Coercive sexual sadism disorder

Essential (Required) Features:

• A sustained, focused and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges or behaviours—that involves the infliction of physical or psychological suffering on a non-consenting person.
• The individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them.

Additional Clinical Features:

• Coercive Sexual Sadism Disorder should not be diagnosed among children and should be diagnosed only with utmost caution among adolescents. Sexual acts may occur impulsively or opportunistically during adolescence rather than representing a recurrent pattern of sexual arousal.
• The diagnosis of Coercive Sexual Sadism Disorder is generally not adequately supported when the evidence indicating a sustained, focused and intense pattern of sexual arousal consists solely of a single or very limited number of instances of coercive sadistic sexual behaviour, as there may be other explanations for specific occurrences (e.g., intoxication, opportunity). In the absence of a report of the individual’s sexual thoughts, fantasies, or urges, examples of other forms of evidence supporting the presence of a coercive sadistic arousal pattern include a preference for specific types of pornography; preference over other forms of sexual behaviour; planning and repeatedly seeking out opportunities to engage in coercive sadistic sexual behaviour; or the results of viewing time measures and/or penile plethysmography.

Boundary with Normality (Threshold):

• By definition, Coercive Sexual Sadism Disorder specifically excludes consensual sexual sadism and consensual masochism.

Course Features:

• Individuals with Coercive Sexual Sadism Disorder often report the onset of coercive sadistic sexual interest during adolescence.
• Coercive Sexual Sadism Disorder is relatively stable after young adulthood, but sexual thoughts, fantasies, urges, and behaviours may change over time such that an individual who was assigned a diagnosis of Coercive Sexual Sadism Disorder no longer meets the diagnostic requirements.

Developmental Presentations:

• Advancing age may be associated with decreasing coercive sadistic sexual arousal and decreasing behavioural manifestations of Coercive Sexual Sadism Disorder due to increased impulse control and decreased sexual drive.

Sex- and/or Gender-Related Features:

• Coercive Sexual Sadism Disorder is much more common in men.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Compulsive Sexual Behaviour Disorder: Both Coercive Sexual Sadism Disorder and Compulsive Sexual Behaviour Disorder may involve repetitive sexual impulses, urges or behaviours that result in marked distress or impairment. Coercive Sexual Sadism Disorder is characterized by sexual impulses, urges, or behaviours that are manifestations of a sustained, focused and intense pattern of sexual arousal that involves the infliction of physical or psychological suffering on a non-consenting person. In contrast, Compulsive Sexual Behaviour Disorder is characterized by a persistent pattern of failure to control sexual impulses, urges, or behaviours, regardless of the focus of sexual arousal. If an individual with Coercive Sexual Sadism Disorder is able to exercise some degree of control over the behavioural expressions of the arousal pattern, an additional diagnosis of Compulsive Sexual Behavioural Disorder is generally not warranted.
• Boundary with Conduct-Dissocial Disorder: Conduct-Dissocial Disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others. Coercive or sadistic sexual behaviours that occur in the context of Conduct-Dissocial Disorder but that do not reflect an underlying, persistent pattern of sexual arousal involving the infliction of physical or psychological suffering should not be used as a basis for diagnosing Coercive Sexual Sadism Disorder.
• Boundary with Disorders Due to Substance Use: Episodes of impulsive or disinhibited sexual behaviour, including coercive sexual behaviour, may occur during substance intoxication. Such episodes may not be a manifestation of a sustained, focused, and intense sexual arousal pattern. At the same time, some individuals with Coercive Sexual Sadism Disorder may use substances with the intention of engaging in coercive sexual behaviour that does reflect an underlying paraphilic arousal pattern. A diagnosis of Coercive Sexual Sadism Disorder may be assigned together with a Disorder Due to Substance Use if the diagnostic requirements for both disorders are met.
• Boundary with other mental disorders: The occurrence or a history of sexual behaviours involving the infliction of physical or psychological suffering on non-consenting individuals is not sufficient to establish a diagnosis of Coercive Sexual Sadism Disorder. Rather, these behaviours must reflect a sustained, focused, and intense pattern of coercive sexual sadistic arousal. When this is not the case, other causes of the behaviour need to be considered. For example, coercive sexual behaviour may occur in the context of some mental disorders, such as a Bipolar Type I Disorder during Manic or Mixed Episodes or Dementia.
• Boundary with sexual crimes that do not involve a Paraphilic Disorder: Sexual crimes involving coercive sexual behaviours may consist of actions or behaviours that are not associated with a sustained underlying paraphilic arousal pattern. Rather, these behaviours may be transient and occur impulsively or opportunistically. The diagnosis of Coercive Sexual Sadism Disorder requires that these behaviours be a manifestation of a sustained, focused, and intense pattern of sexual arousal.