The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) has provided the most authoritative definition of sexual masochism (arousal from fantasies or the act of being humiliated, beaten, bound, or otherwise made to suffer) and sadism (arousal from fantasies or the act of physical or psychological suffering of another) in the literature.1 Summary estimates for the prevalence of sadomasochistic sexual interests and behavior have been difficult to derive given the complexity of defining the phenomenological domain. DSM-5 summary estimates for sexual masochism (1%–2%) and sadism (2%–30%) offer minimal differentiation between clinical (paraphilic disorder), subclinical (paraphilic interest), and normative manifestations of either response domain.1 Subsequent research has suggested that dominance/submission fantasies and sex play are experienced among many members of the general public.2 Close to one-half of a general population sample in Belgium recalled at least one prior sadomasochistic sexual act, with an additional 22% acknowledging fantasies about domination and/or submission.3 A majority of respondents in one college survey sample even acknowledged past fantasies about sexual bondage.4
Evidence regarding the impact of sadomasochistic fantasies on broader psychosocial functioning has been limited and equivocal in the findings.5 Sadomasochistic desires may pose special limitations on relationship development and maintenance success,6 and correlates between sadistic personality traits and sexual aggression have been established.7–11 Other studies, however, have found evidence of psychosocial adjustment among members of the general population who acknowledge recurrent sadomasochistic sexual fantasies.12–14 This outcome variability supports the wisdom of the DSM-5 in distinguishing between a paraphilic “interest” and “disorder” based on the absence or presence of psychosocial distress and/or impairment.1,15–17
Sadistic and masochistic sexual fantasies typically emerge in adolescence, with only a fraction of these people meeting the necessary diagnostic criteria for a paraphilic disorder by early adulthood. Sadistic behavior is exhibited disproportionately by men,18,19 but prevalence estimates for sexual sadism disorder have been fairly similar for men (2.2%) and women (1.3%) in the DSM-5 and other sources.20
Proposed etiologic contributors for sexual sadomasochism have been limited in number and specificity. They have included biological,21 psychodynamic,22 family conflict,23 chemical addiction,24 and/or personality25,26 dysfunctions that might be catalyzed early in development by critical learning experiences such as exposure to pornography.27–29 Childhood physical and/or sexual abuse has also been associated with sadomasochistic sexual interests among a small subset of victims of maltreatment.30–32 One literature review concluded that women victims of childhood sexual abuse (CSA) had a greater likelihood of developing masochistic interests, with men who were abused as children not inclined to higher rates of either interest.23
Krafft-Ebing33 coined the terms “sadism” and “masochism” in 1890 in the course of his seminal studies of men who were sexually arousal by fantasies of domination and/or humiliation.34 He speculated that fantasy themes of control and subjugation largely arose as a maladaptive coping response of hypersexual men and women who were insecure about their sexuality. Freud35 also speculated that the pleasure and satisfaction derived from domination or humiliation served to satisfy maladjusted sexual needs. Both Krafft-Ebing and Freud identified homosexuality (a term coined by Freud) and sadomasochism as “sexual perversions” with imprecise nexuses, but both men worked to humanize and decriminalize such proclivities as treatable medical conditions. These pioneering researchers were precursors of the current trends in the literature to recognize, even celebrate, the wide individual differences that are evident in the expression of human sexuality.2–4 Paraphilia diagnoses remain reserved for that relatively small subset of men and women who victimize nonconsensual partners or suffer distress or psychosocial impairment secondary to their sadomasochistic fantasies.
Sadomasochism Personality Correlates
Nonsexualized components of sadomasochism have also been increasingly investigated. Sadistic personality disorder even made a brief formal appearance in the DSM, third edition, revised.36 Although subsequent DSM iterations have restricted their diagnostic focus on paraphilic manifestations of sadomasochism, extensive research continues in the field on personality trait dimensions that underlie sadistic and masochistic interpersonal behavior.7,8,37,38 Millon and Davis39 summarized the prototypic personality features of sadistic (eg, dogmatic cognitive style, hostile temperament, combative and abrasive interpersonal style) and masochistic (eg, diffident cognitive style, dysphoric temperament, deferential and discrediting interpersonal style) disorders. The Personality Inventory for the DSM-5 (PID-5)40–42 has been used as well to establish significant associations between psychometric indicators of sadistic inclinations and the five personality trait domains of antagonism,11,43,44 negative affect,43,44 disinhibition,43,44 detachment,43,44 and psychoticism.11,43
This study examined the distribution of domination and humiliation fantasies within a general national sample. Attempts will be made to link selected developmental antecedents and sexual maladjustment indicators to these two sexual interests. The following analyses were designed to test whether prominent domination or humiliation fantasies were associated with (1) developmental antecedents (particularly CSA prior to age 13 years), (2) sexual distress and impairment, (3) maladaptive personality functioning, and (4) relatively higher levels of personality dysfunction among respondents with particularly high levels of sexual distress.
Procedure and Sample Composition
This survey was created using Qualtrics software and was disseminated using an online survey platform for participants to take surveys and questionnaires in exchange for monetary compensation. Account-specific identification and payment options verification protects against multiple completions of the survey by the same respondent. The online survey platform has garnered favorable external reviews as a valid and representative crowdsourcing investigative platform.45,46 Respondents were told that the purpose of the survey was to explore associations between sexual interests and relationship difficulties. Respondents were compensated 50 cents for approximately 30 minutes of participation. This project was approved by the University of North Dakota Institutional Review Board with informed consent required for all respondents.
This analysis relied on archival data used previously in one prior study of asphyxiophilia.47 The sadomasochistic interests and sample subsets of the present study were not examined in this earlier publication. A total of 802 respondents were classified for this analysis using the Paraphilic Interest Questionnaire [PIQ],48 which provided a method for respondents to anonymously identify the physical and thematic cues that were relied upon to “achieve arousal in over 80% of your sexual fantasies.” PIQ thematic items were clustered in the three areas: power (domination, humiliation, spanking, and rape); risk (exhibitionism, voyeurism, frotteurism, telephone scatologia, and asphyxiophilia); and extrapersonal (cuckoldry, cannibalism, necrophilia, corpophilia, urolagnia, and other) sexual fantasies. Fetish cues were sampled regarding the age, clothing, and physical appearance of the optimal target of interest. This study isolated respondent subsets who acknowledged relying on the fantasies of either “asserting dominance over someone” or “being humiliated or made to suffer” to “achieve arousal in over 80% of your sexual fantasies.”
The PIQ provided both attention verification and a sexual interest reliability check in the form of an initial panel of the same sexual fantasy cues that served as a primary focus at least once previously in the life of the respondent. A small subset (n = 7) of respondents was excluded when they failed to respond appropriately to an attentional check immediately after completion of the sexual interest panels. A larger subset (n = 156, 18.2%) was then excluded due to their inconsistent responding in back-to-back panels regarding their primary (>80% of time) and historic (at least once) indulgence in the targeted sexual fantasies (domination, n = 14 [13.4%]; humiliation, n = 9 [19.6%]; both, n = 6 [24%]; neither, n = 127 [n = 16.4%]). The cohort identified with both interests was left unanalyzed given its small cell size. Respondent age was covaried in these analyses to control its potential impact on selected criterion measures that potentially varied over development (eg, number of sex partners, mental health history, ethical idealism, relationship conflicts, religiosity). Table 1 documents the final sample distribution for these sexual interests.
Paraphilic Interest Group Prevalence Rate Comparisons
Sexual Abuse & Assault Self-Report. This childhood sexual abuse measure49 was provided by the Consortium of Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) project ( https://sites.cscc.unc.edu/cscc/projects/LONGSCAN) coordinated at the University of North Carolina. This index was developed for use with children and adolescents who are victims of sexual assault.49 The items are repeated to sample acts perpetrated against the respondent prior to age 13 years. The CSA score utilized in this study was calculated as a sum of the affirmative answers to each of the dichotomous items. Minor wording modifications were made for adult sampling purposes (ie, “genitalia” instead of “sexual parts;” “rape” in place of “put a part of his body inside your private parts”). Final sample items after the stem (“Did any of these events happen to you during your childhood?”) included “Someone touched your genitalia in some way;” “A stranger raped you;” “Someone put their mouth on your genitalia or made you put your mouth on their genitalia.” LONGSCAN provides concurrent validation data.
Brief Sexual Attitudes Scale. The Brief Sexual Attitudes Scale (BSAS)50 is a 23-item Likert-type scale. The permissiveness scale (10 items), communion scale (5 items), and instrumentality scale (5 items) were used in this study. The BSAS scales are internally consistent, with Cronbach's alpha scores ranging from .71 to .93. Higher scores reflect greater endorsement of subscale content.
Sexual Desire Inventory-2. The Sexual Desire Inventory-251 is 14-item Likert-type scale measuring desire to engage in solitary and/or dyadic sexual behavior (eg, When you first see an attractive person, how strong is your sexual desire? Compared to other people your age and sex, how would you rate your desire to behave sexually with a partner? Compared to other people your age and sex, how would you rate your desire to behave sexually by yourself? How long could you go comfortably without having sexual activity of some kind?). Scores range from 0 to 112 (Cronbach's alpha scores range from .86 to .96), with higher total scores indicating greater sexual desire or interest experienced in the last month. A customized item provided an estimate of the number of lifetime sexual intercourse partners (restricted to a maximum of 100).
Religious Commitment Inventory-10. The Religious Commitment Inventory-1052 is a 10-item Likert-type scale assessing how much a person is involved in their religion. The scale can be divided into the intrapersonal religious commitment and interpersonal religious commitment subscales with internal consistencies of 0.92 and 0.87, respectively. Scores range from 10 to 50, with higher scores indicating greater religious involvement.
Ethics Position Questionnaire. The Ethics Position Questionnaire53 is 20-item Likert-type scale measuring the degree of endorsement in idealism and the rejection of universal rules in favor of relativism producing three subscales (idealism, relativism, and veracity). The idealism subscale was used in this study, which correlates highly with moral judgment making and is robust across cultural variations.54,55 The higher the score the greater the endorsement of idealistic ethical ideology in making moral judgments.
Sexual Addiction Screening Test-Revised. The Sexual Addiction Screening Test-Revised (SAST-R)56 is a 25-item dichotomous inventory that measures levels of distress and impairment arising from sexual compulsions. The aggregated SAST-R total score, referred to as the core dimension, has been found optimal as a valid diagnostic indicator (core >6) of sexual distress and impairment severe enough to require hospitalization. The SAST-R also provides dimensional component scores as well in five important areas of sexual functioning. The Preoccupation with Sex Scale assesses the frequency with which one thinks about sexual intercourse (“Do you find yourself preoccupied with sexual thoughts” or “Is sex almost all you think about”). The Loss of Control Scale assesses how much control one believes they have to stop or reduce their sexual desire (“Have you made efforts to quit a type of sexual activity and failed” or “Do you ever think your sexual desire is stronger than you are”). The Relationship Disturbance Scale assesses relationship difficulties due to sexual activities (“Has your sexual behavior ever created problems for you and your family” or “Has anyone been hurt emotionally because of your sexual behavior”). The Affect Disturbance Scale assesses the distress experienced from one's sexual activities (“Do you feel that your sexual behavior is not normal” or “Have you felt degraded by sexual behaviors”). The Internet Scale assesses a person's sexual activities online (“The internet has created sexual problems for me” or “I spend too much time online for sexual purposes”). The reliability (alpha scores ranging from .89 to .95) and validity of the SAST-R have been established in many sources.57–61 A customized item was added to identify the total number of sessions the respondent has had with mental health professionals where concern about the “nature of your sexual fantasies” was discussed (0 = none/never; 1 = once; 2 = twice; 3 = 3 times; 4 = 4 times; 5 = 5 or more sessions; 6 = I have received formal treatment for my sexual fantasies).
Personality Inventory for the DSM-5 (brief form). The DSM-5 initiated a transition in the formulation and measurement of personality disturbance from categorical (theoretical) to dimensional (empirical) conceptual models. Although the same categorical criteria were retained in the DSM-5 iteration, the task force functionally initiated a moratorium to allow time for accelerated research on dimensional measurement approaches such as the PID-5.40–42,62 The PID-5 and its 25-item brief version [PID-5-BF42] can be accessed on the American Psychiatric Association website ( www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures). Both measure five trait domains (antagonism, disinhibition, negative affect, detachment, and psychoticism), with the longer version providing an additional 25 constituent facet scores. All items are scaled using the same four-point metric (0 = very false or often false; 1 = sometimes or somewhat false; 2 = sometimes or somewhat true; and 3 = very true or often true). Trait domain scores range from 0 to 15 and are not calculated if more than 25% of the contributing items were left blank. Missing scores within this exclusion criterion are assigned the average of the completed items. The reliabilities and concurrent validities of the trait domain scores of the PID-5-BF have been established in recent studies.63–67
These results can be best generalized to American women (57.7%) and men (42.3%) between the ages of 18 and 84 years (mean = 36.69, standard deviation = 11.8) who are represented in the following demographic distributions: education (less than high school, 0.9%; high school graduate, 11.4%; some college, 27.7%; associate's degree, 13.5%; bachelor's degree, 33.6%; master's degree or equivalent, 11.6%; PhD/MD/JD, 1.3%); marital status (married or cohabitating, 57.9%; separated or divorced, 13.5%; single, 28.6%); religion (Christian, 52.6%; Muslim, 1.2%; Jewish, 2.6%; agnostic, 14.4%; atheist, 17%; other, 12.2%); or sexual orientation (heterosexual, 82.6%; gay/lesbian, 5%; bisexual, 9.1%; other, 3.3%). Ethnicity in this general population sample was distributed as follows: White, 73.4%; Black, 8.2%; Hispanic, 4.9%; Asian, 5.6%; American Indian, 0.9%; multiracial, 6.2%; and other, 0.8%. Recent United States ethnicity census figures illustrate similarities and differences with these sample distributions (White, 60.7%; Black, 13.4%; Hispanic, 18.1%; Asian, 5.8%; American Indian, 1.3%; Multiracial, 2.7%).68
The endorsement of domination sexual fantasies were distributed differentially among the heterosexual (13.7%,) gay/lesbian (12.2%), and bisexual (21.8%) respondents (χ2  = 3.92, P = .141). The endorsement of humiliation sexual fantasies occurred more frequently among the bisexual (19.2%) as compared to the heterosexual (5.4%) or gay/lesbian (2.4%) respondents (χ2  = 22.9, P < .001). This elevation in humiliation fantasies occurred for both the men (χ2  = 10.17, P = .006) and the women (χ2  = 13.01, P = .001) in this sample. Humiliation fantasies within the three sexual orientation groups did not differ significantly by gender (χ2  = 2.34, P = .310).
The prevalence rates of persistent exclusive domination or humiliation sexual fantasies in this sample were 12.1% and 4.6%, respectively (Table 1). Although gender effects were found for nine of the maladjustment indicators, these cell distributions were not found to differ significantly by gender (χ2  = 5.92, P = .052). Gender did not interact with group assignment for any of the developmental or maladjustment indicators.
Table 2 presents descriptive statistics for the developmental and maladjustment indicators examined in this study. Core SAST-R scores exceeding 6 were used to identify respondents who were sexually distressed and compulsive. The prevalence rate of sexual distress among control respondents in this general population sample was 12.4%, with significantly higher rates found among others who acknowledged prominent humiliation (33.3%) or domination (24.7%) sexual fantasies (χ2  = 19.10, P < .001). The risk of maladaptive sexual distress was elevated by both humiliation (relative risk [RR] = 3.69 [95% confidence interval [CI]: 1.59–4.55, P < .001) and domination (RR = 3.29 [95% CI: 1.32–3.01], P = .001) sexual fantasies.
Descriptive Statistics for Developmental and Maladjustment Indicators in Total Sample
Table 3 documents differences in developmental and maladjustment indicator scores across the sexual interest groups. Domination fantasies were associated with heightened hypersexuality and permissive attitudes toward sex. Humiliation fantasies were associated with hypersexuality and promiscuity. Evidence of elevated sexual distress was pronounced, particularly for respondents who recurrently fantasized about being humiliated or made to suffer by sexual partners. Antagonistic, disinhibited, and eccentric personality dispositions, particularly among this masochistic subset, were also evident. These maladaptive personality indicators were not relatively higher among respondents exhibiting elevated (SAST-R Core >6) sexual distress and impairment (Λ [10, 1,398] = 1.34, P = .202). Respondent age had a small effect on selected criterion measures but was controlled as a covariate in all analyses. A set of unreported collateral analyses were also conducted to assure that none of these findings were confounded by respondent age.
Paraphilic Interest Group Differences in Developmental and Maladjustment Indicators
The Control and Domination groups differed significantly on the following measures: Sexual Desire Inventory (SDI)-2 hypersexuality; BSAS permissiveness; mental health treatment; antagonism, disinhibition, psychoticism, and all six SAST-R sexual distress indicators. The Control and Humiliation groups differed significantly on the following measures: SDI-2 hypersexuality; number of sex partners, and all six SAST-R sexual distress indicators. The Domination and Humiliation groups differed significantly on the following measures: number of sex partners, BSAS permissiveness, mental health treatment, core sexual addiction; loss of control; and affective disturbance.
CSA severity did not differ between the three comparison groups for either men or women. The prevalence rates for any past CSA (Sexual Abuse & Assault Self-Report >0) were 29.7%, 7.2%, and 13.6% for the humiliation, domination, and comparison groups, respectively. The relative risk of developing humiliation fantasies was associated with CSA victimization prior to age 13 years for the women (RR = 2.69 [95% CI: 1.32–5.91], P = .007) but not the men (RR = .02 [95% CI: 0.14–7.67], P = .982). CSA did not appear to elevate the risk of developing sadistic interests for either the women (RR = 0.71 [95% CI: 0.33–1.69), P = .478) or the men (RR = 1.44 [95% CI: 0.04–1.67], P = .148).
Respondents included in the humiliation (“being humiliated or made to suffer”) or domination (“asserting dominance over someone”) cohorts in this study reported that those respective fantasies were relied upon to achieve arousal in more than 80% of their sexual activities. All of these respondents first indicated that the same fantasies occurred at least once previously in his or her life, and respondents were excluded from analysis in those cases in which an inconsistency to this answer was identified. This assignment process generated fairly well-defined groups, with an interest in either being the perpetrator or victim of sadomasochistic acts, but not both. The prevalence rates for domination (12.1%) or humiliation (4.6%) seemed generally consistent with estimates provided in the DSM-5, but they did appear to be relatively smaller than found in other sources.2–4 The definitional standard required in this study (reliance on the specified content to achieve arousal in more than 80% of sexual acts) was more stringent than those applied previously. This higher benchmark (and consistency check item) assured that the respondents assigned to each group relied almost exclusively on the selected erotic theme.
Developmental antecedents for domination fantasies included permissive attitudes toward sex and hypersexuality. Humiliation sexual interests were associated with hypersexuality and promiscuity. Female victims of CSA prior to age 13 years were more likely (RR = 2.7) to develop humiliation fantasies than counterparts who were not abused. CSA was not associated with domination interests for either gender. Religiosity and ethnical ideals did not differ significantly between the three groups. Respondents describing frequent humiliation fantasies were more likely to be sexually victimized before adolescence and then develop what appears to be precocious sexual interests and behavior. The precursors to domination interests may be traced more logically to coarsened personality development than sexual victimization.
Respondents harboring sadistic or humiliation fantasies were far more likely to describe heightened sexual distress on all of the SAST-R indicators. Clinical elevations (SAST-R >6) were observed among 33.3% (RR = 3.7) and 24.7% (RR = 3.3) of the humiliation and domination groups, respectively, as opposed to only 12.4% for comparison respondents. These links between sadomasochistic fantasizing and maladjustment were largely restricted to sexual functioning symptomatology as measured by the SAST-R. Respondents assigned to these two target groups did report more concerns than their normative counterparts regarding their sexual preoccupation, behavioral control, affective regulation, relationship conflicts, and internet use. The definitional standard applied in this study was designed to isolate respondents whose sex lives were largely driven by domination or humiliation fantasies. In this regard, these two cohorts may have expressed greater symptomatic manifestations of sadomasochism than those found in studies of the phenomenon when no severity or frequency definitional anchors were applied.
None of the five PID-5-BF domain scores were elevated within the humiliation cohort despite evidence of sexual distress on all five SAST-R indicators within this cohort. Evidence of antagonism, disinhibition, and especially psychoticism was evident, however, among respondents who indulged in domination fantasies. These findings support other data showing intuitive links between sadistic tendencies and antagonism6,41,42 and disinhibition.41,42
DSM-5 formulations for sexual sadomasochism emphasize distinctions between these paraphilic interests and formal disorders.1,13,14 It is a popular contemporary perspective to avoid value judgments in the establishment of disorder criteria by defining psychopathology on the basis of distress or impairment that emerges secondary to symptom clusters. Evidence of personality pathology in this data set was not more pronounced within the domination group among respondents describing high levels of sexual distress.
Study Limitations and Future Directions
These cross-sectional survey results were generated from self-reports without validation from external criteria. Although all disclosures were anonymous, selected respondents may have harbored concerns that linkages could have somehow been established between their identity and highly sensitive disclosures. The exclusion rate of 18.2% due to inconsistent item endorsements regarding domination and/or humiliation fantasies seemed reassuring given the sensitivity of the questions asked in this survey. Results from crowdsourcing sites may not generalize well to clinical or other more specialized samples that vary substantially from these respondents in the ethnicity (this sample was 75% White), age, sexual orientation, geographic region, cultural mores, and many other factors. It is also worth noting that the control condition (“neither”) in this design consisted of respondents who denied ever engaging in a domination or humiliation fantasy. This cohort may disproportionately represent members of the general public with higher social desirability needs. Elaborations were not provided regarding the broader nature of the fantasy content, and item interpretations presumably varied extensively by respondent.
Some prior research has suggested that sadistic and/or masochistic fantasies may differ in frequency and quality as a partial function of sexual orientation.3 Although respondents who are gay were distributed evenly across the three comparison groups, the humiliation subset was disproportionately represented by respondents who are bisexual. It was also interesting to observe that humiliation for the women was associated with CSA victimization prior to age 13 years. The extent to which CSA constituted an initial form of humiliation early in life could not be determined through this protocol. Although gender group distributions and interactions were not observed for any of the antecedent or maladjustment measures, much closer analysis should be given in future studies to gender and ethnic differences in the development and expression of sadomasochistic sexual fantasies. Traits of antagonism and disinhibition seemed consistent with domination interests, but the potential role of psychoticism6,38 in the genesis of sadistic sexual fantasies seems less intuitive and warrants future attention. The constituent facets of this PID-5 trait domain (unusual beliefs and experiences, eccentricity, and cognitive and perceptual dsyregulation) have not been examined previously as potential antecedents of sadomasochism.
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Paraphilic Interest Group Prevalence Rate Comparisons
||Women, n (%)
||Men, n (%)
||Total, n (%)
Descriptive Statistics for Developmental and Maladjustment Indicators in Total Sample
||Cohen's d (gender effect)a
|Sexual abuse (before age 13 years)
|Number of sex partners
|EPQ ethical idealism
|Mental health sessions
|Sexual distress indicators (SAST-R)b
|Core sexual addiction
|Loss of control
|Maladaptive personality traits (PID-5)c
Paraphilic Interest Group Differences in Developmental and Maladjustment Indicators
||Indicator score, M (SD)
|Comparison (n = 649)
||Domination (n = 97)
||Humiliation (n = 37)
|Sexual abuse (before age 13 years)
|Number of sex partners
|EPQ ethical idealism
|Mental health treatment
|Sexual distress indicators (SAST-R)
|Core sexual addiction
|Loss of control
|Maladaptive personality traits (PID-5-BF)