically receiving pain, suffering, and/or humiliation. Fantasies, sexual urges, or behaviors through which the individual is beaten, bound, humiliated, or subjected to pain in some ways characterize this disorder. Some that suffer from sexual masochism may be uncomfortable with or bothered by these fantasies and sexual urges, so they may not act on them when engaged in sexual activity with other people but may carry them out in private. There is a dangerous and potentially fatal form of masochism called hypoxyphilia, in which individuals experience sexual pleasure or arousal by way of oxygen deprivation, such as choking with hands or other materials. Hypoxyphilia is a dangerous act, where the victim achieves sexual arousal and attempts to enhance his or her experience of an orgasm by oxygen deprivation; to this occurs via strangulation, using a plastic bag or a mask. Mistakes while engaging in hypoxyphilia can result in serious injury, brain damage, or death. Paraphilic Infantilism, another form of Sexual Masochism involves the victim’s desire to be treated as an infant. Such individuals often wear diapers in these situations. The majority of Infantilists are heterosexual males. This may be due to the feeling of freedom and loss of responsibility some attempt to achieve through Infantilism.
• Sexual masochism is a paraphilia, where a sexual sadist will have a partner who willingly acts with him or her. Sexual masochists have a desire or need for pain or humiliation to enhance sexual arousal so that gratification may be attained. During sexual excitation or sexual contact, the individual is humiliated, beaten, or receives some type of pain or suffering. For the masochist, she or he is typically bound to increase the feeling of helplessness. Like sexual sadism, some masochists are bothered by their fantasies, and they may appear, but not acted on, during sexual activity. This situation usually involves a fantasy rape without any possibility of escape. Some act on fantasies in private; usually these would include self-mutilation, sticking themselves with pins, or giving themselves electric shocks. If the partner is involved, the acts might include blindfolding, restraint, spanking, whipping, cutting, and some form or humiliation.
• Sexual masochism is very different from Sexual Sadism, yet oftentimes the two are linked. Sexual masochism tends to be chronic once it appears, and the acts may increase in severity, eventually leading to serious injury or to death. Sexual Sadism is also chronic and the behaviors can increase in severity. Also, there is a term known as sadomasochism which is used to illustrate the occasion where sadism and masochism are both present in one person but portrayed as different disorders, or according to which theory is used, it can also be used as a replacement for both terms.However, Masochism, like Sadism, is formed from a proper name. The term is derived from an Australian novelist, Leopold von Sacher-Masoch, who explains this disorder in his novels.

Hitler as a Masochist

Otto Strasser told the OSS officials during interviews on May 13, 1943 that Hitler’s niece, Geli Raubal, had confided in him a story about Hitler’s perversion. She had told him that “Hitler made her undress… He would lie down on the floor. Then she would have to squat over his face where he could examine her at close range and this made him very excited. When the excitement reached it’s peak, he demanded that she urinate on him and that gave him his sexual pleasure. Geli said the whole performance was extremely disgusting to her and … it gave her no gratification.” This leads many to believe that Hitler may have been a masochist. A personal friend to Hitler, Father Bernard Stempfle, supported this claim along with the claim of Geli Raubal. He said that there was a compromising letter written to Geli from Hitler that fortunately for Hitler Geli never received. The letter was said to contain Hitler’s mention of his masochistic and coprophilic inclinations. Another accusation of his masochism came from the German film star, Renaté Mueller. She had been invited to join Hitler for the night in his Chanceller, where after they had reached the undressing point Hitler “lay on the floor… condemned himself as unworthy, heaped all kinds of accusations on his own head, and just groveled around in an agonizing manner. The scene became intolerable to her, and she finally acceded to his wishes to kick him. This excited him greatly; He became more and more excited”

(Waite, R. G. L. (1977). The Psychopathic God Adolf Hitler. New York: Basic Books, Inc., Publishers.).

Child vs. adult presentation

Masochistic sexual fantasies often begin in childhood, but children are not diagnosed with this disorder. Sexual masochism is generally diagnosed by early adulthood. This disorder takes on a chronic course which can vary by person in severity and in dangerousness. For some, the dangerousness will rise to a level and plateau, for others it could become so severe or dangerous it could lead to permanent damage or even death. Private acts may include: self mutilation, sticking with pins, electric shocks, cutting, burning, and choking. Partnered acts may include: spanking, whipping, handcuffing, chaining, blindfolding, and humiliation in the form of defecation, urination, cross dressing, and mocking animal behavior (such as dogs or cats).

Gender and cultural differences in presentation

Males are more commonly diagnosed with sexual masochism than females. Cultures may differ on how the individuals satisfy their sexual urges toward this disorder, but all cultures that have been examined are similar in presentation.

Epidemiology

Approximately thirty percent of masochists also participate in sadistic behaviors (sadism). There are less than 2 people per million in the U.S. and other countries that die from hypoxyphilia, oxygen deprivation. There is no significant difference between the prevalence of Sexual Masochism in heterosexuals and homosexuals.

Etiology

The causes of sexual masochism are unclear; however, there a handful of theories that attempt to shed some light on the etiology of SM. Some theories attempt to explain the presence of sexual paraphilias in a general sense. Paraphilias involve sexual sadism and masochism with unusual masturbatory behaviors and with the use of special sexual devices and props. Most urges are acted upon alone and, though they may seem highly unusual to the average person, they usually cause no harm to the primary individual or to others. In some cases, such behaviors can indeed cause harm and can be serious in some cases. Unusual sexual practices stem from boredom of traditional sex or out of curiosity. This theory uses learning theory to back up its assertion that paraphilias develop because inappropriate sexual fantasies are suppressed and become stronger when forbidden. When the individual can finally act on them, they are in distress or arousal and so the paraphilia becomes associated with the arousal. Another theory explains this behavior as a form of escape (from old routine). Theories that stem from the psychoanalytic camp suggest that childhood trauma plays a role in the development of sexual masochism or sadism. This disorder is incompletely understood, and the etiology remains unclear.

Empirically supported treatments

Behavioral treatment is used to treat paraphilias and focuses on correcting and maintaining healthy arousal patterns and masturbation. Other behavioral therapies may include social skills training and cognitive restructuring. Medications can also be used treatment to reduce fantasies and behaviors relating to paraphilias. The goal of medication treatment is to reduce the sex drive so the number of sexual fantasies, erections, and sexual behaviors such as masturbation and sexual intercourse, diminishes.

Prognosis

• Because of the chronic course of sexual masochism and the uncertainty of its causes, treatment is often difficult. The fact that many masochistic fantasies are socially unacceptable or unusual leads some people who may have the disorder not to seek or continue treatment.
• Treating a paraphilia is often a sensitive subject for many mental health professionals. Severe or difficult cases of sexual masochism should be referred to professionals who have experience treating such cases.