Wednesday, August 20, 2014

Etiology and Other Aspects of Sexual Sadism Disorder

Sexual sadism disorder as defined by the current version of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) is a paraphilic disorder that involves one individual inflicting physical or psychological acts of violence on another non-consenting person, while receiving sexual gratification from the suffering of the victim (APA, 2013).  It has been 20 years since consensual sadomasochistic behavior left its old place among mental disorders. As society progressed towards more liberal views, policy-makers finally realized that the harm comes when there is an evidence of it, i.e. when a person experiences distress or deals damage on someone who never consigned himself to such treatment. On the other hand, if a person is agreeable with sadomasochistic behavior and doesn’t harm others by it, that should not be considered pathological. Although sadistic behaviors are certainly a part of the continuum and exist in everyone to some degree, such as the phenomenon of “cute aggression” may attest (Arnold, 2013) or findings by Buckels, Jones, and Paulhus (2013) that confirmed existence of everyday sadism, we have to recognize malevolent or clinical forms of sexual sadism. Thus, the population of primary focus of this paper is that of offenders and extreme sadists. The DSM-5 states that up to 75% of sexually motivated homicides were committed by sexual sadists (APA, 2013). It follows that the extreme (clinical) form of sexual sadism, found mostly in criminals is of particular interest for forensic and investigative psychology. Studying sexual sadism disorder may potentially have influence in practical world, such as helping police to construct a profile of sexual offender. When studying sadism, among other things, researchers must consider the etiology. When does it become dangerous? Why would some be predisposed to such behavior? The answers to these and other questions will be necessary for prevention, treatment of sexual sadism disorder and, ultimately, for the better understanding of the human nature.

First coined by Austro-German psychiatrist Richard von Krafft-Ebing in 1899, term sadism is derived from the name of 18th century French aristocrat Marquis de Sade, who practiced and described sadism in the novels he wrote. It doesn’t mean, however, that violent sexual practiced didn’t exist before de Sade. In fact, there is evidence in the depiction of both humans and satyrs on historical artifacts in the form of vase paintings from Ancient Greece that Greeks certainly fantasized about what we call these days BDSM (an acronym for  bondage, discipline, sadism and masochism)(Jones, 2010), a set of sexual practices, which include consensual or nonclinical sadism. Other evidence comes from the accounts of eminent historical figures, such as Chinese and Roman emperors, Qin Shi Huang (260 - 210 BC) and Caligula (12 - 41 AD), who were known for their cruelty and sexual orgies. It is a pity, that certain records never survived to modern days to give us complete understanding of changes that underwent in human sexual behavior over the decades.

(Depiction of de Sade by  H. Biberstein)

There are other sources of information about human behavior. Nature often provides analogies of human behaviors in animals and one might question if sadism can be found among those behaviors. However, research of sadism in animals is virtually non-existent. There is research on other violent behaviors related to sex, such as resisted mating (or rape) in ducks and orangutans, which is usually found to have some evolutionary purpose (Crawford & Galdikas, 1986), unlike human extreme sadistic behavior, which is not necessary aiding the survival or reproductive capabilities of the individual, but rather does the reverse. Feelings and emotions experienced by animals constitute a part of an ambiguous and highly controversial area of study. Very few facts about it can be stated with certainty. Human sadists, on the other hand, torment others in order to gain some form of pleasure for themselves, which brings us into discussion of other symptoms of sexual sadism disorder.                                                                                 (Head of Emperor Caligula)

The definition of sexual sadism disorder depends largely on its symptomology. One characteristic common to all paraphilias is an increased sexual drive with some individuals masturbating as many as ten per day (Butcher, Hooley & Mineka, 2014). It is not quite a symptom, but it also appears that most paraphilias, including sexual sadism disorder occur almost exclusively in males. In his essays, Freud attributed the occurrence of sadism in men to the fact that male sexuality always contained a component of aggression (Strachey & Freud, 2000). Moreover, in some cases killing his victim would facilitate an orgasm in a sexual sadist (Stone, 2010), which exemplifies the extreme of male sexual aggression. Current version of the DSM (unlike older versions) specifically states that for sadism to be considered a mental disorder it must be enacted on a non-consenting person or the fantasies associated with sadism must bring severe distress or impairment in functioning (APA, 2013). There are other general characteristics shared by sexual sadism with all paraphilias such as, generally speaking, sexual gratification through the means that are directed either towards inanimate object or an abstract feeling (such as pain of others in sadism). In other words, libido is misdirected in some way or another, but how and why it is so misdirected, is the issue of etiology.

One the most fascinating and important questions we can ask about sexual sadism concerns the etiology or the cause of it. What is the reason for such behavior? What drives an individual to inflict suffering on a non-consenting person? Just like phenomenon of cute aggression, sadism may be the extension of our experience of one another (Arnold, 2013). Martens (2011) says that sadistic behavior is a manifestation of the desire of the sadist to establish deep emotional communication with the victim. So, is it the lack of interpersonal communication that drives people to commit extreme acts of sexual violence? Martens (2011) argues that sadism is not an isolated phenomenon and does not involve a single emotion, but involves many other different needs and factors, while loneliness is just one of them. Indeed, Mokros, Weiss, Schilling, Nitschke, and Eher (2014) found evidence for dimensionality of sadism, suggesting that it is not separated into distinct categories but is part of the continuum. The fact that everyday sadism is not as rare as one may think supports this idea (Buckels et al., 2013). If regular people, who have no sadistic fantasies can, nevertheless, experience pleasure from inflicting suffering on others, means that extreme sexual sadism is not a separate category, but an escalated and multiplied severity of symptoms, present in each of us to a much smaller extent. This universality leads us to explore some psychodynamic factors.

The researchers, like Berner (1997), for instance, theorize that traumatic childhood experiences, which involved physical or psychological pain, witnessing traumatic events (later eroticized or reenacted) and having a cold parent lays at the core of sexual sadism. These longitudinal and psychodynamic elements describe the factors that influenced person’s overall development, not just what drives him at a particular moment, such as, for instance, the desire for communication (Martens, 2010). Freud related sadism and masochism to the manifestations of universal characteristics of sexual life, such as activity and passivity, respectively (Strachey & Freud, 2000). Again, concepts of passivity and activity lay on the continuum and describe universal aspects of sexual behavior. A number of studies found that childhood abuse may serve as a predictor of sexual sadism (Fedoroff, 2008; Nordling & Sandnabba, 2000). Nordling and Sandnabba (2000), for instance, found a small but statistically significant portion of higher childhood sexual abuse in the group of people sampled from two BDSM clubs (i.e. subclinical sadomasochist population). Another study found that isolation in childhood can serve as a predictor of development of sadistic tendencies (Hill, Habermann, Berner, & Briken, 2006), which is true even for women (in terms of both early neglect and abuse) (Southern, 2002). This finding provides some support for Berner’s theory of early traumatic experiences (1997).

There are some, who attribute sexual sadism to a single main factor, such as aggression (Proulx, Blais, & Beauregard, 2006) or coercion (Mokros et al., 2014), but just as objects of tantalizing lust in fetishism are different (bras, shoes, etc.), so are the main themes for each individual sexual sadist may be idiosyncratic as well. The study by Harris, Lalumière, Seto, Rice, and Chaplin (2012) that measured erectile responses of rapists versus non-rapists to the cues of violence and coercion (non-consent) shows that there is no significant difference between responses to those cues. Mokros et al. (2014) found that items of their scale that pertained to sexual violence and sexual coercion, in fact, constitute a single factor. These findings suggest that attributing sexual arousal in sadism to a single factor would be fallacious.  

Aside from theoretical etiologies of sexual sadism disorder, there are various biological factors that may be relevant. It was found, for instance, that EEG of sexual sadists differs from non-sadists by significant desynchronization of EEG rhythms and abnormalities in temporal lobes (Aggrawal, 2008; Stein, 2000; Young, Justice, and Edberg, 2010). Langevin et al. (1988) found significant association between sadism and right temporal horn damage. Although there is no association between brain structure and sexual sadism of single importance, further research in the area may be helpful to establish causal relationship between brain or endocrine abnormalities and sexual sadism disorder. 

There is an uncertainty in defining and diagnosing sexual sadism disorder. Aggrawal (2008) stated that it is very hard to prove that inflicting pain is what actually brings sexual gratification to the patient in question. Self-report has never been esteemed as a reliable measure. When research is conducted on subclinical  (or general) population, there is a chance that people will not report the full extent of their sexual fantasies and, therefore, the rates of sexual sadism will be lower than they really are (Nitschke, Mokros, Osterheider, & Marshall, 2013). There is a chance that offenders may commit sexual crime along with robbery not because they are actual sexual sadists, but because there was an opportunity to commit violent sexual act. Some researchers advocate the decrease in reliance on self-reporting measures when making the diagnosis; instead, they suggest diagnosing based on actions revealed through examination of the crime scene and exact biographical details, both of which are evident and known for certain (Mokros et al., 2014). 
Several scales were developed as a diagnostic aid for identifying sexual sadism disorder. The Severe Sexual Sadism Scale seems to be gaining most of the reverence from the psychological community. It consists of 11 dichotomous (yes or no) questions, which bear relation to forensics.  Nitschke, Osterheider, and Mokros (2009), found it to have a high reliability (rtt = .93), while others found it to have good validity and reliability (rtt = .86), (Mokros, Schilling, Eher, & Nitschke, 2012). Introduction of this scale into regular use will improve diagnostic accuracy of sexual sadism disorder. As a result, less people will be needlessly civilly committed due to misdiagnosis as a part of the doctrine established in Kansas v. Hendricks (1997). 

In that case, Leroy Hendricks was diagnosed with pedophilia. Under the Kansas's Sexually Violent Predator Act, any individual who has “mental abnormality” or “personality disorder” and, therefore, poses threat via his uncontrollable predatory sexual behavior, can be involuntarily civilly committed (Kansas v. Hendricks, 1997). Although committing someone after he served his prison sentence may appear unconstitutional due to the double jeopardy (convicting twice for the same crime), Kansas v. Hendricks (1997) was decided in favor of such civil commitment. It became an avenue to commit some misdiagnosed (or overdiagnosed) individuals. 

The DSM states the onset of the sexual sadism to be around nineteen years old, while sexual sadism by itself to be a lifelong feature (APA, 2013). Interestingly, in the interview with Stone Philips, serial killer Jeffrey Dahmer states that the less he was able 
           (Leroy Hendricks)
to share his thoughts with his family (especially father, who was generally unresponsive and inattentive to his son’s needs), the worse became his perverted fantasies (Phillips, 1994). The DSM states that preoccupation with sadism-themed pornography is one of the factors associated with sexual sadism disorder (APA, 2013), which, in terms of the course of the disorder may serve as a sign of its early development. Increasing age will likely be related to subsiding symptoms. It is likely that a lot of severe sexual sadists will be imprisoned for sexual offence later in life. Thus, it is unclear, whether sadism actually decreases or it is only absence of the opportunity that prevents researchers from seeing what is really happening.

Sexual sadism disorder is often comorbid with other paraphilias and mental disorders. In one study, 95 % of sexual sadists also presented dysthymia (Aggrawal, 2008). Psychopathy is almost universally believed to be related to sadistic behavior (Juni, 2010), as well as narcissism (Rosegrant, 2012). Myers,  Burket, and Husted (2006), found significant overlaps in diagnosis of sadistic personality disorder and other Axis II disorders. Although axial system has been dropped from the DSM-5, the extensiveness (as that of personality disorders) and the dimensionality of sexual sadism disorder is bound to be considered in future research when seeking explanations of the comorbidities. Ultimately, the relation of sexual sadism disorder to other paraphilias and traits (e.g. psychopathy), may reveal deeper secrets of the sadism itself. As Martens (2011) postulated, sexual sadism is a dimensional construct and involves many different needs and drives, thus, in order to unveil the full complexity of it, the researchers must see possible connections and overlaps with other disorders.

Sexual masochism disorder is often seen as the other side of the same coin with sadism (Strachey & Freud, 2000). Indeed, it may be helpful to understand masochism, in order to study sadism. In sadomasochist relationships the two counterparts fit their sexual fantasies precisely to fulfill the needs of one another and, thus, obtain sexual gratification. Pain and humiliation inflicted by sadists is precisely what masochists crave, hence, a masochist would probably know more about sadism than a regular person.

The treatment of sexual sadism, just as the treatment of psychopathy is almost impossible even at the early stage, when patient is in his teens (Stone, 2010). Another problem is that few sadists will actually come to seek treatment. Most sex offenders who are released after serving their prison sentence but diagnosed with sexual sadism may be indefinitely civilly committed (Kansas v. Hendricks, 1997), which seldom has any real effect on their treatment. In psychotherapy, patients will often try to influence therapist into entering sadomasochistic relationship, which poses additional obstacle to improvement (Rosegrant, 2012). Overall, the treatment of sadism appears to be stuck in one place and further research will be required in this area.
Sexual sadism disorder is too complex to be defined by a single factor. Etiology of sadism points to the interplay of several factors (Morkos et al., 2014). Although there is research that found some predictors of sadism (Hill, Habermann, Berner, & Briken, 2006), it is still quite sparse. This suggests that we may not be able to foresee and prevent severe forms of clinical sadism. Treatment of sexual sadism disorder doesn’t offer any optimistic insights either. Perhaps, due to its relation to psychopathy (Juni, 2010) and other mental disorders (Myers et al., 2006; Rosegrant, 2012), sexual sadism is just as embedded in someone as if it was a part of his innate character.  There is progress to be made in research that involves subclinical sadist populations, such as representatives of BDSM subculture (e.g. Nordling & Sandnabba, 2000). Research and analysis of this specific population will be helpful in determining more tenets of sexual sadism. Researchers can’t possibly know the idiosyncratic and ritualized behaviors of every individual who displays sadistic tendencies. Finding a response from BDSM communities and establishing cooperative relationship will prompt forward the research of sexual sadism disorder in a new direction.

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I wrote this review initially as a college paper for Abnormal Psychology class.

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