ArticlePDF AvailableLiterature Review

A Systematic Scoping Review of the Prevalence, Etiological, Psychological, and Interpersonal Factors Associated with BDSM

Authors:

Abstract and Figures

BDSM (bondage, discipline, dominance, submission, and sadomasochism) encompasses a diverse set of sexual interests. Research interests in BDSM have been historically underpinned by examining potential mental health issues, unhealthy fixations on specific sexual behaviors, and/or the presence of childhood trauma, as is predicted by psychopathological and psycho-10 analytic models. The objective of this scoping review was to provide an overview of the current landscape of BDSM research, including incidence rates, evidence for psychopathological, psychoanalytical, biological, and social etiological factors, demographics of BDSM practitioners , and the psychological correlates of those with BDSM interests. After the literature search and screening process, 60 articles were included. BDSM related fantasies were found to 15 be common (40-70%) in both males and females, while about 20% reported engaging in BDSM. Results show little support for psychopathologic or psychoanalytic models. In the selected samples studied, BDSM practitioners appear to be white, well educated, young, and do not show higher rates of mental health or relationship problems. Research supports BDSM being used as a broadening of sexual interests and behaviors instead of a fixation on a specific interest. Future 20 empirical research should focus on non-pathological models of BDSM, discrimination of BDSM practitioners, interpersonal relationships, and biological factors.
Content may be subject to copyright.
ANNUAL REVIEW OF SEX RESEARCH SPECIAL ISSUE
A Systematic Scoping Review of the Prevalence, Etiological,
Psychological, and Interpersonal Factors Associated with BDSM
Ashley Brown , Edward D. Barker, and Qazi Rahman
5Psychology Department, Institute of Psychiatry, Psychology, and Neuroscience, Kings College
London
BDSM (bondage, discipline, dominance, submission, and sadomasochism) encompasses
a diverse set of sexual interests. Research interests in BDSM have been historically underpinned
by examining potential mental health issues, unhealthy xations on specic sexual behaviors,
and/or the presence of childhood trauma, as is predicted by psychopathological and psycho-
10 analytic models. The objective of this scoping review was to provide an overview of the current
landscape of BDSM research, including incidence rates, evidence for psychopathological,
psychoanalytical, biological, and social etiological factors, demographics of BDSM practi-
tioners, and the psychological correlates of those with BDSM interests. After the literature
search and screening process, 60 articles were included. BDSM related fantasies were found to
15 be common (40-70%) in both males and females, while about 20% reported engaging in BDSM.
Results show little support for psychopathologic or psychoanalytic models. In the selected
samples studied, BDSM practitioners appear to be white, well educated, young, and do not show
higher rates of mental health or relationship problems. Research supports BDSM being used as
a broadening of sexual interests and behaviors instead of a xation on a specic interest. Future
20 empirical research should focus on non-pathological models of BDSM, discrimination of BDSM
practitioners, interpersonal relationships, and biological factors.
Although people may use BDSM and sadomasochism inter-
changeably, BDSM is broader in scope, and represents three
overlapping acronyms: bondage and discipline (BD), domina-
25 tion and submission (DS), and sadomasochism (SM). A precise
denition of BDSM is difcult to generate, but it generally
includes sexual behaviors that involve some sort of power
exchange between two or more partners and/or the use of pain
to elicit sexual pleasure, though sensations other than pain (e.g.,
30 pleasure)arealsofrequentlyusedinplay(Williams,2006;see
Weinberg, Williams, & Moser, 1984 forasimilardenition
based on qualitative data). This power exchange is rooted in
afrmative consent; all parties involved consent to the beha-
viors taking place and can withdraw consent at any time (e.g.,
35 through the use of a safeword). It is useful to note that the
experience and purpose of pain in a BDSM context differs
between individuals. A behavior may be considered painful by
some, but not by others. In contemporary settings, BDSM has
grown into a subculture complete with events, social networks,
40and differing social identities (Williams, 2006), though due to it
being historically pathologized, peoples interests in BDSM
may hide their sexual proclivities from others (Freud, 1906/
1953;Krafft-Ebing,1886). Because of its basis in an exchange
of power, BDSM oriented individuals choose identities within
45that power difference. Submissives, bottoms, and masochists
are the most common identities on the side of relinquishing
power, with dominants, tops, and sadists assuming power.
Dominants and submissives do not necessarily enjoy giving or
receiving pain, while sadists and masochists do not necessarily
50want to serve or be served by their partners. Switches are those
that assume roles on either side, usually dependent on context
and partner.
Because BDSM was historically thought of as being
caused by mental illness, pathology, or complications occur-
55ring in childhood, it has been associated with paraphilic
disorders. This view still partially exists, with sexual
Correspondence should be addressed to Ashley Brown, Psychology
Department, Institute of Psychiatry, Psychology, and Neuroscience, Kings
College London, 5th Floor Bermondsey Wing, Guys Hospital, London
SE1 9RT. E-mail: ashley.brown@kcl.ac.uk;qazi.rahman@kcl.ac.uk
THE JOURNAL OF SEX RESEARCH,00(00), 140, 2019
© 2019 The Society for the Scientic Study of Sexuality
ISSN: 0022-4499 print/1559-8519 online
DOI: https://doi.org/10.1080/00224499.2019.1665619
sadism, sexual masochism, and fetishistic disorder being
listed in both the DSM-5 and ICD-10 (but the ICD -11 has
since removed sexual masochism). Many sex researchers
60 contest the inclusion of some of these in diagnostic manuals
because they stigmatize BDSM practitioners as well as
medicalize what may be relatively benign and even com-
mon sexual interests (Moser, 2018,2016; Seto, Kingston, &
Bourget, 2014; Shindel & Moser, 2011; Wright, 2006).
65 Having BDSM sexual interests alone no longer meet the
criteria of a paraphilic disorder. In order to meet the diag-
nostic criteria for sexual masochism or sexual sadism dis-
order, an individual must have experienced clinically
signicant distress or impairment due to their sexual desires
70 or must have acted on these sexual urges with
a nonconsenting person (American Psychiatric Association
[APA], 2013). However, these criteria are vague, and the
level or cause of distress has received little clarication.
Despite the attention being paid to aspects of BDSM in
75 individual disciplines (e.g., psychiatry, psychology), there have
been no substantial reviews of the existing literature and thus
there is little understanding of the current landscape of the
BDSM research evidence base. The purpose of this scoping
review is to help ll this gap. The review includes literature on
80 theories of the development of BDSM, prevalence rates, BDSM
specic roles and behaviors within the BDSM community, and
relationship factors that affect BDSM practitioners.
Method
Objective
85 We conducted a scoping review using the following
research question: What is the prevalence, etiological factors,
psychological and interpersonal correlates associated with
BDSM?Scoping reviews in the behavioral and social sciences
(including sex research) are well-suited for broad topic areas
90 that contain primarily emerging literature or are in under-
studied areas, behaviors or psychological traits. Such reviews
differ from systematic reviews in that they aim to 1) broadly
map and identify gaps in a particular eldofstudy,2)address
broader, exploratory research questions, and 3) narratively
95 describe the quantity and quality of research without using
formal quality assessment or meta-analytic techniques (see
Grant & Booth, 2009 for more information about how review
styles differ). The methods for this scoping review were in
accordance with the 2015 Joanna Briggs Institute methodology
100 (Peters, Godfrey, McInerney, Parker, & Baldini Soares, 2015).
The uniqueness of scoping reviews is that they provide
a methodology that allows a narrative assessment of emerging
evidence (e.g., in new or rare elds) and thus offer a rst step in
research development. In new, under-studied, or minority elds
105 of study (typical in sex research), a scoping review also provides
more exibility than traditional systematic reviews. It allows
researchers to describe more clearly the diversity of the litera-
ture and studies using a range of methodologies that are often
omitted due to the strict protocols of systematic reviews. The
110general scoping procedure includes identifying a specicarea
of emerging research, identifying the important sub-areas (or
generating a series of broad research questions), identifying the
relevant studies and generating appropriate inclusion and exclu-
sion criteria, study search and extraction, charting the relevant
115study data (e.g., in tabular form), and summarizing and report-
ing the studies (Arksey & OMalley, 2005). More specically,
scoping reviews differ from narrative reviews in that they 1)
take a systematic (and comprehensive) approach to data search
and extraction, 2) aim to investigate areas of research that are
120more focused than those found in narrative reviews (which are
very open-ended and unfocused), and 3) include analysis and
critique of study design and overall quality.
Inclusion and Exclusion Criteria
Inclusion required 1) full text papers (i.e., not a conference
125abstract); 2) papers published in English; 3) the paper was in
a peer reviewed journal; 4) empirical studies of BDSM,
sadomasochism, or fetishism in relation to the variables
being investigated, as stated in the objective. Exclusion cri-
teria were 1) exclusively qualitative studies (quantitative
130sections of mixed methods studies were included); 2) the
article did not contain original research; 3) publication before
2000
1
; 4) a sample size less than 12; and 5) a sample com-
prised exclusively of clinical or incarcerated populations.
Search Strategy
135The following databases were searched on February 26th,
2019: Embase; MEDLINE; PsycARTICLES; PsycINFO.
The search was updated on June 27th, 2019. Search terms
were selected based on their relevance to BDSM and the
areas of interest and agreed upon by AB and QR. See Table 1
140for full search methodology and terms.
Results
Study Characteristics
Before exclusion criteria were applied, 3,915 articles
were identied with the search terms. Of the 3,100 that
145remained after deduplication, title and abstract screening
eliminated 2,957. After full text scans of the remaining 76
articles and 57 articles identied through other sources, 59
articles were eligible for inclusion (see Figure 1 for full
search results). All 133 articles included in the full text scan
150had references checked to ensure saturation of the relevant
material. One additional article met inclusion criteria after
the updated search, bringing the total number of articles
included in this review to 60. Table 2 gives information on
the samples, methods, and effect sizes of each study.
1
One study published in 1999 was not excluded, as the data from this
study was highly relevant and was used in four other studies that were
published in 2000, 2006, 2001, and two published in 2002.
BROWN, BARKER AND RAHMAN
2
Prevalence Rates of BDSM Related Fantasies and
155 Behaviors
One nationally representative study found 68.8% of
participants reported at least one BDSM fantasy or practice
(Holvoet et al., 2017). Twenty-two percent of participants
reported fantasies without acting on them; the remainder
160 indicated engagement in at least one BDSM behavior. Sub-
missive (9.5%) and masochistic acts (15.3% reported being
hit by a partner) were more common than dominant (8%)
and sadistic (11% doing the hitting) acts (cf. Joyal &
Carpentier, 2017). While many reported BDSM fantasies,
165only 7.6% identied as BDSM practitioners. Another study
found similar rates of BDSM related fantasies, with over
half of all participants reporting at least one BDSM-related
fantasy (Joyal, Cossette, & Lapierre, 2015).
Table 1. Database search terms
Database Date Searched Search Terms
Embase;
MEDLINE; PsycARTICLES;
PsycINFO (on Ovid)
February 26
th
, 2019
Updated search on
June 27
th
, 2019
1. ((personality or mental health or anxiety or depression or individual differences or biological or
neurodevelopment or genetic or hormones or neural or learning or modeling or conditioning or
relationships or interpersonal or marriage or polyamor* or communication or sexual health or
sexual risk or consent or sexual knowledge or sex education) not (offend* or forensic or criminal
or medic*)).ab,ti.
2. ((bdsm or sadism or masochism or sadomasochism or kink* or bondage or leather or fetish* or
domination or submission) not (offend* or forensic or criminal or medic*)).ab,ti.
3. limit 2 to english language
4. limit 3 to human
5. limit 4 to yr = 2000 -Current
6. 1 and 6
Figure 1. PRISMA ow diagram for search. Please note that the search was updated on June 27th, 2019 and includes one additional article.
A SYSTEMATIC SCOPING REVIEW OF BDSM
3
Table 2. Methodology and outcome information for articles included in review
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Ahlers et al. 2011 Demographics;
Incidence
Rates*
367 men Opportunistic sub-
sample of
a representative
sample of Berlin
men. This was
a nested sample
from a larger
study.
Quantitative survey, in-
person
Nested study in a larger survey
(n= 6,000) that used multiple
pre-existing measures of health
and sexual functioning/interests
OR (95% CI), Those with at least
one paraphilic associated
arousal pattern compared to
those with none were more
likely to:
Be single: 2.64 (1.05, 6.64),
p= .040
Masturbate at least once per week:
4.40 (1.7810.91), p= .001
Use pornography: 2.65 (1.54,
4.59), p< .001
Ever have an STD: 2.60 (2.24,
3.03), p< .001
Have HIV: 2.89 (1.49, 5.60)
p= .001
Alison et al. 2001 Etiology; BDSM
ID, Engagement,
and Behaviors
184 (22 women,
162 men)
Opportunistic
sampling from 2
BDSM clubs in
Finland, via mail
Quantitative survey, via
mail
Questionnaires from Nordling
et al. (2000/2006), Sandnabba
et al. (1999/2002), & Santtilla
et al. (2001/2002) about BDSM
and sexual experience,
childhood background, and
mental/physical health
Females engaged in more
humiliation behaviors than
males: d= 0.37, p< .05
Males engaged in more
hypermasculine behaviors than
females: d= 0.62, p< .01
Gay males preferred
hypermasculine behaviors more
than heterosexual males:
d= 0.42, p< .01
Heterosexual males preferred
humiliation behaviors more
than gay males: d= 0.43,
p< .01
Bailey et al. 2003 Incidence Rates 1,218 women Purposive and
snowball
sampling of gay
and bisexual
women in
England and
Scotland
Quantitative survey, in-
person
Questionnaire created for use in
sexual health clinics
OR (95% CI), Women who had
sex with both men and women
(in the past 10 years) were more
likely than women who only
had sex with women to engage
in sadomasochism: 3.66 (2.40,
5.58), p< .001
BROWN, BARKER AND RAHMAN
4
Baughman et al. 2014 Psychological
Correlates
643 (190 men,
435 women)
Convenience
sampling of
undergraduate
students in
Canada
Quantitative survey,
online during
a proctored testing
session
Pre-existing measures of the Dark
Triad and sexual fantasies
Psychopathy was positively
related to intimate (r2= .040,
p< .05), exploratory (r2= .068,
p< .05), impersonal (r2= .168,
p< .01), and sadomasochistic
(r2= .109, p< .01) sexual
fantasies. Sadomasochistic
fantasies were positively related
to narcissism (r2= .010,
p< .05), but not
Machiavellianism (r2= .004,
p> .05)
Botta et al. 2019 Demographics*;
BDSM ID,
Engagement,
and Behaviors
266 (141 men,
125 women)
Snowball sampling
online of Italian
BDSM identied
individuals
Quantitative survey,
online
In addition to pre-existing
measures of sexual complaints
and sexual satisfaction,
questions about demographics,
BDSM role, and sexual
behaviors were created for this
study
Women were more likely than
men to list physical pain as
a favorite BDSM activity:
ϕ= .241, p< .001
OR (95% CI):
Men more likely than women to
identify as dominant: 2.15
(1.28, 3.63), p= .006
Women more likely than men to
identify as a submissive: 2.47
(1.50, 4.09), p< .001
Women not more likely than men
to identify as a switch: 0.79
(0.45, 1.38), p= .488
Brown et al. 2017 Demographics;
Psychological
Correlates
576 (384 males,
173 females,
19 other)
Convenience
sampling of
BDSM identied
individuals across
online platforms
Quantitative survey,
online
Demographic questionnaire about
BDSM ID/involvement and
pre-existing measures of suicide
and pain tolerance
The total indirect effect of
fearlessness about death and
perceived pain tolerance as
mediators for the relationship
between BDSM engagement
and suicide attempts was
signicant for men (95% CI
[.046, .371], p< .05) but not for
women (95% CI [.007, .355],
p> .05).
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
5
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Chivers et al. 2014 BDSM ID,
Engagement,
and Behaviors*;
Demographics
Study 1: 54 men
Study 2:46
women
Study 1: Community
convenience
sample of men in
Canada
Study 2: Community
convenience
sample of women
in Canada
Study 1 & 2: Quantitative
quasi-experimental and
survey design, in-
person
Study 1: measured both genital
and sexual arousal to audio
narratives, paraphilias scale
Study 2: same as study 1, but with
the addition of measures of
sexual orientation and identity
Study 1:
Men with masochistic sexual
interest (MMI) had greater
subjective arousal to
masochistic sex than neutral
stimuli: η2
p= .843, p< .001
MMI did not differ in subjective
arousal to conventional and
masochistic sex narratives:
η2
p= .211, p= .060
MMI had sig. greater subjective
response to masochistic sex
stories than men with
conventual sexual interest
(MCI): d= 0.90, p= .015
MMI had sig. greater genital
arousal to masochistic sex than
neutral stimuli: η2
p= .739,
p< .001
MMI did not differ in genital
arousal to conventional and
masochistic sex narratives:
η2
p= .002, p= .865
MMI had sig. greater genital
arousal to masochistic sex than
MCI: d= 1.06, p< .001
Study 2:
Women with masochistic interests
(WMI) reported greater same-
sex attraction than women
without these interests:
η2
p= .336, p< .001
WMI had sig greater subjective
masochism index than women
with conventional sexual
interests (WCI): d= 1.83,
p< .001
WMI had greater genital
masochism index than WCI:
d= 0.91, p= .014
BROWN, BARKER AND RAHMAN
6
Connolly 2006 Etiology; BDSM
ID, Engagement,
and Behaviors*;
Demographics*;
Interpersonal
Factors;
Psychological
Correlates*
132 (73 males,
56 females, 3
transgender
individuals)
Convenience sample
of BDSM club/
organization
participants in
California
Quantitative survey, in-
person proctored
testing sessions
Detailed demographic
questionnaire and 7 pre-existing
measures of psychopathology
BDSM participants had lower
depression (η2
p= .440, p< .001),
anxiety (η2
p= .847, p< .001),
PTSD/trauma (η2
p= .494,
p< .001), and BPD (d=1.24,
p< .001) scores than population
norms
BDSM participants had higher
dissociation scores than
population norms:η2
p= .127,
p< .001
Higher submission scores were
related to higher PTSD scores
when compared to domination
scores: β=.22, p< .05
BDSM participants had slightly
lower psychological sadism
(η2
p= .147, p< .001) and
masochism (η2
p= .207, p< .001)
scores than population norms.
More submissiveness predicted
more paranoia symptoms
(β=.24, p< .05) and
dependence (β=.22, p< .05).
More dominance predicted
histrionic (β= .36, p< .01) and
narcissistic personality disorder
symptoms (β= .31, p< .01).
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
7
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Cross & Matheson 2006 Etiology*;
Psychological
Correlates
Study 1: 154 (93
BDSM ID [24
females, 69
males], 61
control/non
BDSM ID [15
females, 46
males])
Study 1: Online
convenience
sample of both
BDSM and non
BDSM identied
participants
Study 1: Quantitative
survey via email or
mail
Study 1: Multiple pre-existing
measures of mental health,
sexual behaviors, and gender
bias
*Study 2 & 3: These studies were
not included due to exclusion
criteria
Study 1:
Authoritarianism was signicantly
higher in control group
compared to the BDSM group:
η2
p= .039, p= .034.
No signicant differences in
feminist beliefs between
switches (d= 0.36, p= .115),
masochists (d= 0.31, p= .086),
or sadists (d= 0.13, p= .559)
and controls. No signicant
differences between switches
(d= 0.04, p= .861) or sadists
(d= 0.17, p= .501) and
masochists or switches and
sadists (d= 0.14, p= .589).
Males had signicantly higher
traditional gender role beliefs
than females: η2
p= .080,
p< .001.
OR (95% CI), Sadists were not
less likely to be employed than
controls: 0.96 (0.38, 2.42),
p= .862
Damon 2003 Etiology;
Demographics
342 males Online and in-
person
convenience
sample of
sadomasochistically
identied males
Mixed methods survey via email
or mail
Measures of SM experience
created for the study, plus pre-
existing measures of self-
esteem and sexism
Submissives had lower
self-esteem than
dominants: η2
p= .046,
p< .001
Submissives had higher
benevolent (η2
p= .115,
p< .001) and hostile
(η2
p= .033, p= .004)
sexism than dominants
Dancer et al. 2006 Interpersonal
Factors
146 (66 males,
80 females)
Online convenience
sample of self-
identied 24/7
slaves
Quantitative survey,
online
A measure created about the 24/7
slaveexperience
Not applicable/calculable for
results presented in review
BROWN, BARKER AND RAHMAN
8
Dawson et al. 2016 Etiology;
Incidence Rates;
Psychological
Correlates
1,226 (351 men,
785 women,
90
unidentied)
Opportunity sample
of Canadian
undergraduate
students
Quantitative survey,
online
A measure of paraphilic interest,
plus pre-existing measures of
sex drive, gender beliefs,
personality, and neuro-
developmental factors
Average level of arousal to
fantasies for men compared to
women:
Fetishism: d= 0.48, p< .001
(more arousal for men)
Sadism: d= 0.26, p< .001
(more arousal for men)
Masochism: d=0.01, p= .901
More arousal to masochism was
related to more arousal from
sadism: r2= .43, p< .001
OR (95% CI), Men report arousal
to sadistic sexual interest more
often than women: 2.11 (1.48,
3.00), p< .001
Men have a higher incidence rate
of atypical sexual interests than
women: d= 0.04 p< .001
No association between non-right
handedness and paraphilic
interest in men: r2= .006,
p= .217
Non-right handedness weakly
associated with paraphilic
interest in women: r2= .007,
p= .031
Total indirect effect of natal sex on
paraphilic interests mediated by
sex drive: β=.24 95% CI
[.31, .18]
There were signicant positive
relationships between
hypersexuality (men: r2= .063,
p< .001, women: r2= .091,
p< .001), sexual compulsivity
(men: r2= .067, p< .001,
women: r2= .057, p< .001),
impulsivity (men: r2= .016,
p< .05, women: r2= .009,
p< .05), sensation seeking
(men: r2= .009, p< .05,
women: r2= .017, p< .001),
and total paraphilia scores
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
9
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Fuss et al. 2018 Interpersonal
Factors
546 (347 women,
189 men, 10
unidentied)
Convenience and
snowball sample
of mental health
professionals (via
email) from
Germany, Austria,
or Switzerland
Randomized controlled
trial, quantitative
survey, online
Case vignettes created for the
study, pre-existing measures of
stigma and a measure of
estimated psychopathology
Mental health practitioners (MHP)
gave lower pathology scores to
female subjects than male
subjects in sexual sadism
vignettes (η2
p= .033, p< .001),
but not in sexual masochism
vignettes (η2
p= .000, p= .964).
MHP trained in psychoanalysis
pathologized sexually sadistic
behaviors more than people
trained in CBT: η2
p= .013,
p= .005.
Males with sexual sadism were
perceived as being more
dangerous (η2
p= .042, p< .001)
and MHP indicated they wanted
more social distance from males
(η2
p= .041, p< .001) than
females.
In the sexual sadism vignettes,
female subjects were less likely
to be diagnosed as mentally
disordered than men: ϕ= .162,
p< .001.
Hawley & Hensley 2009 Etiology* 470 (231 women,
239 men)
Opportunity sample
of college
students at
a university in
Kansas
Quantitative survey,
online
Sexual fantasy vignettes created
for use in this study, measures
of social dominance/resource
control, and short measure of
neuroticism adapted from a pre-
existing Big 5
Women preferred the male
domination scenario more than
men preferred the male
domination scenario: η2
p= .368,
p< .001
Hébert & Weaver 2014 Demographics*;
Psychological
Correlates*
270 (93 males,
168 females, 7
transgender/
intersex
individuals, 2
unidentied)
Convenience sample
from BDSM
related subreddits
Quantitative survey,
online
BDSM related demographic
questions and pre-existing
measures of desire for control,
personality, self-esteem, life
satisfaction, and interpersonal
reactivity
Submissives scored higher than
dominants on emotionality:
η2
p= .020, p= .020
Dominants scored higher than
submissives on desire for
control (η2
p= .029, p= .006) and
extraversion (η2
p= .030,
p= .005)
BROWN, BARKER AND RAHMAN
10
Hillier 2019 Eitiology;
Psychological
Correlates
68 (39 female, 23
male, 6 other)
Convenience sample
from online kink
identied
individuals
Quantitative survey,
online
Socio-demographic data, kink role
identication and behaviors,
preestablished measures of
childhood trauma and the Big 5
Trauma scores did not
signicantly predict dominance
(p= .064, R2not given) or
submission (p= .935, R2= .00)
scores
Neither neuroticism or
extraversion predicted
dominance (p= .382,
R2
adj = .001) or submission
(p= .470, R2
adj = .007)
Holvoet et al. 2017 BDSM ID,
Engagement,
and Behaviors*;
Incidence Rates;
Interpersonal
Factors
1,027 (459 men,
565 women, 3
other)
Representative
sample of Belgian
citizens
Quantitative survey,
online
Measure created for the study of
various BDSM interests and
questions about BDSM
involvement/identication
Positive relationship between
dominance and submission sum
scores: r2= .702, p< .001
Women had signicantly higher
submission sum scores than
men: η2
p= .010, p< .001
Men had signicantly higher
domination sum scores than
women: η2
p= .041, p< .001
Houngbedji & Gullem 2016 Incidence Rates 95 (62 men, 33
women)
Online convenience
sample of French
swingers
Quantitative survey,
online
Socio-demographic data,
questions about swinging and
other sexual practices, self-
report use of drugs, and a pre-
existing measure of sensation
seeking
Not applicable to/calculable for
results presented in review
Joyal 2015 Demographics*;
Incidence
Rates*
1,516 (799
women, 717
men)
Online convenience
community
sample of US
adults
Quantitative survey,
online
A revised version of the Wilson
Sex Fantasy Questionnaire
Not applicable to/calculable for
results presented in review
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
11
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Joyal & Carpentier 2017 Etiology;
Demographics;
Incidence Rates
1,040 (475 men,
565 women)
Semi-representative
sample of adults
in Quebec, via
telephone and
online
Quantitative, survey
administered via
telephone or online
Questionnaire created for this
study that included
demographic information,
sexual behavior/experience,
pornography consumption,
paraphilic sexual arousal, and
sexual satisfaction
OR (95% CI):
Women had a higher desire to
engage in masochism (1.7
[1.32.0], p= .001) and
fetishism (1.4 [1.11.7],
p= .015) than men, and men
had a higher desire to engage in
sadism (1.9 [1.23.1], p= .007)
Women had higher lifetime
engagement rates of masochism
(2.0 [1.4, 2.5], p< .001) than
men, and men had higher
lifetime engagement rates of
sadism (2.0 [1.1, 3.4], p= .014)
and fetishism (1.4 [1.1, 1.9],
p= .012)
Joyal et al. 2015 Etiology;
Incidence Rates
1,516 (799
women, 717
men)
Community
convenience/
snowball sample
of adults in
Quebec
advertised both
online and in
other media
Mixed methods survey,
online or via telephone
A revised version of the Wilson
Sex Fantasy Questionnaire, plus
a qualitative section (not
included in review) where
participants described their
sexual fantasies
OR (95% CI) for presence of
fantasies for women compared
to men:
Women had a higher prevalence
rate for the fantasy of being
dominated (1.60, [1.301.97],
p< .001) and being spanked or
whipped (1.43 [1.15, 1.78],
p= .001) than men
Men had a higher prevalence rate
of the fantasies of dominating
others (0.60, [0.49, 0.73],
p< .001)
spanking or whipping others
(0.41, [.33, .51], p< .001), and
forcing someone to have sex
(0.43, [0.32, 0.57], p< .001)
Women reported more intense
fantasies about being dominated
(d= 0.29, p< .001)
and being whipped or spanked
(d= 0.19, p< .001) than men
Men reported more intense
fantasies about dominating
someone else than women:
d= 0.26, p< .001
More domination fantasies were
linked to more submission
fantasies: r2= .250, p< .001
Mens overall ratings of sexual
arousal to sexual fantasies were
higher than womens: η2
p= .106,
p< .001
BROWN, BARKER AND RAHMAN
12
Jozifkova et al. 2012 Etiology 340 (157 men,
183 women)
Opportunity sample
of last-year high
school students
from 15 high
schools in Prague.
This was a nested
study.
Quantitative survey, in-
person
A questionnaire designed for this
and a larger study, focused on
relationship partner preference
and bondage/dominance/
submission
For males, dominance scores
signicantly correlated with 7/8
items about desiring
hierarchical disparity between
partners (r2= .027-.098,
p< .001 - < .05); for females
only 2 items correlated with
dominance scores (r2= .028-
.102, p< .001 < .05)
Opportunism scores ns. with 8
items for males (r2= .002-.015,
p> .05) or females (r2= .000-
.016, p> .05).
Kelsey et al. 2013 Interpersonal
Factors
766 (437
females, 329
males)
Convenience sample
of licensed
psychotherapists
residing in the US
via email
Quantitative survey,
online
A questionnaire designed for this
study including information on
socio-demographics,
professional information (e.g.,
degree type/therapy style),
beliefs about treating BDSM
identied clients, and attitudes
toward BDSM
Therapists with experience
treating BDSM identied
patients reported more positive
attitudes toward BDSM:
r2= .023, p< .001
Therapists who felt competent to
treat BDSM clients had
signicantly more positive
attitudes than those who did not
consider themselves to be
competent: d= 0.82, p< .001
Therapists with no graduate
training on BDSM had less
accepting attitudes than those
with some training: d= 0.29,
p< .001
Kimberly et al. 2018 Interpersonal
Factors*
238 women Convenience sample
of women online
and through other
media
Mixed methods survey,
online
Pre-existing measures of physical
satisfaction, sexual
communication, and a measure
(created for study) of basic
BDSM behavior.
Engaging in BDSM related to an
increase in comfort discussing
sexual topics, controlling for
relationship status: β= .25,
p< .001.
Engaging in BDSM not related to
an increase in physical
relationship satisfaction:
β= .13, p= .060
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
13
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Klement et al. 2017a BDSM ID,
Engagement,
and Behaviors
67 (33 women,
26 men, 3
transgender
individuals, 5
not specied)
Opportunity in-
person sample of
adults attending
a BDSM event in
Arizona
Mixed methods in-person,
survey and behavioral
observation
Survey created for study asked
about BDSM role and
experience, sexual arousal,
psychological state both during
and after event. Cortisol
measured via saliva.
Sexual arousal increased from
before to during the
sadomasochistic (SM) event:
d= 0.53, p= .037.
Negative affect decreased from
before to during SM event:
d= 0.58, p= .014.
Stress levels decreased from
before to during SM event:
d= 0.54, p= .022.
Klement et al. 2017b Etiology 185 (111 women,
74 men)
Convenience sample
from 3 groups:
MTurk, college
students, and the
BDSM
community
Quantitative survey,
online
Pre-existing measures of sexism,
rape myth acceptance, victim
blaming, and expectation/
acceptance of sexual aggression
No signicant differences between
the BDSM and two control
samples on levels of hostile
sexism (η2
p= .019, p= .185) or
expectation of sexual
aggression (η2
p= .015, p= .266)
BDSM had signicantly lower
benevolent sexism (η2
p= .154,
p< .001) rape myth acceptance
(η2
p= .144, p< .001), victim
blaming (η2
p= .060, p= .004),
and acceptance of sexual
aggression (η2
p= .043, p< .027)
scores than control groups
Lammers & Imhoff 2016 Etiology; BDSM
ID, Engagement,
and Behaviors
14,306 (9,016
women, 5,290
men)
Opportunity/
convenience
sample from
readers of two
magazines in the
Netherlands
Quantitative survey,
online
Information of occupational
hierarchy (position), and a pre-
existing measure of sexual
interest
Men were more strongly aroused
to sadistic thoughts than
women: d= 0.48, p< .001.
Social power related to arousal to
sadistic thoughts: B= .026,
p= .011.
Power increased arousal to
sadistic thought for women
(B= .032, p< .001), but not
men (B=.024, p= .146)
Women were more aroused by
masochistic thoughts than men:
d= 0.21, p< .001
Social power increased mens
arousal to female masochism:
B= .062, p< .001
BROWN, BARKER AND RAHMAN
14
Långström & Hanson 2006 Demographics 2,450 (1279
men, 1171
women)
Random sample of
Swedish adults
via mail
Quantitative survey, in-
person interviews
Measures of impersonal sex, life/
sexual satisfaction, sexual
history, paraphilic sexual
arousal, drug use, and other risk
factors
OR (95% CI), Women (14.16
[3.02, 66.31], p< .001) and men
(13.36 [4.12, 43.32], p< .001)
who engaged in more sexual
activities and reported
hypersexuality more likely to
deliberately use pain during sex
compared to those with low
sexual activity and low
hypersexuality.
Lodi-Smith et al. 2014 Demographics*;
Psychological
Correlates
595 (244 males,
334 females,
17 gender
uid)
Convenience sample
online
Quantitative survey,
online
Pre-existing measures of the Big
5, the Dark Triad, and sexually
deviant behavior
In multiple regression, only
openness (β= .23, p< .01) was
signicant predictor of
sadomasochistic activities in
men.
In the same regression for women,
more openness (β= .14,
p< .01), low conscientiousness
(β=.12, p< .05) and
Machiavellianism (β= .20,
p< .01) all signicantly
predicted sadomasochistic
behaviors
Luo & Zhang 2018a Etiology;
Psychological
Correlates
Study 1: 363
(283 BDSM
ID [190 males,
97 females],
80 non BDSM
ID/control [41
males, 39
females])
Study 2:64
females
Study 1:
Convenience
online sample of
Chinese BDSM
and non-BDSM
identied
individuals
Study 2:
Convenience
sample of 64
Chinese females
that identied as
submissive
Study 1: Quantitative
quasi-experimental and
survey design, online
Study 2: Quantitative
quasi-experimental and
survey design, in-
person
Study 1: Pre-existing measures of
interpersonal reactivity, self-
esteem, SES, life satisfaction,
a relationship assessment, and
12 female face photographs
rated for pain/enjoyment/
arousal and relationship to
BDSM
Study 2: 48 digital pictures of
female faces as stimuli and
participantsreactions
measured by both EEG and
subjective ratings
Study 1:
Female submissive had lower trait
empathy than switches and
controls, but not dominants:
η2
p= .210, p< .001.
Female submissives had lower
subjective empathetic responses
than controls: η2
p= .447,
p< .001.
Study 2:
Female submissives had lower
subjective empathetic responses
than controls: η2
p
(average) = .665, p< .001.
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
15
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Luo & Zhang 2018b Etiology;
Psychological
Correlates
26 females Opportunity sample
of 26 Chinese
female
submissives,
recruited from
Luo and Zhang
(2018a)
Quantitative quasi-
experimental and
survey design, in-
person
48 digital pictures of female faces
as stimuli and participants
reactions measured by both
EEG and subjective ratings of
pain/enjoyment/arousal and the
images relationship to BDSM
Female submissivesresponses in
the N1, early LPP, and late LLP
neural responses to others
suffering inhibited in gag vs no
gag condition:
N1 (measured across 6
electrodes): η2
p= .120 - .280,
p< .001 - < .05.
Early LLP (6 electrodes):
η2
p= .110 - .190, p= .006 - .049.
Late LLP (8 electrodes):
η2
p= .180 - .210, p= .003 - .007.
Martinez 2018 BDSM ID,
Engagement,
and Behaviors*
202 (102 women,
96 men, 2
genderqueer)
Convenience
sampling online
of adults (no
geographical
limitations)
Mixed methods survey,
online
A questionnaire created for this
study asked about
demographics, BDSM
experiences/identication, and
body satisfaction information.
The qualitative component was
not included in this review.
There was a signicant effect of
both gender (η2
p= .041,
p= .024) and sexual identity
(η2
p= .081, p< .001) on BDSM
role uidity.
Women had higher role uidity
than men: d= 0.39, p= .006.
OR (95% CI),
Men more likely than women to
identify as being in the
dominant category: 9.52 (4.62,
19.63), p< .001.
Women more likely than men to
identify as being in the
submissive category: 5.94
(3.17, 11.11), p< .001.
Switches were not less likely to be
heterosexual than submissives:
0.66 (0.31, 1.38), p= .354.
Switches were less likely to be
heterosexual than dominants:
0.11 (0.05, 0.26), p< .001.
BROWN, BARKER AND RAHMAN
16
Moskowitz et al. 2011 Interpersonal
Relationship
Factors
2,209 men (665
BDSM
identied,
1,554 non
BDSM
identied)
Convenience in-
person sample of
both BDSM
Leathermen and
non-Leathermen
at two separate
unrelated events
Quantitative, in person
survey
A questionnaire created for this
study and asked about
Leatherman afliation, HIV
status, HIV testing, STI testing,
number of partners, and
condom use
OR (95% CI): Leather (BDSM)
identied men were more likely
than non-leather men to be HIV
positive: 1.62 (1.19, 2.21),
p< .01
Leather submissives were more
likely to be HIV positive than
non-leather men of any BDSM
role identication: 2.19 (1.46,
3.26), p< .001
Nordling et al. 2000 Etiology*;
Psychological
Correlates
186 (164 males,
22 females)
Opportunistic
sampling from 2
BDSM clubs in
Finland via mail
Quantitative survey, via
mail
Questionnaire from Alison et al.
(2001), Nordling et al. (2006),
Sandnabba et al. (1999), &
Santtila et al. (2001) about
BDSM and sexual experience,
childhood background, and
mental/physical health
OR (95% CI), Abused participants
had more of the following than
non-abused:
Suicide attempts: 17.18 (4.92,
59.96), p< .001
Psychiatric in-patient visits: 8.83
(2.69, 28.98), p< .001
Out-patient psychological
counseling: 11.71 (2.64, 51.95),
p= .003
Visits to GP about BDSM-related
injuries: 6.88 (1.07, 44.22),
p< .010
Likelihood of abused vs non-
abused BDSM participants to
engage in BDSM club
behaviors: r= .122, p= .003
Nordling et al. 2006 BDSM ID,
Engagement,
and Behaviors
186 (164 males,
22 females)
Opportunistic
sampling from 2
BDSM clubs in
Finland via mail
Quantitative survey, via
mail
Questionnaire from Alison et al.
(2001), Nordling et al. (2000),
Sandnabba et al. (1999), &
Santtila et al. (2001) about
BDSM and sexual experience,
childhood, mental/physical
health
More heterosexuality was related
to a preference for masochism
in men (ρ=.16, p= .042) and
in women (ρ=.66, p< .001)
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
17
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Oliveira Júnior & Abdo 2010 Demographics*;
Incidence Rates;
Psychological
Correlates
7,022 (3,188
women, 3,834
men)
Opportunistic, in-
person sampling
of adults in 18
cities in 13
Brazilian states
Quantitative survey, in-
person
Questionnaire created for this
study that measured
demographics, general life
habits, sexual behavior/history/
orientation, general health, and
sexual difculties
OR (95% CI), Men more likely
than women to participate in
more than one usual sexual
behavior (USB) compared to
only one unusual sexual
behavior: 2.15 (2.27, 2.77),
p< .001.
Men (1.75 [1.29, 2.37], p< .001)
and women (1.50 [1.05, 2.14],
p= .033) with at least one USB
more likely than men without
an USB to show PTSD
symptoms.
Men (4.74 [2.39, 9.42], p< .001)
and women (3.39 [2.38, 4.83],
p< .001) with at least one USB
more likely than those without
to have ever been a victim of
sexual violence.
Pascoal et al. 2015 BDSM ID,
Engagement,
and Behaviors*;
Demographics*
68 (22 women,
46 men)
Convenience/
snowball sample
of BDSM
identied
individuals in
Portugal through
local BDSM
organizations
Quantitative survey,
online
A BDSM questionnaire created
for this study asking about age
of rst experience, most liked
practices, self-report measures
of sexual dysfunction, and
a pre-existing measure of sexual
satisfaction
Not applicable to/calculable for
results presented in review
Rahman & Symeonides 2008 Etiology 200 men Opportunistic/
snowball in-
person sampling
from adult men in
the London area
Quantitative survey, in-
person
Pre-existing measures of sexual
fantasy (WSFQ), handedness,
sibling sex composition, digit
ratios
Those with more paraphilic
interest had more older brothers
than those with low paraphilic
interest: d= 0.49, p= .001.
High paraphilics had trend toward
having more non-right
handedness than low
paraphilics: d= 0.26, p.070
Rehor 2015 BDSM ID,
Engagement,
and Behaviors*;
Demographics*
1,580 women Opportunistic/
convenience
sampling through
kink communities
and online BDSM
pages. There was
no geographic
limitation
Quantitative survey,
online
Bespoke measure of interest/
participation in a wide range of
BDSM, role-play, erotic,
exhibitionistic, fetishistic, and
other sexual behaviors
Not applicable to/calculable for
results presented in review
BROWN, BARKER AND RAHMAN
18
Richters et al. 2014 Demographics;
Incidence Rates
20,094 (9,985
men, 9,730
women)
Representative
sample of
Australian men
and women
recruited via
telephone
Quantitative survey, via
telephone interview
Demographics, and bespoke
questions about masturbation,
pornography consumption,
a range of sexual behaviors (e.
g., BDSM, sex toy use, role-
play, anal, etc.), and paying for
sex.
OR (95% CI) for current study:
Women participated less than men
in BDSM (0.63 [0.430.92],
p= .017) but not in role play
(1.15 [0.891.49], p= .292).
OR (95% CI) of percentage of
sample indicating participation
in following activities in
Richters et al. (2003) compared
to the percentage of the Richters
et al. (2014):
BDSM, men: 1.42 (0.942.14),
p= .095
BDSM, women: 1.29 (0.702.38),
p= .422
Role play, men: 2.18 (1.583.02),
p< .001 (higher in 2014 cf.
2003)
Role play, women: 2.62
(1.893.64), p< .001 (higher in
2014 cf. 2003)
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
19
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Richters et al. 2008 Etiology;
Demographics;
Psychological
Correlates
19,307 (10,173
men, 9,134
women)
Representative
sample of
Australian men
and women
recruited via
telephone
Quantitative survey, via
telephone interview,
a nested study in
Richters et al. (2003).
Survey from Richters et al. (2003)
and further questions about
participation in less common
sexual activities (e.g., BDSM),
history of sexual coercion,
psychological wellbeing, and
sexual difculties
OR (95% CI) for the experience/
engagement in the following
among BDSM vs non-BDSM
participants:
Sexual coercion before 16:
Men: 2.03 (0.75, 3.38), p= .228
Women: 0.99 (0.36, 3.03),
p= .987
Psychological distress:
Men: 0.33 (0.14, 0.80), p= .010
(BDSM group lower)
Women: 2.20 (0.88, 6.26),
p=.118
Masturbation (lifetime):
Men: 1.46 (0.49, 4.34), p= .493
Women: 3.89 (1.37, 11.07),
p= .011 (BDSM higher)
Bisexual experience:
Men: 4.44 (2.96, 9.33), p< .001
(BDSM higher)
Women: 5.69 (1.97, 16.42),
p= .001 (BDSM higher)
More than 50 sexual partners:
Men: 3.13 (1.28, 7.66), p= .012
(BDSM higher)
Women: 6.76 (1.93, 23.69),
p= .003 (BDSM higher)
Sexual difculties (8 were
measured):
Men: 0.57 (0.24, 1.33) - 2.93
(0.78, 11.00), p= .110 - .997
Women: 0.58 (0.22, 1.56) - 1.81
(0.73, 4.46), p= .198 - .897
Richters et al. 2003 Incidence Rates;
Psychological
Correlates
19,307 (10,173
men, 9,134
women)
Representative
sample of
Australian men
and women
recruited via
telephone
Quantitative survey, via
telephone interview
Bespoke survey asking about
demographic information,
autoerotic, esoteric, and other
sexual behaviors (e.g., role
playing, anal sex)
OR (95% CI):
There were no differences
between men and women in the
engagement of
BDSM (0.68 [0.361.29],
p= .239) or
role play (0.94 [0.641.37],
p= .730)
BROWN, BARKER AND RAHMAN
20
Rogak & Connor 2017 Interpersonal
Factors
163 (75 males,
84 females, 3
transgender
individuals)
Convenience/
snowball sample
of BDSM
participants in
committed
relationships from
two BDSM
related websites
Quantitative survey,
online
An inventory of BDSM
participation was created for
this study, and was preceded by
a pre-existing measure of
dyadic adjustment
Dominants and submissives did
not differ in overall dyadic
adjustment/relationship
satisfaction: d= 0.10, p= .603.
BDSM participants scored above
the criterion variable for dyadic
adjustment indicating
relationship distress: d= 0.32,
p< .001.
Roush et al. 2017 Demographics;
Interpersonal
Factors;
Psychological
Correlates
321 (198 males,
108 females, 9
transgender
individuals, 4
other
identied)
Convenience sample
of individuals
who endorsed
BDSM
involvement from
BDSM-related
web forums
Quantitative survey,
online
Demographics and pre-existing
measures of suicidal ideation,
depression, interpersonal needs,
and other measures of well
being
Thwarted belongingness and
perceived burdensomeness
mediated the relationship
between shame and suicidal
ideation in BDSM practitioners,
R2= .57, p< .001
Rye et al. 2015 Interpersonal
Factors;
Psychological
Correlates
94 females Convenience sample
of female students
in an
undergraduate
research
experience group
Quantitative survey, in-
person survey during
a larger testing session
Two newspaper-like articles about
BDSM (stimuli) and
accompanied by questions
about perceptions of BDSM.
Pre-existing measures of sexual
communication and comfort,
sexual anxiety and sexual
liberalism
Erotophilia (via scores on 7
measures) was positively
related to personal feelings
about BDSM (r2= .109 - .462,
p< .001) and to comfort in
discussing BDSM (r2= .058 -
.303, p< .001 - < .05).
Personal feelings about discussing
BDSM did not change based on
whether participants received
a positive or negative media
portrayal passage, η2
p= .000,
p= .863.
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
21
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Sagarin et al. 2009 Interpersonal
Factors*
Study 1:13(6
women, 7
men)
Study 2: 45 (19
women, 26
men)
Study 1 & 2:
Opportunistic in-
person sample of
attendees of
a BDSM even in
Arizona
Study 1 & 2: Quantitative,
in-person survey, and
hormone level testing
Study 1 & 2: Researchers created
two surveys- one for before
a scene took place, and one for
after- that asked about BDSM
roles, anticipation/result of the
scene, and measures of their
perception of scene partner.
Salivary testosterone where
samples taken before and after
the scene occurred.
Study 1:
Between baseline and 20 minutes
after the BDSM scene, bottoms
cortisol levels rose signicantly
(η2
p= .326, p= .040), but tops
levels did not (η2
p= .000,
p> .050).
Study 2:
Between baseline and 20 minutes
after the BDSM scene, bottoms
cortisol levels rose signicantly
(η2
p= .236, p= .002), but tops
levels did not (η2
p= .000,
p> .050).
One measure of relationship
satisfaction/closeness increased
signicantly from before to
after the BDSM scene,
regardless of how scene went
(p< .001).
Sanchez et al. 2006 Etiology 36 females Convenience, in-
person sample of
undergraduate
females at the
University of
Michigan
Quantitative behavioral
observation, quasi-
experimental design
A lexical-decision task with eye
tracking was created for use in
this study with stimuli that were
associated with sex or
dominance/submission
Women responded faster to sex
primed submissive words than
neutral primed submissive
words: η2
p= .110, p= .030.
Women responded slower to sex
primed dominant words than to
neutral primed dominant words:
η2
p= .360, p< .001.
There was no difference in mens
response time to sex primed
submissive and neutral primed
submissive words:
η2
p= .068, p= .190.
Men responded slower to sex
primed dominant words than
neutral primed dominant words:
η2
p= .508, p< .001.
BROWN, BARKER AND RAHMAN
22
Sandnabba et al. 1999 BDSM ID,
Engagement,
and Behaviors
164 males Opportunistic
sampling from 2
BDSM clubs in
Finland via mail
Quantitative survey, via
mail
Questionnaires from Alison et al.
(2001), Nordling et al. (2000/
2006), Sandnabba, Santtila,
Nordling, Beetz, and Alison
(2002), & Santtila et al. (2001)
about BDSM and sexual
experience, childhood
background, and mental/
physical health
Gay men were older than
heterosexual men at age of rst
awareness of BDSM interest
(η2
p= .093, p= .004) and at age
of rst BDSM experience
(η2
p= .086, p= .006).
There was a non-signicant
tendency for heterosexual men
to be masochists and gay men to
be sadists:
A signicant proportion of
participants had lighter BDSM
sessions than they wanted
(ϕ= .647, p< .001) and
believed they wanted heavier
sessions than their partners
(ϕ= .410, p< .001).
Sandnabba et al. 2002 BDSM ID,
Engagement,
and Behaviors
12 males Opportunistic
sampling from 2
BDSM clubs in
Finland via mail
This was a sub
sample from
a larger study
Quantitative survey, via
mail
Questionnaires from Alison et al.
(2001), Nordling et al. (2000),
Sandnabba et al. (1999), &
Santtila et al. (2001) about
BDSM and sexual experience,
childhood background, and
mental/physical health
Zoophilic oriented participants
were more likely to have
participated in more
sadomasochistic behaviors than
matched non-zoophilic BDSM
controls, including the use of
knives (ϕ= .607, p< .01), skin
branding (ϕ= .519, p< .05),
face slapping (ϕ= .467,
p< .05), and urologia (ϕ= .430,
p< .05)
Santtila et al. 2002 BDSM ID,
Engagement,
and Behaviors*
186 (164 males,
22 females)
Opportunistic
sampling from 2
BDSM clubs in
Finland via mail
Quantitative survey, via
mail
Questionnaires fromAlison et al.
(2001), Nordling et al. (2006),
Sandnabba et al. (1999), &
Santtilla et al. (2001)about
BDSM and sexual experience,
childhood background, and
mental/physical health
Not applicable to/calculable for
results presented in review
Santtila et al. 2001 Etiology 164 males Opportunistic
sampling from 2
BDSM clubs in
Finland via mail
Quantitative survey, via
mail
Questionnaires from Alison et al.
(2001), Nordling et al. (2006),
Sandnabba et al. (1999), &
Santtilla et al. (2002) about
BDSM and sexual experience,
childhood background, and
mental/physical health
Likelihood of sadistic participants
having more ambivalent and
less secure attachment and
masochists having more secure
and less ambivalent attachment:
CramersV= .401, p= .006
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
23
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Shulman & Home 2006 Etiology;
Psychological
Correlates
261 women Convenience online
sample of adult
women residing
in US
Quantitative survey,
online
Pre-existing measures of sexual
fantasy, experience, guilt,
opinions, and feminist
perspectives
Ns. relationship between feminist
beliefs and forceful sexual
fantasy (r2= .014, p= .053) or
between CSA and sex guilt
(r2= .002, p= .318).
Lower sex guilt related to more
erotophilia (r2= .645, p< .001)
and forceful sexual fantasies
(r2= .071, p< .001).
Higher erotophilia was related to
more forceful sexual fantasies:
r2= .132, p< .001.
Higher erotophilia was related to
lower sex guilt: r2= .645,
p< .001.
Tomassilli et al. 2009 Demographics;
Incidence Rates
347 women Convenience in-
person sample of
gay and lesbian
women at two
community events
in New York City
Quantitative survey, in-
person
A measure of demographics and
engagement in bondage/
domination, SM, photo/video
exhibitionism, and
asphyxiation/breath play was
created for this study
OR (95% CI) for participation in
kinky sexual behaviors for
lesbian vs bisexual women:
Sadomasochism: 0.66 (0.34, 1.27),
p= .211
Bondage and domination: 0.65
(.37, 1.16), p= .144
Photo or video exhibitionism: 0.35
(0.19, 0.64), p< .001 (bisexual
women more)
Breath play: 1.00 (0.28, 3.58),
p= .647
Women who engaged in the
following sexual behaviors
were younger at their age of
rst sexual behavior than
women who did not engage in
these:
Bondage and domination:
d= 0.35, p= .004
Sadomasochism: d= 0.34,
p= .019
BROWN, BARKER AND RAHMAN
24
Watts et al. 2017 Psychological
Correlates
608 (443 women,
165 men)
Convenience sample
of undergraduate
students from two
universities in the
Southeastern US
Quantitative survey,
distribution/data
collection method not
specied
Measures of paraphilic interests
and existing measures of
personality disorder symptoms,
erotophilia, psychopathy, and
narcissism
Sexual sadism was signicantly
positively correlated with:
Narcissistic entitlement and
exploitativeness: r2= .032,
p< .01
Four of ve measures of
psychopathy: r2= .058 - .194,
p< .01
Schizotypal personality disorder
symptoms: r2= .078, p< .01
Antisocial personality disorder
symptoms: r2= .584, p< .01
Borderline personality disorder
symptoms: r2= .260, p< .01
Williams et al. 2016 Etiology 935 (293 men,
561 women,
15 transgender
individuals, 50
queer or
gender uid)
Convenience online
sample of adults
who regularly
practiced BDSM
Quantitative survey,
online
A measure of demographics,
BDSM role identication, and
both serious and casual leisure
was developed for use in this
study
Dominants were signicantly
more likely than submissives to
indicate BDSM was serious (cf.
casual) leisure on 4/6 serious
leisure items: CramersV, .055-
.070, p< .001 - .034
Williams et al. 2009 Incidence Rates;
Psychological
Correlates
Study 1: 103 men
Study 2: 88 men
Study 1 & 2:
Convenience, in-
person sample of
undergraduate
students from
a large Western
university
Study 1 & 2: Quantitative
survey, in-person
Study 1: A demographic
questionnaire including
questions about pornography
use, and a pre-existing measure
of deviant fantasies and
behaviors
Study 2: In addition to the survey
from study 1, participants
completed Big 5 and Dark Triad
measures
Study 1: Positive relationship
between sum deviant behaviors
and fantasies: r2= .504,
p< .001
Study 2: Positive relationship
between sum deviant behaviors
and fantasies: r2= .518,
p< .001
Sadistic sexual fantasies were
positively related to narcissism
(r2= .096, p= .003) and
psychopathy (r2= .078,
p= .008)
Bondage fantasies were positively
related to psychopathy
(r2= .058, p= .024)
Sadistic sexual behaviors were
also positively related to
narcissism (r2= .053, p= .031)
and psychopathy (r2= .058,
p= .024)
Bondage sexual behaviors were
positively related to
psychopathy (r2= .058,
p= .024)
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
25
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Wismeijer & Van Assen 2013 Demographics;
Psychological
Correlates
902 (464 males,
438 females)
Convenience sample
of BDSM
respondents from
a BDSM website
in the Netherlands
Quantitative survey,
online
Demographics and information
about BDSM role, pre-existing
measures of attachment,
personality, rejection
sensitivity, and subjective well-
being
Submissives had more anxious
attachment than dominants,
neither differed signicantly
from switches: η2
p= .038,
p= .038
Submissives, switches, and
dominants did not differ in
avoidant attachment: η2
p= .006,
p= .543
Non-BDSM females had lower
relationship condence than
BDSM females: η2
p= .016,
p= .001
BDSM participants had higher
scores of openness to
experience (η2
p= .045,
p< .001), extraversion
(η2
p= .008, p< .05), and
conscientiousness (η2
p= .019,
p< .001) and lower scores on
rejection sensitivity (η2
p= .022,
p< .001), neuroticism
(η2
p= .033, p< .001), and
agreeableness (η2
p= .018,
p< .001) than non-BDSM
controls.
Dominants and switches scored
higher on openness to
experiences than submissives:
η2
p= .045, p< .001
Submissives scored higher on
agreeableness than dominants:
η2
p= .018, p< .001.
BROWN, BARKER AND RAHMAN
26
Yost 2010 Interpersonal
Factors
Study 1: 213
(150 women,
63 men)
Study 2: 258
(140 men, 118
women)
Study 1:
Convenience in-
person sample of
undergraduate
students from
a US liberal arts
university
Study 2:
Convenience in-
person sample of
undergraduate
students from
a large public US
university
Study 1 & 2: Quantitative
survey, online
Study 1: Measure of attitudes
about sadomasochism and pre-
existing measures of social
desirability, authoritarianism,
sexual conservatism, and rape
myth acceptance
Study 2: Validation of model in
study 1 and existing measures
of social desirability,
authoritarianism, and sexual
orientation attitudes
The samples from study 1 & 2
were combined for the analyses
presented in review
In a multiple regression, more
homophobia (β= .21, p= .030),
sexual conservatism (β= .38,
p< .001), social conservatism,
as measured by right wing
authoritarianism (β= .18,
p= .08), and more rape myth
acceptance (β=.15, p= .040)
predicted more prejudice
toward sadomasochism
practitioners
People who engaged in
sadomasochism had less
prejudice toward
sadomasochism than those who
did not: d= 1.2, p< .001
People who knew others that
engaged in BDSM had less
prejudicial attitudes than those
who did not: d= 0.84, p< .001
As knowledge about
sadomasochism increased,
attitudes become more positive
on all four sub-scales:
r2= .010 - .032, p< .001 - < .05
Yost & Hunter 2012 Demographics 272 (144 women,
128 men)
Convenience sample
of self-identied
BDSM
participants
recruited online
and in US based
BDSM events/
organizations
Quantitative survey,
online
A bespoke measure that asked
about BDSM self-identication,
role, and participation
OR (95% CI):
Women were signicantly more
likely than men to identify as
submissive: 3.33 (2.02, 5.50),
p< .001
Men were signicantly more
likely than women to identify as
dominant: 3.85 (2.13, 6.94),
p< .001
Women were not more likely than
men to be switches: 0.79 (0.46,
1.35), p= .467
(Continued )
A SYSTEMATIC SCOPING REVIEW OF BDSM
27
Table 2. (Continued)
Author(s) Pub. Year
Appears in
Review Section n Sampling Strategy
Study Design/Data
Collection Method Primary Measures
Outcomes of Interest and
Indicative Effect Sizes
Zubriggen & Yost 2004 Etiology;
Incidence Rates
162 (85 men, 77
women)
Convenience sample
of adults from
a midwestern US
city via media
advertisements/
notices
Mixed methods survey,
via mail
Responses to open-ended
questions about sexual
fantasies; pre-existing measures
on rape myth acceptance,
attitudes toward women, sexual
beliefs, and social desirability.
Fantasies were labeled
categorically based on content
(e.g., domination/submission)
Domination was more likely to
appear in mens sexual fantasies
than in womens:
d= .38, p= .02
No difference in the frequency of
appearance of submission in
sexual fantasies between men
and women
d= .25, p=.11
Women were more likely to
portray themselves as
submissive in their fantasies
and men were more likely to
portray themselves as
dominant:
η2
p= .046, p= .006
*Effect sizes either could not be calculated for all outcomes of interest in this section or they were not applicable to results presented
BROWN, BARKER AND RAHMAN
28
Conversely, a nationally representative study from Austra-
170 lia in 2003 found that approximately 2% had participated in
BDSM (Richters, Grulich, de Visser, Smith, & Rissel, 2003),
and this only increased marginally (but non-signicantly) in
a follow up study 10 years later (Richters et al., 2014).
However, researchers did not offer any examples or deni-
175 tions of BDSM outside the meaning of the acronym, and thus,
theseratesmaybeunderestimates.
Returning to the DSM-5s (APA, 2013) paraphilic clas-
sications (many of which relate to BDSM), Joyal and
Carpentier (2017) asked participants about their interest in
180 the eight paraphilias: sadism, masochism, voyeurism, exhi-
bitionism, fetishism, pedophilia, frotteurism, and transvest-
ism. Just over 45% acknowledged a desire for at least one
paraphilic behavior, and 33.8% had engaged in a paraphilic
behavior at least once in their life. Neither sadism, maso-
185 chism, nor fetishism (fantasy or behavior) were statistically
rare (less than a 2.3% incidence rate), and only sadism could
be considered unusual (less than 15.9% incidence). Rates
were even lower for engaging in behaviors consistently
(>10 times over the lifetime): 3.5% for fetishism, 1.4% for
190 masochism, and 0.3% for sadism. This highlights the impor-
tance of distinguishing between sub-groups who report
different levels of desire and engagement in BDSM.
Joyal (2015) studied broader atypical sexual interests and
reported that of 45 fantasies (as described by the Wilson Sex
195 Fantasy Questionnaire [WSFQ]), the mostintense fantasy was
normophilic (or non-paraphilic): receiving oral sex (for both
sexes). The mean intensity of the most intense normophilic
fantasy did not differ signicantly from the most intense
paraphilic fantasy. Four of seven clusters (57%) of the entire
200 sample reported a most intense paraphilic fantasy that was
statistically as intense or more intense than their most intense
normophilic fantasy. As the DSM-5 (APA, 2013,p.685)
denes a paraphilia as any sexual interests greater than or
equal to normophilic [i.e., genital stimulation] sexual inter-
205 ests, these results from Joyal (2015) were taken to suggest
that 57% of this sample met the criteria for having
a paraphilia. Similarly, Ahlers et al. (2011) indicated that
62.4% of men reported some degree of arousal to at least
one paraphilia fantasy (and 44.4% paraphilic behaviors
210 related to at least one of these) but only 1.7% experienced
distress because of it, indicating that paraphilic interests are
sub-clinical for most people. These studies highlight that
many non-normophilic interests (including those related to
BDSM) are not statistically atypical.
215 Several studies indicate that BDSM interests may repre-
sent a broadening of individualssexual repertoire rather
than being truly paraphilic(e.g., Cross & Matheson,
2006; Houngbedji & Guillem, 2016; Oliveira Júnior &
Abdo, 2010; Williams, Cooper, Howell, Yuille, & Paulhus,
220 2009). For example, Oliveira Júnior and Abdo (2010)stu-
died 10 unusual sexual behaviors: fetish, voyeurism, incest,
threesomes, exhibitionism, sadomasochism, group sex,
money in exchange for sex, sexual practice with animals,
and swinging. Twenty per cent of the sample reported
225practicing only one behavior, while 18% reported practicing
two or more. Nine percent reported practicing sadomaso-
chism and 13.4% reported fetishism. Overall, ndings sug-
gest that BDSM related fantasies and behaviors are
relatively common, though behavior prevalence rates are
230typically lower than fantasies.
Sex Differences. Although BDSM fantasies and
behaviors are prevalent in both men and women, there
appear to be sex differences herein (Joyal et al., 2015). For
example, Zurbriggen and Yost (2004) found that mens
235fantasies were more likely to include portrayals of
themselves as dominant, and women were more likely to
fantasize about submission. However, regardless of sex,
arousal to masochism and sadism were strongly related.
Dawson, Bannerman, and Lalumière (2016) found men
240indicated signicantly more arousal than women for
fetishism (28% vs 11%) and sadism (19% vs 10%). For
masochism, women reported more arousal (17%) than men
(15%). Similarly, Joyal et al. (2015) reported that women
(64.6%) reported fantasizing about being dominated
245signicantly more than men (53.5%), while men (59.6%)
reported fantasizing about dominating someone
signicantly more than women (46.7%). Focusing on other
aspects of BDSM play, a 2017 study (Joyal & Carpentier)
found that signicantly more women (27.8%) than men
250(19.2%) reported desire to engage in masochism and 9.5%
of men and 5.1% of women expressed desire for sadism.
Fetishism was found to be an interest for 40.4% of men and
47.9% of women.
As expected, prevalence rates of BDSM behaviors were
255lower than the prevalence of BDSM fantasies for both males
and females. In general, research has found that men are more
likely than women to report engaging in unusual sexual beha-
viors (Holvoet et al., 2017; Oliveira Júnior & Abdo, 2010). One
of the few studies that did not nd any signicant sex differ-
260ences in prevalence rates of BDSM behaviors was an Austra-
lian study that collected data from a nationally representative
sample of men and women aged 1659. This found that 2% of
men and 1.4% of women had participated in BDSM in the past
12 months (Richters et al., 2003). Researchers also asked if they
265hadparticipatedinroleplayordressingup,towhich4%ofmen
and 3.7% of women answered afrmatively. In relation to
specic BDSM behaviors, Joyal and Carpentier (2017) found
that more women (23.7%) reported experiencing sexual maso-
chism than men (13.9%). Two studies on bisexual and gay
270women found that about 19% reported some engagement in
sadomasochism, 33% participated in bondage and domination,
22.2% in photo or video exhibitionism, and 5.2% in breath play
(Bailey, Farquhar, Owen, & Whittaker, 2003; Tomassilli,
Golub, Bimbi, & Parsons, 2009).
275Etiological Theories of BDSM
Recent empirical literature has aimed to test the psycho-
analytic, social, and bio-medical models, as well as offer
A SYSTEMATIC SCOPING REVIEW OF BDSM
29
new etiological theories for the development of BDSM
interests. We have sequestered these areas to their own sub-
280 sections below. However, here it is worth mentioning a key
study by Cross and Matheson (2006) which tested four
possible etiological theories in one study: psychopathologi-
cal, radical feminist, escape-from-self, and psychoanalytic.
The psychopathology model hypothesizes that BDSM inter-
285 ests are abnormal traits caused by physical or psychological
disease and thus should covary with measures of psycho-
pathology. The feminist model argues that participation in
BDSM is inherently misogynistic, regardless of which sex
assumes which BDSM role, and pleasure from degradation
290 or torture is indicative of an internalized patriarchy. The
escape-from-self theory (Baumeister, 1988) posits that
masochism provides escape from excessive levels of self-
control. As successful people (in career or personal life) may
have high levels of self-control, this model predicts that
295 successful individuals will tend more toward masochism
than sadism because they desire to relinquish their own
control. People who identify as sadistic are doing so not to
relinquish the self, but out of a need to assert control and
bolster their own self-concept. Psychoanalytic theory sug-
300 gests that BDSM traits may be linked to sexual guilt as
compensatory mechanisms for a dysfunctional superego, or
that a weak superego might result in greater thrill-seeking as
a compensation (Freud, 1953).
To test these competing hypotheses, Cross and Matheson
305 (2006) compared people who identied as either a sadist,
masochist, or switch, with a non-BDSM control group.
None were supported. Masochists were not more prone to
distress or mental instability than other groups. Authoritar-
ianism scores were signicantly higher among the control
310 group compared to switches. In general, all groups held pro-
feminist attitudes, suggesting that BDSM interests are not
due to internalized patriarchal norms (cf., Shulman &
Home, 2006). Another study found that BDSM practi-
tioners, when compared to two non-BDSM control groups,
315 did not signicantly differ on hostile sexism and acceptance
of sexual aggression, and had lower levels of benevolent
sexism, rape myth acceptance, and victim blaming (Kle-
ment, Sagarin, & Lee, 2017b). Although one study found
that women implicitly associated sex with submission, con-
320 trary to the feminist theory, men did not implicitly associate
dominance with sex (Sanchez, Kiefer, & Ybarra, 2006). As
for the escape-from-self hypothesis, there were no signi-
cant differences in scores on measures of risk-taking beha-
viors (Cross & Matheson, 2006). Sadists did not differ in
325 employment (or success level) from non-BDSM controls,
and masochists were not more inclined to engage in esca-
pists behaviors. Sexual guilt and thrill-seeking levels did not
differ between sadists, masochists, and switches, offering
little empirical support for psychoanalytic predictions
330 (Cross & Matheson, 2006).
Child Abuse and Trauma. Despite lack of scientic
support, psychoanalytic theories for BDSM persist in
popular culture. These variously take the form of a belief
that a proclivity for BDSM is anchored in childhood sexual
335abuse (CSA, or that early abuse cascades into psychosexual,
developmental or other personality dysfunction which
results in BDSM; Freud, 1962,1924/1961,1938). Thus,
psychoanalytic theory predicts that those with BDSM
interests should have underlying psychological and
340personality dysfunction, as these interests are rooted in
trauma that will result in mental health issues. However,
studies linking CSA and sadomasochistic preferences tend
to be case studies from those with other psychological
problems (Blizard, 2001; Rothstein, 1991). Thus, it is
345difcult to tease apart the overlap between CSA, other
mental health disorders, and BDSM traits.
Contrary to the prediction that most persons with BDSM
interests should have experienced some form of trauma, BDSM
practitioners had comparable PTSD and trauma-related phe-
350nomena scores and incidence rates of trauma similar to popula-
tion averages (8%), though more submissiveness was
associated with an increased PTSD symptom score (Connolly,
2006). BDSM practitioners did not show higher borderline
personality or dissociative identity disorder symptoms. Simi-
355larly, a population study found no link between psychopathol-
ogy, abuse, and BDSM (Richters, de Visser, Rissel, Grulich, &
Smith, 2008). When comparing those who had practiced
BDSM in the last 12 months to those who had not, engagement
in BDSM was unrelated to having been sexually coerced before
360the age of 16. Men who engaged in BDSM were also signi-
cantly less likely to have psychological distress and women
who engaged in BDSM did not differ signicantly in psycho-
logical distress to those who had not.
Shulman and Home (2006) tested the guilt reduction
365theory, which hypothesizes that women with high sex guilt
have more forceful sexual fantasies as the fantasies absolves
them of the guilt they might experience if they initiated or
said yes to a sexual scenario. Sex guilt refers to the feeling
of shame or embarrassment one might experience due to
370participating in or fantasizing about sexual activity. Guilt
reduction theory stipulates that those with high sex guilt will
feel less guilty if they are in a sexual scenario where they are
unable to reject sexual advances as they do not have the
burden of asking for (or even saying yes to) sex. CSA may
375result in high levels of sex guilt, which would then cascade
into fantasies of force (related to the domination and sub-
mission aspects of BDSM). However, results indicated that
CSA was not directly related to sex guilt but did have
a direct path to erotophilia (an individuals general propen-
380sity to respond to sexual cues). Most notable was the nding
that low levels of sex guilt and high levels of erotophilia
predicted forceful sexual fantasies. Stronger feminist beliefs
coupled with low levels of guilt were also related to eroto-
philia and more sexual experience. This indicated that,
385although CSA may be related to forceful sexual fantasies,
it is not the only potential origin of these fantasies.
Nordling, Sandnabba, and Santtila (2000) tested the
hypothesis that BDSM practitioners who experienced CSA
BROWN, BARKER AND RAHMAN
30
would seek out sadomasochistic relationships because they
390 viewed violence as a normal part of sexuality, show greater
psychological distress, and have poorer social adjustment.
Both male and female BDSM practitioners were more likely
to have experienced CSA than the general population (7.9%
males in the current sample compared to 1-3% in the
395 population; 22.7% to 6-8% for females, respectively). How-
ever, it is important to note that most (90.4%) BDSM
practitioners in this study reported no abuse at all, providing
little support for the theory that most BDSM practitioners
have previously experienced abuse. The association
400 between CSA and BDSM should also be interpreted with
caution given the small sample size of abused participants.
More recently, a study focused on investigating the role of
childhood trauma in kinky sexual behavior in adults found
that trauma did not signicantly predict either dominance or
405 submissive sexual behaviors within a sample of kink-
identied participants, indicating that trauma is not
a common precipitating factor of BDSM interests (Hillier,
2019).
Attachment. Some psychodynamic accounts propose
410 that children who are abused develop poor attachment, which
results in masochistic or sadistic ego states used to preserve
their self-concept and attachment to parents. One study on 164
men from two BDSM clubs indicated that attachment (based
on retrospective descriptions of parental relationships) to the
415 mother (but not the father) was signicantly correlated with
BDSM orientation. Specically, sadistic participants were
more likely to have avoidant attachment and less likely to
have secure attachment, and masochistic participants were
more likely to have secure attachment and less likely to have
420 avoidant attachment (Santtila, Sandnabba, & Nordling, 2001).
The distributions of attachment styles in this sample were
similar to population samples. Wismeijer and Van Assen
(2013) reported similar results (i.e., no signicant differences
in attachment styles between BDSM sub-groups and controls;
425 see also Connolly, 2006;Richtersetal.,2008). Overall, the
ndings offer weak support for attachment hypotheses.
Disinhibition. In a less psychopathology-focused study,
Lammers and Imhoff (2016) put forth the disinhibition
hypothesis, which states that having social power leads to
430 behavioral disinhibition; powerful people are more likely to
act impulsively because they can. Consistent with the
disinhibition hypothesis, men, who had more social power
(determined by their position at their job, with managerial or
leadership roles ranked as being higher in social power than
435 hourly-wage or non-leadership positions), were signicantly
more aroused by sadistic thoughts. Results demonstrated that
social power was positively related to arousal by sadistic
thoughts, and this effect was moderated by gender
(controlling for age). The same was found for women and
440 masochism. Position of power increased arousal to sadistic
thoughts among women but not men. Additionally, there was
a small positive effect of social power on masochistic arousal
for men, indicating that mens increase in social power was
linked with arousal to female-associated masochism.
445A related hypothesis argued that BDSM preferences may
be related to a compensation for a lack of power in child-
hood (Damon, 2003). Individuals who perceive a lack of
power in daily life may seek out opportunities to show
dominance by exerting control over others. Contrary to the
450hypothesis, submissives, not dominants, were found to have
lower levels of self-esteem and higher levels of sexism
(Malovich & Stake, 1990; Valentine, 1998). Thus, the
hypothesis of using dominance as a way to compensate for
low levels of self-esteem also appears unsupported.
455Neurological and Biological Differences. Also
critical of the psychopathological model, Luo and Zhang
(2018a) quantied neural empathetic responses of BDSM
practitioners. The use of pain in BDSM led early researchers
to view these practices as linked to psychopathy, which has
460been related to diminished empathy, and antisocial, and
borderline personality disorder (Soderstrom, 2003). Luo and
Zhang (2018a) found that female submissives showed reduced
trait empathy and subjective empathetic response and more
BDSM experiences were associated with even more reduction
465in empathy. Frequent exposure to pain inicting situations may
diminish empathic responses over time, as has been
demonstrated in medical professionals frequently exposed to
seeingthoseinpain(Chengetal.,2007).
Luo and Zhang (2018b) then looked at the potential
470inuence of humiliation (via wearing a ball gag) and bon-
dage on female submissivesempathetic neural response.
Results showed that the subjective feeling of humiliation
and objective loss of ability to move facial muscles due to
the gag decreased their empathetic response, suggesting that
475the lower empathetic response was context dependent.
Thus, any diminished empathetic response may be due to,
instead of the cause of, BDSM practices.
Other studies have found relationships between neurode-
velopmental factors and paraphilic preferences in men.
480Rahman and Symeonides (2008) found that greater para-
philic interests were associated with greater non-right hand-
edness and numbers of older brothers (a potential marker of
prenatal events which may inuence brain development,
such as maternal immune responses) in men. However, the
485associations were small and Dawson et al. (2016) did not
replicate the association between paraphilic interests and
non-right handedness. Conversely, it was weakly, but non-
signicantly, associated with paraphilic interest in women.
This may be because neurodevelopmental markers may be
490related to paraphilic disorders (like pedophilia) rather than
to low-level atypical sexual interests. However, we found no
literature (using our criteria) on genetic (e.g., twin studies),
hormonal (e.g., studies on the role of sex steroids) or other
psychobiological correlates.
495Leisure. One study tested the novel theory that BDSM
may simply be a leisure or recreational activity (Williams,
A SYSTEMATIC SCOPING REVIEW OF BDSM
31
Prior, Alvarado, Thomas, & Christensen, 2016). Leisure is
dened as an activity, context, or time period with positive
psychological benets that is also personally meaningful,
500 freely chosen, and intrinsically motivated (Kleiber, Walker,
& Mannell, 2011). Similarly, recreation involves engaging
in pleasurable activities, usually during ones leisure time.
The notion of BDSM as leisure could help explain why
some people, like those that identify as asexual, do not view
505 their participation in BDSM as erotic or sexual. Because
BDSM practitioners frequently refer to their practices with
terms like toys, games, play, or fantasy, it is conceivable that
this can be seen as leisure and have no deeper, pathological,
etiological origin for many practitioners. Participants were
510 not given denitions of either recreation or leisure but were
simply asked whether they considered BDSM to t into
either of these categories. Sixty-four percent of participants
reported that BDSM participation was recreational and 58%
reported that it was leisure most or all of the time. Dominant
515 participants were signicantly more likely than submissives
to rate BDSM activities to be more serious, rather than
casual, on four of the six items related to this continuum.
This may be due to their need to master certain skills (like
handling of whips) and their responsibility to keep their
520 submissive safe during a scene.
Evolutionary Hypotheses. Other causal hypotheses
include evolutionary accounts which argue that sexual
arousal by a power difference between partners is
a successful mating strategy. Arousal by a higher ranking
525 and dominant male can facilitate mating with a partner with
good genes and good resources (Gangestad, Simpson,
Cousins, Garver-Apgar, & Christensen, 2004; Llaurens,
Raymond, & Faurie, 2009). In support, Jozifkova, Bartos,
and Flegr (2012) cited ndings where hierarchically
530 incongruent pairs had more offspring than those with
equal status, regardless of which gender partner was
higher ranking. If this strategy does not work, individuals
may also adopt an alternative, opportunistic strategy in
order to maximize their potential for reproductive success.
535 Thus, dominance and submission may come from
a dominance strategy, and preference for bondage may
come from an opportunistic strategy (i.e. putting a sexual
partner in a position where they are physically unable to get
away from the encounter). As predicted, for males,
540 dominance scores correlated with questions pertaining to
a desire for hierarchical disparity between partners, but the
opportunistic score (representing a preference for bondage)
was not correlated with any of the items. In women,
dominance only correlated signicantly with two of the
545 eight questions asking about preference for hierarchical
disparity in relationships and no questions about
hierarchical disparity preference correlated signicantly
with opportunism scores.
A model based on evolutionarily advantageous resource
550 control was also tested (Hawley & Hensley, 2009). People
were categorized as having either 1) coercive strategies,
where people gain access to resources by simply taking
them as a show of social dominance, 2) prosocial strategies,
where people gain access to resources through cooperation,
555or 3) a combination of the two (bi-strategic). The research-
ers predicted that women who are more dominant (or adopt
a coercive strategy) would show more forceful sexual fan-
tasies than submissive women because they are drawn to
dominant men that they themselves are competitive enough
560to win over. The rst study found that womens predilection
for forceful submission was greater than mens preference
to fantasize about forceful domination. Bi-strategic women
showed the greatest divergence between preferences: they
preferred to be dominated more than they preferred to
565dominate, supporting the initial hypothesis. As predicted,
dominant men were more likely to entertain dominance
fantasies.
Sex Drive. Although some research (Lammers &
Imhoff, 2016) points to BDSM being associated with
570subversion of gender norms, sex differences remain. Men
are consistently found to report a higher incidence of
atypical sexual interests, including BDSM (Dawson et al.,
2016; Joyal et al., 2015). The exception appears to be
masochism, in which more women than men report having
575this fantasy (Joyal et al., 2015). Dawson et al. (2016) found
the men reported arousal to sadistic sexual interests more
often than women, consistent with other studies. However,
sex drive was an important mediator of these associations,
indicating that higher sex drive is a possible etiological
580factor in the development of BDSM interests.
As has been demonstrated, it seems to be highly unlikely
that there is a single cause of BDSM interests. There is good
evidence that BDSM practitioners do not suffer from more
psychological problems than the general population (Con-
585nolly, 2006; Cross & Matheson, 2006; Richters et al., 2008)
and do not show levels of empathetic neural responses
associated with psychopathy (Luo & Zhang, 2018a,
2018b), as is predicted by psychopathological and psycho-
analytic models. If CSA is a contributing etiological factor
590in a small subset of BDSM practitioners (Nordling et al.,
2000), it is more likely to be related to hypersexuality or
erotophilia than BDSM interests themselves (Shulman &
Home, 2006). Though many of the studies reviewed were
limited by the use of self-selected sampling, those with
595large, representative samples (Richters et al., 2014,2008,
2003) have reached similar conclusions.
In sum, causal factors may include BDSM engagement for
leisure (Williams et al., 2016), inuence of high sex drive
(Lammers & Imhoff, 2016) to mate selection techniques (Jozif-
600kova et al., 2012) and positions of social power (Hawley &
Hensley, 2009). However, the cross-sectional nature of these
studies makes causal pathways difcult to determine and the
use of self-selected samples limit generalizability. Notable is the
lack of good research on genetic, hormonal, and neural corre-
605lates. Collectively, data suggest there is no singular causal factor
of BDSM, but rather multiple factors.
BROWN, BARKER AND RAHMAN
32
Demographic Characteristics of BDSM Practitioners
The majority of studies on BDSM practitioners have
found that they are typically white, well-educated, and
610 young (e.g., Brown, Roush, Mitchell, & Cukrowicz, 2017;
Connolly, 2006; Damon, 2003; Hébert & Weaver, 2014;
Lodi-Smith, Shepard, & Wagner, 2014; Oliveira Júnior &
Abdo, 2010; Pascoal, Cardoso, & Henriques, 2015; Richters
et al., 2014). Only two studies diverged from this demo-
615 graphic pattern (Joyal, 2015; Wismeijer & Van Assen, 2013,
although the latter still reported greater education levels).
Additionally, BDSM practitioners have higher rates of
non-monogamy. One study found 40% reported some form
of non-monogamous relationship (Rehor, 2015), another
620 found that 31.4% practiced BDSM with someone other
than their primary romantic partner (Hébert & Weaver,
2014), a third found that 32.7% identied as non-
mongamous or polyamorous (Connolly, 2006), and
a fourth reported rates of polyamory of around 14%
625 (Botta, Nimbi, Tripodi, Silvaggi, & Simonelli, 2019). This
may be related to ndings by Wismeijer and Van Assen
(2013) that non-BDSM females scored signicantly lower
on condence in relationships than the female BDSM prac-
titioners. However, because BDSM is a niche sexual inter-
630 est, it may lead to higher rates of being single as it becomes
more difcult to nd a partner with shared interests (Ahlers
et al., 2011).
Identifying as non-heterosexual is also related to BDSM.
One study found that women with masochistic interests
635 reported greater same sex attraction than women with con-
ventional sexual interests (Chivers, Roy, Grimbos, Cantor,
& Seto, 2014). Another study found that BDSM involve-
ment was signicantly more likely for bisexual men and gay
men and women, and those with any BDSM experience
640 were more likely to report bisexual experiences (Richters
et al., 2008). Hébert and Weaver (2014) found that 30.7% of
BDSM practitioners identied as bisexual, while 4.9%
identied as homosexual. Connolly (2006) found that
34.1% identied as exclusively heterosexual, while Botta
645 et al. (2019) reported that 39.7% of men and 30.4% of
women identied as exclusively heterosexual.
Sexual Experience and Functioning. When it comes
to sexual experience, the results indicate that BDSM
practitioners typically have more partners over their
650 lifetime (Oliveira Júnior & Abdo, 2010; Richters et al.,
2008), have more sexual experience, and have sex at an
earlier age (Oliveira Júnior & Abdo, 2010; Tomassilli et al.,
2009). There is little evidence for an association between
BDSM practices and sexual difculties (Richters et al.,
655 2008). For example, BDSM-identied men reported
signicantly lower levels of sexual distress, and arousal
did not differ between BDSM and non-BDSM sexual
contexts (Pascoal et al., 2015). Women reported
signicantly less distress about maintenance of arousal in
660 BDSM contexts than non-BDSM contexts, though overall
sexual satisfaction did not differ.
However, Långström and Hanson (2006) reported an
association between impersonal sex, hypersexuality, and
paraphilic interests, such that hypersexuality was related to
665the deliberate use of pain during sex. Oliveira Júnior and
Abdo (2010) also reported that those with at least one
atypical sexual behavior reported higher rates of STIs, and
men reported a higher incidence rate of HIV/AIDS. Another
study in a gay leather community found that those who
670identied as leather men were 61% more likely than a non-
leather control group to be HIV positive (Moskowitz, Seal,
Rintamaki, & Rieger, 2011). Those who identied as sub-
missive were also more likely to be HIV-positive than non-
leather identied participants. Further investigations are
675needed on the relationship between BDSM involvement
and physical and sexual health.
BDSM Identication, Engagement, and Behaviors
Arousal Patterns. Previous research (Chivers, Seto,
& Blanchard, 2007; Suschinsky, Lalumière, & Chivers,
6802009) has indicated that heterosexual women do not show
gender or activity specic arousal patterns, unlike men
(Seto, Lalumière, Harris, & Chivers, 2012). One study
tested whether or not activity-specic genital arousal was
different for men and women who reported masochistic
685interests (Chivers et al., 2014). Men with masochistic
interests reported signicantly greater subjective and
genital arousal to masochistic sex than neutral stimuli but
did not differ in their subjective ratings of conventional and
masochistic sex narratives. Women with masochistic
690interests showed the greatest subjective arousal to
conventional and masochistic sex (with no signicant
differences between them). Both men and women with
masochistic interests showed more subjective and genital
arousal to masochistic sex than any participants with
695conventional interests. Overall, participants with sexual
interests in masochism, regardless of gender, showed
nonspecic arousal patterns, responding similarly to both
conventional and masochistic sex, once again supporting the
notion that BDSM interests are not used as a complete
700replacement of conventional sexual behaviors
Individuals can also broaden their interests once already
within the BDSM community. Typically, this is done by
altering their role identication and/or adopting new or
more extreme behaviors. Klement, Sagarin, and Lee
705(2017a) reported on data from a BDSM event centered on
the extremes of sadomasochism (where participants insert
needles, hooks, or hang heavy weights from the skin). It was
found that engaging in these behaviors increased sexual
arousal and decreased both negative affect and stress levels.
710Role Identication
One study of BDSM participants asked about BDSM
identity and uidity and found BDSM role identication
showed a signicant relationship to gender and sexual
A SYSTEMATIC SCOPING REVIEW OF BDSM
33
identities (Martinez, 2018). As expected, women were more
715 likely to be in the submissive category, and men were more
likely to be in the dominant category. This gender/BDSM
identication divide was also found in other studies (Botta
et al., 2019; Yost & Hunter, 2012). Genderqueer participants
were more likely than men or women to identify as
720 switches, and switches were signicantly less likely to be
heterosexual than dominants (Martinez, 2018). Queer and
pansexual participants had the highest rate of equally shar-
ing role frequencies, followed by lesbians/gays, bisexuals/
heteroexibles, and heterosexuals. Genderqueer individuals
725 had higher role uidity than women, and women had higher
uidity than men. Results support ndings that suggest that,
for a sub-set of BDSM participants, BDSM role can liberate
individuals from, not reinforce, gender roles (Lammers &
Imhoff, 2016).
730 BDSM Behaviors. Exemplifying the broad spectrum of
sexual behaviors that may be adopted by BDSM practitioners
wasastudybyRehor(2015) looking at the behaviors of women
who identied with the kink community. More than 50%
reported they had participated in sadomasochistic activities
735 like breast play, paddling, ogging, pinching, whipping, and
caning. Over half indicated that they had engaged in verbal or
physical humiliation, exhibitionism, sensory deprivation,
physical punishment, breath play, obedience training,
domestic service/submission activities or forced activities for
740 their own sexual gratication. Over 87% engaged in at least 1 of
10 role play scenarios- in order from most to least common:
master/slave, fear play (e.g., kidnapping), occupation (e.g.,
boss), animal play, medical play, age regression, religion,
incest, age progression, and necrophilia. About 75% indicated
745 arousal by an object in at least one of ve fetish categories
(clothing, body parts, fabrics, uniforms, body uids). Other
research (Connolly, 2006) found the most preferred BDSM
activities were whipping, caning, and ogging, followed by
bondage and spanking. Botta et al. (2019) reported that 58.9%
750 of male and 54.4% of female BDSM practitioners listed
bondage as one of their most favorite BDSM activities, 73.8%
of males and 90.4% of women favored physical pain, and
56.7% of men and 59.2% of women enjoyed humiliation (cf.
Pascoal et al., 2015).
755 Regarding the extremity of behaviors, 14.4% categorized
themselves as being light players, 39% as medium players,
30.5% as heavy, and 15.3% as edge (the most extreme)
players (Connolly, 2006). Regardless of the intensity, 90.5%
stated they used safe words. Most participants still had non-
760 BDSM sex, with only 11.2% indicating that BDSM was their
only form of sexual activity. About 13% had also reported
occasionally paying for BDSM services from professional
dominants or submissives. The majority (88.4%) of all parti-
cipants reported engaging in sexual activity without elements
765 of BDSM before they had their rst experience with BDSM
(Nordling, Sandnabba, Santtila, & Alison, 2006)
With respect to the structure of these diverse behaviors,
Alison, Santtila, Sandnabba, and Nordling (2001), similar to
other studies, reported 27% of BDSM practitioners identied as
770sadistic/dominant, 22.7% as switches, and 50.2% as masochis-
tic/submissive. Analysis revealed four domains of behavior:
hypermasculinity, administration of pain, humiliation, and phy-
sical restriction. Women engaged in signicantly more humi-
liation (e.g., use of gags) than men, whereas men engaged in
775more hypermasculine behaviors than women. Gay men pre-
ferred hypermasculine behaviors (e.g., rimming, penis binding,
sting) and straight men preferred humiliation (see also Nord-
ling et al., 2006). It is possible that these behaviors take on
differentmeaningsbasedonanemphasisonhumiliationor
780hypermasculinity (Alison et al., 2001). Thus, BDSM play can
be viewed as a set of behaviors that take on different meanings
to individuals based on partner and context. In all four domains,
asignicant underlying, nonrandom, structure emerged, sug-
gesting that the 29 behaviors investigated were clustered in
785a predictable way (Santtila, Sandnabba, Alison, & Nordling,
2002). Participants tended to engage in behaviors with increas-
ing intensity, with less extreme behaviors typically preceding
more intense behaviors, indicating that, over time, BDSM
practitioners adopt more intense behaviors.
790Further analysis focused specically on the 162 males in
the above three studies (Sandnabba, Santtila, & Nordling,
1999). The median age of rst awareness of BDSM interest
was 1820, and the median age of rst BDSM experience
was 2125, again with gay men being older than hetero-
795sexual men for both of these. Gay men became aware of
their BDSM interests and had their rst BDSM experience
at an older age than the exclusively heterosexual men
(Nordling et al., 2006). When asked about the intensity of
their BDSM scenes, a signicant number of participants
800indicated that they had lighter sessions than they wanted
(Sandnabba et al., 1999). Moreover, participants believed
they preferred heavier sessions than their partners wanted,
regardless of BDSM role identity.
When asked about the place of BDSM behaviors, one study
805found that 85.5% reported doing so at home (Holvoet et al.,
2017) and another found that 83.8% reported practicing BDSM
at home, while only 4.4% of BDSM activities were reported to
take place in BDSM clubs (Pascoal et al., 2015). This points to
a potential sampling bias, as many studies on BDSM recruit
810from BDSM clubs and events, though the behaviors of those
who practice in and out of the home appear similar.
Collectively, results from each of these studies indicate that
BDSM identication and behaviors can change over time,
though the uidity of these differ between individuals. They
815also show that, for a majority, BDSM behaviors are in addition
to, not a replacement of, more typical sexual behaviors (Alison
et al., 2001;Chiversetal.,2014; Rehor, 2015; Sandnabba et al.,
1999; Sandnabba et al., 2002). This supports non-pathological
models of atypical sexual interests that focus on the broadening
820of sexuality (Cross & Matheson, 2006).
BROWN, BARKER AND RAHMAN
34
Psychological Correlates
Mental Health and Clinical Considerations. In
general, BDSM practitioners are comparable to the general
population in terms of mental health (Connolly, 2006; Cross
825 & Matheson, 2006; Richters et al., 2008,2003). For
example, it was found that BDSM practitioners reported
lower depression scores, but typical levels of anxiety,
compared to population norms (Connolly, 2006). However,
some studies have found sub-groups of BDSM practitioners
830 report more psychological problems. On measures of
dissociation, submissiveness was related to reported
memory disturbance and depersonalization, regardless of
gender (Connolly, 2006). Another study found that men
and women who engaged in these behaviors were more
835 likely to show posttraumatic symptoms than those who did
not engage in these behaviors, and both men and women
who reported engaging in at least one atypical sexual
behavior were signicantly more likely to be a victim of
sexual violence (Oliveira Júnior & Abdo, 2010). However,
840 participants did not differ from population norms on
depression, anxiety, panic, or phobias.
Other studies indicated that BDSM participants with
a history of sexual abuse may be at risk of mental health issues
(Nordling et al., 2000). For instance, Nordling et al. (2000)
845 found that BDSM practitioners with a history of CSA were
more likely to have ever attempted suicide, had more hospital
psychological treatment, and were more likely to visit
a physician regarding BDSM related injuries. Brown et al.
(2017) investigated the potential risk of suicide attempts,
850 based on the interpersonal theory of suicide, in which an
acquired capability for suicide develops via habituation to
exposure to painful or traumatic events (Van Orden et al.,
2010). As participating in or watching a BDSM scene could
be considered painful and/or emotionally provocative, partici-
855 pants may habituate over time, and thus increase their risk of
suicide. For males, (no association was found for females) more
engagement in BDSM was associated with an increased chance
of a suicide attempt, but only when this relationship was
mediated by both fearlessness about death and perceived pain
860 tolerance. Twelve percent reported at least one suicide attempt;
a rate higher than the general population. Roush, Brown,
Mitchell, and Cukrowicz (2017) reported 37.4% (higher than
the estimated 3.7% of US adults) of the BDSM practitioners
reported some level of suicide ideation in the past two weeks.
865 However, feelings of thwarted belongingness and perceived
burdensomeness mediated the relationship between shame and
suicidal ideation in this sample, suggesting that the stigmatiza-
tion of BDSM (not BDSM itself) may be a causal factor for
depressive symptoms.
870 Although some of this research points to mental health
issues, it does not indicate that most practitioners suffer from
clinically signicant psychological problems. A sub-section of
BDSM practitioners, perhaps those who suffered non-BDSM
related trauma, may be at an increased risk of psychological
875 distress. Studies that point to mental health problems have used
small sample sizes (Nordling et al., 2000)orincludedother
sexual interests, like pedophilia (Oliveira Júnior & Abdo, 2010)
in their results. There is greater need to separate comorbid
problems and diagnostic versus symptom-based denitions of
880poor psychological health.
Personality. Hébert and Weaver (2014)foundthatBDSM
practitioners did not differ from population norms on honesty-
humility, emotionality, extraversion, agreeableness, conscientio-
usness, desire for control, self-esteem, life satisfaction, and
885empathy. However, dominants and submissives scored lower
on altruism. When compared to other BDSM orientations,
submissives scored higher on openness to experience and
emotionality, and dominants scored higher on desire for control
and extraversion. Compared to controls, results from another
890study found that BDSM participants scored higher on openness
to experience, extraversion, and conscientiousness, and lower on
rejection sensitivity, neuroticism, agreeableness (Wismeijer &
Van A s se n, 2013). When comparing across orientations, switches
and dominants scored higher on openness than submissives and
895submissives scored higher on agreeableness than dominants.
Additionally, a 2019 study found that neither extraversion or
neuroticism were predictors of dominant or submissive role
identication (Hillier, 2019).
Dawson et al. (2016) found that hypersexuality, sexual
900compulsivity, impulsivity, and sensation seeking were
positively related to paraphilic interest scores. Generally,
measures associated with excessive or compulsive sexual
behavior, along with sociosexuality, were correlated with
paraphilic interests. As previously mentioned, Shulman
905and Home (2006) found that erotophilia predicted fanta-
sies involving submissiveness and force and was nega-
tively related to sex guilt. Rye, Serani, and Bramberger
(2015) reported that erotophilia was positively related to
personal feelings about BDSM and comfort in discussing
910BDSM.
Some research has studied Dark Triad traits (psychopa-
thy, narcissism, and Machiavellianism) and personality dis-
order characteristics in relation to BDSM. One such study
using the WSFQ reported that while psychopathy was sig-
915nicantly related to all four fantasy domains (intimate,
exploratory, impersonal, and sadomasochism), it was most
strongly correlated with impersonal fantasies (Baughman,
Jonason, Veselka, & Vernon, 2014). Sadomasochism
appeared most strongly and signicantly related to psycho-
920pathy, followed by narcissism, and Machiavellianism
(which was not signicant; see also Williams et al., 2009).
One study of adults with sub-clinical paraphilic interests
found that, out of the Big 5 and the Dark Triad, only
openness predicted sadomasochism in men, and openness,
925low conscientiousness, and Machiavellianism predicted
sadomasochism in women (Lodi-Smith et al., 2014). Con-
nolly (2006) found dominants scored higher on measures of
narcissism and histrionic symptoms than the normative
values, but this effect was greater in men. BDSM partici-
930pants did not score signicantly above non-clinical popula-
tion norms for histrionic, avoidant, or dependent personality
A SYSTEMATIC SCOPING REVIEW OF BDSM
35
disorder symptoms, though submissives did have signi-
cantly higher dependence scores than dominants (see also
Watts, Nagel, Latzman, & Lilienfeld, 2019).
935 Interpersonal Relationship Factors
Due to social stigma, BDSM participants may be hesitant
to disclose their interests in personal and clinical settings.
On disclosure, 34.1% reported feeling they could tell most
of the adults in their lives about their BDSM interests,
940 52.4% said they could tell some people in their lives,
9.5% said they did not feel comfortable disclosing to any-
one, and 4% reported they had to permanently hide their
interests (Connolly, 2006). The majority (53.7%) felt
uncomfortable by the prospect of their BDSM interests
945 being discovered by others; 1.6% of these individuals said
it terried them. Another study found that fewer than 5%
had disclosed to a family member, 25.6% to a friend, and
3.8% to a colleague (Holvoet et al., 2017).
Research on attitudes toward BDSM found that as parti-
950 cipants reported more prejudice toward sadomasochists,
they also reported more homophobia and social and sexual
conservativism (Yost, 2010). Endorsement of false state-
ments about rape was also related to the belief that BDSM
practitioners were violent and dangerous. However, as
955 knowledge about BDSM, involvement in BDSM, or know-
ing individuals involved in BDSM increased, prejudice
decreased. Pre-existing beliefs about BDSM was also
found to shape attitudes toward BDSM more than media
portrayal (Rye et al., 2015).
960 These mixed social attitudes toward BDSM can lead to
lack of disclosure in clinical contexts, with many BDSM
practitioners being worried about disclosure during therapy
(Kelsey, Stiles, Spiller, & Diekhoff, 2013; Roush et al.,
2017). A study of licensed mental health professionals
965 found that 76% reported having at least one client that
engaged in BDSM (Kelsey et al., 2013). Sixty-seven percent
agreed that it could be part of a healthy relationship, and
70% disagreed that it should be treated through therapy.
Therapists who had more experience with BDSM clients
970 had signicantly more positive attitudes about BDSM.
However, over half (52%) did not consider themselves
competent enough to see BDSM clients, and 64% reported
having no graduate training mentioning BDSM. Research
on psychotherapist perceptions suggest that there may be
975 more bias against male clients who disclose dominant or
sadistic sexual interests, seeing them as more dangerous
(Fuss, Briken, & Klein, 2018). Those trained in psycho-
analysis also pathologized sadistic behaviors more than
those trained in cognitive behavioral therapy, tting with
980 the etiological theories supported by psychoanalytic
thought.
Contrary to some stereotypes, research suggests that
BDSM can be benecial to both social and romantic rela-
tionships. Drawing primarily from a sample of BDSM
985 practitioners who attended related events, almost 90% said
they held a membership at one or more BDSM organiza-
tions, 73% indicated they attended events regularly, 70.9%
indicated this involvement provided them with an avenue
for social support, 85% said it helped them make friends,
990and 83.4% said it gave them educational opportunities
(Connolly, 2006). For BDSM practitioners in committed
relationships, dyadic adjustment scale scores on consensus,
satisfaction, and cohesion subscales did not differ between
BDSM orientations (Rogak & Connor, 2017).
995
Another study found that there were no signicant differ-
ences in relationship communication anxiety between those
who did and did not participate in spanking, bondage,
submissive behaviors, and BDSM in general (Kimberly,
Williams, & Creel, 2018). Engagement in BDSM was
1000related to a signicant increase in sexual communication
comfort, though it did not relate directly to an increase in
relationship satisfaction. Other studies using biomarkers
such as cortisol levels also reported that BDSM engagement
may be associated with greater couple bonding (Sagarin,
1005Cutler, Cutler, Lawler-Sagarin, & Matuszewich, 2009).
High relationship satisfaction was also found in what some
consider to be the most intense BDSM relationship- the
Master/slaverelationship. For example, 88% of partici-
pants in Master/slave relationships stated that they were
1010satised or completely satised with their relationship
(Dancer, Kleinplatz, & Moser, 2006). Overall, empirical
research has demonstrated that BDSM relationship func-
tionality and satisfaction is not signicantly different from
the general population (Kimberly et al., 2018; Rogak &
1015Connor, 2017).
Discussion
There is a disparate literature on various aspects of
BDSM, including potential origins, psychological and rela-
tionship correlates. However, this literature is often placed
1020under the umbrella of paraphilias, and there are no
reviews which offer a coherent overview of these segments
of the BDSM literature. The purpose of this review was to
address this gap. Despite the difculties in generalizing
across studies which differ in methodological approach,
1025population characteristics, and analyses, we are able to
make some broad conclusions and directions for future
inquiry. There appears to be little support for psychoanalytic
or psychopathological theories of BDSM development (e.g.,
Cross & Matheson, 2006; Connolly, 2006; Richters et al.,
10302014). Feminist models, which imply that BDSM power
dynamics are related to sexism, are also not supported (e.g.,
Klement et al., 2017b; Shulman & Home, 2006). There was
no strong evidence for models that suggest that BDSM
participants have increased risk of CSA or maladaptive
1035attachment styles (Richters et al., 2008; Santtila et al.,
2001), although CSA may play a role in a sub-set of
individuals (Nordling et al., 2000). Empirical evidence
was shown for theories that regard BDSM as a form of
BROWN, BARKER AND RAHMAN
36
leisure (Williams et al., 2016), a facet of sex drive (Lam-
1040 mers & Imhoff, 2016), or as a broadening of sexual reper-
toire (e.g., Cross & Matheson, 2006; Tomassilli et al.,
2009). The primary etiological nding of this review chal-
lenges the historical psychopathological model of BDSM
interests, suggesting that future research should instead
1045 focus on looking into new, more complex etiological path-
ways for the development of specic sexual interests.
Studies on prevalence of BDSM interests differ, with
reports ranging from 2% (Richters et al., 2003) to close to
70% (Holvoet et al., 2017). This range is most likely due to
1050 differing denitions, classications, and sampling biases
(e.g., from self-selected samples), although most research
agrees that BDSM interests are not statistically rare (dened
here as less than a 2.3% prevalence rate; Joyal et al., 2015;
Zurbriggen & Yost, 2004). While interests and fantasy rates
1055 are quite high, engagement in BDSM is lower, usually
around 20%-30% (Bailey et al., 2003; Joyal & Carpentier,
2017; Tomassilli et al., 2009). Thus, is it important to note
that having these sexual fantasies do not mean that indivi-
duals necessarily enact them. This distinction is sometimes
1060 obscured in the literature we reviewed.
Individuals who participate in, and identify with, BDSM
tend to be white, well educated, young, and are more likely
than the population to be non-heterosexual, though most
studies presented here do not draw from representative sam-
1065 ples (Hébert & Weaver, 2014; Richters et al., 2014; Tomassilli
et al., 2009). They also tend to have higher rates of non-
monogamous relationships and report more sexual partners
and experience (Oliveira Júnior & Abdo, 2010; Richters et al.,
2008). Men are more likely to identify as dominants, tops, or
1070 sadists, while women are more likely to identify as submis-
sives, bottoms, or masochists, but this pattern is not as strong
in non-binary or non-heterosexual practitioners (Martinez,
2018; Zurbriggen & Yost, 2004). Importantly, BDSM does
not appear to replace normophilic behaviors (Cross & Math-
1075 eson, 2006; Houngbedji & Guillem, 2016; Williams et al.,
2009). Findings here imply that there is a need to reframe the
current scientic view of what is considered atypicalin
sexuality with more comprehensive research on prevalence
rates of sexual fantasies and behavior both in the population
1080 and BDSM communities. Additionally, results from this
review indicate a need to investigate the complex relation-
ships between sexual orientation, relationship style prefer-
ences, gender, and sexual interests.
While there is some evidence (e.g., Baughman et al.,
1085 2014) for BDSM practitioners showing higher levels of
narcissism and psychopathy, these levels did not warrant
a clinical diagnosis (Mahmut, Homewood, & Stevenson,
2008). A small sub-set of BDSM practitioners may be at
a higher risk of suicide (e.g., Brown et al., 2017). In contrast
1090 to pathology-focused models, BDSM practitioners are less
sexist (Connolly, 2006; Klement et al., 2017b; Shulman &
Home, 2006), more open to new experiences (e.g., Hébert &
Weaver, 2014; Lodi-Smith et al., 2014), more extraverted
(Wismeijer & Van Assen, 2013), and better at relationship
1095communication (Kimberly et al., 2018; Rogak & Connor,
2017). Though there is little evidence for a link between
psychopathology and BDSM, this review has identied
potential sub-groups of BDSM practitioners who may be
at a higher risk for developing mental health issues.
1100Research should focus on identifying characteristics of
these subgroups, as it may provide clinically important
information about BDSM-identied individuals who experi-
ence psychological distress.
One of the larger ndings of this review was that BDSM
1105may be an expansion of unusual sexual fantasies and beha-
vior (e.g., Cross & Matheson, 2006; Houngbedji & Guillem,
2016). This suggests that further work should focus on
better understanding the psychometric structure underlying
this trait. For example, BDSM interests and behavior may
1110be part of a latent factor of paraphilic interests, form a factor
on its own, or be part of a hierarchical structure linked by
a third factor such as general atypical sexual interests or sex
drive. Future research should also focus on a broader range
of measures of mental health, the investigation of biological
1115factors, the relationship between BDSM and sexual orienta-
tion, and discrimination of BDSM-identied people.
Limitations of this scoping review include restriction of
the literature to peer-reviewed articles published between
2000 and 2019, and omitting articles which used only
1120qualitative approaches. Including qualitative studies may
have helped provide new observations based on BDSM
practitioner experiences in some of the topics (e.g., relation-
ships). We also restricted sample sizes in studies to 12 or
more. The sample of literature also focused on that which
1125was published in Western and English-language journals
and so does not fully reect the research priorities or
cultural contexts of other locations. Understanding the
basic prevalence, developmental factors, psychological,
and relationship correlates of BDSM is a prerequisite for
1130informing future research directions.
In sum, our results highlight the elds interest in
prevalence of BDSM interests and behaviors, psycholo-
gical factors implicated in the development of BDSM
(e.g., personality traits), the inuence on relationship
1135processes, and particularly the focus on BDSM as
a broadening of sexual interests and behavior. Results
also highlight important denitional limitations in the
extant literature, and lack of attention to sampling and
selection biases in studies. There is a notable lack of
1140work on the development and use of psychometrically
validated measures of BDSM and on biological corre-
lates which are implicated in the development of atypical
sexual interests (Seto, 2017).
ORCID
1145Ashley Brown http://orcid.org/0000-0001-6743-3773
A SYSTEMATIC SCOPING REVIEW OF BDSM
37