Sexual Fantasies: What's 'Pathologic'?

'Uncommon' Sexual Fantasies More Common Than Realized

Liam Davenport

November 06, 2014

Very few sexual fantasies are uncommon, with both men and women expressing a wide range of fantasies, a finding that calls into question current definitions of pathologic behaviors.

Results of a large survey conducted by investigators at the Université du Québec à Trois-Rivières and the Philippe-Pinel Institute of Montreal, Canada, indicate that both men and women fantasize about domination and submission, and that both themes are commonly reported by the same individual. However, there were differences between the sexes, with women less likely to want to act on their fantasies.

"It is clear that one should be careful before labeling a sexual fantasy, as the majority of the 55 on the questionnaire were not found to be either rare or unusual," the investigators, led by Christian C. Joyal, PhD, write.

The study was published online October 30 in the Journal of Sexual Medicine.

Fantasies Differ for Men and Women

The researchers recruited participants via advertisements in public places, interviews with the authors on a local radio show and in local daily newspapers and magazines, presentations to groups of elderly people, word of mouth, a Facebook page, and university mailing lists.

Of the 1516 participants, 799 (52.7%) were women, which is close to the female-to-male ratio of Quebec's general adult population. On other measures, the sample was not representative of the general population. The majority of respondents (85.1%) described themselves as heterosexual; 3.6% described themselves as homosexual, and the remainder as bisexual.

The team administered a modified version of the Wilson Sex Fantasy Questionnaire, bringing it into line with current cultural and social trends. The resulting 55-item questionnaire asked participants to rate fantasies in terms of intensity of interest from 1 (not at all) to 7 (very strong). A final, open question allowed additional fantasies to be gathered.

Sexual fantasies were defined as rare if they were shared by fewer than 2.3% of participants or were 2 standard deviations (SD) below the mean, as unusual if shared by fewer than 15.9% of participants or were 1 SD below the mean, as common if they were shared by more than 50% of participants, and as typical if shared by more than 84.1% of participants or were 1 SD above the mean.

There were two rare fantasies: sex with a child younger than 12 years; and sex with an animal.

Unusual fantasies for women were of urinating on a partner, being urinated on, cross-dressing, being forced to have sex, abusing an intoxicated person, having sex with a prostitute, and having sex with a small-breasted woman.

For men, unusual fantasies were of urinating on a partner, being urinated on, having sex with two other men, and having sex with more than three men.

What's Pathologic?

Interestingly, only five sexual fantasies were typical: fantasies of feeling romantic emotions during a sexual relationship; fantasies in which atmosphere and location are important; fantasies involving a romantic location; of receiving oral sex; and, for men, of having sex with two women.

Of the remaining fantasies, 23 were common in men, and 11 were common in women.

Significant proportions of women (28.9% to 64.6%) reported fantasies about being sexually dominated, and similar proportions were observed in men.

The fantasy of being dominated was significantly correlated with both submission and domination fantasies. Fantasizing about being dominated was also a significant predictor of total fantasy score, accounting for 16% of the variance in both men and women.

Overall, men had higher sexual fantasy scores than women (153.7 ± 56 vs 114.9 ± 57; P < .0001), and there were significant differences between the two groups, including fantasies of experiencing romantic emotions during sex, of receiving oral sex, of having sex outside a relationship, and of having anal sex.

Approximately one third of women fantasized about homosexual activities, despite the fact that only 19% considered themselves bisexual or homosexual. For men, approximately one quarter had homosexual fantasies, although 89.5% considered themselves heterosexual.

Finally, women were less likely than men to want to live out their fantasy, with approximately half of women who had submissive fantasies saying that they would not want them to be realized.


Although praising the study as offering a larger sample and broader questionnaire than previous investigations, Richard Krueger, MD, associate clinical professor of psychiatry, Columbia University College of Physicians and Surgeons, in New York City, observed that it has several limitations.

"This is a self-select population [and] that these are not representative of the general population," he said.

"The other thing is that these are just fantasies. It doesn't really go to whether they cause distress, dysfunction, or result in action on a nonconsenting individual. So this doesn't really describe 'disorder' or 'pathology' ― it's just a flat description of fantasies," Dr Krueger added.

An interesting aspect of the study, however, is that it reveals the commonness of many fantasies.

"Many fantasies that one might suspect would be unusual are, in fact, endorsed by a significant portion of individuals. Yet this doesn't mean that these are pathological at all, it just means that people have them," said Dr Krueger.

"The only way that it becomes pathological is if [it involves] distress, dysfunction, or action on a nonconsenting person."

This would imply that there remains a gap in the body of knowledge on sexual fantasies.

"What's needed are studies involving epidemiological assessment of fantasies in the general population," said Dr Krueger.

Lack of Clarity

Noting a shift in the landscape of sexual fantasies, he added that "there are an increasing number of sexually atypical patterns of interest, fantasy, and behavior. These are, again, not pathological but variants."

"It's clear that the Internet is allowing for the development and expression of patterns of atypical sexual behavior. People that otherwise might have fantasies about...who knows...having sex with clowns or other strange things can all of a sudden hook up and connect with groups which present this and which express it," he added.

"I think that the Internet is really having a quite profound influence upon atypical patterns of sexual interest, particularly of atypical sexual interest...but it's entirely unknown if these are pathological or not."

This lack of clarity over current sexual mores and their relationship with pathologic behaviors forms part of a wider debate on the terms used in, and the role of, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-10).

Dr Joyal believes that in some ways, the definition of pathologic fantasies used in DSM-5 represents a backward step compared with previous versions.

"A sexual fantasy associated with distress or suffering or nonconsenting partners should definitely be considered as problematic (a disorder). However, contrarily to the ICD-10, the term paraphilia (para, outside the norms; philia, liking) is used in the DSM."

"The ICD term of sexual preference disorder is much better in my opinion because it implies that any preference could be problematic, not just the eight specified in the DSM.... Thus, if a gay man is distressed by his thoughts about an adult consenting women, he still has a problem, whatever the commonality of his fantasies. So why restrain the definition to so-called paraphilic themes?"

Divergent Opinions

Furthermore, the lack of knowledge over the commonness of sexual fantasies has hampered understanding of what constitutes pathologic behavior under the DSM-5.

"Again contrarily to the ICD-10, sexual fantasies, without any urge or behaviors, are sufficient to meet the criteria of paraphilia in the DSM, as long as they are intense and recurrent," Dr Joyal said. "But the ground on which it was decided that themes such as fetishism (high heels) and bondage (tying up a partner on the bed) were 'anomalous' (DSM-5) or 'uncommon' (DSM-IV) are never given in the text."

"According to the website of the next version of the ICD (ICD-11), the authors are seriously considering following the DSM-5 on many aspects of the new paraphilia chapter. I would suggest doing the exact opposite," he added.

However, Dr Krueger takes a different view. "I think that the ICD-10 manual, and I have been involved in drafting new definitions for ICD-11, pathologizes any sexual behavior which is preferential."

"There's been a lot of complaint and criticism of the ICD-10 because anything that's preferential is considered pathological, so to speak, whereas in the DSM, sexual fantasies have to be distressing, severely distressing, or causing impairment in function, or have to result in activity involving a nonconsenting person or entity."

"I think that a lot of people generally feel...stigmatized by these diagnostic manuals. I think that the DSM tends to be less stigmatizing, and the ICD-11 will be likewise less stigmatizing," he added.

This study was sponsored in part by a team grant to the Groupe de Recherche sur les Agresseurs Sexuels (GRAS, Jean Proulx, director) from the Fonds de Recherche Québécois sur la Société et la Culture (FRQSC). Dr Joyal and Dr Kreuger report no relevant financial relationships.

J Sex Med. Published online October 30, 2014. Abstract


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.