Out On The Couch

Depathologizing Kink in Therapy

Posted: 4-17-21 | Rachel Gombos

Collage of various couples and people engaging in relationships and/or kink activities representing the diversity of kink experiences and importance of kink affirmative therapy

Please note that this article contains content related to sexual trauma.

Surviving sexual trauma can change the way that sexual contact is experienced and enjoyed, and the prevalence of posttraumatic stress disorder symptoms in sexual assault survivors is outrageously high, at around 94% (Chivers-Wilson, 2006). At the same time, rediscovering enjoyable physical contact as a survivor of trauma is possible and empowering. It is is what set me on my journey of practicing sex-affirming therapy and sharing quality sex education. 

Sex- and kink-affirming therapy 

When kink and trauma intersect in the therapy room, a clinician may wonder where to begin and how to maintain safety as a priority. One can start by understanding what it means to be a sex-affirming therapist. While research on the subject is limited, clinicians are well advised to remain present with clients when they disclose engaging in a practice of kink or other sexual self-exploration. Clinicians can bear witness to clients beginning to understand and accept the rollercoaster of healing, and will need to have familiarity with specifics of ethical kink culture.

This culture includes consent, limits, clear communication, and fun, with a goal of creating space for empowerment. Despite assumptions and erroneous associations in mainstream culture between kink and pathology, no extant research confirms kink practices are harmful to those with a trauma history. Therefore, no basis exists for discouragement or pathologizing of kink practice (Coppens et al., 2019; Richters et al., 2008). In fact, there is no statistically significant difference between kink practitioners and their non-kinky counterparts in terms of a history of traumatic experiences (Coppens et al., 2019).

In a study examining self-identified BDSM practitioners’ experiences in therapy, some participants reported that their therapists required them to give up kink practices in order to remain in treatment (Kolmes et al., 2006). Available research also indicates that many therapists rely on inadequate and/or inaccurate information on BDSM and kink practices (Ford & Hendrick, 2003). Other findings suggest that clinicians are uncomfortable working with kink-identified clients, and may use unhelpful or even unethical practices that ultimately lead to inappropriately pathologizing BDSM practices (Lawrence & Love-Crowell, 2008). This may lead clinicians to ask why, when considering that research shows us that kink practice is healthy and that there is no correlation between kink practice and trauma, we still find oppressive patterns in therapeutic practices.

What influences our beliefs around kink?

It is important to explore why we may associate BDSM and kink with “emotionally disturbed” people. The average individual’s exposure to these practices comes from mainstream television shows, movies, and novelizations. 

Barker et al. (2013) explore the multiple and overlapping “healing narratives”–widely defined as engagement in kink related to trauma survival–of BDSM, using plots from the aforementioned media. They caution that the concept of healing narratives may reinforce the misconception that all BDSM practitioners engage in kink practices to address their problems. This concept reinforces marginalization of kink practitioners with a schema of brokenness. 

As clinicians, we are likely to discuss with our clients the impact of media consumption on our perceptions of both ourselves and others. Mainstream references to BDSM that immediately come to mind probably include movies like 50 Shades of Gray or Secretary, or episodes of television shows such as Criminal Minds. It is understandable, if we are exposed to and associate our thoughts about kink with these representations, that we would have a limited understanding of BDSM. Hence, it is no surprise that on a wider level, BDSM practices are frequently equated with pathology. 

Kink as a healthy sexual practice

Widespread historical teachings around sexuality exist within a framework of shame and continue to influence us today. For example, the 18th century philosopher Immanuel Kant believed that fulfillment of sexual desire is not possible without acting immorally, perpetuating the connection of shame and desire (Shrage & Stewart, 2015). 

Differing points of view and beliefs can make thinking about sexuality, shame, and kink uncomfortable. Whether or not this is the case for you, I invite you to ask yourself two questions:

  1. What if kink is healthy?
  2. What if kink is a positive thing?

If we could assume both of these things, how would that change the way in which we relate to our own bodies and sexuality? How might these assumptions change the ways in which we relate to our clients’ sexuality and sexual practices? 

The World Health Organization (n.d.) has this to say about sexual health: “When viewed affirmatively, [it] requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.” This passage might inspire us to feel empowered not only to say “no” when we need to–but also to say “yes” to that which brings us pleasure. In the therapy room, we reinforce the power of saying yes by affirming clients’ rights to sexual exploration. 

I would be remiss in not reminding us all that often, the consent practices surrounding kinky acts–not the acts themselves–are empowering. Still, some folks might use kink to take back their power and define their self-narrative. While not every trauma survivor will find kink to be an empowering or even appealing practice, I have been fortunate enough to hear the stories of clients who have rediscovered their voices when encouraged to embrace their desires.

Per my first article in this series, creating the expectations of communication, boundary setting, and active consent are all essential to safe and healthy kink practices. These elements can help empower survivors to find their voices in trauma treatment. When clients practice articulating their needs and are met with respect and support, this can positively influence other areas of their lives.

Next steps for sex-positive therapists

Therapists must be lifelong learners, consistently challenging their own beliefs as they face new experiences. Considering the two questions above a little further can evolve into an exploration of the impact of kink suppression and lack of affirmation in the therapy room. If we agree that kink practices are healthy and positive, and evidence shows that psychotherapists can play an active role in oppression, how does this affect our clients?

In her exploration of this topic, Rice (2020) cites that increased anxiety and/or depression, relationship stress, loneliness, development of negative coping skills, outbursts of emotion, irritability, and change in behavior are all among the psychological impacts of suppressing kink identity. When therapists ask or encourage clients to suppress kinky behaviors and/or identities, they not only fail to demonstrate support, but in fact take an actively oppressive role.

It is the responsibility of providers to ensure that they gain a clear understanding of the common practices of consent and negotiation surrounding kink. Taking advantage of ongoing training and continuing education opportunities will help psychotherapists ensure that they are affirming their clients’ desires and practices safely and healthily. In the third and final article in this series, I will continue to explore the process of educating ourselves as practitioners and what it looks like to take steps toward becoming a sex-positive therapist. 


Buehler, S. (2017). What every mental health professional needs to know about sex. Springer Publishing Company.

Chivers-Wilson K. A. (2006). Sexual assault and posttraumatic stress disorder: a review of the biological, psychological and sociological factors and treatments. McGill journal of medicine: an international forum for the advancement of medical sciences by students, 9(2), 111–118.

Coppens, V., Ten Brink, S., Huys, W., Fransen, E., & Morrens, M. (2019). A Survey on BDSM-related activities: BDSM experience correlates with age of first exposure, interest profile, and role identity. The Journal of Sex Research, 1-8. https://www.tandfonline.com/doi/full/10.1080/00224499.2018.1558437

Ford, M. P., & Hendrick, S. S. (2003). Therapists’ sexual values for self and clients: Implications for practice and training. Professional Psychology: Research and Practice, 34(1), 80–87. doi:10.1037/0735-7028.34.1.80

Harris, S. M., & Hays, K. W. (2008). Family therapist comfort with and willingness to discuss client sexuality. Journal of Marital and Family Therapy, 34, 239-250.

Lawrence, A. A., & Love-Crowell, J. (2008). Psychotherapists’ experience with clients who engage in consensual sadomasochism: A qualitative study. Journal of Sex & Marital Therapy, 34(1), 63–81. doi:10.1080/00926230701620936

Kolmes, K., Stock, W., & Moser, C. (2006). Investigating Bias in Psychotherapy with BDSM Clients. Journal of Homosexuality, 50(2/3), 301–324. https://doi.org/10.1300/J082v50n02_15

Nagoski, Emily (2015). Come as you are: The surprising new science that will transform your sex life. Simon & Schuster Paperbacks.

Rice, E. (2020, May 19). The Psychological Impact of Suppressing Kink Identity [PowerPoint Slides]. The Affirmative Couch. https://affirmativecouch.com/product/the-psychological-impact-of-suppressing-kink-identity/

Shrage, L.J., Stewart, S.C. (2015). Philosophizing about sex. Broadview Press. 

World Health Organization. (n.d.). Sexual Health. https://www.who.int/health-topics/sexual-health#tab=tab_1

Learn more about kink affirmative therapy in our continuing education courses

Red background with flogger and leather handcuffs. Fundamentals of Kink presented by Elyssa Helfer, MA, LMFT 2 CE Course Text: “The Healing Power of Open Relationships presented by Kathy Slaughter, LCSW 4 CE Course” under an image of a mobile of different colored hearts to represent how early childhood attachment can influence adult relationships and how open relationships can be healing of attachment wounds.Two hands tied up by rope with the words "The psychological impact of suppressing kink identity" presented by Elyssa Rice, MA, LMFT 2 CE Course underneath

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