Dunkley and Brotto's “Clinical Considerations in Treating BDSM Practioners: A Review” (2018)
“Clinical Considerations in Treating BDSM Practioners: A Review” [PDF]
Despite the increased visibility of BDSM, stigma attached to the practice is widespread, and misconceptions about BDSM practitioners are common (Newmahr, 2010; Silva, 2015). Over the last few decades there has been a sociological shift in how BDSM is conceptualized. Diagnostic changes to the DSM-5 were made, with the intention of reducing stigma. The DSM-5 (American Psychiatric Association [APA], 2013) and DSM-IV-TR (APA, 2000) criteria for paraphilia, sexual sadism, and sexual masochism are shown in Table 1. These changes clarify that nonconventional sexual interests and behaviors are not evidence of psychopathology. Consensual sadism and masochism no longer warrant a diagnosis unless significant clinical distress about their interest, not due to societal disapproval, is present.
Kolmes and Weitzman (2010) highlight the differences between a kink-aware and a kink-friendly therapist. According to these authors, a kink-aware therapist recognizes BDSM as a normal part of sexual expression, is able to distinguish healthy BDSM from nonconsensual abuse, is aware of what constitutes safe versus unsafe BDSM, has a general understanding of the intricacies of BDSM, and is aware of kink-specific issues that might come up in therapy, such as the coming-out process, communication about BDSM interests with nonkinky partners, negotiation of boundaries within and outside of the relationship, and the stress experienced in keeping the practice of BDSM secret. A kink-friendly therapist is one who may not have educated himself or herself on BDSM, but is able to maintain an open mind and can refrain from judging kinky clients negatively on the basis of their interests.
Compared to nonpractitioners, research has found BDSM practitioners to have the same rates of mental illness and psychological adjustment (Connolly, 2006; Cross & Matheson, 2006), as well as psychological distress (Richters, de Visser, Rissel, & Smith, 2006). Another study on personality characteristics found BDSM practitioners to be less neurotic, more extroverted, more open to new experiences, more conscientious, and less agreeable compared with nonpractitioners (Wismeijer & Assen, 2013). Weinberg (2006) reviewed the literature on BDSM spanning three decades and found the empirical research to suggest that BDSM practitioners are psychologically and socially well adjusted.
Findings such as these have led several authors to conclude that BDSM is best regarded as a recreational leisure activity, as opposed to the manifestation of psychopathology (e.g., Newmahr, 2010; Williams, 2009; Williams, Prior, Alvarado, Thomas, & Christensen, 2016).
Although nondistressing sexual sadism and sexual masochism are no longer deemed to be mental disorders according to the DSM-5 (APA, 2013), many clinicians remain uninformed of this. Awareness of gender and sexual diversities is only minimally discussed in most psychological training programs (Glyde, 2015). This lack of awareness creates the potential for doing harm to sexual-minority clients. The available research suggests that many therapists have inadequate or inaccurate information on BDSM practices, are uncomfortable working with BDSM clients, use unhelpful or even unethical practices with BDSM clients, and inappropriately pathologize BDSM practices (Ford & Hendrick, 2003; Kolmes, 2003; Lawrence & Love-Crowell, 2008).
Based on the reported experiences of BDSM practitioners, it is not uncommon for some mental health professionals to make negative comments about BDSM in a way that is considered unacceptable with respect to other areas of sexuality (Hudson-Allez, 2005). The association between BDSM-identification and social stigma is concerning in light of research that has documented the negative impact on healthcare usage when people experience stigma from medical professionals (Chesney & Smith, 1999). Three of the most common examples of biased, inadequate, or inappropriate care in the treatment of BDSM practitioners are confusing consensual BDSM with abuse, assuming that BDSM interests are indicative of a history of abuse, and deeming BDSM unhealthy (Kolmes, Stock, & Moser, 2006).
Prevalence estimates of BDSM practitioners are comparable to the number of adults involved in same-sex activity, suggesting that therapists can expect to encounter clients who practice BDSM as often as they encounter lesbian, gay, and bisexual clients (Lawrence & Love-Crowell, 2008). This comparison has important implications, as one study found practicing therapists reported being significantly more uncomfortable treating clients who practiced BDSM than with clients who engaged in same-sex or group-sex activity (Ford & Hendrick, 2003).
To clinicians with little experience with this topic, countertransferential feelings such as shock, fear, disgust, anxiety, and revulsion are common (Nichols, 2006). These feelings can produce a deep-seated conviction that the client’ s behavior is self-destructive, often without tangible reasons to justify the resolve of this conviction. Countertransference is likely present in instances where clinicians believe their client’s pathology is clear in the absence of concrete evidence of harm.
In addition to fears of negative appraisal, participants expressed concerns about counselors breaking confidentiality based on erroneous assumptions about others being at risk for harm due to BDSM activities.
Nichols (2006) similarly highlighted the need for a greater professional understanding of BDSM, and Kolmes et al. (2006) argued that clinicians should not provide services outside of their areas of education and training as a matter of ethics, and that any psychologist treating a client that practices BDSM has a professional responsibility to cultivate a greater understanding of BDSM. Kolmes et al. (2006) further advised that BDSM practitioners represent a distinct subculture and that specialized training is needed for ethical treatment of this population.
[P]olyamory and various other forms of consensual nonmonogamy are common in the BDSM community; thus, knowledge of such relationship styles is important when working with this population (Lawrence & Love-Crowell, 2008). A basic understanding of relationships involving power exchange represents another area in which therapists working with BDSM clients should familiarize themselves. Such knowledge is especially important when treating clients who are involved in “lifestyle” BDSM relationships, wherein dominance and submission transcends sexual activity and is interwoven throughout many or all aspects of the relationship (Lawrence & Love-Crowell, 2008).
Participants spoke of the multifaceted ways they benefited from the interpersonal interactions with like-minded others enabled by community involvement. BDSM communities were reported to nurture both sexual relationships and platonic relationships that extend beyond BDSM. A sense of community was another strong social feature that emerged, referring to a broader sense of kinship and connection with a group of people. Acceptance represented another important social feature, with communities providing an environment where members’ interests and identities are validated, celebrated, and shared.
A strong emphasis on safety and consent also arose as a prominent feature of BDSM communities. While results generally highlighted positive features, negative aspects of the community were also identified, such as internal conflict among members.
A prominent fear among BDSM practitioners, especially women, is that kink activities will be confused with intimate partner violence or abuse (Waldura et al., 2016). However, it is important to recognize that real, nonconsensual abuse can occur within the confines of a BDSM relationship. Abuse in BDSM relationships can go beyond violations of physical or sexual boundaries, and involve partner manipulation, both financial and psychological. Clinicians working with BDSM practitioners must be able to differentiate healthy BDSM relationships from domestic violence and assault, as well as recognize abuse within BDSM relationships. In order to accomplish this, mental health professionals need to be educated on how boundaries are established and maintained in BDSM relationships (Kolmes et al., 2006). Jozifkova (2013) provides a useful guideline on how to identify abuse in BDSM relationships. In brief, markers distinguishing BDSM from violence include voluntariness, communication, a safe word or ability to withdraw consent, safer sex, and access to information about BDSM. Similarly, healthy BDSM relationships differ from abusive relationships based on the following: (a) the presence of fear versus feelings of safety distinguishes abuse from consensual BDSM; (b) the ability to use a safe word, rescind consent, and have the withdrawal of consent respected separates BDSM from abuse; (c) in healthy BDSM relationships, partners are able to discriminate between BDSM activity and common everyday life; (d) in abusive relationships, the victim is often intentionally isolated from his or her friends and family; this is not the case in healthy BDSM relationships; (e) emotional highs and lows marked by periods of violence and reconciliation are common in abusive relationships, while healthy BDSM relationships do not exhibit this pattern; (f) a clear disparity in social hierarchy between partners exists in abusive BDSM relationships, and in some healthy BDSM relationships; the level of disparity in everyday life is the distinguishing factor, such that everyday hierarchy disparity is mild in functional healthy relationships; (g) respect for one another is present in healthy BDSM relationships, regardless of power dynamics; and (h) negotiation and communication are emphasized in healthy BDSM relationships, but are absent or disrespected in abusive relationships.
Physical indicators can also help distinguish consensual BDSM from abuse. Moser (2006) provides a list of physical differences between markers of abuse and BDSM for mental health professionals and physicians: (a) BDSM rarely results in facial bruising or defensive marks that are received on the forearms; (b) marks obtained during a BDSM scene usually have a pattern and are well defined, indicating that the bottom partner remained still—marks resulting from physical abuse are typically more random, and the soft-tissue bruising is unlikely to be focused in a single area; (c) the common areas for stimulation-based play are the buttocks, thighs, upper back, breasts, or the genitals (i.e., the fleshy parts of the body that can withstand intense stimulation)—marks involving the lower back, bony areas, eyes, and ears are unusual.
Despite its increasing visibility, stigma, discrimination, and misinformation concerning the practice of BDSM are common among mental health-care providers and the general public. Clinicians should be educated on the nuances of providing therapy to BDSM practitioners.
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