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

Kink-Aware Therapy: Consent and Negotiation

Posted: 12-16-20 | Rachel Gombos

Collage including images of floggers, handcuffs, a couple on a couch in conversation, and two men holding hands. This represents how consent and negotiation are important for therapists to help kink clients with.

By Rachel Gombos MSW, LISW

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

In this article, the first in a three-part series about kink-aware therapy, I will lay the groundwork for practitioners to gain an understanding of BDSM and key concepts such as consent and negotiation. Many may believe that BDSM represents bondage, dominance, and sadomasochism practiced during sex–yet these encompass only a small portion of the practices present in the BDSM and kink communities. After emerging in the late 80s and early 90s, the term BDSM itself has gone through a transformation as of the early 2000s (Taormino, 2012) to become more inclusive. 

With the passage of time and availability of content on the Internet, the use of BDSM as an umbrella term has expanded to reflect the history of kink vocabulary and the wide variety of practices it encompasses. These include bondage and discipline, domination and submission, and sadism and masochism. While the differences among them may not be immediately clear, these terms are neither mutually inclusive nor exclusive, and kink activity is not limited to sexual experiences. 

BDSM has traditionally been pathologized through psychiatric diagnostic manuals such as the DSM (Reiersøl & Skeid, 2006), the effects of which are evidenced by report data. For instance, Kolmes, Stock and Moser (2006) report a concern among consensual BDSM participants that they will receive biased care from mental health professionals. This information was gleaned from a survey administered to both BDSM-involved individuals who have received psychological services and to mental health professionals themselves. 

There are a number of reasons why a client might not disclose their participation in kink and BDSM to a provider. Regardless of the context, remaining affirming and empowering combats the classical psychoanalytic and medical traditions of pathologizing BDSM and kink. Because of this, along with evidence suggesting that kinky clients may fear that providers will focus on their “unconventional” sexual desires instead of their concerns, it’s essential that providers become familiar with some basics of kink-affirming therapy. 

Moser and Kleinplatz (2004) propose that when therapists accept their clients’ sexuality, clients are empowered to focus on their own concerns rather than defend themselves. The client’s BDSM practices are not “curable,” and any connected distress and dysfunction needs to be understood in the context of discrimination and stigma. 

Creating safety in therapy allows clinicians to dispel harmful myths surrounding kink and trauma, and where necessary, to facilitate healing through the basic tenets of kink: consent, empowerment, autonomy, advocacy, and fun. There are two common but contradictory myths, neither more damaging than the other, that prevent many clients from talking about kink with their therapists. Learning about these myths is a way to challenge provider bias, and constitutes a great step toward developing kink awareness. The first is that trauma inherently causes kink, and the other is that you cannot engage in kink if you have a trauma history. 

In consideration to the first myth, I refer to a lesson from my undergraduate psychology course regarding a twin sibling study. The study stated that a set of identical twins were separated at birth and both were obsessively clean. When asked why they thought they had this trait, one sibling reported that they had learned it from their adoptive parents. The other stated that their adoptive parents were so dirty that they vowed to never be this way. Perpetuating the connection of experience to meaning not only reinforces shame, but creates a space in which therapists may potentially pathologize a person’s existence. It can be a function of human nature to look back over our lives to find meaning and significance, yet the narratives we choose are not always rooted in a truth of cause and effect. Truthfully, we do not know why individuals develop the fetishes or kinks that they do. 

The second myth regarding trauma histories proposes that engaging in kink will cause further harm and will be addressed at length in my next article.

Navigating Kink: The Basics for Kink-Affirmative Therapists

It is important that clients who are first realizing their interest in kink educate themselves before taking action. This is the only safe way to engage in kink. Similarly, therapists require education regarding kink dynamics in order to provide kink-aware therapy and provide a safer space for clients. Consensual kink upholds partner/personal consent, limit setting, and full disclosure of the risks that exist in a kink dynamic, as well as other important considerations that help keep each participant safe. 

Let’s explore the extensive communication surrounding consent, limits, safewords, aftercare, and risk awareness that create a foundation for a healthy sexual dynamic. 

Here is a terrific guideline to consent that is as easy as FRIESS* from Planned Parenthood (2020). I’ve added an extra S for an important factor you may encourage your clients to take into consideration.

Freely give





*Sober (C. Cathers, personal communication, November 22, 2020)

Consent is freely given when it does not entail any degree of coercion, threat, or intimidation and it is reversible. This means that consent can be retracted at any time; consenting parties have the right to change their minds. Consent can only be considered informed and specific when every participant is aware of and agrees upon what is going to happen, what would be okay if it happened, what cannot and will not happen, and where, when, and how events are to take place. Think of kink-informed consent like a contract that outlines the expectations and understandings clearly for everyone. 

Sober has been added as a reminder that if any participant is under the influence of mind-altering substances, consent cannot be freely given (C. Cathers, personal communication, November 22, 2020)

Within BDSM communities, practices are always understood to be Risk-Aware and Consensual. You may see activities commonly referred to as RACK:




For example, if a client wants to engage in impact play or any other kink activity such as spanking, caning, flogging, etc., that is great! First, it is important to learn some basic human anatomy so they know where it is safe to give and receive impact before they attempt impact play. Education first upholds awareness so that each participant knows how to create an interaction that is safe while still understanding the risks that are involved in any type of BDSM and kink activity. 

 There are wonderful educational books and Internet-based resources out there. Two of my personal favorites for fun education are SM 101: A Realistic Introduction by Jay Wiseman and videos by Evie Lupine, which you can find on YouTube. Please keep in mind these are not substitutes for completing accredited CE courses or learning from kink educators, but they are a great start. Remember that risk-aware kink practices are meant to keep everyone safe and enjoying themselves.

Negotiation, if done properly, is a collaboration towards a common goal: each partner’s pleasure. Negotiation always comes before a kinky interaction and includes factors like participants’ wants, needs, and soft and hard limits. Soft limits look like activities one is willing to try under the right circumstances, but that must be discussed and agreed upon before trying. Meantime, hard limits are the ones to which a participant says, “No, I am not interested in trying this at all under any circumstances.”

To unpack this a little further, negotiation is multifaceted and will include information such as the logistics of who will be involved, in what capacity, and in which roles. Everyone’s responsibilities must be considered further through the negotiation agreement. A thorough negotiation will also include safety information, including any injuries or illnesses, triggers, psychological limitations, and safewords. If you have further interest in learning about limits or encouraging a client to discover theirs, there are wonderful tools available; my personal favorite is the The Yes, No, Maybe Workbook by Princess Kali. 

Discussing and utilizing safewords is another essential aspect of kink safety. Use of a safeword communicates to all participants that a change or complete stoppage of play is needed. A few recommendations include making sure that the word is something easy to remember, but also something that you would not normally utter during kink or sexual activity. Deciding upon a nonverbal gesture is another important consideration, as some activities render a person unable to speak. Gestures can range from a hand signal to a double tap on one’s partner. Working with safewords can be a great exercise in helping clients learn boundary setting and communicating needs. 

When kinky play ends, aftercare allows all participants to feel safe, connected, and cared for. This can facilitate a sense of being grounded, an important factor considering the mental and physical “drop” that is described after the rush of endorphins experienced during play. No matter a participant’s role, drop can be experienced and may include aches and pains, feelings of guilt, and sadness or fatigue. This experience is normal and a routine of aftercare can help restore balance. Aftercare looks different for everyone in the same way that drop does, but often includes cuddling, reassurance, praise, a drink of water, or even a warm bath. It can be helpful to elucidate in the therapy room that asking partners what they need after play lays a foundation for stability and connectedness. 

While this article does not comprise a definitive list of all things kink, or even all of the basics, I hope it will serve as a starting point as to why kink is healthy and why we should be talking about it in therapy. In the second part of this series I will explore further how having a kink-aware practice reduces stigma, and how we can increase our comfort in working with kinky clients whose past experiences have included trauma. 

A Few General Resources for Kink-Affirmative Therapists:

American Sex Podcast with Sunny Megatron

Community-Academic Consortium for Research on Alternative Sexuality

Kink Academy

National Coalition for Sexual Freedom

SM 101: A Realistic Introduction by Jay Wiseman

The Yes, No, Maybe Workbook by Princess Kali

Evie Lupine’s YouTube videos

School of Squirt BDSM Ideas: An Illustrated Guide

Learn More about Kink Affirmative Therapy

Red background with flogger and leather handcuffs. Fundamentals of Kink presented by Elyssa Helfer, MA, LMFT 2 CE Course

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



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

Kleinplatz, P., & Moser, C. (2004). Toward Clinical Guidelines for Working with BDSM Clients. Contemporary Sexuality, 38(6), 1–4.

Reiersøl, O., & Skeid, S. (2006). The ICD diagnoses of fetishism and sadomasochism. In P.J. Kleinplatz & C. Moser (Eds.), Sadomasochism: Powerful pleasures (pp. 243262). Harrington Park Press.

Sexual Consent. (2020). Planned Parenthood. Retrieved November 23, 2020 from https://www.plannedparenthood.org/learn/relationships/sexual-consent 

Taormino, T (2012). The Ultimate Guide to Kink: BDSM, Role Play and other Erotic Edge. Cleis Press Inc.