Psychological Assessment

2012, Vol. 24, No. 3, 764 769

2011 American Psychological Association

1040-3590/11/$12.00 DOI: 10.1037/a0026419

BRIEF REPORT

The Severe Sexual Sadism Scale: Cross-Validation and Scale Properties

Andreas Mokros

Frank Schilling

Psychiatric University Hospital Zurich, Zurich, Switzerland, and

University of Regensburg

Federal Evaluation Centre for Violent and Sexual Offenders,

Vienna, Austria

Reinhard Eher

Joachim Nitschke

Federal Evaluation Centre for Violent and Sexual Offenders,

Vienna, Austria, and University of Ulm

Ansbach District Hospital, Ansbach, Germany

The Severe Sexual Sadism Scale (SSSS) is a screening device for the file-based assessment of
forensically relevant sexual sadism. The SSSS consists of 11 dichotomous (yes/no) items that code
behavioral indicators of severe sexual sadism within sexual offenses. Based on an Austrian sample of 105
sexual offenders, the present study replicated the 1-dimensional scale structure of the SSSS, as evidenced
by confirmatory factor analysis. More specifically, the scale was commensurate with the 1-parameter
logistic test model (Rasch model). Reliability was estimated to be good. Criterion validity for the clinical
diagnosis of sexual sadism was good. With a cutoff value of 7 points, sensitivity and specificity were
estimated at 56% and 90%, respectively.
Keywords: sexual sadism, scale development, Rasch, psychometrics, sensitivity

study with 15 experienced clinicians who independently judged 12

case vignettes on whether a diagnosis of sexual sadism was present
in each case, Marshall, Kennedy, Yates, and Serran (2002) found
an unacceptably low interrater agreement of .14. Similarly,
Levenson (2004) noted an insufficient level of observer agreement
of .30 with regard to sexual sadism. Doren and Elwood
(2009), on the other hand, reported rates of agreement in excess of
90% among 34 experienced raters concerning the diagnosis of
sexual sadism. Doren and Elwood did not provide any statistics
correcting for chance agreement (such as ), however.
Consequently, several authors emphasized the potential utility
of behavioral indicators instead of clinical self-report data for
diagnosis (e.g., Knight & Prentky, 1990; Marshall & Kennedy,
2003; McLawsen, Jackson, Vannoy, Gagliardi, & Scalora, 2008;
Yates, Hucker, & Kingston, 2008). The use of behavioral indicators deriving from information on the offense seems pragmatic: It
is plausible that sexual sadists are particularly unwilling to disclose
violent sexual fantasies and urges that focus on extreme forms of
violence, degradation, or humiliation of others, especially within
forensic settings (cf. Dietz, Hazelwood, & Warren, 1990).
It needs to be acknowledged, though, that the current Criterion A for sexual sadism in the revised fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM
IVTR; American Psychiatric Association, 2000)like its presumable revision in DSM5 (Krueger, 2010, p. 342)focuses
on recurrent, intense sexually arousing fantasies or sexual
urges in which the psychological or physical suffering of a
nonconsenting victim is experienced as sexually arousing.
These urges or fantasies may involve corresponding acts or lead
to distress or interpersonal problems in other ways (Criterion
B). Furthermore, violent sexual fantasies seem to be particularly common among individuals who committed grievous sex-

The paraphilia of sexual sadism involves sexual fantasies, urges,

and behaviors that center around the subjugation and humiliation
of another human being. The afflicted individual obtains sexual
gratification from exerting power over another person through acts
of cruelty or degradation. Although aspects of power and subjugation may be part of consensual sadomasochistic role play, severe
sexual sadism refers to the forensically relevant form of the disorder in which someone else is being victimized against his or her
own will. This clearly has legal implications, as it may lead to
sexual offenses such as rape or sexual homicide.
Given the link between paraphilia and sexual reoffending in
general (Hanson & Morton-Bourgon, 2005) and the putatively
increased risk for sexual offense relapses among sexual sadists in
particular (Berner, Berger, & Hill, 2003; Kingston, Seto, & Bradford, 2009), there is a need to diagnose sexual sadism as accurately
as possible within forensic settings. The results on the reliability of
the criteria for diagnosing sexual sadism are inconclusive: In a

This article was published Online First December 5, 2011.

Andreas Mokros, Center for Forensic Psychiatry, Psychiatric University
Hospital Zurich, Zurich, Switzerland, and Department of Forensic Psychiatry and Psychotherapy, School of Medicine, University of Regensburg,
Regensburg, Germany; Frank Schilling, Federal Evaluation Centre for
Violent and Sexual Offenders, Vienna, Austria; Reinhard Eher, Federal
Evaluation Centre for Violent and Sexual Offenders, Vienna, Austria, and
Forensic Psychotherapy Unit, University of Ulm, Ulm, Germany; Joachim
Nitschke, Forensic Psychiatric Clinic, Ansbach District Hospital, Ansbach,
Germany.
Correspondence concerning this article should be addressed to Andreas
Mokros, Center for Forensic Psychiatry, Psychiatric University Hospital
Zurich, Lenggstrasse 31, PO Box 1931, CH-8032 Zurich, Switzerland.
E-mail: andreas.mokros@puk.zh.ch
764

SEVERE SEXUAL SADISM SCALE

ually sadistic offenses (Burgess, Hartman, Ressler, Douglas, &

McCormack, 1986; MacCulloch, Snowden, Wood, & Mills,
1983). This may suggest a possibly causal or at least a shaping
or maintaining influence of such deviant sexual fantasies on
subsequent violent acts (McGuire, Carlisle, & Young, 1965)
even though sexual fantasies including dominance are estimated
to occur in 13%54% of men, according to various surveys with
participants from the general population (Leitenberg & Henning, 1995). Hence, behavioral indicators should not replace the
diagnostic relevance of sadistic fantasies, but they will likely
prove useful, particularly within forensic settings where denial
of sexually sadistic fantasies may be more common than in
clinical work (Leitenberg & Henning, 1995).
Furthermore, it has been suggested to distinguish more clearly
between the relevance of a diagnosis of sexual sadism for forensic
purposes and consensual sadomasochistic role play in the community within DSM5 (Krueger, 2010). It should therefore be emphasized that the use of the behavioral indicators of severe sexual
sadism described herein is limited to cases in which sexual violence or bodily harm has been inflicted by the testee against a
nonconsenting victim. Although some actions within consensual
sadomasochistic role play may appear phenomenologically similar
by virtue of accepting dominant or submissive roles (e.g., Santtila,
Sandnabba, & Nordling, 2006), consensual sadomasochistic role
play as such can serve various motives (such as hedonism or
escapism; Taylor & Ussher, 2001) and does not imply psychological distress or prior traumatization of the person, according to a
recent national survey (Richters, de Visser, Rissel, Grulich, &
Smith, 2008).
In a comparison of psychiatric diagnosis with behavioral indicators of sexual sadism, Kingston, Seto, Firestone, and Bradford
(2010) found that only the latter yielded significant predictive
validity for sexual offense recidivism. Following the findings from
Marshall et al. (2002), Marshall and Hucker (2006) put forward a
list of 15 dichotomous (yes/no) behavioral indicators of severe
sexual sadism. On the basis of a German sample of sexual offenders from a high-secure forensic psychiatric hospital (N 100),
Nitschke, Osterheider, and Mokros (2009) empirically derived an
11-item subset from this list (including the additional item of
Insertion of objects into victims bodily orifice[s]). The resulting
Severe Sexual Sadism Scale (SSSS; see Table 2 for items) showed
high reliability (rtt .93) within the construction sample. More
specifically, the SSSS fulfilled the statistical properties of a deterministic (Guttman) scale. A sum score of at least 4 points on the
SSSS differentiated perfectly between the (clinically assessed)
sexual sadists and nonsadists within the construction sample. Furthermore, the sum score on the SSSS correlated significantly with
psychopathy as measured with the total score on the Psychopathy
ChecklistRevised (Hare, 2003): r .29 (Mokros, Osterheider,
Hucker, & Nitschke, 2011). The average interrater reliability
across the individual item codings on the SSSS, given by Nitschke
et al. (2009), was .86 (range: .651.00).
Given that analyses of the SSSS were so far limited to the
construction sample, it is paramount to test whether the scale
properties (in particular, internal consistency, reliability, and onedimensionality) carry over to other samples. Hence, we analyzed
data from another sample of sexual offenders. We hypothesized:

765

Hypothesis 1: Severe sexual sadism as measured with the

11-item set of the SSSS is a unitary (one-dimensional) construct.
Hypothesis 2: The SSSS total score is a sufficient statistic for
the level of the underlying trait (sexual sadism), as evidenced
by a deterministic (Guttman) scale.

Method
Participants
Participants were 105 adult male sexual offenders who had been
evaluated between 2002 and 2004 at the Federal Evaluation Centre
for Violent and Sexual Offenders (FECVSO) of the Austrian
Prison Service (Schilling, Ross, Pfafflin, & Eher, 2010). The
FECVSO is a department of the Austrian Federal Ministry of
Justice. Participants were included consecutively if they had a
sexual crime (rape, sexual homicide) as the index offense. In brief,
since the end of 2001 every sexual offender convicted of an
unconditional prison sentence by an Austrian court has to be
reported to the FECVSO. After a file-based risk assessment of
every offender, a substantial proportion of these reported offenders
(about 60%) are routinely seen for risk assessment by experienced
forensic psychiatrists and psychologists at the FECVSO. Selection
of offenders for clinical forensic assessment is done by one of the
following criteria: a total score of more than 5 points in the
Static-99 actuarial risk assessment instrument (Hanson & Thornton, 2000), age under 25, a prison sentence of more than 4 years,
a conviction for a child sexual abuse offense with a nonrelated
victim, and any offender reconvicted for a sexual crime. Consequently, all participants in the present sample were interviewed
clinically (Eher, Matthes, Schilling, Haubner-MacLean, & Rettenberger, 2011).

Design and Procedure

The criteria of the SSSS (Nitschke et al., 2009; cf. Marshall &
Hucker, 2006) were coded based on clinical and court files. Coding was done by an experienced forensic psychologist who had not
been involved in the diagnostic assessment and risk assessment
procedures for the cases at hand within the FECVSO, and thus was
blinded against the clinical diagnoses. Items were initially coded
on a 5-point Likert-type scale (with verbal anchoring points of 0
clearly absent, 1 possibly present, 2 present to some extent,
3 clearly present, and 4 clearly dominant feature). In order to
make the data commensurate with the analyses done by Nitschke
et al. (2009), the data were dichotomized by collapsing coding
Categories 0 and 1 as not present and coding Categories 2 4 as
present.
Data were analyzed with the PASW Statistics program, Version
18.0.0 (SPSS, Chicago, IL), with the exception of factor analyses
that were carried out with Mplus, Version 6.11, for Mac (Muthen
& Muthen, Los Angeles, CA). The factor analyses used a uniform
least squares estimation algorithm (using the unweighted least
squares estimator for exploratory and the means-and-varianceadjusted unweighted least squares estimator for confirmatory factor analysis). Finally, Rasch scaling was implemented in Maple,
Version 14.01 (Waterloo Maple, Waterloo, Canada), by the first

MOKROS, SCHILLING, EHER, AND NITSCHKE

766

author, with conditional maximum likelihood estimation of item

parameters based on the paired-comparison algorithm described by
Ford (1957). Person parameters were estimated with the weighted
maximum likelihood method described by Warm (1989). Similarly, kernel density estimation was facilitated with Maple, Version 14.01, by means of a Gaussian normal kernel and a normal
bandwidth parameter.

Results
On average, participants in the sample were 33.19 years old
(SD 9.71; range: 15.31 60.28) at the time of the judicial verdict.
The length of the determinate prison sentences of 102 participants
was 50.44 months (SD 46.02; range: 6 258) on average; an
additional two offenders were sentenced to life imprisonment.
Data on length of sentence was not available for one offender.
According to the assessment of the experienced forensic psychiatrists and psychologists at the FECVSO, a subsample of 18
participants (17.1%) were diagnosed as suffering from sexual
sadism according to DSMIVTR criteria.
A subset of six cases was chosen at random and coded independently by the third and fourth authors. Averaging joint occurrences and disparities across the six cases and focusing on the 11
items of the SSSS as derived by Nitschke et al. (2009) yielded an
overall index of interrater agreement of .58 (95% CI [.40,
.77]). According to the criteria given by Landis and Koch (1977),
this would indicate a moderate level of agreement. Concerning the
total score on the SSSS, the consistency variant of the intraclass
correlation coefficient (type [2, 1], single measure) calculated to
.82.
As Table 1 shows, most of the items of the SSSS were positively
correlated. Exceptions were the two least frequent criteria (Item 5
[Offender mutilates sexual parts of the victims body] and Item
8 [Offender mutilates nonsexual parts of the victims body]);
these two items showed negative correlations with some of the
other items. Overall, the mean tetrachoric correlation between the
11 items was .41. In an exploratory factor analysis, a one-factorial
solution (variance explained 4.72) accounted for two thirds
(68%) of the total communality (6.97) as estimated by Thurstones
method (based on maximum correlation coefficients) and nearly
half (43%) of the total variance.

Confirmatory factor analysis of the SSSS items yielded a reasonable fit for a one-factorial solution, with absolute fit indices,
2(44) 54.60, p .13, and root-mean-square error of approximation .05 (90% CI [.00, .09]). The relative fit indices, comparative fit index .89 and TuckerLewis index .87, fell below
the commonly accepted margin of .95, however. As Table 2
indicates, factor loadings ranged from .31 to .97, with the majority
of items (six out of 11) showing factor loadings well above .55. In
the light of the results from the confirmatory factor analysis,
Hypothesis 1 could be retained: The items of the SSSS appeared to
represent a one-dimensional scale.
Hypothesis 2, however, could not be retained: The number of
Guttman errors (i.e., instances in which a less frequent behavior
was present in a single case, whereas a more frequent one was not)
was too high. Across the 11 items of the SSSS, we noted 240
Guttman errors for all 105 cases. This resulted in a coefficient of
reproducibility of .79 a value that fell short of the commonly
accepted threshold of .90. Consequently, the data did not conform
to a deterministic (Guttman) scale. Because some items showed
negative correlations with other items, nonparametric item response theory (Mokken scaling) was not an option either. Consequently, we tested a one-parameter logistic (Rasch) model. The
score distribution log-likelihood of the estimated model (with 21
parameters) was 476.33, compared with a log-likelihood of the
saturated model of 382.24 at 2,047 parameters. The value of the
Akaike information criterion, based on the score distribution loglikelihood of the estimated model, was 994.66. The Akaike information criterion for the saturated model was 4858.48. Item parameters ranged from 2.96 for the most frequent item (Item 6
[Offender engages in gratuitous violence toward the victim]) to
2.66 for the least frequent Item 8 (denoting mutilation of nonsexual
parts of the victims body).
According to the item fit index (standardized weighted mean
square residual, or infit) described by Wright and Masters (1982),
all items showed acceptable fit, with the exception of Item 9
(Victim is abducted or confined), which showed significant
underfit with a weighted mean square residual coefficient of 2.16.
This means that Item 9 was too indiscriminate, with a too high
proportion of Guttman errors. The unweighted mean square residual coefficient (outfit) of 1.23 for Item 9 indicated an acceptable
model fit at p .89.

Table 1
Matrix of Tetrachoric Correlations
Variable

10

11

1
2
3
4
5
6
7
8
9
10
11

.50
.37
.68
.01
.44
.61
.18
.41
.69
.61

.62
.61
.47
.48
.32
.11
.36
.53
.32

.78
.14
.36
.16
.06
.39
.75
.56

.21
.28
.25
.31
.60
.79
.84

.22
.23
.77
.00
.30
.72

.02
.15
.10
.35
.40

.31
.15
.61
.28

.19
.46
.60

.45
.15

.81

p .05.

p .01.

p .001 (all two-sided).

SEVERE SEXUAL SADISM SCALE

767

Table 2
Factor Loadings (From Confirmatory Factor Analysis) and Item Parameters (From Rasch Modeling) of the
Severe Sexual Sadism Scale
Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Offender is sexually aroused by the act.

Offender exercises power/control/domination over the victim.
Offender humiliates or degrades the victim.
Offender tortures the victim or engages in acts of cruelty on the victim.
Offender mutilates sexual parts of the victims body.
Offender engages in gratuitous violence toward the victim.
Offender keeps trophies of the victim.
Offender mutilates nonsexual parts of the victims body.
Victim is abducted or confined.
Evidence of ritualism in the offense.
Insertion of objects into victims bodily orifices.

Percent present

Factor loading

Infit

61.0
59.0
29.5
24.8
4.8
79.0
9.5
3.8
60.0
35.2
9.5

.73
.56
.70
.92
.31
.44
.46
.40
.46
.97
.85

1.9681
1.7340
0.0250
0.4487
2.2053
2.9562
1.6583
2.6603
1.7947
0.4864
1.9417

0.1415
0.5342
0.3060
1.1040
0.3285
0.9442
0.9157
0.1077
2.1623
1.6244
0.5436

.556
.703
.620
.135
.371
.827
.820
.457
.985
.052
.293

Note. i item difficulty parameter according to Rasch scaling; infit weighted mean square standardized residual (z transform): an item fit statistic
that denotes significant underfit (i.e., lack of discrimination if infit is greater than 1.96, p .975) or overfit (i.e., an almost deterministic response pattern
if infit is less than 1.96, p .025; Wright & Masters, 1982).

Under Andrichs (1988) method (i.e., estimating error variance based on the standard error of measurement of person
parameters), the reliability of the 11-item Rasch scale was
estimated at rtt .86 in the sample. Internal consistency of the
scale was estimated at Cronbachs .75 and Guttmans 2
.78.
The test characteristic curve plots the total score on the SSSS
as a function of the underlying trait level (see Figure 1). The
test characteristic curve had the steepest ascent at a trait level of
0.05, indicating that this trait level differentiated best between cases. A trait level of 0.05 would correspond with the
range between the total scores values of 5 ( 0.32) and 6
( 0.33).
The score distribution of the sexual sadists was swamped by
the score distribution of the nonsadistic sexual offenders due to
sexual sadists representing the minority (17%) in the sample
(see Figure 2). The two graphs in Figure 2 come closest to
intersection at a raw score total of 7.55. The intersection would

thus imply a cutoff at a total score of 7. A cutoff value of 7

points would afford a sensitivity (true-positive rate) of 56%, a
specificity (true-negative rate) of 90%, and a selection ratio (or
posterior probability) of 53% within the present sample. The
cutoff of 4 points originally recommended by Nitschke et al.
(2009) would yield a sensitivity of 83%, a specificity of 58%,
and a selection ratio (posterior probability) of 29%. Generally,
the probability that a sexual sadist, drawn at random from the
subsample of sexual sadists, would have a higher score on the
SSSS than a randomly chosen nonsadistic sexual offender was
81%. This value represents the area under a receiver operating
characteristic curve: .81 ( p .001, 95% CI [.72, .91]). Expressed in terms of standard deviation units, the difference
between the arithmetic mean of sexual sadists on the SSSS
(M 5.94, SD 1.86, Mdn 7) and the corresponding score
of the nonsadistic sexual offenders (M 3.31, SD 2.22,
Mdn 3) calculated to d 1.23, which represents a large
effect size.

Figure 1. Test characteristic curve of the Severe Sexual Sadism Scale (solid line) describing the relationship
between the latent trait () and the total score, with 95% confidence bands (dashed lines).

MOKROS, SCHILLING, EHER, AND NITSCHKE

768

Figure 2. Kernel-density estimates for the distributions of total scores

among sexual sadists (N 18; solid line) and nonsadistic sexual offenders
(N 87; dashed line). Density curves were scaled according to relative
group size. SSSS Severe Sexual Sadism Scale.

Given the difficulties in ascertaining sexually sadistic fantasies

or urges of sexual offenders within forensic settings, the SSSS may
therefore become a potentially useful complement to other diagnostic procedures. The use of the scale is limited to forensic cases
in which sexual offenses or violent acts were committed against
nonconsenting victims. It should be acknowledged, though, that
development and replication of the 11-item set were based on data
from two German-speaking countries (Austria and Germany).
Consequently, it would be necessary to test the scale properties in
English-speaking and other countries as well. Furthermore, it
should be noted that the construction (N 100) and the present
testing sample (N 105) were comparatively small. In particular,
the present testing sample did not allow for splitting the sample in
order to conduct a test on the homogeneity of person parameters
(Andersen, 1973). Therefore, replications with larger data sets are
needed. Finally, it would be highly interesting to find out whether
the total score on the SSSS is predictive of violent or sexual
reoffending among sexual offenders released from custody. A
study that addresses this issue and uses a retrospective coding of
cases is currently under way.

Discussion
The present study replicated the structure of an 11-item set
indicative of severe sexual sadism with a sample of 105 sexual
offenders from Austria (18 of whom had been diagnosed as sexual
sadists). Confirmatory factor analysis supported the view that the
items represent a one-dimensional scale. However, the deterministic (Guttman) properties that were identified in the construction
sample (Nitschke et al., 2009) could not be confirmed. Still, the 11
items were commensurate with the one-parameter logistic (Rasch)
model. Hence, the item set retained the properties of forming a
cumulative scale and, more importantly, of the total score as a
sufficient statistic for the underlying trait. Similarly, OMeara,
Davies, and Hammond (2011) recently applied Rasch modeling to
a brief self-rating scale from a related domain, the Short Sadistic
Impulse Scale, capturing a (nonsexual) sadistic personality trait.
Estimates of reliability as well as sensitivity and specificity were
lower than in the construction sample. Still, at rtt .86, the
reliability of the scale within the present sample met the standard
for clinical decisions (rtt .85) suggested by Rosenthal and
Rosnow (1991). In the current testing sample, the criterion validity
of the SSSS with regard to the clinical DSMIVTR diagnosis of
sexual sadism was good, with a large effect size for distinguishing
participant groups. The cutoff of 4 points suggested by Nitschke et
al. (2009) would lead to 42% false positives and 17% false
negatives, affording a biased selection ratio in the present sample
(with a base rate of 17.1% sexual sadists): Among the individuals
above the cutoff, only one in three would meet the clinical criteria
for sexual sadism. The latent trait level corresponding with the
cutoff value of 4 ( 0.97) was clearly below the margin
yielding optimum information ( 0.05). Consequently, future
research should address the question whether the cutoff of 4 points
is too low. For the higher cutoff of 7 points that afforded a more
acceptable specificity (90%) and a selection ratio above 50%, the
standard error of measurement of the associated trait level (
0.99) was 0.82. The range of 0.99 1 standard error of
measurement covers the interval [0.12, 1.81]. Expressed in terms
of the total score, this would entail the neighboring values of 6
points ( 0.33) and 8 points ( 1.64), respectively.

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Received May 4, 2011

Revision received October 24, 2011
Accepted October 27, 2011