Sexual Sadism Disorder 695
Development and Course
Community individuals with paraphilias have reported a mean age at onset for masoch-
ism of 19.3 years, although earlier ages, in cluding puberty and childhood, have also been
reported for the onset of masochistic fantasi es. Very little is known about persistence over
time. Sexual masochism disorder per definition  requires one or more contributing factors,
which may change over time with or without treatment. These include subjective distress
(e.g., guilt, shame, intense sexual frustration,  loneliness), psychiatri c morbidity, hypersex-
uality and sexual impulsivity, and psychosocial  impairment. Therefore, the course of sex-
ual masochism disorder is likely to vary with age. Advancing age is likely to have the same
reducing effect on sexual preference involvin g sexual masochism as it has on other para-
philic or normophilic sexual behavior. 
Functional Consequences of Sexual Masochism Disorder
The functional consequences of sexual maso chism disorder are unknown. However, mas-
ochists are at risk of accidental death while practicing asphyxiophilia or other autoerotic
procedures. 
Differential Diagnosis
Many of the conditions that could be differ ential diagnoses for sexual masochism disorder
(e.g., transvestic fetishism, sexual sadism di sorder, hypersexuality, alcohol and substance
use disorders) sometimes occur also as comorbid diagnoses. Therefore, it is necessary to
carefully evaluate the evidence for sexual masochism disorder, keep ing the possibility of
other paraphilias or other mental  disorders as part of the di fferential diagnosis. Sexual
masochism in the absence of distress (i.e., no disorder) is also includ ed in the differential,