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“Vicious

You hit me with a flower

You do it every hour

Oh baby you are so vicious.”

Lou Reed “Vicious”

1 Introduction

Sexual behavior has at least a double aspect: to obtain sexual pleasure and to carry out the reproductive function. In addition, such conduct is directed toward a particular object that can be autoerotic (masturbation) or aloerotic (homo- or heterosexual relationships).

Perversions, sexual inclination disorders, or paraphilias are a sexual, psychic, social, political, transhistorical, and structural phenomenon throughout all human societies and civilizations. In fact, all cultures share common elements: the prohibition of incest, the delineation of forms of dementia or mental insanity, and the description of what is accepted as monstrous or abnormal.

Although depraved people may be sublime when they turn their passions into art, creation, or mysticism (e.g. Sade, Sacher-Masoch, Mishima, Pasolini, etc.), or abject when they submit to their murderous or antisocial impulses, they are part of ourselves, part of our human condition, since they exhibit what we try to hide: our own negativity, our dark side [1].

Sexual perversions have been the subject of numerous works, including scholars’ dictionaries of sexuality, eroticism and pornography. However, there is not a record of the “depraved” people. Michel Foucault had planned to include in his Histoire de la Sexualité a chapter devoted to the world of evil, that is, to those who have been described as such by a society concerned about dissociating themselves from their own dark side:

“Who are nowadays the depraved? And where does perversion begin? In a world where science has replaced divine authority, body has substituted the soul and aberration has substituted the evil, perversion remains regardless of what we think about it or what we don’t, as a symptom of dehumanization, of annihilation” [1].

2 Historical Background

Before talking about paraphilias we should point out that although two genres coexist, most of the sexual perversions listed in psychopathology manuals have been conceptually developed by men. This is not a coincidence or a trivial fact if we consider the development of the history of human sexuality, especially from a gender perspective.

For centuries the idea of two genders has not existed, since male has prevailed over female throughout history, building the female figure into opposition to the male one, and even considering the vagina to be a reversed penis. Galen, whose works remained important until the Renaissance, believed that women were less complete than men in relation to the reproductive parts concerning reproduction. This author, based on the works of Aristotle and on the higher internal body temperature of men, argued that women had a natural disposition to submit and serve and considered them to be weak, crippled. According to Galen, the male fetus was able to turn his genitals out and thereby become a complete human being, while the female genitalia remained inverted and underdeveloped [2].

During the Middle Ages Alberto Magno went further, stating that if a girl originated during this process it was because of certain factors that have prevented the attachment to her body, hence the woman was not in her nature a human being, but a failed birth. In the eighteenth century the ovaries were considered to be female sperm ducts. While men had sexual attributes that can display and enhance, women were deprived of a place, and they were invested on a nonidentity, not only a physical one but also a linguistic deficiency, and consequently a social and cultural fault. The fact that women were derived from a proper and recognized denomination of their own sexual organs resulted in the separation of girls from their bodies and later in distancing them from their own sexual identity [2].

The lack of proper terminology establishes a difference between men who “have something” and women who do not. This certainly plays a role in the nuclear development of female sexuality, in how desire is outlined and how potential female perversions are subsequently established. The fear of daughters’ sexuality is in fact greater than the fear that arises from their sexual health. How would girls describe what happens to them when they suffer sexual abuse if they do not even know how to name their own genitals?

Harriet Lerner, in an article published in 1970, mentions a well-known book, which explains: “a young woman has two ovaries, uterus and vagina. These are her sex organs. Young men’s sex organs are the penis and testicles. One of the first changes in the body of the girl during puberty is the growth of pubic hair around the vaginal opening”. In the face of this statement the author adds: “Such a partial and misleading name of the female genitalia can induce any young at puberty to sit on the floor of the bathroom with a mirror and come to the conclusion that it is a deformed creature” [3].

Young women cannot talk to each other about their genitals, and each reference to them remains reduced to the strictly private sphere, where no one speaks about it. What kind of perversion can women develop (with the exception of masochism, given the supposed willingness to submit postulated by Galen), if they lack even a name that identifies their genitals?

The repression of female sexuality in the western world, associated with the preponderance of the Christian religion, has been constant over time and history. This fact has a significant impact on both the oppression of women and the denial of their rights. The representations of hell and the jaws of depths in medieval painting are staged by obvious vaginal attributes. According to a famous saying (so widespread that it is collected in the Malleus Maleficarum, from the Latin “Hammer of the Witches”) there are three insatiable things: the hell, the grave, and the vulva of women [1].

Thus, we should not forget that the original sin (ancestral sin) was committed by Eve (before her the snake, identified with the devil, also did it). As a result all Mankind was expelled from Paradise. By offering that apple to man, Eve becomes his guide. The idea of women being men’s teachers is so threatening that Paul the Apostle prohibits them from any kind of verbal expression in public: “Women should listen to instruction in silence with all submission, and they should not be allowed to teach in public or over a man. I want them to remain silent, because God made Adam first, then Eve, and not Adam but Eve was deceived, and being deceived she felt into sin” [1].

If moderation in language is considered an ideal for all women, in the case of nuns this culminates in the requirement of tears instead of speaking. For art historian Silke Tammen, this fact has a direct effect on the distinction between femininity and passivity. Not only do female sexuality and legends about the vagina dentata sound threatening but so does the female voice, and legends speak about seafarers who, after listening to the sirens singing, lose their sanity and jump into the sea in search of them [1].

The archetypal fatal woman (femme fatale) who attracts men into the depths by revealing her body (such as Salome, the Jewish princess described in the Bible) has been a source of inspiration for writers, painters, and artists throughout history, especially in the nineteenth and twentieth centuries.

Women, who were considered to be impure by Christianity only because of their femininity, had to be purified. For this purpose in the Middle Ages mystic women organized sacrifice rituals that ranged from flagellation to devouring filth. The purpose of all these rituals is to destroy the physical body or expose it to the torments of the flesh, while they obtain some form of sexual satisfaction. The body, broken or bruised, fascinates the saints and holies. This particular relationship with the flesh is because Christianity is the only religion in which God is incarnated to live and die as a man, and incidentally as a victim. It is clear that this religion confers to the male body such a predominant status.

St. Margaret Mary Alacoque was so frail that the slightest piece of dirt made her stomach sick. However, when Jesus “called her to order” to clean the vomit from a sick patient, she could not think of anything but turning the vomit into her food. In another occasion she ate the excrement of a dysenteric woman, and she stated that the contact with excrement raised in her a vision of Christ that kept her lips close to his injury: “If I had a thousand bodies, a thousand loves, a thousand lives, I would sacrifice all of them for being submitted to you” [1].

St. Catherine of Siena came to declare that she had not eaten anything as delicious as the pus of cancerous breasts. Later she heard Christ speaking to her: “My beloved woman, you have experienced for me a hard battle and with my help you have been victorious. You’ve never been so dear to me and so pleasant as now” [1].

3 Definition and Conceptual Aspects

We understand perversion, paraphilia or sexual orientation disorder from a medical point of view, the deviation from the sexual act considered “normal” (see Table 11.1).

Table 11.1 “Abnormal or deviant” sexual behavior
Full size table

The paraphilia or sexual perversion is defined by a set of fantasies, needs or unusual sexual behavior, generally repetitive, that produce sexual arousal in some people, and that are clearly far away from the previous precepts.

In the past, a much more extensive view of perversion was held regarding the diagnosis of modern paraphilias. It is worth mentioning it because some doctors continue to have the same beliefs as before. This means that in some places we can still talk about perversion when orgasm is reached with different sex objects, with different parts of the body (not only the genitals), or when orgasm is subject to certain non-genital extrinsic conditions that cannot provide sexual pleasure by themselves.

These attitudes lead to a double view of sexuality among doctors: the “official” opinion, advocated by the scientific and research societies, defining paraphilias as very specific clinical situations, and another, “unofficial” view of some professionals still sticking to approaches of 40 or 50 years ago that leave a strong sociocultural and religious mark.

Laplanche and Pontalis [4] further extend the field to designate as perversions the whole range of psychosexual activities accompanying the previously explained atypia in obtaining sexual pleasure. According to Spanish psychoanalyst Coderch [5] perverse individuals exclude genital union with a person of the opposite sex from the fact of obtaining sexual pleasure, or they even subject it to certain acts that do not belong to sexual intercourse, such as the presence of a third individual, cruelty, harm to the couple, the use of a particular type of clothing to have sexual relations, sexual relations with minors or sexual relations related by blood.

The main element for the diagnosis of a paraphilia is the presence in these individuals of specific and repetitive sexual fantasies with a double conscious and unconscious component, in which both excitation and sexual practice and attainment of orgasm are associated. The influence of these fantasies and of their behavioral manifestations are beyond strictly sexual arousal, and come to invade all spheres of an individual’s living and fantasies, making them the preferred or the only ways of obtaining sexual satisfaction.

The presence of a sexuality that is called perverse based on the most classical psychopathological criteria is a constant in much of universal art and literature. For western civilization from Sade to Von Sacher-Masoch, from Henry Miller to Lucian Freud, from Robert Mapplethorpe to Helmut Newton, from Bernardo Bertolucci to Federico Fellini, from Pier Paolo Pasolini to Stanley Kubrick, sexuality often diverts from that ideal encounter that is considered to be “normal,” and this also indicates the great variety of artistic evidence since the origins of humanity.

In fact, is art possible without violence or eroticism? Do sex and blood not form the basis of any artistic work? Camille Paglia [6], a specialist in art history and disciple of Harold Bloom, claims that sex and violence are always close to the social and personal surface. In her opinion all culture, even in the highest expression of art, is but a means by which the human being protects itself from nature, which is cruel and merciless. And nature is blood and semen, violence and sex, which hovers inevitably over every cultural product. For Paglia, “all the roads which arise from Rousseau take to Sade.” Sexuality and eroticism are an inevitable result of the intersection between nature and culture.

4 Epidemiological Aspects

In a study in which 94 men are interrogated (a general, not a clinical population) about their sexual fantasies during masturbation or intercourse: 61.7 % say they fantasize about initiating a girl into sexuality; 33 % describe fantasizing about raping adult women; 11.7 % describe masochistic fantasies; 5.3 % fantasize about having sex with animals; and 3.2 % describe fantasies about initiating a boy [7].

Meanwhile, another study on a non-clinical population comprising 60 male college students shows that 42 % admits having practiced voyeurism; 35 % frotteurism; 8 % have made obscene phone calls; 5 % have participated in coercive sexual practices; 3 % have had sexual contact with girls under 12; and 2 % has practiced exhibitionism. In total, 65 % say that they have participated in some form of paraphilic behavior. In this same group 54 % recognize that they have an interest in practicing voyeurism; 7 % want to practice exhibitionism, and 5 % crave sexual contact with children under 12 years of age [8].

With regard to clinical populations, the data collected over 90 treatment programs in the United States relating to 2,129 cases of individuals seeking psychiatric evaluation, we can conclude the following: 37.1 % have been involved in child abuse; 20.2 % in voyeurism; 13.8 % in indecent exposure; 13.3 % in fetishism; 11.2 % in frotteurism; and 10.7 % in public masturbation [7].

Meanwhile another study of 561 paraphilic people (mostly men) who have committed more than 291,000 such acts against more than 195,000 victims, indicates that 37.3 % were victims of exhibitionism; 28.6 % of frotteurism; 13.6 % of voyeurism; 11.8 % of child abuse outside of the home; 3.5 % of public masturbation; 2.3 % of abuse of girls outside of the home; 1 % were victims of obscene phone calls; 0.9 % of bestiality; 0.5 % of the rape of adult women; 0.2 % of child abuse at home; another 0.2 % of urophilia; and 0.1 % of sadism, fetishism, masochism or coprophilia [7].

The true prevalence of sexual perversions is unknown to us. The best estimations derive from cases of legal claims, according to which the most widespread paraphilia is pedophilia [9]. Such disorders are practically confined to the male sex. Half of them have symptoms before they are 18 years old, and decline significantly (at least from a criminal point of view) past the 50s. Frequently, the same individual of up to three or four different paraphilias, depending on the biographical timeline considered. In the latter case the adjective “polymorphous perverse” is applied to describe the coexistence of multiple sexual deviations in the same person [10].

According to new edition of the American Psychiatric Association’s DSM-5 [11]:

  • “Voyeuristic acts are the most common of potentially law-breaking sexual behaviors. The population prevalence of Voyeuristic Disorder is unknown. However, based on voyeuristic sexual acts in nonclinical samples, the highest possible lifetime prevalence for Voyeuristic Disorder is approximately 12 % in males and 4 % in females (ratio male–female 3:1).

  • “The prevalence of Exhibitionistic Disorder is also unknown. However, based on exhibitionistic sexual acts in nonclinical or general populations, the highest possible prevalence for Exhibitionistic Disorder in the male population is 2–4 %. The prevalence of this disorder in females is even more uncertain, but it is generally believed to be much lower than in males.

  • “The prevalence of frotteuristic acts, including the uninvited sexual touching of or rubbing against another individual may occur in up to 30 % of adult males in the general population. Approximately 10–14 % of adult males seen in outpatient settings for Paraphilic Disorders and hypersexuality have a presentation that meets diagnostic criteria for Frotteuristic Disorder. Hence, whereas the population prevalence of Frotteuristic Disorder is unknown, it is not likely that it exceeds the rate found in selected clinical settings.

  • “The population prevalence of Sexual Masochism Disorder is once again unknown. In Australia, it has been estimated that 2.2 % of males and 1.3 % of females had been involved in bondage and discipline, sadomasochism, or dominance and submission in the past 12 months. Community individuals with paraphilias have reported a mean age at onset for masochism of 19.3 years, although earlier ages, including puberty and childhood, have also been reported for the onset of masochistic fantasies. Very little is known about persistence of this disorder over time.

  • “The population prevalence of Sexual Sadism Disorder is equally unknown and it is largely based on individuals in forensic settings. Depending on the criteria for sexual sadism, prevalence varies widely from 2 to 30 %. Among civilly committed sexual offenders in the United States, less than 10 % have sexual sadism. Among individuals who have committed sexually motivated homicides, rates of sexual sadism disorder range from 37 to 75 %. Individuals with sexual sadism in forensic samples are almost exclusively male, but a representative sample of the population in Australia reported than 2.2 % of men and 1.3 % of women said they had been involved in bondage an discipline, sadomasochism, or dominance and submission in the previous year. Information on the development and course of Sexual Sadism Disorder is extremely limited. One study reported that females became aware of their sadomasochistic orientation as young adults, and another reported that the mean age at onset of sadism in a group of males was 19.4 years. Whereas sexual sadism is probably a lifelong characteristic, Sexual Sadism Disorder may fluctuate according to the individual’s subjective distress or his or her propensity to harm nonconsenting others. Advancing age is likely to have the same reducing effect on this disorder as it has on other paraphilic or normophilic sexual behavior.

  • “The population prevalence of Pedophilic Disorder is once again unknown. The highest possible prevalence for Pedophilic Disorder in the male population is approximately 3–5 %. The population prevalence of Pedophilic Disorder in females is even more uncertain, but it is likely a small fraction of the prevalence in males.

  • “The population prevalence of Fetishistic Disorder is unknown, and in clinical samples this disorder is nearly exclusively reported for males. Usually paraphilias have an onset during puberty, but fetishes can develop prior to adolescence. Once established, Fetishistic Disorder tends to have a continuous course that fluctuates in intensity and frequency of urges or behavior.

  • “The prevalence of Transvestic Disorder is unknown. Transvestic Disorder is rare in males and extremely rare in females. Fewer than 3 % of males report having ever been sexually aroused by dressing in women’s attire. The percentage of individuals who have cross-dressed with sexual arousal more than once or a few times in their lifetimes would be even lower. The majority of males with Transvestic Disorder identify themselves as heterosexuals, although some individuals have occasional interaction with other males, especially when they are cross-dressed. In males, the first signs of Transvestic Disorder may begin in childhood, in the form of strong fascination with a particular item of women’s attire. Prior to puberty, cross-dressing produces generalized feelings of pleasurable excitement. With the arrival of puberty, dressing in women’s clothes begins to excite penile erection, and in some cases, leads directly to first ejaculation. In many cases, cross-dressing elicits less and less sexual excitement as the individual grows older. Eventually it may produce no discernible penile response at all. The desire to cross-dress, at the same time, remains the same or grows even stronger. Individuals who report such a diminution of sexual response typically report that the sexual excitement of cross-dressing has been replaced by feelings of comfort or well-being. In some cases, the course of Transvestic Disorder is continuous, and in others is episodic. Some cases of transvestic disorder progress to Gender Dysphoria. The males in these cases, who may be indistinguishable from other with Transvestic Disorder in adolescence or early childhood, gradually develop desires to remain in the female role for longer periods and to feminize their anatomy. The development of Gender Dysphoria is usually accompanied by a self-reported reduction or elimination of sexual arousal in association with cross-dressing.” This topic will be widely examined in the correspondent chapter on this book.

It is important to emphasize the fact that these data should be understood with considerable caution and as a mere orientation toward reality for several reasons. Surveys attempt to capture behaviors considered to be negative by society, and sometimes clearly criminal cases, which must be clarified and not obscured. There are behaviors in certain situations and with certain intensity and frequency that cannot be classified as paraphilias in a clinical sense. Normal sexuality includes partial aspects that overlap with what we call perversions, differing only by the context, intensity, exclusivity, compulsion or other aspects. The young man or woman who enjoys watching the naked body of his/her partner is not a voyeur in the clinical sense; the boy or girl picking sexy lingerie for his/her partner is not an exhibitionist, and so on. Sexual behaviors that include some specific aspects of paraphilias should be distinguished from other behaviors that meet the diagnostic criteria.

5 Etiopathogenesis

Among the main hypothesis about the origin of disorders of sexual preferences there are biological factors involved, such as alterations in the neurodevelopment, in the levels of sexual hormones in plasma, mild neurological symptoms, certain chromosomal abnormalities, electroencephalographic alterations, epilepsy and mental impairment [9]. In general, all are extremely unspecific and inadequate from an epistemological point of view.

This group of disorders has been associated with a higher prevalence of severe psychiatric pathology as well as with cluster B Personality Disorders [11]. Also, the influence of the social and cultural environment of the individual, as well as his particular biographical moment, must not be ignored as a clear role in its sexual preferences.

Paraphilic disorders have also been related to childhood sexual abuse, substance misuse and sexual preoccupation/hypersexuality as risk factors, although the causal relationship with paraphilias is uncertain and the specificity unclear.

Male gender and the male domination paradigm is core to the construction of perversions, which are a predominantly male field, with the exception of masochism. In this way, sexuality becomes social, relational, determined and built by power. Sexuality becomes a factory of domination and passivity.

Pornography is a clear example of an exercise of domination. It makes women become objects for sexual use and transaction, and makes its potential consumers desire them as objects but also crave to possess or dominate them, often in a cruel and ruthless way. Gender inequality, submission, the hierarchical position and the objectification that results from an explicit denial of self-determination and the apparent consent of sexual desire, are the most appealing traits of these object-women.

Andrea Dworkin claims that the main subject of pornography is male power. In general terms, the role of a woman in pornography is to be raped and possessed by men, either through a camera or a script, always in the name of the watcher. This sexuality of observation, of visual intromission, of domination and access, of entertainment, turns sex into a kind of sport for its audience [12].

6 The Dynamics of Perversion: Origin and Development

Over the past few years the term “sexual perversion” has been substituted for others such as “paraphilia” (which etymologically has its origin in Greek: “further” and “love”) [11], disorder of sexual behavior or disorders of sexual preferences (International Classification of Diseases version 10 [ICD-10]) [8], with a more sociological than a clinical base, given that these disorders suppose a behavioral deviation from statistical normality. The main point is to avoid moral judgments regarding the pathological origin of these aforementioned disorders.

Coderch claims that traditionally and from a clinical point of view the term “perversion” has been used to define any function or instinct that deviates from its natural goal (for example, pica can be considered a perversion of the instinct of nutrition). That a certain phenomenon may not be in line with the statistical norm does not necessarily bestow upon it a pathological nature (for example, the influenza infection is a pathological phenomenon from a medical point of view, although it may be considered normal from a statistical point of view during certain seasons of the year; running 100 m in 10 s is also a deviation of the statistical norm, although it has no medical pathological connotation by any means) [5]. This author defends preserving the term “perversion” to refer to this kind of disorders.

Castilla del Pino [13], another Spanish psychiatrist, considers that physicians in their daily routine either openly or covertly corrupt their medical judgments with their own moral judgments: men (and women) are social beings, with their own problems regarding themselves and their relationships (dependence on social class, group, personal expectations) and therefore they are often tendentious concerning the direction of their own moral, religious, political or cultural convictions. This author criticizes the evolution of these medical and psychopathological concepts, as he claims that the substitution of moral/immoral for normal/abnormal is nothing but a deletion of terms with no changes in the hidden attitude toward the concepts they represent. He adds that no action can be considered inherently moral or immoral, mainly because it is its application within a context that confers the said quality upon the action. Empathizing with the context of the individuals in their relationships, not in our own context, that is the key. This fact becomes decisive in judging our own or other people’s sexual behaviors.

The concept of “perversion,” semantic traits aside, has been modified through time owing to the contributions granted by psychoanalysis. Before Freud, and throughout the twentieth century, research carried out by several authors on deviations of sexual behavior was focused on descriptive and nosological contributions.

Freud [14] considers that the main aspects of pathological sexual behavior consist in the exclusivity, repetitive and persistent substitution of adult genital sexual relationships for other activities with an infantile and pre-genital nature, as a result of a defensive mechanism toward the unbearable castration anxiety experienced during the “Oedipal period.” This author places perversions as the reverse of neurotic disorders, with infantile drives surpassing the defense mechanisms of the Ego and transforming them into neurotic symptoms.

Freud interprets perversions as the product of a fixation that results in a disorder of the maturative evolution of normal sexual impulses. He later changes his point of view, giving perversions a more defensive (and therefore neurotic) connotation, in which regression and repression play a determinant role against a conflictive “Oedipus complex” [15].

In the specific case of Leonardo Da Vinci, a Renaissance figure whose “pure homosexuality” Freud has no doubt about, the father of psychoanalysis thinks that the accidental circumstance of his illegitimate birth and the excessive tenderness of his mother had a decisive influence on the development of his personality and his consequent fate, which led his libido to be sublimated into a desire to know, determining the sexual inactivity of his life [15].

However, precautions must be taken with the creation of myths (and the “Oedipus complex” represents one of them). From a psychoanalytical perspective we find authors who demonstrate that self-awareness and other-awareness evolve through the possibility that separate minds may implicate sharing feelings and intentions within a process of mutual recognition. This recognition may be established in a mother/son dyad, or father/daughter, or in any other asymmetrical relationship, as long as there is no falsification of the other person’s needs through fabrications or representations that justify or hide domination [16].

Robert Graves dissects the double function of the myth: on the one hand, its attempt to give sense to the enigmas of life; on the other one, the concealment of violence to justify a certain social system. This author also remarks on its power, which becomes part of the same definition of myth: allegoric fiction that contains a creative or even magical force in which the people that created it are included, ruling their lives and behavior [17].

The Oedipus complex is a myth built from psychoanalytical theory. It excludes the concealment, the masking of a relationship of power, and participates in its dilution. Historically, adults have not been conscious of the generational transmission of the drama that results from the father–mother/son–daughter relationships. What is being hidden in the theory that portrays Oedipus as a representation of the recognition of the difference between the two sexes? Basically, Oedipus is not a normal child, but someone who has suffered extreme parental violence. Son of Laius and Jocasta, Oedipus lacks parents as he is abandoned (by them) in the mountains. In the play by Sophocles the chorus says: “Is he son of Pan, of Apollo, of Hermes, of Bacchus, of one of Helicon’s nymphs?” [18]. The abandoned boy may become everything or nothing. He is an enigma. A naked man, alone, and nobody knows how he came into the world. He is the most intimate essence of a man, even lacking the social shield that should protect him (his parents). His only protection comes from the mercy of a man, a stranger, a shepherd that decides to nurture him. A defenseless child, saved from doom. We already have a naked man introduced into the world of humanity. What will become of him? Because the loneliness of a man is, in Oedipus’ case, notable because of his irregular family situation: a birth that should not have been, parents who should not have been parents, and conflict and constant risk for everyone.

Oedipus does not really represent any children. The androcentrism of the psychoanalytical theory about differences between the sexes starts here, in the double absence of the father toward the mother and daughter, thus, they both find the path to developing their own subjectivity [16].

Femininity and masculinity are not roles or intended behaviors, but an organizing principle of the whole subjectivity: ego, super-ego, and sexual desire. The object of desire is not an anatomical body, but a body built by all the inter-subjective thoughts and practices. Both boys and girls organize themselves through their relationships with other objects (for example, their mother), which are not just objects as both boys and girls can recognize those objects as different from them and similar to them at the same time. This way, inter-subjectivity has an effect in the structuration of the psyche.

The application of a sexual double standard on women leads them to find it increasingly difficult to achieve a mental balance because they only find admiration and recognition through their physical appearance, and their psyche endures extra effort to reconcile the multiple requests of their motivational systems [19].

Since these fantasies and behaviors are not shared with other people and are kept secret for fear of reprisal or punishment, they remain in time until the individual becomes aware of the incompatibility of his (her) interests with the social and cultural rules and conditions of the times in which he (she) lives. Once this moment arrives, those activities have already become a repetitive and compulsive personality pattern with an effect on the basic needs of the individual, who is unable to discard them [9].

McDougall [20] and Chasseguet-Smirgel [21, 22] agree with regard to pointing out the importance of perversion as a creation of a new reality in which the barriers between generations and sexes are removed, providing an escape from anguish with a new reality. Both authors consider perversion to be an individual’s reaction to a narcissistic injury connected to the “primary scene” and the perception of the difference between the two sexes.

With his viewpoint, Stoller keeps a distance from this classical approach to perversion to remark on an alternative origin of this narcissistic injury: questioning sexual identity during childhood. As a reaction, the adult develops a sexual relationship defined by a need to control the object, and therefore with a sadomasochistic trait regardless of the final form of the perverse behavior. Stoller considers aggression to be the common basic factor among all perversions, which allows revenge for all the pain suffered during childhood. In some of these behaviors the aggression is expressed in a conscious and direct way, as in sadomasochistic practices [23].

One of the most relevant authors with the current psychoanalytical outlook, Otto Friedemann Kernberg [24], agrees with Stoller on targeting sadomasochistic traits as the basis for all perversions, and even for “normal” sexual relationships. Kernberg points out the existence of different dynamics depending on the expression of perversions in the context of the different organization of personality. He retains the basic concept for stable perversions that appear within a neurotic structure. He assigns a dynamic such as that described by the British object relations school to perversions that are found in borderline organizations of personality. And he considers Chasseguet-Smirgel’s concepts appropriate for their application to perversions that appear within a narcissistic structure, especially when applied to a malignant narcissism.

According to Kernberg [25] the core affect of severe psychopathological conditions (that include perversions) is hatred, an aggressive, complex, chronic, and stable affect with regard to its cognitive component, with a powerful characterological basis, accompanied by a rationalizing habit and severe distortions of personality concerning the function of the Ego and the Superego of the individual. Hate, intensified by some unconscious motivations (such as a search for revenge rooted in early affective experiences) claims to destroy of the object, both as an unconscious fantasy and in its conscious dimension. However, paradoxically the object that the individual wants to destroy is also needed and desired, which results in a circular dynamic of perversion.

According to González Torres [26], the most significant contribution by Otto Kernberg in this field is based on his opinion that polymorphic perverse sexuality plays a necessary role in the normal sexual relationships. He retains the inquisitiveness set by Stoller years before in this field. Kernberg states that the perverse traits of a normal sexual life assume a way to express aggressive impulses within a couple, avoiding the progression from what is strictly sexual toward a mechanic and unpleasant activity. The capability to unconsciously integrate love and hatred into a polymorphous sexual behavior provides a way of allowing the “use” or “exploitation” of the partner within sex play, safeguarding the object-relation at the same time. This supposes a “splitting” or duplication of sex play, in which the reality of the object-relation is sustained while the other reality of the object, regressive and fantastic, is performed playfully as part of sexual desire and arousal.

In reference to this last point, it should be mentioned that authors such as Oyebode [10] reserve the term “polymorphous perverse” for those people who show all deviations of sexual behavior or paraphilias, while from a psychoanalytical perspective the approach is different, and perverse and polymorphous sexuality are inseparable parts of the sexual life of boys and girls in the early stages of their libidinal development, establishing a basis for the integration of the said behaviors into normal sexual relationships, affective relationships and fantasies in adulthood, in a pleasant way.

Castilla del Pino suggests that a large part of the prodromal behavior of normal sexual activity, and even a greater share in the case of pathological activity, is demonstrated by rituals that reveal the existence of traces of fixations that took place before the stages of libidinal development, making kisses or bites “benign” oral expressions. Even keeping the focus strictly on genital sexual relationships with the desired object, a sublimation of pre-genital object-relationships appears frequently, granting a significant role to hidden fantasies [13].

Kernberg [25] states that the body of the beloved becomes a geography of personal meanings, so that the fantasized early polymorphous perverse relations to the parental objects are condensed in the admiring and invasive relationship with the lover’s body parts. Erotic desire is rooted in the pleasure of unconsciously enacting polymorphous perverse fantasies and activities, including symbolic activation of the earliest object relations of the infant with the mother and of the small child with both parents. All this is expressed in the perverse components of intercourse and sexual play (fellatio, cunnilingus, anal penetration, and in exhibitionistic, voyeuristic, and sadistic sexual play). All of them, by the way, are sexual perversions that are almost exclusive to the male gender.

The study of perversions within the male gender, although still scanty, contrasts with the absence of studies about perversions and sexuality, both normal and pathological, in the female population. In addition, there is a current lack of appropriate vocabulary to refer to the external female genitals, using, for example, “vagina” and “vulva” as if they were synonyms, as if using these terms incorrectly were harmless to the sexual and psychological development of women.

Psychoanalyst Harriet Lerner claims that naming female genitalia incorrectly is almost as surprising in its consequences as it is regarding the silence that surrounds this. It is true that in the USA female genitalia are not mutilated, the clitoris and labia are not amputated, as is performed in countless girls and women in other cultures. Here, the job is carried out not with a knife but with words: the result is a psychological genital mutilation. Language can be as sharp and fast as a surgical scalpel blade. What is not named does not exist [3].

Psychoanalysis intends to monopolize the true discourse about female sexuality. A discourse that is apparently true upon the logic of this truth: precisely, that femininity only has a place within the models and laws that have been promulgated by men. This means that only one sex exists, not two. One single practice and portrayal of sexuality, with its history, its needs, its reverses, its flaws, its negative or negatives, which are supported by the female sex.

Following the theory of psychosexual development published in 1908 by Freud, 3- to 5-year-old girls discover they lack a penis, and conclude that they are missing something, that they have been castrated. This concept of “penis envy,” joined by the “fear of castration” that children endure, performed on both an individual level and on the collective consciousness of sexuality, with obvious negative consequences due to denying women a sexuality determined by themselves, depriving them of their creative skills, even of their potential perversions [19].

Furthermore, Freud claims that the greatest wish of every girl, and later on of every woman (“penis envy”) is the desire to have a phallus, and that desire can only be replaced by the desire to conceive a baby. Irigaray agrees by stating that the woman can only be completed when she becomes a mother, by bringing into the world a child who becomes a “substitute for the penis,” and with some luck the baby will have one himself. According to Freud, the perfect fulfillment of becoming a woman consists of creating a male sex while neglecting her own sex [19].

With the imaginary lack of existence of female genitalia other non-existences are approached. Jacques Lacan claims: “A woman can but be excluded by the nature of things, which is the nature of words and it must be said that if there is something that women themselves complain about enough for the time being, that’s it. It’s just that they don’t know what they’re saying—that’s the whole difference between them and myself” [16]. Isn’t this an aberration from an intellectual point of view?

In psychoanalysis rivalry between sexes has been approached mainly in genital terms, confusing the shape with what it represents, confusing genitality with the broad spectrum of human action that masculinity symbolizes. Psychoanalysis aspires to provide a scientific explanation, while it merely strengthens a circular myth. Women and men inserted into this cultural and para-scientific discourse continue to conceive the creativity and potential of the woman, in traditionally non-female areas, as some kind of misappropriation or transgression: phallic women, men threatened by mutilation.

The hierarchical order between genders is still being masked and emphasized through the constant appeal to the difference between sexes, reducing the complexity of the conflicts that are inherent to human otherness and inequality [16].

7 Paraphilic Disorders According to the DSM-5

Paraphilic disorders included in the new DSM-5 edition (American Psychiatric Association, 2014) are [11, 27–34]:

  • Voyeuristic disorder—spying on others in private activities.

  • Exhibitionistic disorder—exposing the genitals.

  • Frotteuristic disorder—touching or rubbing against a nonconsenting individual.

  • Sexual masochism disorder—this is undergoing humiliation, bondage or suffering.

  • Sexual sadism disorder—inflicting humiliation, bondage or suffering.

  • Pedophilic disorder—sexual focus on children.

  • Fetishistic disorder—using nonliving objects or having a highly specific focus on nongenital body parts.

  • Transvestic disorder—engaging in sexually arousing cross-dressing.

These eight disorders have traditionally been selected for specific listing and assignment of explicit diagnostic criteria in the DSM for two main reasons:

  • They are relatively common.

  • Some entail actions for their satisfaction that, because of their noxiousness or potential harm to others, are classed as criminal offenses.

These eight disorders listed above do not exhaust the list of possible paraphilic disorders. In fact many dozens of distinct paraphilias have been identified and named, and almost any of them could, by virtue of its negative consequences for the individual or for others, rise to the level of a paraphilic disorder. The diagnoses of the other specified and unspecified paraphilic disorders are therefore indispensable and will be required in many cases.

The term paraphilia denotes any intense and persistent interest other than sexual in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. In some circumstances the criteria intense and persistent may be difficult to apply, such as in the assessment of persons who are very old or medically ill and who may not have real intense sexual interest of any kind. In such circumstances the term paraphilia may be defined as any sexual interest greater than or equal to normophilic sexual interests. There are also specific paraphilias that are better described as preferential sexual interests than as intense sexual interests.

According to DSM-5 some paraphilias primarily concern the individual’s erotic activities, and others the individual’s erotic targets. In DSM-5 paraphilias are not ipso facto mental disorders. There is a distinction between paraphilias and paraphilic disorders. A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risked harm to others. A paraphilia is necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention. The distinction between paraphilias and paraphilic disorders was implemented in the DSM-5 without making any changes to the basic structure of the diagnostic criteria, as they have existed since DSM-III-R.

The change proposed for the DSM-5 is that individuals who meet both criterion A (which specifies the qualitative nature of the paraphilia) and criterion B (which specifies the negative consequences of the paraphilia) would now be diagnosed as having a paraphilic disorder. A diagnosis would not be given to individuals whose symptoms meet criterion A but not criterion B, which is given to those who have a paraphilia but not a paraphilic disorder.

An overarching change in the DSM-5 (compared with DSM-IV) is the addition of the course specifiers “in a controlled environment” and “in remission” to the diagnostic criteria sets for all the paraphilic disorders. These specifiers are added to indicate important changes in an individual’s status.

It has already been said that it is not rare for an individual to manifest two or more paraphilias. In some cases, the paraphilic foci are closely related. In other cases, the connection between the paraphilias is not obvious, and the presence of many paraphilias may be coincidental or else related to some generalized vulnerability to anomalies of psychosexual development.

One last consideration: the most widely applicable framework for assessing the strength of a paraphilia itself is one in which the examinees’ paraphilic sexual fantasies, urges, or behaviors are evaluated in relation to their normophilic sexual interests and behaviors. Not only the distress and impairment stipulated in criterion B but also the possibility of a reactive depression, anxiety, guilt, poor work story and impaired social relations among others must be clinically evaluated.

8 Sadism and Masochism

Sadism and masochism cannot be separated as they are the two complementary sides of the same disease, the sadomasochistic disorder, as Freud enunciated back in 1905: “A sadist is always at the same time a masochist” [14].

According to Freud, masochism is not the manifestation of an instinct, but derives from sadism and invariably appears to be intensively associated with it. Subsequently, the pages of the psychoanalytical literature are flooded with sadomasochism, as it includes one of the most basic human drives and in its extended form, aggressiveness, which is involved in many of our behaviors.

Ey infers that sadistic and masochistic movements form a dialectical couple, being linked in the same way as activity and passivity, pleasure and pain, tension and relaxation. This author also reflects the relationship among sadomasochism, death drive and its role in the so-called “repetition automatism,” of which perversion is a prominent example [35].

Castilla del Pino [13] believes that sometimes sadistic or masochistic behavior constitutes part of the rituals of normal sex foreplay. Many of these rituals are connected with the identification of the male and female roles by the boy and girl mainly through linkage to the “primal scene,” parental intercourse, which is ambivalently portrayed as a scene of aggression but rather voluptuously.

However, as Butler says the boy gets easily separated from the mother and identifies with the father, who has the power, but the girl always maintains ambivalence toward the mother figure, who carries less sociocultural weight [36].

8.1 Sadism

Sadism is the search for and provocation of moral or physical damage to the couple as a way of obtaining sexual pleasure and satisfaction. It may be expressed at different levels in the form of murder, rape, harassment, beating, pinching, flagellation, burns, bites, chains, and torture.

All these practices are part of the sexual and literary Donatien Alphonse François de Sade repertoire, the man who obtained both success and scandal when he wrote “Justine,” and who marked the birth of the sadistic mythology. The same man who back in 1780, imprisoned and in the middle of his life, wrote to his wife [37]: “my way of thinking, you say, cannot be approved. And who cares? A man who acquires a way of thinking for others is crazy! My way of thinking is the result of my reflections; it is part of my existence, of my organization. I’m not anybody to change that, and if I were, I would not do it. This mindset that you reproach me is the only comfort of my life, relieves all my pains in prison, composes all my pleasures in the world and I need it more than life. It is not my way of thinking that has brought misfortune to me, but other people’s.”

Sade continues to be a tragic author, with more of a pariah existence than a marquis, who spends half of his life locked between inmates and crazy people, in prison or in Charenton’s asylum, where he wrote an unclassifiable work defined as “gospel of evil”, “a sudden abyss” or “subversion of the difference between vice and virtue”. His stories encourage people to take up the revolutionary act to deflagration, thinking that this way, in a destructive fantasy, the transition between the old and the new society is precipitated. Later, he was considered to be a precursor of sexology, or an heir of Satanism. Sade also makes evil desirable through his writings [1].

Obviously, actions of a sadistic nature and individuals that perpetrate them have provided multiple diagnostic interpretations, within an overall perverse behavior scheme. In this context a careful differential diagnosis should be made, as the motley quality of them sometimes denotes the performance of schizophrenic patients, feeble-minded, insane, or people affected by dissociative episodes, impulse control disorder or organic personality disorder.

Sadism has undergone numerous etiopathogenic interpretations. These include alterations in the child’s early learning, a result of the manifestations of sexual aggression directed toward him during his childhood by parents or alternative figures, perceived changes in the parental image and models, hormonal, neuropsychiatric or genetic alterations, all plausible but inadequate when considered separately [9].

For psychoanalysis, sadism is connected to other forms of perverse behavior, in the sense that it is a defense against castration anxiety (again the myth loop). Thus, the sadistic sexual pleasure is only felt when the individual does to others what he fears to have done to himself; thus, weakening and subjecting his partner exorcises the fear of being punished and dominated himself.

Coderch [5] makes a distinction between erotic sadism and criminal sadism:

  • “In the first, the behaviour of the sadistic individual exceeds the defense against castration anxiety, and provides a defense against the self-destructive impulses of thanatic origin (death drive), which he avoids directing them towards others.

  • “In the erotic sadism, sadistic behaviors are more fictitious than real, this is false and agreed with their victims, which fail to feel a true physical or moral harm. The objective here is to lose his fears verifying that, in the end, the punishment inflicted on his partners (the same that he avoids) is not as bad as a real castration but only some suffering and symbolic amputations that seem tolerable.”

In those cases when real damage to the couple is caused (without reaching the extreme of criminal sadism) the role played by the individual’s superego is determinant; in these cases, the purpose of the sadistic act is to make the victim love and forgive the offender, so that he can be free of his fantasy of guilt, which deprives him of sexual satisfaction.

According to psychoanalytic theory fantasies of being beaten up and punished by the father are the regressive expression of the desire to be sexually loved by him, in a passive feminine kind of relationship on the individual’s part and supplemented with masochistic fantasies, as will be exposed later.

According to Castilla del Pino [13] the incidence of the superego appears in the playful trait that sadistic behavior appears to have; in other words, in not taking seriously the aggression produced. From here it is inferred that, with few exceptions (discussed below), the sadist imposes a limit on his aggression toward the sexual object, and rarely culminates in total destruction.

Regarding criminal sadism, it can be said that it expresses an extreme cruelty that can reach the homicide stage without any apparent justification (absence of self-defense, hatred toward the victim, or profit), or complicity or physical intimacy between the sadist and his victim, which allows us to consider the practiced violence (unjustified) as part of a sexual activity.

The person responsible for sending millions of Jewish people to the gas chamber in World War II, Adolf Eichmann, was not a sadist, a psychopath, a pervert, a monster, nor was he suffering from some visible mental illness. He was normal, horrifyingly ordinary. After sending millions of individuals to the gas chamber, he stated that he had just been following orders, even denying being anti-Semitic. It would have been comforting to think that Eichmann was a monster. From the point of view of our legal institutions and our moral standards, his normality is much more terrifying than all the atrocities he committed, because it implies that this new kind of offender commits his crimes under circumstances that almost prevent him from knowing or guessing that he is performing acts of evil [1].

In her reporting of the 1961 Adolf Eichmann trial for The New Yorker, which evolved into Eichmann in Jerusalem: a Report of the Banality of Evil, the philosopher and political theorist Hannah Arendt coined the phrase “the banality of evil” to describe Eichmann. She raised the question of whether evil is radical or simply a function of thoughtlessness, a tendency of ordinary people to obey orders and conform to mass opinion without a critical evaluation of the consequences of their actions and inaction. As she was also critical of the way the trial was conducted in Israel, and of the way that some Jewish leaders acted during the Holocaust, Arendt was criticized by many Jewish public figures, who charged her with a coldness and lack of sympathy for the victims of the Holocaust [38].

The Nazi regime based on its own criteria reaches the extreme threshold to decide not only that certain groups of people do not deserve to live in the country of residence, but also decide the place and time of their extermination. Indeed, what is striking in the testimonies of the Nazi mass murderers is the terrifying normalcy they show, which is not the symptom of a perversion in the clinical sense of the term (sexual), but an adherence to a perverse system as a way of undergoing an extreme dehumanization of man toward man, which can only be invented by mankind, since the animal kingdom never finds joy in evil, and is not perverse or criminal.

The criminal in the sense of Sade submits to a wild nature that defines him, but does not accept submission (unlike the Nazi war criminal) to the power of a State that leads him to obey a law of crime: “The executioners have no voice” said Bataille, and “if they had one, it’d be the voice of the State” [1].

In fact, Sade remarks that since human nature is essentially criminal, the abolition of the capital punishment must be unconditional: “Capital punishment is pointless. Not only does it not repress crime, which is natural to man, but adds one crime to another by causing the death of two men instead of one” [37].

This kind of sadism, according to Coderch [5], should not be included within perversions, because the existence of a certain degree of sexual arousal in this kind of crimes is possible, then taking a different path and being led to serve a destructive instinct (the aggressive instinct), rendering, therefore, the initial excitation merely a trigger.

A different way of expressing the sadistic behavior is called moral sadism [39], in which sadism can be degraded or diluted toward symbolic behavior in which the sexual component is not experienced by the individual as such. Among its methods of expression we find the unjustified verbal violence that some people display, abuse of authority, corporal punishment and even the declaration and practice of war. The confessions of children who are victims of sexual abuse, also reveal, as Shengold points out, mental torture in which hatred and indifference, silence and masked madness are necessary conditions [40].

Radical Islamists consider women as objects of desire, as the ultimate expression of perversion, even more than the homosexuals, who just disguise their masculinity. Thus, when the woman escapes from voluntary servitude, seeks to run away from slavery as her only destiny, they consider that she should be battered, bruised, tortured, stoned, and murdered. By embodying a form of radical impurity, she is permitted to choose between the concealment of her body and the death of his identity [1].

8.2 Masochism

Masochism can be defined as an opposite to sadism, that is, the search and provocation of a person’s own suffering as a way of obtaining sexual pleasure.

According to Laplanche and Pontalis [4] masochism is a sexual perversion in which sexual satisfaction is linked to the suffering or humiliation suffered by the subject: “Actually what defines this behavior is more a scene of humiliation than a real appetite for pain: the masochistic partner requires staging, this is really a ritual, a form of contract” [35].

In masochism the fantasy of being humiliated and subjected plays a key role; thus, imagination gets imposed to more active behaviors, typical of sadism. Masochistic people have a recurring obsession with sexual fantasies and impulses related to their submission to humiliation, corporal punishment, or any other activity that results in pain or degradation. However, up to 30 % of them have concurrently sadistic fantasies [9], which once again links the two concepts together.

This sexual behavior deviation owes its name to the detailed practices by Leopold von Sacher-Masoch, famous Austrian novelist of the nineteenth century whose characters reached their sexual pleasure by being abused and dominated by certain women, having previously and solemnly signed different contracts in which the rules of behavior of both signatories [41] were collected.

From a cognitive perspective and learning theories it is postulated that masochist individuals may have experienced situations in which they have been subjected to intense suffering during their childhood, or may have observed such situations in their closest people’s lives; thus, they finally become convinced that suffering and pain are necessary requirements for achieving sexual pleasure [9].

Castilla del Pino argues that we must look for the origin of secondary masochism in a mother who frustrates the “oedipal expectations” of the child. The child attempts aggression against her, but he experiences guilt and thus the need to be punished, hence, the feeling of being rewarded for the pain. From here, a model of gratification that plays through a sadistic sexual partner [13] is produced. This author argues that masochistic fantasies are frequent during masturbation and intercourse, and during homosexual anal intercourse.

Regarding feminine masochism, also derived from a psychoanalytical point of view from the “Oedipus conflict,” like the previous one, it is not exactly a defense against castration anxiety but a real desire to be castrated by the father and loved by him, as the mother is. According to Melanie Klein the primary origin of masochism in women stems from the oral-sadistic period and the desire to incorporate the father’s penis, which subsequently and once inside her body is experienced as bad, destructive, and aggressive, targeting it with a whole group of sadistic impulses with the help of her partner, typically a sadist, who through another evil penis destroys all the harmful objects inside her [5].

Even if in this chapter we continue to discuss sadomasochism from a psychodynamic perspective (after all psychoanalysis is the theory that has devoted more research to these aspects of the human psyche), it is evident that psychoanalytical jargon regarding psychosexual development and the perverse behavior of individuals tends to make us blush for being unscientific, interpretative, outdated, and sexist.

Celia Amorós, Spanish philosopher and first female winner of the Spanish National Essay Prize in 2006, states that the relationship between feminism and psychoanalysis has been and continues to be paradoxical, given that feminism emerged and developed denouncing the subordinate role that culture has built for women, while psychoanalysis is one of the institutions that has helped to raise representations of women as subordinates. Feminism believes that Freudian positions are essentialist, and condemn femininity to the fate that anatomy has provided it with, to be considered a deviation, a reproduction or a flaw in the pattern that works as a standard of development [42].

Returning to the previous focus, facing these forms of masochism allegedly secondary to castration anxiety, Coderch [5], quoting Freud’s opinion, speaks of a primary erogenous masochism, in which the pain, far from avoiding greater suffering (castration), provides pleasure. The explanation of these cases is once again related to the early affective experiences during the “summit affective states” [13], in which a sharp rise in tension (including that produced by displeasure) is a source of sexual arousal, and it becomes fixated as such for the rest of the individual’s life.

During the libidinal development of the baby a basic conflict between the life instincts (Eros) and death (Thanatos) arises. The libido, the representative of the instinct of life, is projected outwardly as a method of defense against self-destruction, part of the death instinct, placing the management of this on sexual function and thus embodying the sadistic impulses. However, another part of the death instinct is inside the individual and results in the primary or erogenous masochism, representative of the death instinct, and from this moment it is linked to the libido being itself a source of pleasure. The part of the thanatic instinct projected outward may in certain circumstances be internalized again, returning regressively to the primary object and producing the secondary masochism. This will be more evident and intense, the higher the erogenous or primary masochism, and will perform as a defensive mechanism against castration anxiety, allowing sexual pleasure to be obtained, while the primitive erogenous masochism is a source of pleasure in itself [5].

As in the case of sadism, masochism exists in multiple forms of degradation, including the moral masochism concept developed by Freud and coming to determine the pattern of constant failure of certain individuals, as well as the polysymptomatic courtship typical of some forms of neurosis. In this form of masochism the suffering of the individual appears seemingly detached from any erotic situation or sexual pleasure, and he experiences severe punishment and pain derived from the multiple circumstances of vital events. This applies to people who leave an existential disgrace and quickly get into another that may even be worse, being a slave to some form of repetition compulsion.

In moral masochism it is the Ego of the individual that requires punishment, either by his Superego (in the shape of an excess of pressure, coercion, and moral stiffness) or from external circumstances that are symbolically represented by the superior power of fate [5]. If we say of the Superego of these people that it is very punitive, inflicting an unconscious sense of guilt on them, resulting in an active search for suffering, which although unpleasant is preferred and produces some relief of an intolerable guilt. This kind of masochism is also reflected in the “negative therapeutic reaction,” which consists of the individual’s resistance to the psychoanalytical cure because the psychic suffering deeply satisfies the masochistic needs.

The alleged de-linkage between moral masochism and sexuality is misleading: being punished by the Superego or external factors means to be punished for the father because the Superego is, primarily, the internalized image of the parental couple, the male parent being the main representative of the external force that has power to command, enforce, and punish. Later, that power is transferred to authority figures or to the impersonal forces of destiny [5]. Once again, we observe the gender discourse within androcentric psychoanalytical theory, and also the loop of the Oedipal myth.

According to Kernberg, we all pay a price with minor manifestations of masochistic pathology as a precursor step to the normal integration of the Superego functions in our psychic apparatus “masochism cannot be understood without taking into account the vicissitudes of libidinal and aggressive impulses, the development and pathology of the Superego, the Ego levels of organization, the pathology of internalized object relations and the extent to which normal or pathological narcissistic features predominate” [25].

For instance, the sublimatory ability to withstand pain or hard work as a way to bolster success and future achievements is rooted in this universal masochistic predisposition.

Meanwhile, in those aspects related to “normal” sexuality, the adult capacity to preserve and maintain certain aspects of the polymorphous perverse infantile sexuality includes the possibility of sexual arousal with fantasies and masochistic and sadomasochistic experiences.

Finally, the sadomasochistic aspects of infantile sexuality play in the adult a key role in maintaining the balance between libidinal drives (Eros) and the aggressive impulses (Thanatos), and that basically represents a primitive synthesis between love and hate.

8.3 The “Masochistic Syndromes”: Towards a New Nosology of Masochism

Kernberg proposes a clustering called “masochist syndromes” within two blocks, considering the level of personality structure. As we move forward in this proposed scheme the severity of the symptoms increases.

8.3.1 Neurotic Level of Personality Structure

Within the so-called senior figures, i.e., those with a well-defined Ego identity, a good tolerance to anxiety and frustration, good impulse control, adequate sublimatory capacity, and definitely a strict but well-integrated Superego, we distinguish different types of masochist expression. These include:

  • The depressive-masochistic personality disorder

This group includes the so-called moral masochism discussed earlier, i.e., that kind of masochism in which the subject, as a result of an unconscious sense of guilt, seeks a victim position with no (apparent) sexual pleasure involved.

The depressive-masochistic personality disorder is defined by three major characterological traits: those that reflect an intransigent Superego, those that reflect an overdependence on the love, support, and acceptance of others, and those that reflect difficulties in expressing aggressiveness.

  • The masochistic infatuation

According to Freud, during a normal crush the Self is empty of libidinal cathexes, which are invested in the loved object, which replaces the ideal Ego (an integral part of the Superego).

Chasseguet Smirguel (as Kernberg) [25] believes that this is not exactly true, since if love is reciprocated the self-esteem of both partners is enhanced, thus enriching the libidinal investment of the Self of the one who loves. In other words, this is a two-way interactive process.

Masochistic love is characterized by the unconscious choice of certain objects that are either unable to respond to love, or are unwilling to do so. In this context the individual subjects all the other aspects and aspirations of his life to the pursuit of an inaccessible and idealized love object. Slavery regarding an inaccessible object reveals a sense of narcissistic gratification in these people, who pride themselves on being “the greatest sufferers on earth,” an image dynamically linked to other forms of narcissistic gratification as being “the biggest sinner” or “the worst victim.”

This kind of pathological love represents submission to certain aspects of the Ideal Ego projected on the object; thus, this painful and unsatisfactory love fills the individual with pride and emotional intensity. For Kernberg this way of “suffering love” reflects a primitive infantile narcissism that makes the experiences of the masochistic patient adhere to the strict scope of suffering love and not to other areas of his life, which does not happen in the structures of borderline personalities.

In these more severe cases, narcissism extends to all the object-relations of the individual and permeates all his life. We are no longer talking about the projection of a normal Ideal Self on an inaccessible love object but about a pathological and grandiose Self that makes a considerable effort to establish an affective relationship that unconsciously reaffirms his own grandeur.

These masochistic love relationships in narcissistic personalities represent an unconscious effort to consolidate a symbolic integration within the great Self of the subject of the characteristics of both sexes, thus trying to establish a symbolic union with the idealized object. In these cases it is typical that the relationship with the idealized loved object reflects a condensation of oedipal and pre-oedipal issues: the positive, idealized oedipal love object and the negative, sadist pre-oedipal love object, which is necessary nonetheless. This is definitely a combination of narcissistic and masochistic characterological traits.

  • The masochistic perversion

It is at the neurotic level of the personality structure that the masochistic sexual perversion occurs in the way it has been previously described. Here, sexual masochism takes the shape of a predetermined and performed script in the context of an object relationship experienced as safe.

We will see later how as the individual progresses through the analyzed pathological level, both eroticism and sex drive associated with masochistic behavior disappear, self-injurious behaviors and mutilation increase, and confusion and diffusion about the individual’s sexual identity increases.

8.3.2 Boundary or Border Level of Personality Organization

Here, we are facing different personalities characterized by the presence of overt signs of Ego weakness (lack of tolerance to distress and frustration, poor impulse control, poor sublimatory capacity), predominance of partial and incomplete object relations, prevalence of primitive defense mechanisms (splitting, projective identification, primitive idealization, omnipotent control, devaluation), progressive fading of eroticism or sexual drive and increased confusion and diffusion in terms of sexual identity.

In this group, Kernberg distinguishes three alternative forms of expression of masochism.

  • The sadomasochistic personality disorder

These people usually feel victims of aggression themselves and complain bitterly of being abused, obstinately justifying their own attacks against people they depend on, on the basis of this perception of being attacked.

These are highly dependent personalities, on whose psychodynamic traits we find severe oedipal and pre-oedipal conflicts, as well as an intense internal dependence on certain maternal images experienced as sadistic, dishonest, and controlling. These images influence the development of severe behavioral disorders that are not observed in the depressive-masochistic disorder, which depends more on the Oedipal conflict period.

The projection of the primitive precursors of the Superego onto other people, appearing as paranoid traits, and the tendency of these people to defend their contradictive behaviors through rationalization (i.e., aggressiveness) illustrate the failure of the functions of the Superego at the psychic integration of these individuals, unlike what is observed in the depressive-masochistic disorder, ruled by a rigid and dominating Superego.

  • Sexual masochism with self-destructive traits

These people have in common the following characteristics: strong and primitive aggressive impulses, a severe pathology in the field of object relations, a predominance of oedipal conflicts and goals in the masochistic sexual script, a lack of Superego integration, and finally a confusion about their sexual identity, in order that the homo- and heterosexual interactions are part of his daily life along with sexual masochism, which represents its primary organizer feature.

  • Extreme forms of mutilation and self-sacrifice

Otto Kernberg framed individuals with extreme self-destructive behavior around three possible psychic structures:

  • Histrionic personality disorder. It fits within the borderline personality disorder proposed by the DSM-5 [11] (and personality traits included in the dimensions of antagonism, disinhibition, and negative affectivity), and the emotional instability personality disorder described by ICD-10 [8]. In this group the self-destructiveness arises at moments of intense anger, sometimes mixed with depressive feelings. Self-injurious behaviors represent an unconscious effort to reassert control over the surrounding environment, causing guilt feelings in others (i.e., when someone opposes the desires or does not obey patient expectations).

  • Malignant narcissism. It represents a step forward in severity over the previous group. Here, there are no manifestations of dependence as before. These are distant individuals, with a lack of commitment with other people. Their self-destructive behavior occurs when their pathological grandiosity is challenged, which induces in them a traumatic sense of humiliation or defeat, often accompanied by sadistic behavior. The grandeur of these individuals is satisfied with a sense of triumph over the fear of pain and death, and a sense of superiority over other people, who will feel shocked or angry at their behavior. According to the DSM-5 [11] the dominant personality dimension of these individuals would be antagonism.

  • Atypical psychosis. When we face grotesque and unusual suicide attempts with regard to their particularity and cruelty (self-castration, enucleation of both eyes, lingual tearing), we attend the staging of individuals affected by certain atypical psychotic conditions. The main difference in this group compared with the previous ones lies in the quality of repetitive behavior of self-mutilation. Thus, the eroticism of pain and mutilation seem to have acquired the meaning of a triumph over life and death, pain and fear, and unconsciously mainly over the world of object relations [25]. Needless to say, that from the prognostic standpoint this is the group with poorest therapeutic expectations.

In his book Pain and Passion, Stoller [43] goes through a psychoanalytical–anthropological tour of the sadomasochistic clubs of Los Angeles’ surrounding area, interviewing clients and professionals trying to understand what motivates them, what it is that makes those activities pleasant, and what these people are like in their everyday lives. Stoller ends his journey by passing on more questions than answers, and shows the huge variety of personality structures and ways of life in which these deviations from the norm do occur. Therefore, there is no definitive psychoanalytical formulation that can be applied to all patients with such material. Which leaves us with a more open and exploratory attitude: in this patient, what function does this fantasy or behavior have? What is the patient defending himself from? How does he find enjoyment in it?

Depending on the authors we consult, the origins of masochism can be traced to libidinal and aggressive derivatives of the Id, feelings of guilt, and needs for punishment with their origin in the Superego, or can be considered as a way of having a relationship with internal or external objects, trying to avoid feared situations and object relations [44, 45].

Contemporary proposals (Soccarides, Brenner) support a more integrated perspective with a multiple function connected with the Id, the Ego, and Superego to serve both defensive and adaptive goals. Stolorow [46], following this conciliatory point of view, states that masochistic activities may represent sometimes fruitless efforts (sometimes primitively sexualized) to restore and maintain positive structural cohesion, temporal stability, and positive affective coloring of a poor representation of the crumbling Self. This author also points out that the masochistic self-abasement attempting to extol the object maintains a symbiotic or dependant object relation, illusory but vital, and discards the aggression and damage that would result from the loss of the object if the patient accepted (instead of denied) the hateful and hostile aspects of the object.

Sometimes people (especially women) construct object relations in which the perverse has a relevant weight, as a defense against situations of personal distress related to aggression and social violence, added to personal experiences. In pornography, for instance, the sexualization of gender inequality, the violence against women, abuse and multiple variations of male dominance and female submission can be identified. To the extent that the more unequal, the more sexual. It is a reflection of our society. It is not just that women are the main targets of rape, nor that they are the main group that suffers sexual abuse by family members, friends or authority figures within an early interpersonal sexual encounter. Not even that, being adults, they can be more vulnerable to acts of physical violence by their male partner, nor that they more frequently suffer sexual harassment at work. The key is that this all documents the degree and the extent of abuse, of systematic sexual assault, which suggests the clear permissibility of such a structure based on power.

Perversions appear to be a phenomenon with multiple meanings and can simultaneously cover several defensive lines. In contrast, queer theory, for example, not only tries to fully deconstruct the sexual difference but also embodies a project that seeks to abolish the idea that perversion is necessary for civilization. This theory rejects both biological sex and social gender, and believes that each individual is free to take at any time the role of either of the sexes, their clothes, their behaviors, and their own delusions. Hence, the assertion that the transgressive sexual practices, nomadism, porn, escapism, fetishism, voyeurism, are just the equivalent of the rules issued by the self-proclaimed heterosexual society [1].

To Roudinesco, discourse of the queer theory is nothing but the puritanical continuation of the sadistic utopia. However, while Sade justifies crime, incest, and sodomy as the foundations of an imaginary society centered on an inversion of law, the queer theory transforms human sexuality into a domesticated eroticism, in which any reference to love and hatred has been evacuated. Actually, this theory seeks to erase borders and deny perversion its transgressive power dealing with human sexuality, to the point that erasing its name is equal to converting what has been erased in a variation of normality [1]. Since this area is very complex, and initiatives or innovative contributions do not abound, any constructive effort is welcomed.