A 40-year-old man has had recurrent, intense sexual fantasies involving inflicting suffering on his romantic partner for over a year. His current partner willingly consents to these activities and experiences no harm or distress. He himself reports no guilt, no functional impairment, and the couple regard the behaviour as mutually acceptable. According to DSM-5, which conclusion is correct?

• A He does NOT meet criteria for sexual sadism disorder unless the acts were inflicted on a non-consenting person or caused marked distress or impairment ✓
• B He meets full criteria for sexual sadism disorder because the fantasies have lasted over six months
• C He meets criteria for sexual sadism disorder because consent is irrelevant once the fantasies are recurrent
• D He meets criteria for antisocial personality disorder instead, since sadism implies psychopathy

Explanation

For DSM-5, recurrent arousal from the suffering of others over six months constitutes a paraphilia, but it becomes a sexual sadism disorder only when the urges are acted on with a non-consenting person, or when they cause clinically significant distress or impairment. This consensual, conflict-free scenario fails both additional requirements, making option B the trap. Duration alone never establishes the disorder, and sadism does not imply psychopathy.

Reference: Diagnostic and Statistical Manual of Mental Disorders, 5th ed.

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Written and medically reviewed by the StethoPrep medical team.