Clinical Considerations in Treating BDSM Practitioners: A Review

Abstract

BDSM is an overlapping acronym referring to the practices of Bondage and Discipline, Dominance and Submission, and Sadism and Masochism. This paper reviews the psychological literature on BDSM practitioners, and discusses issues concerning BDSM that are relevant to clinicians and sexual health care providers. The literature concerning the psychological health of BDSM practitioners and clinical issues in treating BDSM practitioners was exhaustively reviewed. BDSM practitioners differ minimally from the general population in terms of psychopathology. Six clinical considerations emerged: Ignoring vs. considering BDSM; Countertransference; Non-Disclosure; Cultural Competence; Closer Relationship Dynamics; BDSM, Abuse, & Pathology.

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Journal of Sex & Marital Therapy
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Clinical Considerations in Treating BDSM
Practitioners: A Review
Cara R. Dunkley & Lori A. Brotto
To cite this article: Cara R. Dunkley & Lori A. Brotto (2018): Clinical Considerations
in Treating BDSM Practitioners: A Review, Journal of Sex & Marital Therapy, DOI:
10.1080/0092623X.2018.1451792
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JOURNAL OF SEX & MARITAL THERAPY
, VOL. , NO. , –
https://doi.org/./X..
Clinical Considerations in Treating BDSM Practitioners: A Review
Cara R. DunkleyaandLoriA.Brotto
b
aDepartment of Psychology, University of British Columbia, Vancouver, British Columbia, Canada; bDepartment of
Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
ABSTRACT
BDSM is an overlapping acronym referring to the practices of bondage and
discipline, dominance and submission, and sadism and masochism. This arti-
cle reviews the psychological literature on BDSM practitioners and discusses
issues concerning BDSM that are relevant to clinicians and sexual health-care
providers. The literature concerning the psychological health of BDSM prac-
titioners and clinical issues in treating BDSM practitioners was exhaustively
reviewed. BDSM practitioners dier minimally from the general population in
terms of psychopathology. Six clinical considerations emerged:ignoring versus
considering BDSM; countertransference; nondisclosure; cultural competence;
closer relationship dynamics; BDSM, abuse, and pathology.
Sexual sadism and sexual masochism describe behaviors that fall under the paraphilia umbrella and are
often accepted as variations of “typical” sexual behaviors. Given the proliferation of sadomasochistic
themes in sexually explicit media (Weiss, 2006a), sadomasochism may represent a more common sex-
ual expression among individuals than was previously assumed (e.g., Moser & Levitt, 1987; Richters, de
Visser, Rissel, Grulich, & Smith, 2008), with an estimated 10% of adults in the general population having
engagedinsomeformofBDSMactivity(Moser&Kleinplatz,2006a). Light forms of sadomasochistic
sexual activity, such as spanking, biting, and hair pulling, are not uncommon among individuals with
more conventional sexual proclivities, with a minority of the population reporting engagement in more
intense forms of sadomasochism, such as whipping, paddling, and bondage (Moser & Kleinplatz, 2006b).
Despite ostensibly high human interest in alternative sexual behavior, the peer-reviewed academic liter-
ature surrounding unusual sexual activities and preferences remains relatively sparse. This review article
aims to (a) provide a brief review of the history of the diagnosis of paraphilia; (b) present an overview
of psychological- and personality-based literature on individuals who engage in alternative sexual prac-
tices; and (c) discuss issues concerning alternative sexuality relevant to clinicians and sexual health-care
providers.
In recent years, BDSM—an overlapping acronym referring to the practices of bondage and disci-
pline, dominance and submission, and sadism and masochism—has garnered an increasing amount of
attention (Newmahr, 2010;Weiss,2006b). Bondage and discipline involves using psychological or phys-
ical restraints, domination and submission involves the exchange of power and control, and sadism and
masochism (or sadomasochism) involves taking pleasure in one’s own, or another’s, pain or humilia-
tion (Hébert & Weaver, 2014). Fetishism is also considered to be part of the BDSM community (Nichols,
2006) and may be colloquially understood as a strong interest in or preference for certain activities, tools,
fabrics, or clothing. Together, the practices comprising BDSM are often referred to as “kink” (Nichols,
2006). BDSM involves the consensual use of physical or psychological stimulation, often in combination
CONTACT Cara R. Dunkley cdunkley@psych.ubc.ca  Laurel Street, Gordon & Leslie Diamond Health Care Centre th Floor,
Vancouver, BC VZ M, Canada.
©  Taylor & Francis

2C. R. DUNKLEY AND L. A. BROTTO
with the eroticization of pain and/or power, to produce arousal and satisfaction (Wiseman, 1996). This
article uses the term BDSM when discussing the diverse practices associated with its broader label, and
SM (sadomasochism) when referring specically to sadism and/or masochism.
Despite the increased visibility of BDSM, stigma attached to the practice is widespread, and mis-
conceptions 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)andDSM-IV-TR (APA, 2000) criteria for paraphilia, sexual sadism, and sexual masochism
are shown in Tab l e 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
signicant clinical distress about their interest, not due to societal disapproval, is present.
Kink-aware and kink-friendly therapists
Kolmes and Weitzman (2010) highlight the dierences between a kink-aware and a kink-friendly ther-
apist. 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-
specic 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 relation-
ship, and the stress experienced in keeping the practice of BDSM secret. A kink-friendly therapist is one
whomaynothaveeducatedhimselforherselfonBDSM,butisabletomaintainanopenmindandcan
refrain from judging kinky clients negatively on the basis of their interests.
Psychological and personality characteristics of BDSM practitioners
The available research suggests that BDSM practitioners dier minimally from the general population
in terms of psychopathology. 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.
Together, these studies highlight the relative good psychological health of BDSM practitioners (Gosselin
& Wilson, 1980; Moser, 1999;Moser&Levitt,1987;Richtersetal.,2008). 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).
Clinical considerations and recommendations
Although nondistressing sexual sadism and sexual masochism are no longer deemed to be mental dis-
orders 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). For example, in a study examining the therapeutic experiences of self-
identied BDSM practitioners, some participants reported that their therapists went as far as requiring
them to give up their involvement with BDSM as a condition to continuing therapy (Kolmes, 2006).

JOURNAL OF SEX & MARITAL THERAPY 3
Tab le  . The DSM- (APA, )andDSM-IV-TR (APA, ) criteria for Paraphilia, Sexual Sadism, and Sexual Masochism.
DSM-IV-TR DSM-
Paraphilia Paraphilia & Paraphilic Disorder
The essential features of a Paraphilia are recurrent, intense
sexually arousing fantasies, sexual urges, or behaviors
generally involving ) nonhuman objects, ) the suffering or
humiliation of oneself or one’s partner, or ) children or other
nonconsenting persons that occur over a period of at least 
months (Criterion A). The diagnosis is made if the person has
acted on these urges with a nonconsenting person or the
urges, sexual fantasies, or behaviours cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning (Criterion B).
The term paraphilia denotes any intense and persistent sexual
interest other than sexual interest in genital stimulation or
preparatory fondling with phenotypically normal, physically
mature, consenting human partners.
Aparaphilic disorder is a paraphilia that is currently causing
distress or impairment to the individual or paraphilia whose
satisfaction has entailed personal harm, or risk of harm, to
others. A paraphilia is necessary but not a sufficient condition
for having a paraphilic disorder, and a paraphilia by itself does
not necessarily justify or require clinical intervention.
In the diagnostic criteria set for each of the listed paraphilic
disorders, Criterion A specifies the qualitative nature of the
paraphilia, and Criterion B specifies the negative consequences
of the paraphilia. In keeping with the distinction between
paraphilias and paraphilic disorders, the term diagnosis should
be reserved for individuals who meet both Criteria A and B. If an
individual meets Criterion A but not Criterion B for a particular
paraphilia, then the individual may be said to have a paraphilia
but not a paraphilic disorder.
Sexual Masochism Sexual Masochism Disorder:
A. Over a period of at least  months, recurrent, intense
sexually arousing fantasies, sexual urges, or behaviors
involving the act (real, not simulated) of being humiliated,
beaten, bound, or otherwise made to suffer.
A. Over a period of at least  months, recurrent and intense
sexual arousal from the act of being humiliated beaten, bound,
or otherwise made to suffer, as manifested by fantasies, urges,
or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupation, or
other important areas of functioning.
B. The fantasies, sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.
Specify if:
With asphyxiophillia: If the individual engages in the
practice of achieving sexual arousal related restriction of
breathing.
Specify if:
In a controlled environment:Thisspecifierisprimarily
applicable to individuals living in institutional or other settings
where opportunities to engage in masochistic sexual behaviors
is restricted.
In full remission: There has been no distress or impairment
in social, occupational, or other areas of function for at least
 years while in an uncontrolled environment.
Sexual Sadism Sexual Sadism Disorder
A. Over a period of at least  months, recurrent, intense
sexually arousing fantasies, sexual urges, or behaviors
involving acts (real, not simulated) in which the psychological
or physical suffering (including humiliation) of the victim is
sexually exciting to the person.
A. Over a period of at least  months, recurrent, and intense
sexual arousal from the physical or psychological suffering of
another person, as manifested by fantasies, urges, or behaviors.
B. The person has acted on these sexual urges with a
nonconsenting person, or the sexual urges or fantasies cause
marked distress or interpersonal difficulty.
B. The individual has acted on these sexual urges with a
nonconsenting person, or the sexual urges or fantasies cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
In a controlled environment:Thisspecifierisprimarily
applicable to individuals living in institutional or other settings
where opportunities to engage in sadistic sexual behaviors are
restricted.
In full remission: The individual has not acted on the urges
with a nonconsenting person, and there has been no distress or
impairment in social, occupational, or other areas of
functioning, for at least  years while in an uncontrolled
environment

4C. R. DUNKLEY AND L. A. BROTTO
Tab le  . Clinical issues to consider in the treatment of BDSM practitioners.
Clinical Consideration Description
Ignoring vs. considering BDSM The problem the client is seeking help with may not be related to BDSM involvement, and in
such cases, BDSM should not be made a central issue in his or her treatment.
Countertransference The psychologist being aware of his or her own emotional reaction to the client’s
involvement in BDSM.
Nondisclosure Fear of negative evaluations may prevent BDSM practitioners from disclosing their sexual
preferences to mental health professionals.
Cultural competence Having a general working knowledge of BDSM practices, cultural values, and associated
phenomena.
Close relationships dynamics Awareness of the issues BDSM practitioners commonly face with respect to the
development and maintenance of interpersonal relationships.
BDSM, abuse, & pathology Being able to distinguish BDSM from abuse and pathology, as well as identify abuse in a
BDSM relationship when present.
Further, BDSM practitioners have lost jobs, housing, and custody of their children based on the legal tes-
timony of psychiatric consultants’ pathologization of BDSM (Kleinplatz & Moser, 2006; National Coali-
tion for Sexual Freedom [NCSF], 2011; Wright, 2006).
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-identication
and social stigma is concerning in light of research that has documented the negative impact on health-
care 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). BDSM participants
who completed an Internet-based survey concerning their experiences with psychotherapy frequently
reported that they had to correct misconceptions about BDSM held by their therapists (Kolmes, 2003).
A follow-up study involving 175 BDSM practitioners reporting on their experience with therapy revealed
118 distinct incidences of therapists providing poor care to BDSM clients (Kolmes et al., 2006). Another
study found that 32% of a sample of BDSM practitioners who had sought counseling reported that the
counselor was insensitive to their sexual identity (Brame, 1999).
In an Internet-based survey of therapists’ attitudes toward BDSM, 76% of therapists reported having
treatedatleastoneclientinvolvedinBDSM,whileonly48%oftherapistsperceivedthemselvesto
be competent in this area (Kelsey, Stiles, Spiller, & Diekho, 2013). Prevalence estimates of BDSM
practitioners are comparable to the number of adults involved in same-sex activity, suggesting that ther-
apists 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 signicantly more uncomfortable treating clients who
practiced BDSM than with clients who engaged in same-sex or group-sex activity (Ford & Hendrick,
2003). Several authors have written about clinical issues in the treatment of BDSM practitioners, the
primary themes of which are discussed below and summarized in Table 2 .
Ignoring versus considering BDSM
More often than not, BDSM practitioners come to therapy for reasons separate from their involvement
in BDSM (Nichols, 2006), such as depression, anxiety, or relationship issues (Connolly, 2006). Indeed,
74.9% of practitioners in the Kolmes et al. (2006) study reported that the issues that brought them to
therapy were in no way related to their BDSM interests, while only 12% reported that their BDSM inter-
ests were related to their reasons for seeking therapy, and 11% reporting that it was tangentially related.
In a qualitative study on psychologists experienced in working with BDSM practitioners, therapists high-
lighted the importance of being able to keep BDSM from becoming a central issue in therapy when it is
peripheral to the client’s presenting concerns (Bezreh, Weinberg, & Edgar, 2012). Clinicians can demon-
strate acceptance and understanding of BDSM by not focusing on their client’s involvement with BDSM.

JOURNAL OF SEX & MARITAL THERAPY 5
It is important to stress that this point stands even if the desire to discuss the client’s sexuality is driven
by curiosity rather than by disapproval or judgment (Nichols, 2006).
With this in mind, it is equally important to consider the potential impact of BDSM involvement
on seemingly unrelated issues. BDSM practitioners are often not open about their BDSM activities in all
areas of life; many individuals hide their BDSM involvement from family, colleagues, and friends. In such
cases, the fear of being “outed” or exposed represents a real concern with the potential for life-altering
consequences. Being exposed could negatively impact a client’s career and close relationships, as well as
have negative repercussions with respect to divorce and child rearing (Nichols, 2006). Clinicians must
be aware of these connections in order to validate clients’ experiences and fears, as well as to assist them
in overcoming associated barriers.
Countertransference
A salient issue that must be considered when working with BDSM practitioners is that of counter-
transference, a psychodynamic term that captures the emotional reaction of the mental health provider
to the client. Lawrence and Love-Crowell (2008) conducted a qualitative study of 14 psychotherapists
experienced in working with BDSM practitioner clients to identify treatment characteristics needed to
provide psychological services. Issues around countertransference emerged as an important feature of
treating BDSM practitioners. Countertransference was found to involve a range of experiences among
therapists in this study, including revulsion, sexual arousal, and advocacy. Emotions and behaviors that
are normally construed as unhealthy, such as powerlessness and shame, are normalized and eroticized
in the context of BDSM (Pillai-Friedman, Pollitt, & Castaldo, 2015). 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. Counter-
transference is likely present in instances where clinicians believe their client’s pathology is clear in
the absence of concrete evidence of harm. Scenes that involve supercial cutting or verbal humiliation
represent relatively common BDSM activities that might lead an uninformed therapist to erroneously
jump to negative conclusions through the projection of the therapist’s own reactions.
In working with BDSM practitioners, clinicians must challenge their own mainstream value system,
theoretical beliefs, practice orientation, and subjective biases about various aspects of BDSM (Pillai-
Friedman et al., 2015). Nichols (2006) oers several suggestions for how therapists can process coun-
tertransference feelings toward BDSM. Adopting an attitude of detached observation may help one to
objectively question adverse reactions or judgments, allowing for a neutral way of analyzing counter-
transferential feelings (Nichols, 2006).
Nondisclosure
Many BDSM practitioners who seek therapy choose to not disclose their sexual preferences to their thera-
pist for fear of negative evaluations (Nichols, 2006). In a study of 115 BDSM practitioners, fewer than half
were “out” to their health-care providers, despite most participants expressing a preference for openness
in order to receive more individualized care (Waldura, Arora, Randall, Farala, & Sprott, 2016). In this
study, the most common reason for not coming out was a fear of stigma. Kolmes et al. (2006) examined
175 BDSM practitioners’ experiences with therapy, and one third of the sample reported choosing not to
disclose their BDSM involvement in therapy (Kolmes et al., 2006). Many of these participants attributed
their reason for nondisclosure to concern over being judged negatively by their therapists. In addition
to fears of negative appraisal, participants expressed concerns about counselors breaking condentiality
based on erroneous assumptions about others being at risk for harm due to BDSM activities. Concern
over stigmatization was also found to have a censoring eect on some BDSM clients in a study by Ho
and Sprott (2009), who analyzed the therapy experiences of 32 BDSM-identied couples. Nondisclosure
of sexual preferences may not interfere with therapy if the client’s issues are unrelated or if the therapy
is short-term; however, withholding such information has the potential to compromise therapy if the
client’s issues involve sexual or relationship problems (Nichols, 2006). Long-term therapy may also be
negatively aected by nondisclosure, as important information concerning meaningful aspects of the
client’s life may be withheld.

6C. R. DUNKLEY AND L. A. BROTTO
Clinicians can encourage self-disclosure through indirect ways, such as having a rainbow ag visi-
ble in the oce, literature on sexual minorities or BDSM on the bookshelves, and including questions
about BDSM on client questionnaires. A clinician can also intentionally bring up BDSM indirectly over
the course of therapy; for example, by mentioning the exceptional communication skills of people who
practice BDSM (Nichols, 2006). During the intake interview, a clinician may facilitate disclosure by ask-
ing about the client’s sexual history in an open-ended and encompassing fashion. Based on the positive
feedback of BDSM practitioners, Waldura et al. (2016) recommend asking, “What else would you like
me to know about your sexuality, so I can take best possible care of you?”
If a client discloses BDSM practice, the clinician may adopt a psychologically neutral and nonjudg-
mentaltherapeuticstance.AgentlecuriosityandopenmindtowarddiscussionofBDSMisencouraged.
Depending on context, the clinician may decide to withhold probing questions about safety and con-
sent until the client is more comfortable discussing his or her practice of BDSM in therapy. When these
potentially sensitive subjects are broached, the clinician should be careful not to display signs of negative
evaluation or judgment; Jozifkova (2013) provides advice on how consent and safety can be nonjudg-
mentally inquired about. In addition to watching one’s language, clinicians should pay particular atten-
tion to their nonverbal behaviors in order to avoid subtle nonverbal messages conveying disapproval or
discomfort with BDSM, such as frowning, stiening of the posture, or pushing the chair farther from
the client (Waldura et al., 2016). If the client only mentions BDSM involvement in passing and not as a
focus of discussion, the clinician is advised not to tirelessly pursue the subject. Any disclosure of BDSM
involvement should be followed up by independently educating oneself on the subject.
Cultural competence
Of the 14 therapists interviewed in Lawrence and Love-Crowell’s (2008)study,allunanimouslyempha-
sized the importance of cultural competence in conducting eective therapy with BDSM clients. Cultural
competence was described in this context as portraying an open and accepting attitude toward BDSM
clients and their activities, as well as having a general working knowledge about BDSM practices, cultural
values, and associated phenomena (e.g., polyamory)—the latter being a signicant requirement above
and beyond just adopting a nonjudgmental and open approach. Therapists in this study also expressed
that it was crucial not to pathologize BDSM involvement and not to regard practicing BDSM as indica-
tive of a mental disorder. The importance of seeking out supervision and consulting with fellow mental
health professionals was also discussed. Nichols (2006) similarly highlighted the need for a greater pro-
fessional understanding of BDSM, and Kolmes et al. (2006)arguedthatcliniciansshouldnotprovide
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
andthatspecializedtrainingisneededforethicaltreatmentofthispopulation.Theseauthorssuggestthat
there is a need for specic guidelines to aid therapists working with kinky individuals, to educate prac-
titioners on the complexity of BDSM, and to enable therapists to better distinguish between behaviors
constituting a healthy expression of SM versus abuse. Kleinplatz and Moser (2004) provide preliminary
guidelines for providing therapy to kinky clients that include many of the considerations discussed here.
The American Psychiatric Association guidelines for working with LGBT clients, which emphasize
refusal to pathologize and the importance of seeking consultation when appropriate, can also be applied
to the treatment of clients who practice BDSM (APA, 2013). To increase competency in providing treat-
ment for BDSM practitioners, clinicians are encouraged to explore information describing BDSM prac-
tices. (See Tabl e 3 for a collection of BDSM community literature resources.) The National Coalition
for Sexual Freedom (NCSF; ncsfreedom.org) is an organization dedicated to creating a political, legal,
andsocialenvironmentintheUnitedStatesthatadvocatesforpeopleinvolvedinalternativesexualand
relationship expressions, and oers many online resources for practitioners and clinicians alike.
Close relationship dynamics
Involvement in BDSM can have signicant implications on the development and maintenance of close
relationships. Stress often results from being “closeted,” as the concealment of BDSM activities from
friends, family, and colleagues can be challenging (Nichols, 2006). Stiles and Clark (2011)discussthe

JOURNAL OF SEX & MARITAL THERAPY 7
Tab le  . BDSM community literature resources.
Author(s) Title
American Psychiatric Association
()
Diagnostic and Statistical Manual of Mental Disorders (th ed.)
Bannon ()Learning the Ropes: A Basic Guide to Safe and Fun S/M Lovemaking
Easton and Hardy ()The New Bottoming Book
Easton and Hardy ()The New ToppingBook
Easton and Liszt ()When Someone You Love Is Kinky
Fulkerson ()Bound by Consent: Concepts of ConsentWithin the Leather and Bondage, Domination,
Sadomasochism (BDSM) Communities
Harrington and Williams ()Playing Well With Others: Your Field Guide to Discovering, Exploring and Navigating the
Kink, Leather and BDSM Communities
Henkin and Holiday ()Consensual Sadomasochism: How to Talk About It and How to Do It Safely
Kleinplatz and Moser () “Toward Clinical Guidelines for Working With BDSM Clients”
Masters ()This Curious Human Phenomenon: An exploration of some uncommonly explored
aspects of BDSM
Miller and Devon ()Screw the Roses, Send Me the Thorns: The Romance and Sexual Sorcery of
Sadomasochism
Morpheous () How to Be Kinky: A Beginner’s Guide to BDSM
National Coalition for Sexual
Freedom (–)
ncsfreedom.org
Nichols () “Psychotherapeutic Issues With “Kinky” Clients: Clinical Problems, Yours and Theirs”
Ortmann and Sprott ()Sexual Outsiders: Understanding BDSM Sexualities and Communities
Tao rm ino ( )The Ultimate Guide to Kink: BDSM, Role Play and the Erotic Edge
Williams () “Different (Painful¡) Strokes for Different Folks: A General Overview of Sexual
Sadomasochism (SM) and Its Diversity”
Wiseman ()SM : A Realistic Introduction
various reasons for concealment of BDSM involvement, levels of concealment and social disclosure,
the use of cover stories, and concealment strategies to improve psychological outcomes. Nichols (2006)
discussed the various issues that can arise with one’s partner and family that are specic to BDSM clients.
Some individuals repress their SM desires and do not disclose their interests to romantic partners. In such
cases, a therapist may be asked to facilitate disclosure, or be sought out specically to help process the
aftermath of disclosure or accidental discovery of BDSM interests.
In addition to problems associated with the “coming-out” process, there are important considera-
tions that must be taken into account when treating clients involved in kinky partnerships. For exam-
ple, polyamory and various other forms of consensual nonmonogamy are common in the BDSM com-
munity; 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 rela-
tionships, wherein dominance and submission transcends sexual activity and is interwoven throughout
many or all aspects of the relationship (Lawrence & Love-Crowell, 2008). Lawrence and Love-Crowell
(2008) found relationship concerns to be the most common presenting issue of BDSM clients, according
to therapists who work with this population. In this study, therapists noted that their BDSM clients often
express diculty in nding partners who share their interests. Disparate levels of interest in BDSM within
established partnerships represent another common relationship problem reported by BDSM clients.
If a client is suering from the burden of hiding or disclosing their sexual interests to an unaware part-
ner, the book entitled When Someone You Love Is Kinky (Easton & Liszt, 2015) could be recommended.
This book aims to help loved ones understand and accept a partner’s interest in BDSM.
BDSM community membership
Clinicians working with BDSM practitioners should be aware of the potential ways organized BDSM
communities may promote positive outcomes for members. The BDSM community represents a social
network of advocacy and support groups, events, and safe spaces for like-minded people to discuss
and engage in BDSM activities. In addition to regulating community norms of safety and consent, the

8C. R. DUNKLEY AND L. A. BROTTO
BDSM community fosters a sense of belonging among members, provides opportunities to socialize and
meet partners, and oers various functional resources, which has particular relevance for clients seeking
therapy.
Graham, Butler, McGraw, Cannes, and Smith (2015) examined the role, meaning, and function of
BDSM communities from the perspective of self-identied BDSM practitioners. Three central themes
emerged, each containing several categories. The rst theme was social features. Participants spoke of the
multifaceted ways they beneted 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. Newmahr (2011)similarly
observed that BDSM communities are also more accepting of other forms of marginalization.
Thesecondthemethatarosewaspersonaldevelopmentintheformofself-improvementandself-
actualization. BDSM communities were said to provide venues that encouraged sexual expression and
personal growth. Participants also recognized various therapeutic elements to community involvement,
as well as enhanced spiritual or philosophical knowledge. Other research supports the therapeutic
benets (Barker, Ianta, & Gupta, 2007;Pitagora&Ophelian,2013;Williams,2012)andspiritual
elements (Nichols, 2006;Weiss,2011;Westerfelhaus,2007)ofBDSMcommunities.
The functional resources oered by BDSM communities emerged as the nal theme. Practitioners
placed a high value on the sharing of educational knowledge and resources, as well as social support. 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 identied,
such as internal conict among members.
TherearemanykindsofeventsheldbytheBDSMcommunity,andknowingwheretostartmaybe
experienced as overwhelming or intimidated by novices. In such cases, a clinician might suggest the client
search for a locally held munch, which is a public socialization venue that serves as a casual introductory
space that people can visit to nd entrance to the BDSM community and discuss topics related to BDSM.
The Internet has increased the visibility and accessibility of the BDSM community, and various
websites provide an online platform for meeting and interacting with like-minded individuals. FetLife
(www.fetlife.com), for example, is a worldwide, online social network comprising more than six mil-
lion BDSM practitioners. It can be thought of as a Facebook for kinky people, and contains numerous
resources for local events as well as online discussion forums. FetLife may represent another resource to
which clinicians can direct their clients.
BDSM, abuse, and pathology
Without training in this area, it can be easy to confuse a loving, consensual BDSM relationship with
an abusive relationship. 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 connes of a BDSM rela-
tionship. Abuse in BDSM relationships can go beyond violations of physical or sexual boundaries, and
involve partner manipulation, both nancial and psychological. Clinicians working with BDSM practi-
tioners must be able to dierentiate healthy BDSM relationships from domestic violence and assault, as
well as recognize abuse within BDSM relationships. In order to accomplish this, mental health profes-
sionals 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 rela-
tionships. 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 dier 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)

JOURNAL OF SEX & MARITAL THERAPY 9
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 rela-
tionships 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 every-
day 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
areabsentordisrespectedinabusiverelationships.
Physical indicators can also help distinguish consensual BDSM from abuse. Moser (2006) provides
a list of physical dierences 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 forear ms;
(b) marks obtained during a BDSM scene usually have a pattern and are well dened, 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 eshy parts of the body that can
withstand intense stimulation)—marks involving the lower back, bony areas, eyes, and ears are unusual.
If confronted with a client who is engaging in SM but is practicing without the expressed consent
of his or her partner, the client’s behavior represents sexual or physical abuse and should be handled
accordingly. If a client is engaging in Domination/submission (D/s) without the full consent of his or her
partner, the client’s behavior may constitute emotional or psychological abuse. If a client discusses sex-
ual excitement over physically hurting or humiliating a nonconsenting person, psychopathology is likely
present. It should be noted here that consensual nonconsent—such as role-playing sexual coercion—does
not constitute psychopathology. Sadism in the context of BDSM can be dierentiated from pathological
sadism (as discussed in the DSM-5)inthatsadisticbehaviorsintheabsenceofconsentarenotarousing
or desirable to a sadist practicing consensual BDSM. Conversely, the lack of consent on the part of the
victim represents a primary source of pleasure in cases of pathological sadism. The NCSF website oers
community assistance guides for victims of sexual assault from within the BDSM scene.
Becoming a kink-aware practitioner
Specic training on treating BDSM-identied clients in therapy involves psychoeducation of accurate
information about this sexual-minority group, awareness of cultural biases and the negative eects
of stigma, and sensitivity to the intricacies presented by BDSM practitioners seeking therapy. Pillai-
Friedman et al. (2015) oer a three-part training program to help mental health care professionals
become kink-aware, which involves Sexual Attitude Reassessments (facilitated education on BDSM),
independent reading, and skill development through supervision. Shahbaz and Chirinos (2017)have
authored a book on becoming a “kink aware” therapist. Ortmann and Sprott (2012) provide a guide for
clinicians seeking to gain competency in working with BDSM practitioners. The community-academic
organization community-academic consortium for research on alternative sexualities (CARAS) created
an instructional video for clinicians working with BDSM clients as part of their BDSM and Therapy
project (https://carasresearch.org,Ta b l e 3). This project also articulates the possible risks of BDSM play,
claries situations where BDSM play may not be healthy or helpful, and instructs clinicians on how to
help BDSM practitioners process negative experiences unique to BDSM play (e.g., having limits pushed
too far in a scene). The NCSF also maintains a network of kink-aware professionals and has website
resources for clinicians. Kink-aware professionals who are interested in having people referred to them
from the NCSF website may submit their name for consideration. Professionals listed on this platform
“must believe that alternative forms of erotic play can be healthy and proper expressions of sexuality,” and
“agree that any form of consensual sexuality between adults can be considered healthy if practiced in a
safe and responsible manner.” National Coalition for Sexual Freedom. How to Become a KAP professional.

10 C. R. DUNKLEY AND L. A. BROTTO
Conclusion
This literature review was intended to provide an up-to-date summary of the psychological character-
istics and treatment of BDSM practitioners. Research suggests that BDSM practitioners are psychologi-
cally and socially well adjusted, and that the practice of BDSM may be best understood as a recreational
leisure activity (Cross & Matheson, 2006; Hébert & Weaver, 2014;Moser&Kleinplatz,2006a;Nichols,
2006; Weinberg, 2006). 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. It is
hoped that this review will serve as a useful resource and referral guide for clinicians aiming to expand
their scope of professional competence to include BDSM practitioners.
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