Paraphilia in Geriatric Patients: A Case Series From a General Hospital Setting.

Stroke can lead to various late-presenting complications that manifest weeks to months after acute stroke. While sexual dysfunction is common among stroke patients, hypersexuality and paraphilia are rare manifestations. This case series presents five cases of paraphilia showing the onset of abnormal sexual behaviors following an incident of stroke. The paraphilias in these five cases include sexual sadism, exhibitionism, transvestic fetishism, sexual masochism, fetishism, and zoophilia. Each case presents a unique manifestation of atypical sexual tendencies along with neuroimaging data and treatment approach. This case series contributes to the knowledge about the relationship between the incidence of stroke and the onset of paraphilia.

What if Marquis de Sade Was a Woman? New Evidence of Sex Differences in Behavioral Manifestation of Sadism.

This study aims to explore the behavioral manifestation of sadism in females involved in sexual crimes. The sample includes 24 female sex offenders for which sadism was assessed with the SeSaS. To conduct a gender-based comparison analysis, we conducted a random selection of 100 sadistic male offenders. Bivariate comparisons and multidimensional scaling analysis were used to determine whether behavioral manifestation and dimensions of sadism are different in female sex offenders. Results showed that sadism in women manifests itself differently from male offenders and practical implications are discussed.

Sexual violence, deviance, and the paraphilias in American psychiatry, 1952-2013.

This article explores arguments within American psychiatry from the 1950s around whether rapists were mentally ill. It analyses debates in the lead-up to the various editions of the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders (DSM) from 1952 to the latest version in 2013, focussing particularly on a diagnostic category called 'Paraphilic Coercive Disorder' (PCD). Since the first DSM, American psychiatrists had routinely considered people who committed certain forms of sexual violence to be suffering from mental disorders. For example, 'Paedophilia' and 'Sexual Sadism' had always been considered valid diagnoses. However, the APA refused to pathologise non-sadistic sexual violence committed against adults. Opposition can be classified into four overlapping arguments: uncertainty about 'normal' male sexual aggression, feminist worries about 'excusing' harmful sexual behaviours, concerns about the misuse of psychiatry in courts, and the need to defend the psychiatric profession from encroachments on their 'territory' by non-medically trained psychologists, social workers, and anti-psychiatric activists.

Emotional intelligence in incarcerated sexual offenders with sexual sadism.

Emotional intelligence (EI) is defined by the ability to perceive, manage, and reason about emotions in oneself and others. Studies have reported deficits in EI abilities among certain antisocial populations such as individuals with psychopathy, and enhanced performance among sexual offenders. Despite EI's relevance to offending behaviour, the association between EI and paraphilic offending has been under-studied. We examined the association between EI, sexual offending, and sexual sadism in 80 incarcerated men with sexual offenses and 207 incarcerated men with non-sexual offences. EI was assessed using the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). Sadism was measured using the Severe Sexual Sadism Scale (SeSaS). Results showed that SeSaS scores were positively associated with Strategic EI (the ability to understand and manage emotions), but were not significantly related to Experiential EI. This may reflect core characteristics of sexual sadism including domination and manipulation, challenging the prevalent notion that higher EI is invariably positive.

Serial sexual murder by juveniles and the role of sexual sadism: An international study.

This is a descriptive study of 21 cases of serial sexual murder by children and adolescents spanning nearly the past century and a half. No earlier cases worldwide were identified. Each of these youth committed two or more sexual homicides prior to age 18. Their psychopathological, psychosocial, crime scene behaviors, and offender-victim relationship characteristics are presented. Additionally, the role of sexual sadism and its measurement using the SADSEX-SH rating scale is addressed. Nearly all of the sample had conduct disorder, a paraphilic disorder, and sadistic fantasies, and two-thirds had sexual sadism disorder. Family dysfunction, serious school problems, and average or above IQ levels were typical. Their modus operandi generally reflected predatory behavior and direct contact methods of killing were most common. Two case reports are provided to illustrate the breadth and complexity of these offenders. Juvenile Serial Sexual Homicide is an extremely rare but persistent phenomenon. Prognostic implications and future research directions are discussed.

The Third Backdoor: How the DSM Casebooks Pathologized Homosexuality.

This study argues that institutional psychiatry's pathologizing stance on homosexuality persisted after 1973, when the American Psychiatric Association removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders. It persisted not only through the well-known diagnoses of "ego-dystonic homosexuality" and "gender identity disorder of childhood," but also through case studies published in four editions of the DSM Casebooks (1981, 1989, 1994, 2002), the APA publications advertised as a "learning companion to the Diagnostic and Statistical Manual." These publications contained harmful and false homosexual stereotypes, associating gay men with child abuse, violence, and sexual sadism; associating homosexuality with mental disturbance while failing to similarly mark heterosexuality or bisexuality; associating psychopathology with gay social contexts while failing to similarly mark non-gay social contexts. This study provides evidence that the DSM Casebooks portrayed homosexual women and bisexuals as invisible, and homosexual men as narcissistic, predatory, and dangerous.

Sadistic Sexual Crimes Against Children: Comparing the Manifestation of Sexual Sadism and Crime-Commission Process.

Individuals who commit sexual offenses against children have been shown to be distinctive from adult offenders across both individual and crime characteristics. However, an examination of the literature shows that there are gaps in the research related to whether sadism manifests differently between those who target child compared to adult victims. The current study therefore aimed to explore the differences in the characteristics, crime-commission process, and the dimensions of sadism between sadistic crimes of children (n = 101) compared to those of adults (n = 433). Sexual sadism was assessed with the Sexual Sadism Scale (SeSaS) and binary logistic regression analysis and multidimensional scale analysis (MDS) were performed to examine differences between these two groups. Our results showed that sadistic fantasies manifested into four dimensions for both adult and child victims. In terms of differences, sadistic sexual offenses involving children appear to be reflective of deviant fantasies related to overlapping paraphilias (e.g., sadism and pedophilia). Conversely, sadistic crimes involving adult victims involve a crime-commission process that involves a greater degree of structure to control their adult victim and decrease their risk of identification. Implications for clinical assessment and police investigations are discussed.

Manifestations of sexual sadism in child sexual assault and the associated victim, offender, and offense characteristics: A latent class analysis.

BACKGROUND: Although sadistic child sexual abuse (SCSA) is rare, existing typologies of child sexual abuse have identified the existence of sadistic subtypes in child molestation, as well in the sexual homicide of children. Nonetheless, no study has sought to determine whether there is heterogeneity in the manifestation of sexual sadism between sadistic child abusers. OBJECTIVE: The present study seeks to examine how SCSA manifests differently between offenders, and whether these differences are associated with specific victim, offender, and offense characteristics. PARTICIPANTS AND SETTING: The current sample includes adult males (N = 101) who were involved in a child sexual assault and scored at least a 4 on the Severe Sexual Sadism Scale (SeSas). All offenses take place in France between 1990 and 2018. METHODS: Latent class analysis was used to analyze the sample for heterogeneity. Bivariate analyses were conducted to identify external variables associated with each of the latent classes. RESULTS: Three distinct latent classes were found: the sadistic kidnapper; the sadistic torturer; and the sadistic ritualist. External validity testing also revealed distinctive characteristics associated with each class. CONCLUSIONS: SCSA involves a heterogenous population with distinctive sadistic behavioral manifestations that vary in severity and relate to differences in crime-commission processes and offender characteristics. These findings offer important insights for crime prevention and correctional practice.

Hormonal response to perceived emotional distress in incarcerated men with sexual sadism.

Sexual sadists derive pleasure from humiliation, domination and infliction of pain on victims. They display increased penile arousal and activation of brain regions involved in sexual arousal and emotional states when viewing stimuli depicting individuals in physical distress. Neuroactive hormones modulate these regions, but it is unknown if sexual sadists also have endocrine responses to depictions of individuals in distress. The present study examined endocrine responses, elicited by viewing a video depicting an individual in extreme emotional distress, in incarcerated adult male sexual offenders (n = 23) with varying levels of sadistic traits. Sadism, was measured by the Severe Sexual Sadism Scale (SeSaS). Testosterone (T), adrenocorticotropic hormone (ACTH), and oxytocin (OT) were assayed before and after participants watched a video depicting an individual in emotional distress. T responses to the video were significantly and positively associated with SeSaS scores. There were no significant associations between sexual sadism and OT or ACTH. Our findings provide physiological evidence of atypical processing of distress cues in sadism consistent with the role of testosterone in sexual arousal and aggressive behaviors. These findings have implications for the evaluation and treatment of sexual sadists.

Sexual Sadism: Its Role in the Crime-Commission Process of Sexual Homicide of Children.

This study investigates the role of sexual sadism in the crime-commission process of sexual homicide (SH) involving child victims. A comparison between sadistic and nonsadistic cases involving child victims is conducted by examining the crime context, crime characteristics, methods of killing, body recovery characteristics, and forensic awareness strategies used by offenders. The sample comes from the Sexual Homicide International Database (SHIelD) including 135 cases of solved SHs involving child victims-35 cases with sexual sadism and 101 cases without sexual sadism. The Sexual Homicide Crime Scene Rating Scale for Sexual Sadism (SADSEX-SH) scale is used to identify sexual sadism from crime scene actions. Bivariate and multivariate analysis are performed to examine the differences between the two groups. Findings indicate that sadistic SH of children are characterized by an important level of structured premeditation, the commission of more diversified sexual acts, the use of specific method of killing, and the partial use of forensic awareness strategies. Practical implications in terms of criminal investigations are discussed.

Sexual Sadism Among Sex Offenders in Switzerland.

The Sexual Sadism Scale (SeSaS) was developed to assist in the diagnosis of sexual sadism, and it revealed adequate psychometric properties in prior research. This study cross validated the SeSaS in Switzerland using a sample of 179 male sex offenders. Specifically, the SeSaS conformed to a Mokken model of double monotonicity (scalability coefficient [H] = .46, coefficient of reproducibility [CR] = .89), indicating that it measures a unidimensional construct of sexual sadism with hierarchically ordered items. The reliability of the scale was acceptable to high (ρ = .80, λ2 = .75, κ = .88). In addition, the SeSaS was strongly associated with sexual sadism diagnoses based on mental health manuals (rpb = .60, odds ratio [OR] = 13.02, area under the curve [AUC] = 1) but not with recidivism. The results suggest that the use of the SeSaS may improve the validity and reliability of sexual sadism diagnoses, therefore playing a role in the assessment and management of sex offenders.

The Role of Consent in the Context of BDSM.

Consent represents a central focus in the controversial realm of BDSM-an overlapping acronym referring to the practices of Bondage and Discipline, Dominance and Submission, and Sadism and Masochism. Many authors have argued that the hallmark feature that distinguishes BDSM activity from abuse and psychopathology is the presence of mutual informed consent of all those involved. This review examines the relevant literature on consent in BDSM, including discussions on safety precautions, consent violations, North American laws pertaining to BDSM practice, and the role of the BDSM community with respect to education and etiquette surrounding consent. Practical information relevant to professionals who work toward the prevention of sexual exploitation and abuse is provided. The explicit approach to consent practiced by those in the BDSM community is proposed as a model for discussions around consent in clinical and educational contexts. Criteria for distinguishing abuse from BDSM and identifying abuse within BDSM relationships are outlined. It is our hope to demystify the consent process and add to the growing body of literature that destigmatizes consensual BDSM practices.

Sexual Sadism and Psychopathy in Sexual Homicide Offenders: An Exploration of Their Associates in a Clinical Sample.

Sexual sadism and psychopathy are often considered synonymous with sexual homicide, but there is limited research on their associates in sexual homicide offenders. Associates of dimensional measures of sexual sadism (Sexual Sadism Scale; SeSaS) and psychopathy (Psychopathy Check List-Revised [PCL-R] total, Factor 1, and Factor 2) were examined in 51 male Scottish cases. Over a third were DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-IV) sexual sadists, just under a third screened in with the SeSaS, and a quarter were "Hare psychopaths." Sexual sadism and PCL-R measures were moderately associated. Sexual sadism predicted control, sexual deviance, and unusual behaviour at crime scenes; attempted homicide and having a co-accused; and multiple sexual homicides and previous sexual offending. PCL-R Factor 1 predicted violent, exploitative, and evading detection behaviours at crime scenes; completed homicide; and previous violent offending. PCL-R Factor 2 predicted impulsive behaviours at crime scenes, substance misuse, and previous general offending. Psychopathy and sexual sadism play key roles in sexual homicide, interact with each other, and determine different aspects of offences and offenders.

MTC Sadism Scale: Toward a Dimensional Assessment of Severe Sexual Sadism With Behavioral Markers.

Sadism was initially described as the experience of sexual pleasure produced by acts of cruelty and bodily punishment. Sadism was conceptualized as if sadists were fundamentally different from nonsadists. Recent studies have suggested that sadism is distributed as a dimension rather than as a category. The aim of the current study was to assess the psychometric properties the MTC Sexual Sadism Scale. Our analyses were conducted on a sample of 486 sexual offenders assessed at a correctional institution in Massachusetts. In summary, the results indicate that the MTC Sexual Sadism Scale possesses good psychometric properties for the dimensional assessment of severe sexual sadism with behavioral markers. Moreover, the scale captures a wide range of intensity of sadism among sexual offenders. These results are consistent with prior research and support the current consensus to move toward a dimensional interpretation of sadism. Implications both for clinical assessment and for research on the development of sadism are discussed.

Diagnostic Issues in the Paraphilias.

PURPOSE OF REVIEW: To examine the empirical bases underlying the diagnoses of the paraphilias. We address issues concerning the reliability of these diagnoses and their implications for etiology, treatment, and prognosis. RECENT FINDINGS: Research on these issues with the paraphilias is quite limited except for those paraphilics whose interests lead them to sexually offend. Even among these clients, research has, for the most part, failed to distinguish those who meet criteria for a paraphilia from those who do not, thereby limiting the possibility of drawing firm conclusions regarding the value of a paraphilic diagnosis. Speculations regarding the etiology of the paraphilias are for the most part limited to those who sexually offend and these theories do not distinguish those who do, or do not, meet paraphilic criteria. Treatment of sex offenders, when effective, appears to have the same impact regardless of whether or not clients meet criteria for a paraphilia. In terms of prognosis, it was only among untreated child molesters that a paraphilic diagnosis (in this case "pedophilia") predicted long-term outcome. In the face of these problems, we suggest a dimensional approach to diagnoses may represent an improvement over the current categorical model.

Sadistic Offender or Sexual Sadism? Taxometric Evidence for a Dimensional Structure of Sexual Sadism.

Severe sexual sadism is a disorder of sexual preferences that focuses on humiliation and domination of the victim, sometimes causing grievous injury or death. Because offenders with high levels of sadism represent a risk to both reoffend and cause considerable harm should they reoffend, a diagnosis of sexual sadism has serious implications. The actual diagnosis of sexual sadism is fraught with problems (i.e., low reliability and validity) and exhibits poor consistency across assessments and studies (Levenson, 2004; Marshall, Kennedy, & Yates, 2002a). Various authors have proposed that sadism should be reconceptualized and have suggested that a dimensional approach may be more effective than a classificatory one for diagnosing sexual sadism (e.g., Marshall & Kennedy, 2003; Nietschke, Osterheider, & Mokros, 2009b). The dimension versus taxon question also impacts debates about the etiology and treatment of sadism. We assessed the taxonicity of sexual sadism by conducting a taxometric analysis of the scores of 474 sex offenders from penitentiary settings on the MTC Sexual Sadism Scale, using Meehl's taxometric methods (Meehl & Yonce, 1994; Waller & Meehl, 1998). Findings indicated that sexual sadism presents a clear underlying dimensional structure. These results are consistent with earlier research supporting a dimensional assessment of sexual sadism and indicate that the diagnosis of sexual sadism should be reconceptualized. The theoretical and clinical implications of these findings are discussed.

Convergent Validity of Three Measures of Sexual Sadism: Value of a Dimensional Measure.

Sexual sadism can be described as the sexual pleasure produced by acts of cruelty and bodily punishment. The most common method for evaluating sexual sadism is clinical evaluation, that is, evaluation based on the diagnostic criteria of nosological instruments such as the Diagnostic and Statistical Manual of Mental Disorders ( DSM) or the International Classification of Diseases (ICD). It is also possible to evaluate sadistic sexual preferences by phallometry, which provides a physiological measure of sexual excitation by deviant and nondeviant scenarios. The most recently developed evaluation method is the Severe Sexual Sadism Scale (SESAS), a dimensional instrument that has been empirically validated. Despite the availability of all these measurement techniques, very little research has been conducted on their degree of convergence. Consequently, the aim of the current study was to assess the relationship between these three measures of sexual sadism. Our analyses were conducted on a sample of rapists ( N = 72), assessed in a maximum-security penitentiary. There was no significant relation between phallometric scores and other measures of sexual sadism. There was, however, an important correlation between SESAS scores and Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) sexual sadism diagnosis. Our results are consistent with other phallometric studies, which reported no difference in the penile responses of individuals diagnosed as sadists and those not diagnosed as sadists. Results and implications for future research are discussed.

Is the Sexual Murderer a Unique Type of Offender? A Typology of Violent Sexual Offenders Using Crime Scene Behaviors.

The empirical literature on sexual homicide has posited the sexual murderer as a unique type of offender who is qualitatively different from other types of offenders. However, recent research has suggested that sexual homicide is a dynamic crime and that sexual assaults can escalate to homicide when specific situational factors are present. This study simultaneously explored the utility of the sexual murderer as a unique type of offender hypothesis and sexual homicide as a differential outcome of sexual assaults hypothesis. This study is based on a sample of 342 males who were convicted of committing a violent sexual offense, which resulted in either physical injury or death of the victim. A series of latent class analyses were performed using crime scene indicators in an attempt to identify discrete groups of sexual offenders. In addition, the effects of modus operandi, situational factors, and offender characteristics on each group were investigated. Results suggest that both hypotheses are supported. A group of offenders was identified who almost exclusively killed their victims and demonstrated a lethal intent by the choice of their offending behavior. Moreover, three other groups of sex offenders were identified with a diverse lethality level, suggesting that these cases could end up as homicide when certain situational factors were present.

Assessment of the paraphilias.

Paraphilias are recurrent, persistent, and intense sexual interests in atypical objects or activities. The most commonly encountered paraphilias in sexological or forensic settings are pedophilia, sexual sadism, exhibitionism, and voyeurism. Paraphilias are often comorbid with other sexual, mood, and personality disorders. Assessment and diagnosis require an integration of multiple sources of clinical information, given the limits and biases of self-report (through clinical interview or questionnaires). Clinicians ideally have access to more objective assessment methods, such as phallometric testing of sexual arousal. The accurate assessment and diagnosis of paraphilias is essential to effective treatment and management.

Sexual sadism in sexual offenders and sexually motivated homicide.

This article gives a clinically oriented overview of forensically relevant forms of sexual sadism disorder and its specific relationship to sexual homicide. In sexual homicide perpetrators, peculiar patterns of sexual sadism may be a motivational pathway to kill. Sexual sadism increases the risk for reoffending in sexual offenders. Through psychotherapy and pharmacological interventions, treatment of sadistic sex offenders has to consider special characteristics that may be different from those of nonsadistic sex offenders. Many of these offenders share a combination of sexual sadistic motives and an intact self-regulation, sometimes combined with a high level of sexual preoccupation.