Sexual sadism, according to DSM-IV, involves “over a period of at least 6 months, recurrent intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.” In addition, there should be clinically significant distress or impairment.

Acting out sexual sadism with consenting partners usually involves only simulated acts. However, the sadist may be distressed and seek treatment because of the concern that he will lose control and actually injure the partner. Although sadism exists as a disorder in women, in heterosexual practices women are more often acting out the fantasies of their masochistic partners rather than expressing their own paraphilic sadistic fantasies. In extreme cases, sexual sadism may be acted out with nonconsensual partners in rape or lust murder.