Assignment Instructions

Assignment Instructions Assignment 2: Note: please refer to the DSM IV TR criteria for sadism for this assignment. Please find a real example of a serial murderer in history and provide examples from the individual that justifies that they meet the clinical definition of a sadist. If you want you may pick a character in a film. That said you MUST fully justify that the individual example meets the clinical definition for sadism. The assignments cover the material from the textbook(s) and the supplemental citations. Each assignment response needs to be 1200 words, with APA 6th ed citations and AT LEAST 5 references. Reading material is attached.


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Assignment Instructions
Assignment 2: Note: please refer to the DSM IV TR criteria for sadism for this assignment. Please
find a real example of a serial murderer in history and provide examples from the individual that
justifies that they meet the clinical definition of a sadist. If you want you may pick a character in a
film. That said you MUST fully justify that the individual example meets the clinical definition for
The assignments cover the material from the textbook(s) and the supplemental citations. Each
assignment response needs to be 1200 words, with APA 6th ed citations and AT LEAST 5 references.
Arch Sex Behav (2010) 39:346â??356
DOI 10.1007/s10508-010-9613-4
The DSM Diagnostic Criteria for Sexual Masochism
Richard B. Krueger
Published online: 10 March 2010
American Psychiatric Association 2010
Abstract I reviewed the empirical literature for 1900â??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 nonforensic 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.
DSM, the existent studies that have offered critiques relevant to
the diagnosis of Sexual Masochism, and the few studies that
have used criteria from the DSM in both forensic and not clearly
forensic populations. It will review other information obtained
from community samples and then offer recommendations for
the diagnostic criteria for DSM-V.
Further, for ease of reference, several tables have been developed. Table 1 contains criticisms relevant to Sexual Masochism,
Table 2 lists studies that have utilized DSM-criteria on Sexual
Masochism in exclusively forensic populations, and Table 3
contains studies that have been done using the DSM on mixed
(consisting of both forensic and non-forensic) populations.
Finally, an appendix listing all of the previous DSM criteria sets
for Sexual Masochism (Appendix 1), along with ICD-9 (World
Health Organization, 1989) and ICD-10 criteria (World Health
Organization, 1992), and ICD-10 research criteria (World
Health Organization, 1993) for sadomasochism are appended
(Appendix 2).
Keywords Paraphilia Sexual sadism
Sexual masochism Hypoxyphilia DSM-V
In contrast to the literature on Sexual Sadism (see Krueger,
2009), there are many fewer studies that have utilized the DSM
in the assessment of Sexual Masochism. This article will review
the evolution of the terminology of Sexual Masochism in the
R. B. Krueger (&)
Sexual Behavior Clinic, New York State Psychiatric Institute,
1051 Riverside Drive, Unit 45, New York, NY 10032, USA
Consisted of a literature search by the librarian of the New York
State Psychiatric Institute using the search terms ofâ??â??sexual masochism,â??â?? â??â??sexual sadism,â??â?? â??â??sadomasochism,â??â?? â??â??domination,â??â??
â??â??bondage,â??â??â??â??BDSM,â??â??â??â??perversion,â??â??â??â??paraphilia,â??â??â??â??sexual homicide,â??â??â??â??sexual murder,â??â??â??â??lust murder,â??â??andâ??â??sex killerâ??â??of PubMed
from 1966 through December 15, 2008, and of Psych Info from
1900 through December 15, 2008. Additionally, all of the prior
Diagnostic and Statistical Manuals were consulted as well as
ICD-9 and ICD-10. Articles were culled and attention was
focused on articles using the DSM to make diagnoses of Sexual
Masochism or offering critiques of the diagnostic criteria for
Sexual Masochism or the paraphilias. Discussion of this literature
and the diagnostic criteria was engaged in with colleagues.
Peer reviewed article
Book chapter
Peer reviewed article
Peer reviewed article
Peer reviewed article
Moser (2001)
Berner et al. (2003)
Moser and Kleinplatz (2005)
Spitzer (2005)
Book chapter
Schmidt (1995), Schmidt
et al. (1998)
McConaghy (1999)
Peer reviewed article
Gert (1992)
Peer reviewed article
Kirk and Kutchins (1994)
Campbell (2007)
Peer reviewed article
Grove et al. (1981)
Peer reviewed article
Peer reviewed article
Suppe (1984)
Peer reviewed article
Silverstein (1984)
Campbell (1999)
Peer reviewed article
Tallent (1977)
Campbell (2004)
All, with focus on DSM-IV-TR
All, with focus on DSM-IV-TR
ICD-10 and DSM-IV
All of DSM paraphilias
Broad review of sexology; all of
All DSM diagnoses
Broad discussion of all of DSM
sexual disorders including
DSM-III-R; all paraphilias
All DSM diagnoses
All DSM diagnoses
DSM-III and the paraphilias
Diagnostic criteria criticized
Table 1 Summary of criticisms relevant to the DSM diagnosis of sexual masochism
Contended thatâ??â??medical disorderâ??â??could be applied to human behavior; said that Moser and Hill had
not presented a single case (child or adult) of someone who had been harmed by being given a
diagnosis of a paraphilia
Asserted there were many factual mistakes in the text; that paraphilias were not mental disorders; that
inclusion of paraphilias in the DSM facilitated discrimination and harm to people with variant
sexual interests; and that, for consenting adults, it was not their sexual interests but the manner in
which they were manifest that was a problem and more appropriate focus for therapy
Current studies on differently selected clinical samples reveal changed distribution with masochism
prevailing in outpatient facilities and sadism in forensic settings; no survey data were presented to
support this impression
Argues DSM â??â??pathologizesâ??â?? individuals who have nonstandard sexual interests despite a lack of
research establishing difference in functioning; presents broad review and criticism; suggests the
classification of â??â??Sexual Interest Disorderâ??â??
Suggested that the DSM-IV stated that the severity of sadistic acts increased over time; that while this
may apply to serial or sadistic murderers, who were extremely rare, the lack of presentation for
treatment of subjects who practiced S & M suggested that this was more benign. Said that this
statement regarding progression was made towards sadism generally and was misleading.
Suggested that, in view of the lack of a relationship of S & M with psychiatric pathology, as was the
case with homosexuality, it would be reasonable that sadomasochism should also not be classified
as a disorder
Evidentiary reliability of DSM-IV consistently flounders because of lack of interrater reliability data.
Later books suggested extended this to sex offender assessment
Summarized that the literature reviews completed for DSM-IV revealed a paucity of data supporting
the scientific conceptual underpinning of current diagnostic terminology regarding sexual
Liked definition of mental disorder; would change definition of paraphilia, specifically transvestic
fetishism, to be consistent with definition of mental disorder
Reanalyzed data gathered in original DSM-III field trials and suggested that earlier claims of Interrater
reliability were overstated
Diagnostic reliability had improved in psychiatry because of carefully constructed interview
schedules and lists of diagnostic criteria, along with rigorous training of raters; much work
remained undone
Sexual deviation is not a diagnostic entity. Paraphilias should be removed from DSM. Burden of proof
that these are personally or socially harmful rests with advocates of DSM: deletion may not change
social attitudes
Paraphilias, like homosexuality, should be removed from the DSM; they represent value judgments
only and not scientifically established criteria
Paraphilias, like homosexuality, should be removed from the DSM; they represent value judgments
only and not scientifically established criteria
Arch Sex Behav (2010) 39:346â??356
Peer reviewed article
The ICD diagnoses of Fetishism, Transvestic Fetishism, and Sadomasochism are outdated and not up
to the scientific standards of the ICD manual. They stigmatize minority groups
All with focus on DSM-IV-TR
Peer reviewed article
Kleinplatz and Moser (2005)
Reiersøl and Skeid (2006)
All with focus on DSM-IV-TR
Peer reviewed article
Fink (2005)
Maintained that Spitzer and Fink did not dispute their analysis of the problems with the DSM-IV-TR
criteria for paraphilias and that conservative organizations flagrantly misrepresented their
statements and intent of the symposium it was presented at and the APA. Stated that public opinion
and not science were the main reason to keep the paraphilias in DSM
Diagnostic criteria criticized
Table 1 continued
Expressed that there must be some way of differentiating between the normal and abnormal ways in
which people get aroused, excited, and fulfilled. Thought it was important to retain paraphilic
diagnosis â??â??in order to save some people from jail and others from themselvesâ??â??
Arch Sex Behav (2010) 39:346â??356
Summary of Evolution of Diagnostic Criteria for Sexual
Masochism in the DSM
Masochism was not mentioned in DSM-I (American Psychiatric Association, 1952). It was added to DSM-II for use in the
United States only (American Psychiatric Association, 1968)
(Appendix 1).
It was continued in DSM-III (American Psychiatric Association, 1980), where this diagnosis was made with either of the
items: â??â??(1) A preferred or exclusive mode of producing sexual excitement is to be humiliated, bound, beaten, or otherwise
made to suffer, or (2) The individual has intentionally participated in an activity in which he or she was physically harmed or
his or her life was threatenedâ??â??(p. 274). Thus, an individual could
have been diagnosed with this disorder only for participating in
such activity with a consensual partner, if this was preferred or
DSM-III-R (American Psychiatric Association, 1987) changed
to require two criteria:â??â??A. Over a period of at least six months,
recurrent, intense sexual urges and sexually arousing fantasies
involving the act (real, not simulated) of being humiliated,
beaten, bound, or otherwise made to suffer.â??â??Andâ??â??B. The person has acted on these urges, or is markedly distressed by them.â??â??
Here again, the occurrence of such urges or fantasies in an individual who was practicing S & M with a consensual partner
was in itself considered pathological, providing substance to the
claims by S & M practitioners that their particular behavior had
been selected out as being pathological per se.
In DSM-IV (American Psychiatric Association, 1994), the A
criterion was continued, substantially unchanged: â??â??A. Over a
period of at least 6 months, recurrent, intense sexually arousing
fantasies, sexual urges, or behaviors involving the act (real, not
simulated) of being humiliated, beaten, bound, or otherwise
made to suffer.â??â?? And the B criterion, as with the other paraphilias, was modified to incorporate elements of subjective distress or dysfunction:â??â??B. The fantasies, sexual urges, or behaviors
cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.â??â??Finally, DSMIV-TR (American Psychiatric Association, 2000) made no
changes in the criteria.
Review of Criticisms Relevant to Sexual Masochism
Many criticisms relevant to Sexual Sadism are also relevant to
Sexual Masochism, and are contained in Table 1 and will not be
repeated here (see Krueger, 2009). Generally, these indicate,
among many concerns, that the paraphilias, or sadomasochism,
should not be included in the DSM because they are not mental disorders, they are unscientific, they are unnecessary, and
to do so pathologizes groups who engage in alternative sexual
36.7% received
diagnosis of sexual
sadism; 5.4% had
sexual masochism
14.8% of those with
sexual sadism also had
sexual masochism
Diagnoses on the basis of review
of written reports done by 20
forensic psychiatrists
Review of psychiatric
court records
Hill et al. (2006,
2007, 2008)
166 men who
were sexual
8.5% sexual sadism; 2%
sexual masochism
Mental health professionals as
part of commitment
Legal files of 120 sexual
offenders in Arizona
Becker et al. (2003)
2 of 45 had sexual
sadism; 0 had sexual
Interview; prospective study
using structured diagnostic
Interview of volunteers
with pedophilia using,
among other things,
sexual SCID
Raymond et al.
45 males with
Number of and
source of subjects
criteria used
Methods of diagnosis and data
Diagnosis of masochism was
examined from the structured
interview for sexual diagnoses
which was used
Conclude that DSM-IV diagnosis of
sexual sadism was more useful
and precise than the ICD-10
sadomasochism; however,
follow-up for an estimated
recidivism for 20 years at risk was
not significantly related to
diagnosis of sexual sadism
Table 2 Summary of studies involving assessment of sexual masochism utilizing the DSM in samples drawn from forensic populations
Arch Sex Behav (2010) 39:346â??356
Indeed, Baumeister and Butler (1997) entitled their chapter
in the edited volume Sexual Deviance as â??â??Sexual Masochism:
Deviance without Pathology,â??â??emphasizing that it was not pathological. In a recent chapter on Sexual Masochism, Hucker
(2008) reviewed the literature. He wrote, addressing the call to
remove the paraphilias from the DSM:
On the other hand, the fact that a minority of sadomasochists do present with serious injuries or die during their
activities (Agnew, 1986; Hucker, 1985) should make us
consider seriously whether removing these behaviors from
the domain of mental disorders is wise at the present time,
especially as there is much room for more research on
the topic. Kurt Freund (Freund, 1976) applied the term
â??â??dangerousâ??â?? to the more extreme forms of sadism and
masochism, and it would seem prudent at this stage in our
knowledge to continue to refer to these more extreme
cases by such a term, thereby distinguishing them from the
more benign manifestations (â??â??mildâ??â??masochism or erotic
submissiveness) of what may well be a continuum of
behaviors that merges with â??â??normalâ??â?? sexual expression.
(pp. 260â??261)
Review of Diagnostic Studies in Forensic Populations
Only three studies mention the diagnosis of Sexual Masochism
based on the DSM in studies of forensic populations and these
do not indicate a high occurrence of this diagnosis. In a study of
45 males with pedophilia using an unvalidated structured clinical interview for the sexual disorders, Raymond, Coleman,
Ohlerking, Christenson, and Miner (1999) found that no subjects met criteria for sexual masochism, despite the discovery of
numerous other paraphilias, in addition to pedophilia.
Becker, Stinson, Tromp, and Messer (2003) reported on a
review of the legal files of 120 sexual offenders who were petitioned for civil commitment in Arizona. A total of 8.5% received
a diagnosis of sexual sadism and only 2% sexual masochism.
Hill, Habermann, Berner, and Briken (2006) examined court
reports on 166 men who had committed a sexual homicide in
Germany. Psychiatric disorders were diagnosed by the raters
according to DSM-IV. Sixty-one men (36.7%) received a diagnosis of Sexual Sadism, 5.4%. received a diagnosis of Sexual
Masochism, and 14.8% of those with Sexual Sadism also had
Sexual Masochism. Structured diagnostic instruments were used
to make diagnoses of personality disorders, but not for the paraphilic disorders.
To summarize, only three studies have been conducted on
forensic populations that mention Sexual Masochism diagnosed
by the DSM, compared with a substantial volume of studies
examining for Sexual Sadism. One of these studies reported no
Sexual Sadism in a group of 45 males with pedophilia, one an
occurrence of 2% out of 120 civilly committed sexual offenders,
and one 5.4% in a group of 166 men who had committed a sexual
Chapter in book referenced
as personal
Prospective interview of 120 120 total; 88 men with
consecutive males
paraphlias, which
presenting for treatment
included 60 sex
of paraphilias or
paraphilia related
Kafka and Hennen
(2002, 2003)
2,129 patients with selfUnknown; presumably
reported behavior at 140
answers to the Abel
sexual treatment clinics
Assessment For Sexual
in North America
Interest Questionnaire
Unknown DSM criteria
Prospective interview; 34
men in paraphilia group
and 26 in the paraphilia
related group
Kafka and Prentky
Some forensic
Prospective interview of 561 Prospective review of 561 DSM-II and DSM-II with
paraphiliacs in
some modification;
Memphis Tennessee
deviant interest was not a
and in New York City;
necessary component of
none were incarcerated;
one-third referred from
mental health; one-third
from legal or forensic,
and one-third other
Diagnostic criteria used
Abel et al. (1987,
Number of and source of
Structured interview
and questionnaire
Not described;
presumably the
Abel Assessment
of Sexual Interest
Structured interview
and questionnaire
Structured clinical
interview from 1
to 5 h
Most subjects reported sex
crimes but had not been
prosecuted for these
Sadism (4%) and
masochism (11%)
Sadism (2.3%) and
masochism (2.5%)
Suggested use of structured
diagnostic interviews in
future with validated
In the paraphilic group, 4 Suggested structured
(12%) of 34 diagnosed
diagnostic interviews and
with sadism and 3
blind interviewing
(9%) diagnosed with
techniques for future
28 sadism, 17
126 rapists
Methods of diagnosis Results
and data used
Table 3 Summary of studies with any mention of sexual masochism utilizing the DSM in samples that are not entirely forensic
Arch Sex Behav (2010) 39:346â??356
Arch Sex Behav (2010) 39:346â??356
homicide. In this group, 14.8% of men who had Sexual Sadism
also had Sexual Masochism. It is also not clear to what extent
sexual masochism was contributory to any criminal behavior in
these studies. Only one of these studies used structured diagnostic instruments to assess for paraphilic disorders.
Review of Diagnostic Studies in Non-Forensic
Abel, Becker, Cunningham-Rather, Mittelman, and Rouleau
(1988) and Abel et al. (1987) reported on an outpatient population of 561 men seeking voluntary evaluation and treatment
for possible paraphilias in Memphis, Tennessee or in New York
City. In the Memphis sample, all categories of paraphilias were
evaluated; in the New York sample, mostly subjects with a diagnosis of rape or child molestation were seen. DSM-II and DSMIII criteria were used, with all subjects reporting recurrent, repetitive urges to carry out deviant sexual behaviors. Subjects were not
included in the research solely because they had committed the
paraphilic behavior. One-third of this sample was referred from
legal or forensic sources, one-third from mental health sources,
and one-third from other sources. Of these, 28 m …
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