Waldura et al's “Fifty Shades of Stigma: Exploring the Health Care Experiences of Kink-Oriented Patients” (2016)
“Fifty Shades of Stigma: Exploring the Health Care Experiences of Kink-Oriented Patients”
An estimated 2% to 10% of the U.S. population engages in non-traditional sexual practices, commonly called kink or BDSM (bondage, discipline, domination and submission, and sadism and masochism).
[I]ndividuals whose sense of self is deeply tied to their kink orientation can suffer from minority stress because their sexual behaviors and identities are often socially maligned.
The link between kink orientation and social stigma is concerning because studies have documented the negative impact on health care access and usage when patients experience stigmatizing interactions with medical professionals. Delays in seeking medical care, decreased testing for HIV, and lack of disclosure of possibly relevant sexual activity to health care providers are behaviors that are predicted by experiencing stigmatizing interactions. Furthermore, anticipated stigma (the expectation that others will shun, discriminate, or express prejudicial attitudes if a concealable stigmatized identity is revealed) predicts levels of stress and depression.
[R]esearch has begun examining kink in relation to personality functioning. These studies have found kink-oriented individuals to be more extraverted and to have larger numbers of sexual partners; however, they have consistently found no association with mental illness, sexual dysfunction, or distress.
In contrast, the medical community has largely ignored the existence of kink orientation, although it is not rare and has the potential to affect health. Medical schools do not routinely include a discussion of kink sexuality in their sexual health curricula, and with rare exceptions, kink sexuality is not included in continuing medical education offerings for clinicians. In addition, a review of the medical literature found no peer-reviewed clinical research describing the physical health of kink-oriented individuals or their use of health care outside of mental health fields.
There was an overall sense that health care providers had little awareness of the possibility of non-traditional sexual arrangements and in general would not ask questions to detect these.
A number of participants felt that their kink orientation had a positive effect on their health because it improved their general sense of well-being and encouraged them to take good care of themselves.
[T]hose whose kink orientation was more central to their identity often wanted their clinicians to be aware of it, even if kink activities did not affect their physical health directly.
The demographic survey showed that most participants (87%) considered themselves part of a kink community that provided them with support and a place to be open about their identity without fear of judgment or discrimination.
One of the most prominent themes was the fear of encountering stigma in the health care setting—a concern that was mentioned by almost all participants ... Women in particular were concerned about being judged for their sexual activities ...
However, despite the pervasive anticipation of stigma, few participants reported direct experiences of judgment or discrimination. When these did occur, they mostly took the form of micro-aggressions (defined as subtle verbal or non-verbal messages conveying disapproval or discomfort with kink orientation). Participants most commonly described body language cues from their clinicians, such as frowning, stiffening of the posture, or pushing the chair farther from the patient. Often, participants could sense disapproval but were unable to describe exactly how they knew they were being judged.
Despite their fears, participants often had good experiences interacting with health care providers, even when they were open about their kink orientation. In fact, a few participants who had visited an emergency department for a kink-related concern and had been honest about the mechanism of injury were pleased with the professionalism of their providers. However, participants often reflected that the San Francisco Bay Area might be an outlier, or “bubble,” and wondered whether it would be harder to find non-judgmental care in other areas.
Participants used different mechanisms to avoid stigma, with the most common being to hide their kink orientation from their providers. Other mechanisms included prescreening providers for openness before enrolling in care, giving false information about one’s identity or activities, attempting to hide physical evidence of kink activities, and avoiding or delaying medical care.
Many kink-oriented participants would prefer to be out to their providers to receive individualized medical care, STI and HIV testing, and counseling to decrease risk.
Other reasons to come out included a desire to form a more honest health partnership with a medical provider, to pre-empt questions about intimate partner violence, and to explain unusual relationship configurations.
The most common reason for not coming out was fear of stigma. Other reasons included not wanting to spend time during the appointment educating providers or reassuring them of the consensual nature of kink behaviors.
A primary concern of participants was the need for clinicians to be able to distinguish between consensual kink behaviors and IPV. Kink, by definition, is a set of activities that have been mutually agreed to by mentally competent adults, whereas abuse is not.
Numerous participants voiced concern that health care providers’ lack of familiarity with kink would cause them to confuse their behaviors with abuse.
Participants voiced a desire for health care providers to take a sexual history that was open-ended enough to encourage participants to come out about their sexual preferences. Many felt that clinicians did not enquire deeply enough about sexual histories or asked questions in a way that made participants feel reluctant to disclose their sexual preferences.
Some participants voiced a desire for individualized STI and blood-borne pathogen screening reflective of their specific risk profile, rather than depending on population-based guidelines. A number of participants wanted STI and blood-borne pathogen testing more often than current guidelines would indicate for someone with their demographic characteristics, and some participants encountered resistance or confusion on the part of medical providers when they requested the testing.
In one case, a participant had a husband and a Master and felt that she could not make important medical decisions without consulting her Master, although he would not normally be recognized or included in a traditional medical context. Participants indicated that they would like health care providers to acknowledge the important people in their lives, even if they fall outside of expected relationship structures.
Although our casual review of popular internet resources showed that advice about kink and health is often sound, it should nevertheless be concerning to the medical establishment that patients do not feel comfortable seeking advice from their clinicians when they need it.
[T]he evolution of the medical stance toward kink can be tracked through changes in the Diagnostic and Statistical Manual. As recently as 1987, the Diagnostic and Statistical Manual, Third Edition, Revised considered anyone who had acted on their kink urges to have a mental illness. In 1994, the Diagnostic and Statistical Manual, Fourth Edition added the requirement that a person be distressed or impaired to classify kink orientation as an illness, and in 2013 the Diagnostic and Statistical Manual, Fifth Edition went a step further by differentiating non-pathologic paraphilias from pathologic paraphilic disorders. Although evidence is building that consensual kink practices can be considered normal variations of human sexual expression, health care providers would likely not have received formal sexual education that includes the most recent thinking about sexual minorities.
With an increasing emphasis on identifying IPV, clinicians are correct to be concerned about any patient presenting with physical or emotional injuries. Participants expressed approval of clinicians’ screening for IPV, but they also felt burdened by the need to explain or defend the consensual nature of their kink activities and they feared the legal and social consequences of IPV accusations. Participants repeatedly requested that clinicians become aware of the existence of kink and be open to the possibility that their injuries might have been consensually acquired.
This study has some limitations. As a qualitative study, conducted in a single urban population, the findings should be generalized with caution. San Francisco is well known for its sexual open-mindedness and we could have encountered different results if we had conducted the study in other parts of the United States or in other nations. Perhaps a more significant limitation might be that we were able to interview only people who openly identified as having an interest in kink and were willing to talk to us about such a personal topic. Thus, our participants might have represented a subset of kink-oriented individuals more heavily involved in kink practices and lifestyle. We imagine that an even larger number of people might practice kink in private and be unconnected to any community; however, we were unable to capture the experiences of those people in our study.
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