Out On The Couch
When practicing kink affirmative therapy, it is important as a clinician to understand the inherent dynamics that play into working with clients who are a part of the Bondage and Discipline, Dominance, and Submission, Sadism and Masochism (BDSM) community. Over 40 percent of the United States population has fantasies about or has engaged in BDSM play (Sprott, 2017), but the Diagnostic and Statistical Manual (DSM) has classified it as a paraphilic disorder (APA, 2022). As a clinician, it is helpful to understand the power dynamics; both in therapy both between therapist and client and within BDSM play. Additionally, affirmative clinicians should be attuned to the stigma many clients experience as members of the BDSM community.
History of BDSM and the DSM
Psychology and psychiatry have a long history of pathologizing sexual activity. Kink affirmative therapy can begin to heal some of these historical wounds. Clients who engage in BDSM practices are liable to be diagnosed with a paraphilic disorder through the eyes of the DSM (Dunkley & Brotto, 2018). An article discussed the inherent risk of misdiagnosing clients with a paraphilic disorder due to conservative values or not being able to discriminate healthy sexual relationships from “deviant” abusive ones (Wylie, 2015). I recommend looking up the definition of paraphilic disorders in the DSM as it encompasses many of the common fetishes in the BDSM community.
The definitions of paraphilic disorders are easy to misinterpret (McManus et al., 2013). Many of the disorders are defining non problematic sexual fetishes such as fetishism, masochism, sadism, “transvestic fetishism.” By having these in the manual it can be easy for a clinician to pathologize healthy sexual expression (McManus et al., 2013). Issues of consent are the key clinical consideration, and most clients engaging in healthy BDSM play are very aware of safety considerations and the boundaries of consent violations. The DSM categorizes activities common in healthy kinky sex life under the umbrella of sexual abuse (Dunkley & Brotto, 2020). BDSM practices between consenting adults are not a pathology, and need to be dismissed from the DSM.
Sex & Power throughout History
Across history, people who engaged in non-traditional sexual practices have been subject to intense discrimination and shame. For example, people in the sadomasochistic (SM) community have historically lost custody of their children, security clearances for government jobs, jobs in general, have been disowned by their families, have been assaulted and discriminated against (Moser & Keinplatz, 2006). In many ways, this mistreatment is similar to that of members of the LGBTQIA+ community, and has only led to further stigmatization of BDSM. It is essential to understand that people engaging in BDSM practices have been discriminated against and shamed as non-traditional sexual practices. Research suggests that up to 40% of Americans and Canadians have had fantasies with Sadism and Masochism sexual practices with about 20% having engaged in these sexual practices (Dunkley & Brotto, 2018). With the discrimination and pathology of BDSM, clients may be resistant to talk about their sexual preferences with therapists (Meyer & Chen, 2019). Stigma, discrimination, and the taboo nature of non-traditional sexual practices creates an environment of shame, guilt, and a secretiveness that makes it challenging for this community to seek help.
Empowering and normalizing open conversations
Clients may be hesitant to disclose information about their sexual life in therapy for many reasons. It is important for therapists to understand that clients have a desire for openness from their clinicians, as well as a fear of disclosing parts of their lives due to stigma (Dunkley & Brotto, 2018). Clinicians can indirectly express such openness through many forms. As stated by Dunkley & Brotto (2018), a clinician can have a pride flag, BDSM literature on bookshelves, affirming client questionnaires that demonstrate a level of normalizing BDSM practices. More overtly, clinicians can convey openness by discussing BDSM relationships with clients in session together. These are effective means for encouraging and promoting a safe environment for a client to engage with their full self.
Clinical Tools and Kink Affirmative Therapy
BDSM and kink are umbrella terms for a wide variety of activities and roles people adopt in exploring their sexual fantasies. The Model of Action and Perceived Power (MAPP) is one tool to explore the dynamic relationships and activities in BDSM play (Hrushka, 2017). The MAPP model give a visual representation of agreed upon power roles and activities kinksters may engage in. By simplifying roles and understanding power exchange, therapists can support their clients to engage in safer sex.
There is a wide range of roles within the BDSM community, and the Hrushka model does not encompass all of them. As a clinician, being open and understanding your client about their desires and needs can help you work with your client more effectively and be a kink-aware therapist. It is vital to be accepting, understanding and knowledgeable about consensual BDSM practices as a therapist. If you find yourself uncomfortable with sexual activities your client is describing, be sure to get additional consultation and support.
Kink Affirmative Therapy & Emotional Experiences
Whether intentionally or not, therapists carry an increased risk of being unsupportive or even discriminatory towards their clients. This may be in part implicit due to the history of pathologizing BDSM practices within our field, as well as negative mainstream coverage of BDSM in the media (Meyer & Chen, 2019). Clinicians’ own sexual history impact the degrees of comfort and capacity to talk about a client’s fantasy life.
For this reason, a therapist needs to be aware of their own biases towards more socially taboo subjects like non-traditional practices of sex and relationships. A 2018 study found that therapists were able to identify their own countertransference when talking with clients about BDSM practices, highlighting feelings of revulsion, and sexual arousal (Dunkley & Brotto, 2018). Powerlessness, shame, and humiliation are seen as negative emotions in the mainstream, but are sexualized in the BDSM community. Clinicians who are trained in working with transference and countertransference dynamics can make use of unconscious emotional communication to support their clients to build more awareness of a healthy sex life.
As clinicians, it is vital to express openness, acceptance, and curiosity in your work with clients who practice BDSM. Many people see their sexual lives as a major part of their identity, and by demonstrating acceptance of BDSM, you are accepting your clients. Clients may have been unable to share this part of themselves in past therapy relationships because of the discrimination, stigma, and taboo nature of BDSM practices. This makes your understanding and affirmation all the more important to creating a safe space to process your clients’ experiences.
Stigma may also impact your work with couples as they struggle to share in sessions with you what they need in their relationships. It is important to promote a space for BDSM clients to feel accepted and understood. As clinicians, we are in a position to change the societal view of BDSM, and sexuality more broadly, as a taboo. This work can start with you, by providing a safe place for clients in the BDSM community, and by promoting openness and acceptance both in the therapy room and outside of it.
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American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Dunkley, C. R., & Brotto, L. A. (2020). The Role of Consent in the Context of BDSM. Sexual Abuse, 32(6), 657–678. https://doi.org/10.1177/1079063219842847
Dunkley, C. R., & Brotto, L. A. (2018). Clinical considerations in treating BDSM practitioners: A Review. Journal of Sex & Marital Therapy, 44(7), 701–712. https://doi.org/10.1080/0092623x.2018.1451792
Hrushka, C. G. (2017). Model of action and perceived power (MAPP). Sexual and Relationship Therapy, 34(4), 411–421. https://doi.org/10.1080/14681994.2017.1291930
Meyer, C. G., & Chen, H.-M. (2019). Vanilla and kink: Power and communication in marriages with a BDSM-identifying partner. Sexuality & Culture, 23(3), 774–792. https://doi.org/10.1007/s12119-019-09590-x
McManus MA, Hargreaves P, Rainbow L, Alison LJ. Paraphilias: definition, diagnosis and treatment. F1000Prime Rep. 2013 Sep 2;5:36. doi: 10.12703/P5-36. PMID: 24049640; PMCID: PMC3769077.
Sprott, R. A., & Benoit Hadcock, B. (2017). Bisexuality, pansexuality, queer identity, and Kink Identity. Sexual and Relationship Therapy, 33(1-2), 214–232. https://doi.org/10.1080/14681994.2017.1347616
Wylie, K. R. (2015). Paraphilia behaviour and disorders. ABC of sexual health. 3rd ed. London: Wiley, 90-2.