(Adapted from an essay originally published February 2023.)

Surprise! Kink is hardly the secret it used to be! What was once taboo has increasingly entered the mainstream through depictions in popular media and the advent of the internet age, where nothing is truly off-limits or inaccessible. Though more openly discussed and more visible now than ever before, kink and its participants remain misunderstood by laypeople and professionals alike. Whether cast inaccurately as freaks, social pariahs, or psychosexual oddities, the stigma faced by kink practitioners pervades so many aspects of therapy treatment. In striving to provide consistently ethical and high-quality care to all clients, it is no longer a choice for mental health professionals working in the field of sexuality to ignore this growing population in favor of enforcing a restricted model of what constitutes “normal” and “acceptable” sexual activity. A more informed, expansive, and affirming approach is necessary for truly holistic treatment.

Defining kink: What is it and who does it?

There is no one true definition for kink, as it is difficult to describe any complex human experience fully in a single string of words. That said, kink is an umbrella term often used to describe “sexually diverse preferences or consensual sexual practices that fall outside the mainstream” (Nevard, 2021). It is frequently used interchangeably with the acronym BDSM, a collective term that includes sexual behaviors of bondage and discipline (BD), dominance and submission(D/s), and sadism and masochism (SM), though an individual need not participate in every single one of these activities to be considered “kinky” (Pillar-Friedman et al, 2015). What unites behaviors generally labeled as “kinky” is a combination of a sensuous attitude towards pain or otherwise intense sensations, arousal and gratification connected to particular erotic objects (fetishes), and/or the incorporation of power dynamics within the sexual relationship (Sprott & Hadcock, 2018). While many identities and interests exist on the spectrum of kink, healthy practice features consensual agreement to enter into the interaction, a mutual definition between participants of what activities constitute the kink element of the interaction, and those activities occurring in a sexual context, though not always explicitly during sexual intercourse (Pillar-Friedman et al., 2015).  

Though often presented in popular culture as niche practice, studies performed over the past several decades by pioneering sexologists including Kinsey, Janus & Janus, Masters & Johnson, and others indicate that anywhere from 25 to 60% of individuals in the United States and Canada have experienced fantasies involving elements of kink, and up to 15% of the population have actually enacted kink in their sexual behaviors (Sprott & Hadcock, 2018). While kink itself describes a broad set of behaviors, it also describes the plethora of sexual identities built around communities that participate in shared kink behaviors. It is estimated that up to 2% of people in the US present open affiliation with kink-based sexual identities (Sprott & Hadcock, 2018).

It’s important to distinguish that not all people who practice kink necessarily adopt a kink-centric identity (Kink Clinical Practice Guidelines Project, 2019). Furthermore, the intersections of kink and other facets of identity are important to consider; the diverse identities of individuals practicing kink serve to inform the ways in which they understand, negotiate, and express their kink identity. Power dynamics in kink become all the more significant when considered through the lens of minority groups, especially in context of the experiences of ethnic minorities who are subject to structural imbalances of power in society at large (Nevard, 2021). The practice of kink is not limited to any one sexual orientation or gender identity, though “there is an over-representation of queer identities as compared to the general population” in many studies (Nevard, 2021). 

Myths and history: What has psychology had to say about kink?

Kink has long carried the connotation of deviant behavior, but it has been especially pathologized and maligned by institutions of law, medicine, and media (Pillai-Friedman et al., 2015). Despite indications that kink-participants are no more likely that non-participants to report high psychological distress or to be experiencing sexual difficulties, practitioners of kink —for much of the history of formal therapeutic practice—have been regularly misdiagnosed as having a mental disorder (Wright, 2010).

So, let’s talk DSM! There’s a lot to be said about it, and here’s a great article that discusses its limitations in depth. However, it is still the primary diagnostic manual most mental health practitioners use in the United States. To know where we are now, it helps to know how we got here. While by no means an exhaustive history, there’s some important context worth knowing. This next section gets a little crunchy, but bear with me.

In the first edition of the DSM, the term "sexual deviation" was used to describe a wide variety of sexual behaviors which were culturally unacceptable at the time—including not only fetishism and sexual sadism, but homosexuality as well (Shorter, 2014). Kink continued to be classified by mental health authorities as essentially indistinguishable from sexual assault and other criminal abuses until the DSM-III, which introduced the term "paraphilias" to describe uncommon sexual interests separate from abusive behavior; it retained, however, the persistent puritanical attitude towards what constitutes acceptable sexual behavior (Wright, 2010). The DSM-5 brought the most significant changes in that harmless paraphilias are now distinguished from paraphilic disorders by way of distinct criteria (First, 2014). Focus has shifted to a distress-based model; for a diagnosis of a paraphilic disorder, the sexual behavior must be the cause of clinically significant distress or impairment in the individual’s social, relational, and/or occupational life (Wright, 2010). The rest, in the view of the American Psychological Association, does not constitute a problem requiring fixing. Well, that’s an improvement!

Despite these apparent advancements in clinical perspective, several persistent myths continue to fuel the pathologization of kink behaviors. One particularly damaging assumption relates an interest in kink to sexual abuse and coercion experiences in childhood. Research literature demonstrates that there is little to no correlation between childhood abuse and adult engagement in kink (Sprott & Hadcock, 2018). Another common myth is that kink-practicing people are inclined towards or possess acute personality disorders. Studies utilizing prominent personality inventories—the MMPI-2, BAI, MCMI-II, and other—found that most kink-practitioners fall within normative ranges and featured no prominent psychopathology (Kink Clinical Practice Guidelines Project, 2019). Kink is also thought to be indicative of especially stunted emotional maturity and a method of avoiding intimacy, but here too there are no apparent differences in psychological functioning or attachment styles between kink-practicing people as compared to non-kinky people (Sprott & Hadcock, 2018). Beyond diagnostic impressions, a sociological assumption is the belief that kink-practicing people are inherently cultural outsiders poorly integrated into–even dangerous to—society. On the contrary, kink-practicing people occupy all walks of life; many attain high levels of education, prominently work in white-collar occupations, and participate in community service; they are socially well-functioning and generally indistinguishable in daily life from non-kinky people (Pillai-Friedman, 2015). The average kink-interested person is not the monstrous or diseased caricature so often presented by medical, social, and psychological literature, and yet these pervasive myths continue to do damage to the people of this population.  

Stigma and shame: How is the therapy relationship impacted?

The fear of social stigma surrounding disclosing kink affiliation is a powerful one, and this unfortunately extends into the therapeutic context. The pathologization of kink has led to discrimination against kink-practicing individuals, discouraging them from seeking treatment for mental health problems regardless of whether they are related to their kink identity or not (Wright, 2010). It is estimated that approximately 25 to 30% of individuals who engage in kink may never tell their therapist about their sexual practices even when clinically relevant to their current course of treatment (Sprott et al., 2017). Across multiple studies, participants identified multiple categories of concerns related to pathologization and bias resulting in misdiagnosis and inadequate care. Individuals expressed fears that their interest in kink would be misattributed as resulting from abuse per common myth and that what they view as a positive aspect of their sexual experience would be treated as a maladaptive and harmful symptom of mental illness (Nevard, 2021). Another common fear was that their kink behaviors would be interpreted as self-harming if masochistic in nature and abusive if sadistic in nature, leading to unnecessary or punitive reporting of safety concerns, particularly if the therapist lacked understanding of BDSM relationship dynamics of negotiation and risk-aware consent (Sprott & Hadcock, 2018).  

Overt discrimination against kink from therapists is relatively uncommon; one study places the rate of such experiences among therapy-seeking kink participants at a mere 4.5% (Sprott & Hadcock, 2018). However, more subtle and pervasive discrimination emerges from counselors without knowledge of kink misinterpreting behaviors or counselors with unexamined beliefs about kink who are unable to truly bracket their values (Nevard, 2021). It should come as no surprise then that many kink-identified people prefer to be treated by therapists with personal kink experience, a pairing that “has been associated with improved client benefit and satisfaction” (Lawrence & Love-Crowell, 2008). Trust in the community is still tenuous, as some kink practitioners report experiences of therapists misrepresenting or over-estimating their knowledge of kink, resulting in labor on the part of the client to educate them (Pillai-Friedman et al., 2015). Studies do indicate that clients tend to be more comfortable with disclosing kink affiliation in therapy if they are aware that the counselor has received integrated, sex-positive, and culturally-competent training for working with sexually diverse identities (Nevard, 2021).  

Staying ethical: What are our responsibilities as therapists?

We all hold our own beliefs and attitudes when it comes to sex and sexuality. Within kink: experiences, emotions, and behaviors that may be considered undesirable in other contexts become eroticized in a manner which may conflict with the therapist’s values (Wright, 2010). Inexperienced therapists treating clients with kink affiliations may encounter countertransference feelings of “shock, fear, anxiety, disgust, and revulsion” in response to disclosure, which may become intellectualized if unaddressed and lead to beliefs beyond evidence that the client’s kink behaviors are destructive towards self or others (Pillai- Friedman et al., 2015). While countertransference responses may provide valuable clinical information, we hold the responsibility as therapists to differentiate our own issues with the material from our clinical judgement (Kleinplatz & Moser, 2004). We need not impose our beliefs and boundaries onto our clients, not in this respect or in any. The ethical therapist must confront and process not only their value system and subjective biases about kink but also their theoretical beliefs, orientation of practice, and individual biases about their own experiences of sex and sexuality (Lawrence & Love-Crowell, 2008).  

In encountering clients in various stages of interaction with kink, whether that is the newly curious individual or a couple with years of lifestyle experience, the basic responsibility of the therapist is to recognize diversity in desires for sexual experiences and acknowledge this as developmentally normal (Pillai- Friedman et al., 2015). This alone is insufficient to qualify one as a truly kink-aware therapist; acceptance is necessary but not enough to competently navigate kink-specific issues and their interactions with other facets of the client’s life for which they may be coming to therapy. Thus, a necessary piece of ethical practice in this area is the development of clinical knowledge with this population through training, consultation, and experiential education (Kink Clinical Practice Guidelines Project, 2019). The ideal is to seek training which “situates kink holistically within the person’s identity rather than... an issue that the person exhibits” (Nevard, 2021). As clinicians, we must be critically aware of our scope of practice and actively work to increase our competence in order to provide kink-practicing clients care which meets the standards of our profession. 

Ground rules: How does one work with kinky clients?

While it would be difficult to provide a complete and infallible guide to every possible encounter with kink that a clinician may have in the course of providing therapy, there are several areas of consideration which form the foundations of constructive practice, ethical responsibility, and critical basic knowledge. The chief reason for the inability to fully encompass all clinical scenarios is also the most important element of understanding kink for a clinician to cultivate: kink is not a monolith. Rather, it is unique to the individual and directly informed by a reciprocal relationship with multiple facets of identity (Sprott et al., 2017). Kink encompasses a broad demographic of people, thus it is important to be attuned to how gender, sexuality, age, ethnicity, nationality, culture, generation, and class shape an individual’s interests and experiences within the realm of kink (Kink Clinical Practice Guidelines Project, 2019). Having an awareness of the psychological dynamics of disclosing hidden identity is valuable, particularly in such cases where kink identity intersects with LGBTQIA+ identities (Sprott & Hadcock, 2018).  

Clinicians must be aware that the ways kink and its interactions with other marginalized identities have been stigmatized and discriminated against do have impact on the lives of our clients. Internalizations of distress related to discrimination may manifest as pathology, and it is the responsibility of the therapist to understand dysfunctions within this context and validate minority distress (Kleinplatz & Moser, 2004). Concurrent with the expectation that a kink-aware therapist not immediately jump to pathologize kink behaviors as mental illness or a trauma response, the therapist should not assume that kink is the reason a person is coming to therapy or that the individual is seeking to change their sexual interests (Sprott & Hadcock, 2018). While kink may provide context, it may not be the content of the presenting problem. It is not our role to assume a client’s goals of treatment, nor is it our purpose to impose particular models of “what constitutes normal sexuality” upon them in misguided attempts to cure what need not be fixed (Kleinplatz & Moser, 2004). Attempts to perform therapy that eradicates kink desires or otherwise converts a person’s sexual interests against the will of the individual are considered grossly unethical (Kink Clinical Practice Guideline Project, 2019). 

The position of the kink-aware therapist is to normalize and empower clients in their identities and interests, and it should not be assumed that an individual’s involvement in kink is having a negative impact on their life and relationships (Sprott et al., 2017). Participating in kink can be life-affirming, sexually healing or entertaining, promote transformative growth, and encourage creativity, conscious engagement in relationships, and increased self-actualization (Kink Clinical Practice Guideline Project, 2019). Though a clinician should not assume the function of kink in the greater scope of the client’s life, the practice of kink may also function as a limited yet intimate context for exploring gender identity and/or sexual orientation, to challenge mainstream cultural categories and beliefs, and be a cathartic or therapeutic act through the physical medium of sexual engagement (Sprott & Hadcock, 2018). 

For a clinician to develop the crucial ability to “distinguish between healthy BDSM and non-consensual abuse,” it is necessary to develop direct knowledge of kink philosophy and practice (Pillai-Friedman et al., 2015). Kink often includes elements of power exchange in which one party is on the receiving end of pain inflicted by another party; the core element which differentiates kink acts from abuse is the informed, explicit, and voluntary presence of consent through negotiation prior to engagement as well as the use of phrases or signals during the act to communicate continued consent (Kink Clinical Practice Guidelines Project, 2019). Kink community holds the values of consent, clear communication, respect for boundaries, integrity of action, and transparency of action as central to what is termed “safe, sane, and consensual” practice (Sprott et al., 2017). Should these elements fail to be present in an ongoing kink relationship, clinicians must maintain awareness that it is possible for intimate partner violence to take place within kink relationships and this is something to assess for in context (Kink Clinical Practice Guidelines Project, 2019).  

Okay, now what?

Kink, ultimately, is a normal part of the sexual spectrum, and the onus is on the therapist to distinguish between healthy practice and problematic engagement. While kink has been historically pathologized and misconstrued by individuals and institutions alike, changing attitudes both societally and in psychological practice necessitate increased awareness and education of how to work with members of this population. Kink-aware therapists not only have an integrated and sex-positive understanding of kink, but they proactively engage with clients to ensure culturally competent and affirming experiences in therapy. Because there continues to be a gap in research literature on kink as it intersects with mental health disorders and other aspects of psychological practice, developing clinical expertise through the study of evidence-based approaches and engaging in consultation with experienced colleagues is absolutely necessary for providing informed and efficacious care to kink-practicing people. 

For the benefit of both client and therapist, it is important to have access to resources and local organizations focused on kink education. Thankfully, many such resources exist! Hooray!

• The National Coalition for Sexual Freedom is a well-established organization committed to promoting the rights of kink communities (as well as alternative relationship communities). Their website contains an abundance of resources, including a What Professionals Need to Know About Kink guide and a library of academic publications on the subject of kink.

• The Kink Clinical Practice Guidelines Project has published and continues to update a growing body of research on how to best support kinky clients in mental health and physical health spaces.

• The American Association of Sexuality Educators, Counselors, and Therapists hosts a vast calendar for CE/trainings in all areas of sexuality, and kink-related ones are often on offer. The Affirmative Couch also offers CE/trainings on many subjects in the broader sphere of kink, queerness, and ENM.

• In addition to live training, there is an abundance of literature on the subject of kink and therapy. A great place to start is Kink-Affirming Practice: Culturally Competent Therapy from the Leather Chair by Stefani Goerlich.

Go forth and learn!

References 

First, M. B. (2014). DSM-5 and Paraphilic Disorders. Journal of the American Academy of Psychiatry and the Law, 42(2), 191–201.  

Kink Clinical Practice Guidelines Project. (2019). Clinical Practice Guidelines for Working with People with Kink Interests. Retrieved from https://www.kinkguidelines.com  

Kleinplatz, P., & Moser, C. (2004). Toward Clinical Guidelines for Working with BDSM Clients. Contemporary Sexuality, 38(6), 1–4. http://pointloma.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=15356084&site=ehost-live  

Lawrence, A. A., & Love-Crowell, J. (2008). Psychotherapists’ experience with clients who engage in consensual sadomasochism: a qualitative study. Journal of Sex & Marital Therapy, 34(1), 63–81. http://pointloma.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=105685536&site=ehost-live 

Nevard, I. (2021). Counselling and the kink community: a thematic analysis. British Journal of Guidance & Counselling, 49(4), 617–628. https://doi-org.pointloma.idm.oclc.org/10.1080/03069885.2019.1703899 

Pillai-Friedman, S., Pollitt, J. L., & Castaldo, A. (2015). Becoming kink-aware – a necessity for sexuality professionals. Sexual & Relationship Therapy, 30(2), 196–210. https://doi-org.pointloma.idm.oclc.org/10.1080/14681994.2014.975681 

Shorter, E. (2014). Sexual sunday school: The DSM and the gatekeeping of morality. AMA Journal of Ethics, 16(11), 932–937. https://doi.org/10.1001/virtualmentor.2014.16.11.mhst1-1411 

Sprott, R. A., & Benoit Hadcock, B. (2018). Bisexuality, pansexuality, queer identity, and kink identity. Sexual & Relationship Therapy, 33(1/2), 214–232. https://doi-org.pointloma.idm.oclc.org/10.1080/14681994.2017.1347616 

Sprott, R. A., Randall, A., Davison, K., Cannon, N., & Witherspoon, R. G. (2017). Alternative or Nontraditional Sexualities and Therapy: A Case Report. Journal of Clinical Psychology, 73(8), 929–937. https://doi-org.pointloma.idm.oclc.org/10.1002/jclp.22511 

Wright, S. (2010). Depathologizing consensual sexual sadism, sexual masochism, transvestic fetishism, and fetishism. Archives of Sexual Behavior, 39(6), 1229–1230. https://doi-org.pointloma.idm.oclc.org/10.1007/s10508-010-9651-y