Activities with a partner include bondage, blindfolding, spanking, flagellation, humiliation by means of urination or defecation on the person, forced cross-dressing, or simulated rape. The intent is to enhance orgasm, but accidental deaths occasionally result from this activity. The disorder commonly begins in early adulthood, although sadistic fantasies often occur during childhood. Generally, the person has insistent, persistent fantasies in which sexual excitement results from suffering inflicted on the partner. The diagnosis is warranted whether the partner consents or not.
Sadism is different from minor manifestations of aggression in normative sexual activity.
At the extreme end of the spectrum, sexual sadism involves brutal rape or torture of victims. Even more extreme is lust murder, in which death of the victim produces sexual excitement. Sexual sadism must sometimes be differentiated from rape, a complex amalgam of sex and power over the victim. However, inflicting suffering is not the motive for most rapists, and the victim's suffering usually does not increase the rapist's sexual excitement. Sexual sadism is usually chronic.