Between submission and pain. Shades of BDSM practices. / Miedzy zaleznoscia a bólem. Odcienie praktyk BDSM.

Many people are interested in BDSM practices. Some people practice and others fantasize about participating in these practices. Several elements are related to BDSM practices that are usually unaccepted in a close relationship, such as a strong dependence of one partner on the other or inflicting pain. BDSM practitioners create various relationships, and in a broader context, their communities. From a clinical perspective, an important issue is whether BDSM relation is consensual and serves the personal and relationship development or it can be a premise for the diagnosis of a paraphilic disorder, or recognizing abuse or mechanism of trauma repetition Adequate understanding of the behaviors that may be described by a patient practicing BDSM requires, however, getting to know the specifics of such relationships. The mental and sexual health professional would be able then to evaluate them adequately, without referring to a subjective norm or bias on stereotype or prejudice.

Current Legal Situation for Patients with Paraphilic disorders and Implications of the ICD-11 for Paraphilic Disorders for Germany.

INTRODUCTION: Recently the guidelines for the diagnosis of paraphilic disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11), have been published. AIM: This article analyzes legal, regulatory, and policy issues relevant to the potential effects of the changes for the classification of paraphilic disorders in the ICD-11 in Germany. METHODS: A forensic and a legal expert in Germany worked with other international experts to conduct this evaluation using an assessment guide provided by the World Health Organization. MAIN OUTCOME MEASURES: Possible effects of the changes for the classification of paraphilic disorders in the ICD-11 on forensic practice, health systems, adjudication of individuals who have committed a sexual offense, and the provision of treatment in Germany. RESULTS: Results highlight the special situation of medical confidentiality in the German health system that facilitates the establishment of preventive networks for the treatment of pedophilic patients. The ICD-11 guidelines will help to clarify the boundary between pedophilic disorder and crimes of child sexual abuse. These will also establish a boundary with other paraphilic diagnostic concepts. We describe the central construct of criminal responsibility in the German legal system in relation to paraphilic disorders, the prominent role of expert witnesses, and the differences in the conceptualization of medical confidentiality within the health care system and within the legal system. CLINICAL IMPLICATIONS: The ICD-11 proposals for paraphilic disorders provide a clearer differentiation, as compared with ICD-10, between variants of normal sexual behavior and sexual behavior that involves a non-consenting person or entity. Particular patterns of sexual preference that are not of relevance to public health, the health care system, or the legal system, such as masochism and fetishism, will no longer be named psychiatric entities and will, therefore, be regarded as private behaviors and destigmatized. STRENGTHS & LIMITATIONS: The assessment shows the specific legal situation in Germany for the treatment of paraphilic patients in a sexual medicine, psychiatric, and legal discourse. However, it was done only by a small number of experts. CONCLUSION: A conclusion of the analysis was that the more specific and narrower definitions in the ICD-11 diagnostic guidelines, compared with those in ICD-10, particularly for pedophilic disorder and coercive sexual sadism disorder, will result in a reduction in false-positive diagnoses. It is unlikely that significant unintended and negative consequences will occur as a result of implementing the ICD-11 guidelines for paraphilic disorders. Briken P, Boetticher A, Krueger RB, et al. Current Legal Situation for Patients with Paraphilic disorders and Implications of the ICD-11 for Paraphilic Disorders for Germany. J Sex Med 2019;16:1615-1622.

The Sadomasochism Checklist: A Tool for the Assessment of Sadomasochistic Behavior.

Various scientific disciplines devoted to the study of sexual behavior are concerned with the understanding of sadomasochistic (SM) practices. However, only a fragmented body of theories, opinions, and studies is available, which limits the systematic study of this field. Empirical studies and tools for the assessment of SM tendencies are particularly sparse. Our aim was to develop a comprehensive tool for the assessment of an individual's engagement in SM practices. A comprehensive 24-item checklist of different types of SM play was generated with the assistance of members of the German SM community, covering both a dominance scale and a submission scale. The sadomasochism checklist was administered in an online study to a sample of 652 adults (345 female, 307 male), with 527 participants being active members in the SM community. Both the frequency of SM behavior and the attraction to the types of SM practices were assessed. Results revealed a one-factor structure for the dominance as well as the submission scale. The distinction between different types of practices (soft play, domination/submission, beating, toys, breath and bodily fluids) was confirmed using principal component analysis. Cronbach's alpha was appropriate. The total scores for the dominance and the submission scale distinguish between participants with different preferences for dominant and submissive practices. The newly developed scale is a reliable and valid tool for the assessment of the frequency of and attraction to SM behavior. It aims to provide the basis for future systematic studies on sadomasochism.

Malignant self-regard: accounting for commonalities in vulnerably narcissistic, depressive, self-defeating, and masochistic personality disorders.

Several personality disorders (PDs) have been of interest in the clinical literature, yet failed to have been adequately represented in the diagnostic manuals. Some of these are masochistic, self-defeating, depressive, and narcissistic PDs. The theoretical and empirical relationships among these disorders are reviewed. It is proposed that a particular type of self-structure, malignant self-regard (MSR), may account for similarities among all of them and provide a better framework upon which to understand the nature of these personality types and their discrimination from related constructs. Subsequently, a questionnaire to assess MSR was created and evaluated for its psychometric properties. The measure was found to be reliable (Cronbach's alpha=.93) and valid, given its correlations with measures of self-defeating, depressive, and vulnerably narcissistic personalities (rs range from .66 to .76). MSR also can be meaningfully differentiated from a nomological network of related constructs, including neuroticism, extraversion, depression, and grandiose narcissism. The utility of assessing self-structures, such as MSR, in the diagnostic manuals is discussed.

Vorarephilia: a case study in masochism and erotic consumption.

Vorarephilia ("vore") is an infrequently presenting paraphilia, characterized by the erotic desire to consume or be consumed by another person or creature. Few data exist on vore though several cases have been reported which appear to be consistent with basic vorarephilic interests. Because this sexual interest cannot be enacted in real life due to physical and/or legal restraints, vorarephilic fantasies are often composed in text or illustrations and shared with other members of this subculture via the Internet. Similarities with aspects of bondage/dominance sadomasochism interests, more specifically dominance and submission, are noted. The current case report describes a man with masochistic sexual interests which intersected with submissive vorarephilic fantasy.

Consensual sadomasochistic sex (BDSM): the roots, the risks, and the distinctions between BDSM and violence.

When practiced consensually, sadomasochistic sex is being increasingly accepted as an alternative sexuality. Here I suggest the possible evolutionary roots of the preferences, draw distinctions between violent, abusive and "healthy" practitioners' partnership, provide clear behavioural markers of the respective situations, and underline some specific problems connected to this sexual preference. Some of the problems are well-known in the community of its practitioners, although they have not yet been described in medical nor scientific sources.

The DSM diagnostic criteria for sexual masochism.

I reviewed the empirical literature for 1900-2008 on the paraphilia of Sexual Masochism for the Sexual and Gender Identity Disorders Work Group for the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The results of this review were tabulated into a general summary of the criticisms relevant to the DSM diagnosis of Sexual Masochism, the assessment of Sexual Masochism utilizing the DSM in samples drawn from forensic populations, and the assessment of Sexual Masochism using the DSM in non-forensic populations. I concluded that the diagnosis of Sexual Masochism should be retained, that minimal modifications of the wording of this diagnosis were warranted, and that there was a need for the development of dimensional and structured diagnostic instruments. It should be noted that this summary reflects my original literature review. Subsequently, interactions with other members of the workgroup and advisors have resulted in modification of these initial suggestions.

Development and validation of the attitudes about sadomasochism scale.

This article describes the development and validation of a new measure, the Attitudes about Sadomasochism Scale (ASMS). Exploratory factor analysis with 213 participants yielded four subscales (Socially Wrong, Violence, Lack of Tolerance, and Real Life). Confirmatory factor analysis with a different sample (n = 258) indicated that this four-factor model fit the data well. Validation analyses using all 471 participants showed that the ASMS positively correlated with other measures of social and sexual conservatism (right-wing authoritarianism, attitudes about lesbians and gay men, sexual conservatism, rape myth acceptance). However, a multiple regression analysis showed that the majority of the variance in the ASMS was not explained by the four measures of conservatism, indicating that the ASMS measures a unique attitudinal construct. Further validation analyses revealed that participants who had prior knowledge about sadomasochism (SM), participants who have engaged in SM, and participants who knew a friend involved in SM all endorsed more positive attitudes on the ASMS. Thus, this study presents a reliable and valid measure of stereotypical and prejudicial attitudes about individuals involved in these nontraditional sexual practices.

Masoquismo y autosadismo / Masochism and self sadism

El autor plantea la diferente organización que sustenta a las distintas clases de masoquismo, tanto desde la perspectiva de la relación objetal, como desde el narcisismo. Parte de Freud para apoyarse en otros autores posteriores. Asimismo, a partir del concepto de masoquismo inacabado de Michel Fain trata de dar una explicación al concepto de autosadismo (AU)

The autor deals with the differences that underlay each kind of masochism. The differences are explained from either an object relationship or narcissism point of view. He starts from Freud´s theories and continues with those from other authors. In addition, he tries to explain the concept of autosadisms (self harm) taking Michel Fain´s incomplete masochism theory as starting point (AU)

Sadism, sadomasochism, sex, and violence.

The true prevalence of sexual sadism (and its variants) is unknown. However, all clinicians will knowingly or unknowingly encounter patients with this disorder. Regretfully, few programs offer adequate education in normal sexuality and even less provide training in the assessment and treatment of pathologic sexual interests. This review synthesizes current theories about possible etiologies of criminal sexual sadism and the resulting implications for diagnosis and treatment of this sexual disorder. Included is a review of theories of criminally sadistic sexual motivations, response patterns, and physiology, including possible neurophysiologic factors and more complex interactions. This review focuses primarily on published English-language scientific studies of sexual sadism. It should be noted that my use of the term sadism refers to nonconsensual sexual aggression.

Should self-defeating personality disorder be revisited in the DSM?

Self-defeating personality disorder (SDPD) was proposed for consideration in the DSM-III-R, but was eventually removed from the manual because of the lack of evidence to support its validity. Yet, after DSM-IV was published, some studies suggested that SDPD may be a viable diagnosis. The purpose of this study was to evaluate SDPD's viability as a diagnostic category. Consequently, SDPD's internal consistency, comorbidity with other Axis I and II disorders, association with psychosocial impairment, and its ability to predict overall impairment in past, current, and global levels of functioning beyond other personality disorder symptomatology was assessed in 1,200 psychiatric evaluated with the Structured Clinical Interview for DSM-IV Personality (Pfohl, Blum, & Zimmerman, 1997). Cronbach's alpha for SDPD criteria was 0.61, and item-total correlations ranged between 0.22-0.38. There was substantial comorbidity of SDPD with depressive, avoidant, and borderline personality disorders, as well as major depression and anxiety disorders. The SDPD group did not significantly differ from psychiatric controls on multiple measures of psychosocial impairment, global functioning, and suicidality. SDPD did not meaningfully add to the prediction of impairment above and beyond other measures of Axis II pathology. It is concluded that the data do not support the reliability, validity, and utility of the SDPD diagnosis.

The ICD diagnoses of fetishism and sadomasochism.

In this article we discuss psychiatric diagnoses of sexual deviation as they appear in the International Classification of Diseases (ICD-10), the internationally accepted classification and diagnostic system of the World Health Organization (WHO). Namely, we discuss the background of three diagnostic categories: Fetishism (F65.0), Fetishistic Transvestism (F65.1), and Sadomasochism (F65.5). Pertinent background issues regarding the above categories are followed by a critique of the usefulness of diagnosing these phenomena today. Specifically, we argue that Fetishism, Fetishistic Transvestism, and Sadomasochism, also labeled Paraphilia or perversion, should not be considered illnesses. Finally, we present the efforts of an initiative known as ReviseF65, which was established in 1997, to abolish these diagnoses.

Autoerotic asphyxia (a case report).

The authors report the case of a young man, 18 years of age, who died as a result of autoerotic asphyxia. In the practice of forensic medicine such cases are presented as deaths from mechanic asphyxia in which, using various means and devices, the neck is constricted or the external respiratory orifices are obstructed with the purpose of achieving sexual gratification as a result of the induced hypoxia. These cases pose serious difficulties to the forensic medicine expert and the coroner because of the difficulties of distinguishing it as homicide, suicide or accident. The young man was found hanging by the neck, suspended on a leather belt attached on the door of his room. A mirror was placed in front of the door, reflecting him in full height. He was dressed in women's clothing (a skirt, a blouse, bikini) and a brassiere padded to resemble female breasts. Pornographic pictures from newspapers and magazines were spread on the floor. The young man had no known history of mental disorders, but there was evidence for bisexual tendencies and behaviour. On the basis of a comprehensive evaluation of the data it was accepted that the death was accidental and was attributed to autoerotic asphyxia. All the characteristic features for an act of autoerotic asphyxia, described in the forensic medicine literature, were found in this case. Autoerotic asphyxia is almost unknown as a distinctive psychopathological entity in this country's forensic medicine practice. The deficiency of theoretical knowledge in this field, as well as the lack of personal practical experience in most of the legal physicians and pathologists could result in erroneous interpretation of such case.

Recognition and management of addictive sexual disorders: guide for the primary care clinician.

With greater awareness of sexual exploitation, professional sexual misconduct, and the sexual issues of public figures, a growing awareness of the problem of sexual addiction is emerging. As a result of public awareness, more cases will be brought to the attention of primary care providers. When primary care providers are confronted by problematic sexual behavior that fits the parameters of addictive illness, they should know what the implications are in order to make appropriate clinical decisions and to evaluate treatment approaches. The purpose of this article is to summarize the nature of the problem, to review critical issues in assessment, to provide treatment options, and to suggest critical factors for monitoring progress.

Masochism revisited: reflections on masochism and its childhood antecedents.

Masochism, originally described as sexual perversion by Sacher von Masoch, was elaborated by Freud to include personality pathology, and further developed by Bieber and others. The DSM-III included sexual perversion and personality pathology as separate diagnoses, but were totally eliminated from the DSM-IV. It is the author's thesis that the masochist's self-abnegating language is diagnostic--a disguised attack expressing fear, hate, and contempt of others.

The depressed masochistic patient: diagnostic and management considerations--a contemporary psychoanalytic perspective.

This article considers the relationship between depression and characterological masochism from a contemporary psychoanalytic perspective. Nosology is discussed historically from Krafft-Ebing to the DSM-III-R category, self-defeating personality disorder. Masochistic character traits are conceptualized as attempts to cope with depressed helpless and hostile feelings that have become part of the core self-concept. Psychotherapeutic strategy for treatment of masochistic patients at different levels of characterological integration is discussed. Many questions about self-defeating personality disorder remain open at present. The need for psychoanalytically informed clinical research on characterological masochism and particularly the relationship between masochism and depression is stressed.