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Transcript
BIAS IN PSYCHOTHERAPY WITH BDSM CLIENTS
and
BDSM IN PSYCHOTHERAPY: A CULTURALLY AWARE CURRICULUM
___________________
A Two Paper Alternative Department Thesis Presented to the Faculty
Of
California State University, East Bay
___________________
In Partial Fulfillment
Of the Requirements for the Degree
Masters of Science in Counseling
_______________
By
Heather J. Powers
June, 2007
Abstract
Bondage, Discipline, and Sadomasochism (BDSM) is a sexual orientation and behavior
often misunderstood by both the psychological community and the public. Although
extreme and obsessive BDSM activities may point to a paraphilic diagnosis, the majority
of people involved in BDSM are well adjusted, successful and productive members of
society. It is important that the mental health community have proper tools for
differentiating between paraphilic disorders and healthy sexual diversity. Paper one
examines the historical and present experiences of BDSM participants as a stigmatized
sexual minority. Paper two addresses twelve clinical guidelines for providing culturally
sensitive care to BDSM clients. These guidelines may be used as a three segment class
for mental health providers interested in working with BDSM oriented clients.
3
BIAS IN PSYCHOTHERAPY WITH BDSM CLIENTS
and
BDSM IN PSYCHOTHERAPY: A CULTURALLY AWARE CURRICULUM
By
Heather J Powers
Approved:
Randi S. Cowdery, Ph.D.
June 6, 2007
Charles Glickman, Ph.D.
June 5, 2007
4
Table of Contents
Abstract…………………………..………………………………….……
2
PAPER ONE: Bias in Psychotherapy with BDSM Clients……………….
6
Introduction………………………………………………………..
6
Characterological, Sexual & Self Identity Diagnostic Criteria……
7
Defining BDSM…………………………………………………...
9
BDSM Behaviors………………………………………………….
10
Who is into BDSM?.........................................................................
11
BDSM Diversity…………………………………………………..
13
The Portrayal of BDSM in Mainstream Society…………………..
14
BDSM Subculture…………………………………………………
16
Historical & Psychological Stigmatization of BDSM Activities…. 17
A Sexual Satisfaction Model of Dysfunction……………………..
20
BDSM versus Domestic Violence………………………………...
20
BDSM & Healing…………………………………………………. 21
BDSM in the therapy Room…………………...………………….. 22
Dual Relationships with BDSM Identified Therapists…………....
24
Paper One Summary…………………………………………………..
25
PAPER TWO: BDSM in Psychotherapy: A Culturally Aware Curriculum 28
Introduction………………………………………………………..…..
28
12 Guidelines for Psychotherapy with clients who engage in
BDSM..............................................................................................
29
5
Unit A – Pathology & Differential Diagnosis……………………..
29
Guideline 1………………………………………………………...
30
Guideline 2………………………………………………………...
30
Guideline 3………………………………………………………...
32
Guideline 4………………………………………………………...
32
Guideline 5………………………………………………………...
33
Unit B – Social Aspects of BDSM………………………………...
33
Guideline 6………………………………………………………...
33
Guideline 7………………………………………………………...
35
Guideline 8………………………………………………………...
35
Unit C – Continuing Education……………………………………
35
Guideline 9………………………………………………………...
36
Guideline 10……………………………………………………….
36
Guideline 11……………………………………………………….
37
Guideline 12……………………………………………………….
38
Paper Two Summary……………………………………………………… 39
Appendices………………………………………………………………..
40
References…………………………………………………………………
46
6
PAPER ONE: Bias in Psychotherapy with BDSM Clients
Introduction
BDSM is a sexual orientation and behavior that includes a consensual exchange
of power between partners and generally involves sexual behavior that plays out that
power differential (Weinberg, 1995). These behaviors are often misunderstood by both
the psychological community and the public. Often, it is assumed that anyone involved in
BDSM activities is suffering from a paraphilic disorder, but when exploring the issue
thoroughly it is clear that this assumption is based upon misconceptions about both the
diagnostic criteria and the behaviors of BDSM participants.
Most people with a BDSM orientation have sex without BDSM elements at least
some of the time (Cutler, 2003) while others enjoy the sensations connected with BDSM
but do not consider them sexual in nature, similar to how an individual might describe
getting a massage. For some participants, BDSM is a key part of their sexual orientation
while for others the activities are more casual, analogous to how one may engage in sex
with a same sex partner without identifying as homosexual or bisexual. Just as sexual
orientation has a gay, bisexual, heterosexual continuum, BDSM has dominant, switched
roles, and submissive continuum. Some of this variety may be attributed to the pop
culture status of BDSM while the rest is simply indicative of the variety present in human
sexual diversity.
Just as with other sexual orientations, participants must not be labeled by behavior
and instead should be educated about alternative sexual orientations, behaviors, ideas and
cultures in a way that allows them to define themselves (Hancock, 1995). This paper
7
addresses the stigma and cultural biases that may affect the therapeutic alliance between
mental health professionals and their kinky clients.
Characterological, Sexual & Self Identity Diagnostic Criteria
Psychological masochism, sexual masochism & the BDSM masochist self identity
are distinctly different phenomenon, yet very few clinicians are educated in these
differences (Maleson, 1984). The same is true of psychological sadism, sexual sadism
and the BDSM sadist self identity. The Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised (American Psychiatric Association, 1987, pg. 371) also
known as the DSM-III-R, described Sadistic Personality Disorder as “a pervasive pattern
of cruel, demeaning, and aggressive behavior, beginning by early adulthood”. It
specifically notes that having a sadistic personality structure and sexual sadism are
separate phenomenon that should be diagnosed discretely. The most current addition, the
DSM-IV-TR (American Psychiatric Association, 2000) make no distinction between the
two and only Sexual Sadism remains listed. According to the DSM-IV-TR, the clinical
definition of sexual sadism is dependant on two distinct criteria, both of which must be
met for a clinical diagnosis.
The first DSM-TR-IV criteria requires “recurrent, intense sexually arousing
fantasies, sexual urges and behaviors involving acts (real, not simulated) in which the
psychological or physical suffering of the victim is sexually exciting to the person”(pg
574). The second criteria requires that the sadist has “acted on these sexual urges with a
non-consenting person, or the sexual urges or fantasies cause marked distress or
interpersonal difficulty” (pg 574).
8
An individual who self-identifies as a BDSM sadist generally prefers acts that are
consensual and pleasurable to their masochistic partner (Nichols, 2006). Similarly,
BDSM masochists do not enjoy pain received outside of their negotiated relationships. A
BDSM masochist who stubs his or her toe does not find pleasure in that pain. Cross and
Matherson (2006) noted that in BDSM relationships “participants consider the power
exchange to be mutually constructed, maintained by tacit and explicit rules and
conventions, and, ultimately, illusory.” For many, BDSM pain is similar to pain received
during other consensual endorphin producing activities like intense exercise or deep
tissue massage.
Although nonconsensual and compulsive BDSM activities may point to a
paraphilic diagnosis, most participants with a sadistic or masochistic self identity are
engaging in consensual BDSM, not paraphilic behavior. The majority of people involved
in BDSM are well adjusted, successful and productive members of society (Moser &
Levitt, 1987). These clients represent a distinct sub-culture and should be treated with the
same dignity and respect that the mental health community would extend to any other
multicultural client. It has been widely noted that diagnosis in psychotherapy is extremely
problematic when a mental health practitioner has not been trained in working with
clients from that culture (Lonner & Ibrahim, 1996; Sue, 1996). It can be postulated that
properly diagnosing and creating an alliance with BDSM participants without training in
the unique cultural biases they face would be equally difficult. Therapists who wish to
work with clients who engage in BDSM behaviors must be trained in BDSM cultural
issues in order to provide adequate care.
9
Defining BDSM
The term BDSM encompasses three distinct subcategories of behavior within its
four letter cyclical acronym; BD (Bondage and Discipline), D/s (Dominance and
submission), and SM (Sadomasochism or Sadism and Masochism). BDSM relationships
may include any or all three categories and range from short term casual “play”
encounters to fulltime “24/7” roles. BDSM behaviors are so diverse in content and
underlying meaning that a concise, all-encompassing definition is difficult to devise.
Weinberg, Williams and Moser (1984), using the term SM, found five features that exist
in most BDSM interactions. These features include:
1. Dominance and submission - the appearance of rule and obedience of
one partner over the other.
2. Consensuality - a voluntary agreement to enter into SM "play"
(interaction) and to honor certain "limits" (ground rules of how involved
and in which direction the play can proceed).
3. Sexual content - the presumption that the activities have a sexual or
erotic meaning for at least one participant.
4. Mutual definition - the assumption of a shared understanding by the
participants that their activities are SM or a similar concept.
5. Role playing - the participants assume roles either for the interaction or
for the relationship that they recognize may not be based in reality.
(Weinberg, Williams, & Moser, 1984).
It is important to note that BDSM based relationships exist on a wide continuum of
behaviors, genders, lifestyles and timelines. While these five elements may describe a
10
large part of BDSM activities, they are not all encompassing. A relationship that
participants do not define as BDSM may include many of these features while another
relationship may not. Some people enjoy a lifestyle that has an ongoing undertone of
BDSM in everyday interactions while other people isolate their BDSM behavior to
occasional sexual encounters (Kleinplatz & Moser, 2006).
BDSM Behaviors
Sexual behaviors vary greatly within BDSM relationships. In a survey by Moser
and Levitt (1987) the most commonly reported activities include flagellation, bondage,
oral sex, and anal sex. The most popular forms of role playing included uniform wearing
and Master/Madame/Mistress and slave roles. BDSM activities can include both physical
and psychological qualities ranging from the physical arousal experienced during
flagellation to the psychological erotic transference of power in a Master/slave paradigm.
Rituals, rules, distinct roles, symbols and discipline also play a large role in many
BDSM relationships, particularly with those who choose to live within their role during
most or all of the time (Dancer, Kleinplatz & Moser, 2006). An example that mixes many
of these would be a slave (role) being required (rule) to kneel and ask permission (ritual)
to put on a collar (symbol). Some individuals see BDSM as just a part of their sexual
repertoire while others feel it also is spiritually and emotionally fulfilling (Kleinplatz,
2006).
BDSM behaviors and fantasies are extremely common in our society. 10% of the
US population admits to engaging in BDSM on at least an occasional basis (Masters,
Johnson, & Kolodny, 1995). Most of these interactions do not cause any serious pain and
are pleasurable to the participants (Reinisch & Beasley, 1990).
11
BDSM fantasies are even more common than behaviors. Hariton (as cited in
Wright & Moser, n.d.) found that up to 49% of women fantasize about submissive roles
during sex with approximately 20% doing so frequently. In the early nineteen fifties,
Kinsey, Pomeroy, Martin, and Gebhard (1953) surveyed Midwest men & women and
determined that up to 12% of women and 20% of men would admit to responding
sexually to sadomasochistic stories. The number who found the texts pleasurable and did
not acknowledge it may have been even higher. Crepault and Couture (1980) surveyed a
group of men in the general population and uncovered that 15% fantasized about sexually
humiliating a woman while 11% had fantasies of physically inflicting pain upon a female
partner. Arndt, Foehl and Good (1985) discovered that 33% of women and 50% of men
had sexual fantasies of tying up their partner. These statistics clearly illustrate that BDSM
activities and fantasies are fairly common within the mainstream population. It is realistic
to assume that most mental health providers have had clients with BDSM related
fantasies or behaviors, even if they did not share these interests in therapy.
Who is into BDSM?
People who engage in BDSM behaviors span the gamut of human diversity. The
majority are generally well adjusted, highly educated and in a high income bracket
(Alison, Santtila, Sandnabba, & Nordling, 2001; Moser & Levit, 1987; Santilla,
Sandnabba, & Nordling, 2000). An individual’s participation in BDSM often is
impossible to gauge based upon their outward presentation. On a recent internet
questionnaire of over 6000 BDSM practitioners, most identified themselves as middle of
the road politically, in committed relationships and engage in BDSM activities primarily
at home (Brame, 2000). Many BDSM practitioners who are considered powerful within
12
society find comfort in the submissive roles. It is common for participants to switch roles
or prefer roles that are different from their professional or public persona (Thomson,
1994). Masters, Johnson, &, Kolodny (1985) noted that many masochists are men who
occupy positions of high status and authority.
Case studies have attempted to show a connection between pathological
childhood family interactions and BDSM (Blos, 1991; Blum, 1991) but these reports
have lacked empirical data to support their findings. These cases often represent
paraphalic exceptions to BDSM behavior rather than the norm because practitioners who
are not feeling distress related to their sexuality will not necessarily discuss their
activities in therapy. Those who have embraced the culture of BDSM generally do not
seek out treatment related to their BDSM unless they are experiencing conflict with a
partner.
Other theorists have suggested that the majority of BDSM practitioners have
suffered childhood sexual abuse and are acting out their trauma in an inherently
unhealthy way (Bass & Davis, 1998). In reality, the number who report experiencing
childhood trauma or sexual abuse is on par with the general population (Santtila et al.,
2000; Brame, 2000). It is also plausible that some survivors of sexual abuse use abusive
fantasies & the consensual exchange of power to reclaim their sexuality (Maltz, 1991).
The negotiation & communication aspects of BDSM may be healing to survivors who
have previously experienced sex as an out of control, nonconsensual act forced upon
them.
With this information, it is reasonable to assume that BDSM behaviors can be
witnessed within the general population and are not confined to a mentally ill subgroup as
13
has been previously assumed. In fact on measures of clinical psychopathology, BDSM
practitioners score on par with the general population (Connolly, 2006). A recent study of
nearly 20,000 Australian adults found that men involved in BDSM scored higher on
scales of psychological wellbeing than other men (Richters, Grulich, Visser, Smith, &
Rissel, 2003). In an Australian Associated Press interview following the study, lead
researcher Juliet Richters concluded that BDSM is simply “a sexual interest or subculture
attractive to a minority, not a pathological symptom of past abuse or difficulty with
‘normal’ sex. (2007)”
BDSM Diversity
The complex, intricate and diverse nature of how BDSM clients come to enjoy
their activities is beyond the scope of this paper. This section is not designed to be
inclusive of all BDSM motivations and instead should be considered a brief overview to
help clinicians explore some aspects of BDSM diversity. What is important to note is that
individuals enjoy BDSM for a myriad of reasons that can be spiritual, emotional, physical
or social. Some participants report knowing that they were interested in BDSM related
activities from childhood (e.g. tying up their neighbor) while others were introduced to it
as an adult through a partner or the media. In one recent study the reported age at which
participants had their first partnered BDSM encounter ranged from 7 to 69 with their
partners ranging in age from 7-70 (Cutler, 2003).
It is critical that therapists acknowledge that BDSM clients have presenting
problems that closely mirror those of the population at large (Connelly, 2006), BDSM
activities may have no connection to their presenting problem at all but still may contain
valuable information, just as information about their job, partners and hobbies might.
14
When a client presents information about the personality traits of a romantic partner,
therapists use that information to inform their work without seeking pathological
underpinnings. This concept should be equally extended to client’s who share
information that their partner identifies as dominant or submissive.
The Portrayal of BDSM in Mainstream Society
Many stereotypes about BDSM identified clients are deeply embedded in
mainstream culture. Most mental health professionals have had exposure to a skewed
portrayal of BDSM participants long before meeting their first BDSM client (Bridoux,
2000). Mainstream American culture has a dual relationship with BDSM, both touting it
as trendy and pathological at the same time. Popular images of BDSM promote the
understanding of BDSM through two distinct mechanisms: acceptance via normalization
and understanding via pathology (Weiss, 2007). Kinky images have become trendy,
particularly in the fashion & music industries (Trebay, 2000). Many are designed for
shock factor. By bringing the images forward they normalize them, but do so in a context
that portrays them as edgy, dangerous, behaviors mainly related to freaks & fringe
artistry.
A dentistry scene in the movie and musical, Little Shop of Horrors, signifies how
sadism and masochism has been conceptualized in mainstream society. In the original
1960’s version, the scene begins with a dentist, Dr. Farb enjoying the pain that he is
inflicting on his dentistry clients. The “sadistic dentist” even attempts to remove teeth
against the will of his first patient, Seymour (Corman, 1960). Jack Nicholson plays a
“masochistic” patient who enjoys the pain of a Novocain free dental experience. In this
scene, Dr. Farb appears to become aroused by imposing pain on his first victim, a non-
15
masochistic patient, but when his second patient enjoys the pain, Dr. Farb appears less
interested in drilling. The updated 1986 musical version updates the scene to add extra
symbolism and a more sexual overtone to the interaction (Oz, 1986). The dentist, played
by Steve Martin, is wearing a leather jacket, a symbol often associated with BDSM
subculture (Bienvenu, 1998). In this newer version the masochistic patient, played by Bill
Murray moans and begs for more, erotically grabbing the dentist’s shoulder while his
teeth are being drilled.
This popular culture portrayal of a BDSM encounter includes both excitement
from the infliction of pain and power exchange dynamic roles; doctor and patient.
Unfortunately it still feeds in to the assumption that sadist-masochist interactions must
have a nonconsensual facet to it. In this case, it is the sadist who is angered by the
masochist. Toward the end of the interaction the masochist enthusiastically screams
“Thank you doctor” to which the sadist replies disgustedly “Get out!”
Margot Weiss (2006) noted that the release of the film Secretary (Shainberg,
2002) represented another shift in how mainstream audiences perceive BDSM sexuality.
In Secretary, the main characters engage in a relationship that includes spanking, bondage
and power exchange. It ends with the male Dominant and female submissive living
happily ever after in a monogamous, married relationship. Paradoxically, this movie also
begins by portraying the female submissive character as a patient in a mental institution
and the male dominant displaying obsessive-compulsive behaviors. The movie
normalizes BDSM by showing how kinky couples are capable of having loving,
connected relationships but also continued to pathologize BDSM practitioners by
insinuating that BDSM is better than the maladaptive behaviors the couple began with.
16
The couple is saved from their individual pathologies by finding BDSM together. This
perpetuates the stigmatizing belief that BDSM practitioners suffer from mental disorders.
BDSM Subculture
Researchers are beginning to examine sadomasochism as a social phenomenon
that is dependant on its cultural context for meaning (Baumeister, 1988). In the 1970’s
both gay and straight BDSM clubs and organizations emerged as a safer social
environment where those who shared common interests could meet (Bienvenu, 1998).
Within a community context, BDSM participants can learn the norms of the subculture
including safer sex practices and risk management. It also serves to reduce stigma and
shame through a shared, normalizing experience.
The BDSM subculture, just like many other cultures, has its own unique language
to express roles, desires, needs & behaviors. There are two popular acronyms for risk
reduction within the BDSM community; SSC (safe, sane, consensual) and RACK (riskaware, consensual kink). A widely distributed essay by Gary Switch (2001) suggests that
“ ‘Risk-aware’ means that both parties to a negotiation have studied the proposed
activities, are informed about the risks involved, and agree how they intend to handle
them; Hence ‘risk-aware’ instead of ‘safe’ ”. This shift in language demonstrates the
dedication within the BDSM community to keeping its members safe from harm and
illustrates the complexities within the subculture.
As with most cultures, BDSM has several subgroups with different normative
ideas. It is dangerous to assume that a client who identified as having BDSM fantasies or
behaviors will categorize themselves in the same way as any other client. Some
participants do not identify their behaviors as BDSM related at all, while others will only
17
relate to specific subgroups. Occasionally, one group will denigrate another to mitigate
the stigmatizing effects caused by how mainstream society views their own group’s
behaviors. Rebecca Plante (2006) discovered that at an east coast spanking party,
sadomasochism was considered “where the weirdos go” while heterosexual spanking was
considered socially acceptable. It seems likely that this is a byproduct of internalized
social stigma.
Historical & Psychological Stigmatization of BDSM activities
Many anthropologists believe that BDSM is embedded in our culture along with
other ideas about aggression and dominant-submissive relationships (Gebhard, 1968).
BDSM dynamics seem to primarily exist in cultures with social complexity and have
been found throughout history. Images of flogging, sexual slavery & power exchange
relationships have existed for centuries. The Kama Sutra, written in the 4th century BC,
includes a chapter on “Blows and Sighs” (Danielou, 1993) that details unrestrained,
aggressive erotic slapping, pinching, biting. In this section it is noted how blows, which
are usually hostile acts, can enhance pleasure.
The term sadomasochism did not exist until Krafft-Ebing’s release of
Psychopathia Sexualis(1882). Krafft-Ebing assumed that all sexuality that was not
directly related to procreation was deviant. Krafft-Ebing saw women as basically sexually
passive, and recorded no female sadists or fetishists in his case studies.
Healthy sexuality was defined only in terms of procreation so female masochists who
were engaging in sexual masochism that may result in pregnancy was not considered a
perversion. These ideas marginalized anyone involved in sexual behavior that deviated
from the heterosexual norm, including gays and lesbians.
18
The birth of psychoanalysis continued to paint BDSM behaviors as the “most
significant of all perversions” (Freud, [1905] 1956). Freud conceptualized sadism and
masochism as two forms of the same perversion. He viewed sadism as “an aggressive
component of the sexual instinct that has become independent and exaggerated and has
been brought to the foreground by displacement” (Freud, [1905], 1956).Freud viewed
masochism as a passive form of sadism that always existed simultaneously alongside
sadism in a single person. He believed that all people involved in BDSM could both find
pleasure in both giving and receiving pain.
In 1952, the Diagnostics and Statistics Manual of Mental Disorders (DSM) was
created as an attempt to make statistics gathering at psychiatric hospitals more uniform
(Grob, 1991). The first edition was short and based upon the psychodynamic psychiatry
that was accepted during that time period. It has changed along with the accepted models
of each era with the most current edition embracing a more bio-medical model of
psychopathology (Wilson, 1993). The DSM revision process now includes many panels,
supervisors and workgroups who are instructed to make changes conservatively
(Schaffer, 1996). The process has been criticized by many for being a political process
that marginalizes groups who do not have the social, financial or political power to
motivate a critical look at diagnostic criteria (Spitzer, 1981 & Caplan, 2004).
As groups gain more social and political power, their voices are more likely to be
found in the language of the DSM (Cooper, 2004) The removal of homosexuality from
the DSM is a clear example of this process (Bayer, 1981). The data reporting the removal
of homosexuality from the list of disorders was limited, but the data supporting its initial
inclusion was even less thorough. The American Psychiatric Association has been
19
similarly criticized for choosing pathology based upon social norms rather than scientific
research in the inclusion of paraphilic disorders in the DSM (Moser, 2001). Many sexual
behaviors that have been classified as pathological in nature, including consensual sadism
and masochism, have not had enough political support for a critical look at how
pathology is determined (Moser, 2003).
Despite the lack of political support for removal of Sadism and Masochism from
the DSM altogether, the most recent revision of their diagnostic manual, the DSM-IV
(American Psychiatric Association, 2000) acknowledges that nonstandard sexual
fantasies and behaviors are not always pathological and added caveats that for a sexual
behavior to qualify as a disorder it must involve clinical distress or nonconsensual
partners.
The question of clinical distress can be a troublesome diagnostic criterion for the
mental health community. A responsible health provider must understand the social
context of BDSM in order to differentiate between socially imposed stressors and
clinically significant distress. It is difficult to differentiate between social stress and
clinical distress without having an education in the stigma and social pressures that
BDSM practitioners face. In fact, even with that information it can be hard to
differentiate between internalized social stigma & true clinical distress.
Sexual minority status increases risk for stress related to teasing, discrimination,
violence & social exclusion related to the stigma connected to their status (DiPlacido,
1998). It is important that the mental health community be aware of the stigma attached
to sexual minority status and address social concerns without imposing their own social
judgment onto their clients. Most BDSM practitioners are perfectly happy with their
20
sexual preferences overall with the social stigma attached to these acts being their main
source of distress (Spengler, 1977).
A Sexual Satisfaction Model of Dysfunction
The DSM’s criterion alone does not prepare a clinician to determine dysfunctional
sexuality from healthy, alternative expressions. A second model of analyzing whether an
individual’s participation in BDSM is dysfunctional is the cure-response pattern model of
sexual arousal (Suppe, 1985). According to Suppe’s model, cues for sexual arousal are
either inhibitory (get in the way of arousal), facilitative (enhance but are not necessary for
arousal), stimulatory (are required for arousal), or non facilitative (do not affect sexual
arousal).
Using this model, BDSM behavior is only a problem if it is the only way for an
individual to get sexually aroused and satisfied. Most BDSM practitioners engage in
many forms of sexuality and can become aroused without BDSM cues. Current literature
suggests that less than 5% of BDSM practitioners are involved in purely BDSM sexuality
(Sandnappa, Santtila, Alison & Nordling, 2002). Following this percentage and the Suppe
model, only one in twenty of all those who engage in BDSM behaviors would meet
criteria for a disorder.
BDSM versus Domestic Violence
Another common misconception is that BDSM is an excuse for domestic violence
perpetrators to be abusive. BDSM does not include violence or non consensual acts
(Kleinplatz & Moser, 2006a). Despite this fact, BDSM participants are at the same risk
as the general population to become involved in abusive relationships. Abusers may
attempt to disguise their abuse through humiliation/degradation play scenarios and mind
21
games (Thomsen, 2002). Abuse in BDSM play differs from consensual activities in that
participants become unable to differentiate their own limits. Lower levels of sexual
satisfaction and self esteem often result from their interactions. Some BDSM activities
may appear abusive to outsiders but are in fact consensually negotiated and enjoyed by
participants. Positive BDSM activities can lead to increased self-esteem and self-respect
(Maltz, 1991) while abusive encounters usually do not.
BDSM and Healing
Some participants find BDSM activities to be an empowering, erotic exploration
that resolves emotional or physical pain from childhood abuse, physical disability and
illness. While trauma is no more common in BDSM participants than in the general
population, erotic encounters often can lead to “transformative intrapsychic, spiritual and
interpersonal growth” (Schnarch, 1991). In this way, healing may occur via corrective
emotional experiences that transform and reintegrate a participant’s relationship with the
past (Kleinplatz, 2001).
This should not be surprising since clinical work with survivors of child sexual
abuse (Courtois, 1993) suggests techniques paralleling those described by observers and
practitioners of BDSM play (Brame, Brame, & Jacobs, 1993; Scott, 1998). Adult
survivors of childhood sexual abuse have difficulty trusting others and often have a great
need to be in control (Cortois 1988). The consensual exploration of trust and control are
two integral elements of most BDSM play that allow participants to discover sexuality in
an environment that may feel safer to them. It allows participants to consensually
redefine past and present trauma through new, positive experiences (Haines, 1999).
22
BDSM play provides a structure in which the participants can experiment with
sexual activities and emotional intimacy within specific boundaries to overcome
inhibitions that have evolved from part interactions (Thomson, 2002). This may allow
them to achieve emotional and sexual communication in ways that they had not been
previously able to obtain. BDSM may also be empowering for people with physical
disabilities and ongoing medical pain but allowing them to play with pleasure and pain on
their own terms (Reynolds, 2007).
BDSM in the Therapy Room
Ever since the early pathologization of sadism and masochism by Sigmund Freud
([1905] 1953) those who participate in alternative sexual activities have been stigmatized
as mentally ill by psychotherapists. Some psychoanalysts have conceptualized BDSM
behaviors as an infantile form of sexuality in which the sadist or masochist both fears and
craves merging with a partner (Avery, 1977; Kernberg, 1988; Gagnier & Robertiello,
1993). These analysts assume that the patient’s relationships are compulsive addictions
founded on the subjugation of the self. They propose that alternative sexual desires need
to be eradicated by creating a self identity for the person that does not include BDSM.
One recent study suggested that sadomasochistic dynamics “function like brainwashing
to oppress women in a subordinate position” (Southern, 2002) and recommended
reprogramming treatments for BDSM therapy clients.
Reprogramming therapies for sexual minority clients were common up until
twenty years ago but are now considered a breach of ethics (Brown, 1996). Research has
shown that these therapies are ineffective, stigmatizing and unethical (Haldeman, 1994).
Despite this knowledge, it is common to hear personal stories about encounters with
23
therapists who have required that clients abstain from all BDSM activities if they are to
continue in therapy.
Some modern psychoanalytic theories embrace BDSM as developmentally
healthy for some clients. Michael Bader (1993) argues that BDSM fantasy and
enactments can help patients understand that others can handle the full expression of their
sexuality. Other psychoanalysts have embraced BDSM as a way to replay childhood
trauma in a way that gives the patient control of their sexuality and reclaims their
sexuality (Dillon-West, 1997).
Several theorists have built their view of BDSM upon Jung’s concept of the
shadow, in which the darker side of human behavior is seen as an essential part of the
psyche (Cowan, 1982). Embracing the shadow is not seen as pathological but instead is
viewed as providing a fuller sense of self knowledge and acceptance (Jung, 1971). To
embrace the shadow side is to embrace all that is human, including the hidden aspects
(Hayden, 2002a). Therapists who follow this theory believe that BDSM is a healthy way
to explore the human potential and get in touch with deep, elemental areas of their psyche
(Hayden, 2002b).
It is clear that BDSM and psychotherapy have had a mixed relationship
throughout history. Mental health professionals have received many messages about the
meaning of BDSM behaviors that are based primarily on case study assumptions and
unsubstantiated theories. With this historical background it is easy to see how biases and
hypotheses about the origin of BDSM behaviors could pollute the practitioner-client
relationship in therapy.
24
There are great lessons to be learned about the human erotic potential from clients
if we embrace the sexual diversity that our clients express rather than immediately
pathologizing activities that do not match our own sexual scripts (Kleinplatz, 2001).
Rather than discouraging a client’s BDSM activities, BDSM aware therapists often use
the data to inform them about the intricacies of their client’s cultural, social and sexual
life.
It is important that therapists who work with BDSM clients provide a culturally
sensitive environment for their clients and be aware of their own biases, values and
limitations (Moser, 1999). In order to best meet the needs of their clients, therapists must
examine their own biases toward BDSM and refer out appropriate resources if they are
unable to provide appropriate care.
Dual Relationships with BDSM identified therapists
In small communities and subcultures, it is common for therapists to be faced
with unique boundary issues; they often must live, work and socialize within the same
limited social group. This is particularly true for mental health practitioners who work
and live in rural areas or are members of minority groups who prefer working with
therapists from their own subculture (Zur, 2005).
Although BDSM identified clients may feel more comfortable working with a
therapist who is a member of their same sub-culture, there are specific dangers of being a
therapist socializing and working within the same community. For therapists who engage
in BDSM relationships, they may be faced with running into their clients at community
events & social parties (Bettinger, 2002). This phenomenon seems similar to the issues
faced by pastoral counselors who often expected to maintain confidentiality with their
25
clients while also interacting with their friends and family during social events and parish
functions (Tieman, 1988).
BDSM oriented therapists also could be stigmatized by their own patients. Some
BDSM clients have expressed concern that therapists who are involved in BDSM
activities may be seeking sexual partners during therapy (Kolmes, Stock & Moser, 2006).
Clients who are particularly distressed may have a hard time recognizing professional
boundaries and it is the clinician’s responsibility to maintain clear guidelines and
treatment goals that are appropriate and beneficial to clients (Craig, 1991).
Mental health practitioners are trained to seek consultation and referrals for cases
involving boundary issues but with a limited number of culturally aware therapists, a
clinician may not have colleagues available for competent consultation (Green & Hanson,
1989). Expanding the network of well-trained mental health practitioners is important for
both the well being of the clients, and the support of therapists working within this
community. These issues highlight the importance of increasing the number of therapists
trained in working with BDSM identified clients both from within the community and
outside it.
Paper One Summary
It is clear that most BDSM activities exist within the continuum of healthy sexual
behavior. While nonconsensual and clinically distressing BDSM encounters may be
pathological in nature, they represent the exception rather than the norm. Clinicians must
be trained in understanding the social context of BDSM, examine their own biases &
have knowledge of culturally appropriate treatment planning to work with BDSM
identified clients.
26
Well-trained clinicians should be able to distinguish between consensual
sadomasochistic behaviors and abuse, acknowledge their own cultural biases for or
against sexual minorities & have a wide gamut of resources for support and referrals.
Clinicians who judge their clients after learning about BDSM behaviors are less likely to
hear about facets of their client’s lives that may be rich with clinical data.
Clients who have felt marginalized by their therapists based upon their BDSM
activities are less likely to share information about their activities openly, which limits
the therapeutic bond and weakens therapy. This means that clients who are both
interested in BDSM and are in an abusive relationship may be less likely to disclose their
concerns to their therapist if abuse does occur.
It is important that BDSM involved clients receive culturally competent care
including acceptance, positive regard & appropriate referrals, even if the therapist does
not understand their client’s sexual desires. BDSM should be viewed as a cultural
phenomenon that may include many different activities, sexual orientations and lifestyles.
Practitioners should be viewed as a sexual minority rather than as pathological deviants.
BDSM participants will most often present in therapy with the same mental health
issues seen in the general population. Culturally competent care with BDSM participants
may closely mirror therapy with other sexual minorities including lesbian, gay, bisexual,
transgender and intersex communities. The issues related to their sexual activities that
may arise include support with confronting social stigma and negotiating boundaries with
new partners (Davison, 1991; Green, 1996). Clinical guidelines for working with sexual
& cultural minorities should be followed until specific BDSM friendly guidelines are
established. Paper two proposes twelve basic guidelines for mental health professionals
27
who are interested in working with BDSM identified clients until formal standards
emerge.
28
PAPER TWO: BDSM in Psychotherapy: A Culturally Aware Curriculum
Introduction
Mental health professionals often look to the American Psychological Association
(APA) for guidelines on ethical treatment of clients in psychotherapy. The APA Ethics
Code (American Psychological Association, 1992a) states that psychologists are expected
to “strive to be aware of their own belief systems, values, needs and limitations and the
effect of these on their work”. It further explains the importance of “psychologists
evaluating their competencies and the limitations of their expertise, especially when
treating groups of people who share distinctive characteristics”.
Multicultural counseling standards are often applied to issues of race and gender,
but culturally sensitive practices should be extended to acknowledge all subcultures
including those who participate in BDSM and other forms of sexuality that are different
from what society might view as the norm. Culture is defined as the belief systems and
value orientations that influence customs, norms, practices and social institutions,
including psychological processes and organizations (Fiske, Kitayama, Markus &
Nisbett, 1998). Culture includes all critical aspects of an individual’s personal identity
and each cultural dimension has unique issues and concerns (American Psychological
Association, 1992b). BDSM activities that are explained as part of an individual’s
identity, whether conceptualized as private interactions between partners or in a larger
social context they are a part of that person’s cultural definition and must be accepted as
such. Guidelines for providing sensitive cultural care must take into consideration the
unique social & psychological aspects of the group being discussed. The twelve
29
guidelines that follow are designed as an introduction to working with BDSM identified
clients. It is intended to be used along side case studies and guest speakers as an
introduction to working with BDSM clients. No one class alone can qualify an individual
to serve as an expert in any population. Instead, competent therapeutic care should be
informed by ongoing education, experts from the subculture and the clients themselves.
12 Guidelines for Psychotherapy with Clients who Engage in BDSM
These guidelines for providing culturally sensitive therapy to BDSM participants
are based upon the format created by the American Psychological Association for
working with lesbian, gay and bisexual clients (American Psychological Association,
2000) and for Multicultural education, training, research, practice & organizational
change for psychologists (1992b).
They are provided as a 12 guideline curriculum, separated into three units that
may be presented as a continuing education course over three hour long sessions or one
three hour session with breaks after each unit. The first unit addresses pathology and
differential diagnosis, the second concerns the social aspects of BDSM while the third
addresses counter transference, consultation and continuing education.
Unit A. Pathology and Differential Diagnosis
When working with stigmatized sexual minorities, differentiating between
pathology and internalized social stigma can be a difficult process (Green, 1996;
Dworkin, 1999). In general, if a client is not experience significant distress, involving
nonconsensual partners or involved in an abusive relationship, the clinician should
assume that their client’s behaviors fall within the normal range of sexual diversity.
30
Guideline 1. Therapists are encouraged to understand that BDSM activities are not
indicative of mental illness.
BDSM activities are often immediately associated with mental illness or
maladjustment (Cross & Matheson, 2006). Despite this assumption, the majority of
people who engage in BDSM behaviors do not qualify for a clinical diagnosis related to
their activities (American Psychiatric Association, 2000). The current standard for
diagnosing mental illness, DSM-IV-TR, states that “sexual sadism/masochism can only
be diagnosed if the sexual fantasies, urges and behaviors persist for at least 6 months and
cause clinically significant distress or impairment in functioning” (American Psychiatric
Association, 1994) The DSM also notes that "a paraphilia must be distinguished from the
non-pathological use of sexual fantasies, behavior or objects as a stimulus for sexual
excitement". Clients who do not fit the diagnostic criteria for psychopathology should be
treated with the same cultural sensitivity due any other sexual minority.
Guideline 2. BDSM aware therapists strive to be knowledgeable about how to
differentiate between consensual BDSM activities and domestic violence.
Although BDSM activities themselves are not evidence of abuse, BDSM
participants are just as susceptible to abusive relationships as any other client. In
consensual BDSM, consent is given freely and activities occur within a negotiated
context. Abuse is either nonconsensual or obtained through coercion that generally
follows a distinct pattern known as the cycle of violence (Walker, 1979). Domestic
violence may be emotional, physical, sexual or financial and is characterized by a
cyclical pattern of making up, calm, escalation and explosive incident. Abuse is
31
characterized by coercion and explosive anger while in BDSM relationships physical
blows are carefully placed, thought out and received as pleasurable.
BDSM advocacy groups are beginning to become active in providing guidelines
for distinguishing consensual activities from abuse (National Leather Association
International, n.d.). Several organizations recently worked together over two consecutive
annual conferences to create a statement formally stating the differences between BDSM
and abuse with a list of specific qualifying questions about the nature of consent (Leather
Leadership Conference, 1999). These guidelines are provided as an attached handout that
can be utilized in therapy with BDSM participants who may be involved in abusive
relationships.
Consensual BDSM activities often leave marks that may appear similar to abuse.
Therapists are trained to recognize bruises and marks on their clients as signs of abuse.
Charles Moser MD, PhD has suggested three key criteria for health professionals to help
distinguishing consensual BDSM markings from domestic violence:
1) BDSM rarely results in facial bruising or marks that are received on the
forearms (defensive marks).
2) Marks obtained during a BDSM scene usually have a pattern and are well
defined, indicating that the submissive partner remained still. In abuse, the
marks are more random and the soft-tissue bruising rarely focused in one area.
3) Common areas for BDSM stimulation are the buttocks, thighs, upper back,
breasts or the genitals. The fleshy parts of the body can be stimulated intensely
and pleasurably. Marks involving the lower back, bony areas, eyes and ears are
unusual (Moser, 2006).
32
Guideline 3. BDSM aware therapists strive to be able to distinguish between clinically
significant distress and socially induced stress related to the BDSM interests.
Most BDSM practitioners are perfectly happy with their sexual preferences with
the social stigma attached to these acts being their main source of sexual distress
(Spengler, 1977). Sexual minorities often suffer from chronic stressors related to fear of
discrimination and rejection by friends, family & society and may internalize these
messages as attitudes toward the self (Meyer, 1995). Repressed sexual desires & distress
over BDSM interests may signify socially imposed, internalized BDSM negativity
(Nichols, 2000) similar to feelings of shame and internalized homophobia sometimes
experienced by gay clients (Nichols, 2006; Falco, 1991). These feelings should be
addressed by the therapist through validation of the distress rather than by attempting to
cure the BDSM desires (Kleinplatz & Moser, 2004).
Guideline 4. Therapists are encouraged not assume that BDSM activities are related to a
client’s presenting problem.
A study of the relationship between mental health issues and BDSM interests
elucidated several key points about how and why BDSM participants disclose their
activities in therapy (Kolmes, Stock & Moser, 2006). The majority of BDSM participants
in therapy did not seek counseling for problems related to their sexuality. Despite this
fact, most participants shared their BDSM interests with their therapist within the first
few sessions explaining that it was a way to gauge how comfortable they would feel
receiving treatment. Therapists who assume that BDSM disclosure is automatically
33
related to the presenting problem may inadvertently lose their client’s trust which can
lead to early termination or future withholding of valuable clinical information.
Guideline 5. Therapists are encouraged not make assumptions about their client’s goals
in therapy based upon their participation in BDSM activities.
Psychotherapy has a long history of treating BDSM desires as pathology to be
cured. In a study of BDSM participants in long term, heterosexual relationships all
subjects reported that they were happy with their BDSM orientation, believed that their
orientation was not changeable (Cutler, 2003). The area of their lives where they were
seeking change was integration of their BDSM activities into daily living. BDSM clients
present in therapy for the same reasons as other clients, depression, anxiety, life
transitions. BDSM clients also may seek therapy to discuss stressors related to “coming
out” including internalized shame and relationship conflicts with existing partners
(Nichols, 2006).
Unit B. Social Aspects of BDSM.
Therapists are encouraged to strive to understand the impact of social interactions
on the lives of their clients. BDSM relationships range from short term interactions to
long term, life time commitments. It is important to allow the client to use his or her own
terminology to describe partnerships and the roles that these relationships play.
Guideline 6. Therapists are encouraged to seek knowledge about the importance of
BDSM relationships in their client’s lives.
BDSM relationships exist along the same continuum as other sexual relationships.
Some BDSM identified individuals engage in masturbatory fantasies only while others
take part in group sex, monogamous sex or non sexual exploration of BDSM sensations.
34
Some limit their power exchange relationships to sexual encounters while others live in
relationships with a full time, consensual power dynamic where one partner creates and
maintains rules and boundaries for the family. For example, a submissive partner may
require permission from a dominant partner before going out with friends. These roles
may seem foreign or abusive to therapists who have not been trained in alternative
expressions of eroticism (Williams, 2006).
Therapists should also be aware of issues of “bleed through” (Nichols, 2006),
where boundaries between roles in the bedroom and roles in the rest of the relationship
blur. These issues may cause relationship distress that involves therapeutic interventions
that address issues within the couple itself that may have little do with their sexuality
itself but manifest in role confusion and blurred boundaries.
Relationship dynamics should be examined using a culturally appropriate lens. If
there is no coercion or abuse apparent, these dynamics should be respected and honored
as part of a valid lifestyle. Embracing a client’s sexual orientation and lifestyle choices
will help establish a therapeutic setting where clients are more likely to disclose
information about all aspects of their life, not just the ones that he or she believes are in
tune with the therapist’s cultural values.
Bert Cutler interviewed heterosexual BDSM partners and found several key
relationship values that appeared frequently including: a belief that dominance and
submission are directly related to close intimacy, a high value placed on communication
and full disclosure within the couple, pride at being able to read their partner and explore
needs until both parties needs have been met and pride in both the dynamics of the
35
relationship and their specific partners. The dominant and submissive roles were both
talked about with equal reverence and without denigration (Cutler, 2003).
Guideline 7. BDSM aware therapists strive to recognize the particular life issues of their
BDSM clients that are related to conflicting cultural norms, values and beliefs.
Conflicting identities can often cause distress for BDSM oriented clients. Societal
messages about power, pain, sex, & relationship dynamics can overlap in a myriad of
ways. Peggy Kleinplatz (2006) describes a couple in sex therapy who was experiencing
shame and guilt about their BDSM desires. The male partner identified as “pro-feminist”
and felt that his dominant desires conflicted with that identity. After exploring his
aggression and thoughts about consensual exchange of power in therapy, the erectile
dysfunction that he initially presented with disappeared. Exploring consensual BDSM
and being comfortable with their fantasies became a life affirming experience.
Guideline 8. BDSM aware therapists strive to understand the ways in which social
stigmatization may pose risks to the mental health of their clients who engage in BDSM
activities.
A list compiled by Margaret Nichols (2006) illustrates some of the most common
misconceptions about BDSM. Summarized briefly, these misconceptions include: 1)
BDSM is mostly about the dominant partner getting his/her way with a passive exploited
submissive 2) BDSM is about physical pain 3) BDSM activities inevitably escalate to
extremes and addictions 4) BDSM is self-destructive 5) BDSM stems from childhood
abuse & 7) BDSM activities are not compatible with traditional sexual activities.
Unit C. Continuing Education.
Mental health practitioners are encouraged to seek out an education in culturally
36
appropriate care before working with any sexual minority (Morrow, 1999), including
BDSM identified clients. This includes education on BDSM culture, history, social
stigma, differential diagnosis, abuse & common client issues.
Guideline 9. Therapists are encouraged to explore their own counter transference,
attitudes and knowledge about BDSM issues and examine how they may affect therapy.
It is important that therapists confront and evaluate their own judgments, feelings
and reactions to BDSM activity before attempting to do therapy with BDSM identified
clients. Common counter transference feelings described by therapists who have little
experience with BDSM include shock, fear, anxiety, disgust, and revulsion (Nichols,
2006). Without proper education, it is easy for these feelings to transfer into a deeply felt
conviction that the client’s behaviors are self-destructive. If a therapist finds his or herself
feeling these deeply held beliefs in the absence of concrete evidence that the client is
being harmed, counter-transference is likely at the root.
Even therapists with the best intention of neutrality are influenced by their own
values and biases (Lopez, 1989; Murray & Abramson, 1983). Kolmes, Stock and Moser
(2006) identified several major categories in which BDSM clients have identified
receiving inappropriate care. These include assuming that BDSM is unhealthy, requiring
clients to give up their BDSM activities to remain in treatment, confusing BDSM with
abuse, assuming that BDSM interests indicate past abuse & misrepresenting their level of
expertise on BDSM issues.
Guideline 10. Therapists are encouraged to make reasonable efforts to encourage safe
disclosure about BDSM interests by creating a therapeutic environment that embraces
alternate sexualities.
37
In a recent study of BDSM clients in therapy, more than half of the participants
had shared their BDSM interests with their therapist, with most doing so within the first
few visits to assess whether they would feel comfortable in treatment (Kolmes, Stock, &
Moser, 2006). Creating an embracing environment may further facilitate client disclosure
and deepen the therapeutic bond.
Often, clients can sense judgment within the first few moments of a clinical
interview. Charles Moser’s book, Healthcare without shame (1999), suggests providing
kink-friendly literature in waiting rooms and reframing questions on intake forms to
create a supportive environment for those with alternative sexualities. Slight alterations in
language can have a great impact on therapeutic bonds. For example, Moser notes that
the question “Who beat you up?” may be less fruitful than “How did you get those welts/
bruises?”
Kolmes, Stock and Moser (2006) compiled a list of what psychotherapy practices
clients consider most useful to them. Themes included asking questions about BDSM,
helping clients overcome shame & stigma, open-mindedness & acceptance, not expecting
the client to do all of the educating about BDSM, understanding the difference between
BDSM & abuse, being involved and identifying with the BDSM lifestyle & the ability to
appreciate the complexities of BDSM and its negative & positive effects on people’s
lives.
Guideline 11. Therapists are encouraged to seek consultation and refer out if they are
uncomfortable, unprepared or unwilling to accept their clients BDSM involvement.
The American Psychological Association’s Ethics Code for Psychologists states
that “Psychologists must only provide services that are within the boundaries of their
38
competence, based on their education, training, supervised experience, consultation,
study or professional experience (American Psychological Association, 2002). Therapists
who practice outside of their scope of knowledge should not be providing therapy on
issues that they are not properly trained for. BDSM clients most often present in therapy
with issues unrelated to their sexual activities. For these issues, therapists with a general
understanding level are within their scope of practice but unless they are aware of and are
actively able to confront their own counter transference issues, the therapist should refer
out to a more appropriate mental health provider.
Just as being in a relationship isn’t adequate training to be a marriage therapist,
having an interest in BDSM alone is not enough to qualify an individual in working with
BDSM issues & clients (Kolmes, Stock, & Moser, 2006). Therapists should have
coursework, supervision and specialty training related to BDSM clients before attempting
to specialize in these issues therapeutically. It is important that therapists seek out
properly trained professionals for consultation and referral when their level of expertise
in the subject doesn’t match the needs of their clients.
Guideline 12. Therapists are encouraged to increase their knowledge and understanding
of BDSM through continuing education, training, supervision and consultation. This
including keeping a list of up to date relevant mental health, educational and community
resources for BDSM clients.
Mental health professionals seeking to work with BDSM identified should seek
out training in BDSM issues from professional organizations like the American
Association of Sexuality Educators, Counselors & Therapists (2007) and consult lists
such as “Kink-Aware professionals” (National Coalition for Sexual Freedom, 2006a) to
39
increase their knowledge of BDSM topics and specialists working within the field. Until
formal guidelines for working with BDSM identified clients emerge, therapists must rely
on professionals who self-identify as specialists in the field (National Coalition for
Sexual Freedom, 2006b.) It is up to each individual therapist to inquire about the training
that their referral sources have obtained and to make educated decisions about where
clients should be referred.
Paper Two Summary
Therapists who may come in contact with BDSM identified clients should have
training in the unique issues that pertain to this group of individuals. BDSM clients
should be viewed as a cultural group and multicultural counseling skills should be used to
reduce the likelihood of perpetuating stigmatizing assumptions and ideas about this
population. Exploring issues of counter-transference and bias should also be an ongoing
part of the therapists work with all sexual minority clients.
The twelve guidelines presented in this paper serve as a guideline that may be
used as a continuing education class for mental health professionals and can be consulted
as one tool in working with the BDSM population. It is important that mental health
professionals maintain a list of educational resources and referrals for their BDSM
identified clients. Clinical research should be expanded to explore BDSM clients in
therapy in depth and formal clinical guidelines should be outlined by professional
organizations.
40
APPENDICES
41
Appendix A
Handouts
12 Guidelines for Psychotherapy with clients who engage in BDSM activities
Unit A. Pathology & Diagnosis
Guideline 1. Therapists are encouraged to understand that BDSM activities are not
indicative of mental illness.
Guideline 2. BDSM aware therapists strive to be knowledgeable about how to
differentiate between consensual BDSM activities and domestic violence.
Guideline 3. BDSM aware therapists strive to distinguish between clinically significant
distress and socially induced stress related to the BDSM interests.
Guideline 4. Therapists are encouraged not assume that BDSM activities are related to a
client’s presenting problem.
Guideline 5. Therapists are encouraged not make assumptions about their client’s goals
in therapy based upon their participation in BDSM activities.
Unit B. Social Factors
Guideline 6. Therapists are encouraged to seek knowledge about the importance of
BDSM relationships in their client’s lives.
Guideline 7. BDSM aware therapists strive to recognize the particular life issues of their
BDSM clients that are related to conflicting cultural norms, values and beliefs.
Guideline 8. BDSM aware therapists strive to understand the ways in which social
stigmatization may pose risks to the mental health of their clients who engage in BDSM
activities.
Unit C. Continuing Education
Guideline 9. Therapists are encouraged to explore their own counter transference,
attitudes and knowledge about BDSM issues and examine how they may affect therapy.
Guideline 10. Therapists are encouraged to make reasonable efforts to encourage safe
disclosure about BDSM interests by creating a therapeutic environment that embraces
alternate sexualities.
Guideline 11. Therapists are encouraged to seek consultation and refer out if they are
uncomfortable, unprepared or unwilling to accept their clients BDSM involvement.
42
Guideline 12. Therapists are encouraged to increase their knowledge and understanding
of BDSM through continuing education, training, supervision and consultation. This
including keeping a list of up to date relevant mental health, educational and community
resources for BDSM clients.
43
Appendix B
Recommended Reading List
Brame, G., Brame, W., & Jacobs, J. (1993). Different loving: The world of sexual
dominance and submission. New York: Villard.
Easton, D. & Liszt, C. (2000). When someone you love is kinky. Oakland: Greenery.
Henkin, W. & Holiday, S. (1996). Consensual Sadomasochism: How to talk about it and
how to do it safely. Columbia: Daedalus
Kleinplatz, P. J. & Moser, C. (Eds.). Sadomasochism: Powerful pleasures. New York:
Harrington Park.
Moser, C. (1999). Health care without shame: A handbook for the sexually diverse and
their caregivers. Oakland: Greenery.
Wiseman, J. (1996). SM 101: A realistic introduction. Oakland: Greenery.
44
Appendix C
Guidelines on SM vs. Abuse from the Leather Leadership Conference III
http://www.leatherleadership.org/library/diffsmabuse.htm
Consent must be judged by balancing the following criteria for each encounter at the time
the acts occurred:
a) Was consent expressly denied or withdrawn?
b) Were there factors that negated the consent?
c) What is the relationship of the participants?
d) What was the nature of the activity?
e) What was the intent of the accused abuser?
Whether an individual’s SM role is top/dominant or bottom/submissive, they could be
suffering abuse if they answer no to any of the following questions:
1. Are your needs and limits respected?
2. Is your relationship built on honesty, trust, and respect?
3. Are you able to express feelings of guilt or jealousy or unhappiness?
4. Can you function in everyday life?
5. Can you refuse to do illegal activities?
6. Can you insist on safe sex practices?
7. Does the relationship interfere with your interaction with family and friends?
8. Can you leave the situation without fearing that you will be harmed, or fearing the
other participant(s) will harm themselves?
9. Can you exercise self-determination with money, employment, and life decisions?
10. Do you feel free to discuss your practices and feelings with anyone you choose?
45
Appendix D
When to intervene
Excerpt from
Demystifying alternative sexual behaviors by Charles Moser, Md., Ph.D.
Full Article Available online
http://www.srmjournal.org/article/PIIS1546250106000260/fulltext
Physicians are often concerned that a patient may be involved in an abusive
relationship. In a BDSM relationship, where the results of the behavior may appear
similar to abuse, it is easy to confuse a loving consensual BDSM relationship with an
abusive one. Just because patients inform you that they are in a BDSM relationship does
not mean that it is not an abusive relationship as well. Just because patients deny
participating in a BDSM relationship does not mean they were abused. Some of the
physical differences are:
1) BDSM rarely results in facial bruising or marks that are received on the forearms
(defensive marks).
2) Marks obtained during a BDSM scene usually have a pattern and are well defined,
indicating that the submissive partner remained still. In abuse, the marks are more
random and the soft-tissue bruising rarely focused in one area.
3) Common areas for BDSM stimulation are the buttocks, thighs, upper back, breasts or
the genitals. The fleshy parts of the body can be stimulated intensely and pleasurably.
Marks involving the lower back, bony areas, eyes and ears are unusual.
46
References
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