Clinical Guidelines for Working with Clients Involved in Kink.

People involved in kink (BDSM or fetish) subcultures often encounter stigma and bias in healthcare settings or when seeking psychotherapy. Such individuals typically encounter well-meaning clinicians who are not prepared to provide culturally competent care or who have not recognized their own biases. Over a two-year period, a team of 20 experienced clinicians and researchers created clinical practice guidelines for working with people involved with kink, incorporating an extensive literature review and documentation of clinical expertise. This article summarizes the guidelines and discusses relevant issues facing clinicians and their clients, as well as implications for clinical practice, research and training.

The Paraphilias and Medical Licensure in the United States.

BACKGROUND: As part of their mission to protect the public from exploitation, state medical boards query physicians about a wide range of topics prior to licensure, including in some cases whether the applicant has been diagnosed with or been treated for paraphilias or paraphilic disorders. AIM: We investigated the prevalence of questions inquiring about the applicants' history of paraphilias and paraphilic disorders on applications for medical licensure. METHODS: The allopathic medical licensure application forms for each of the 50 United States and the District of Columbia were reviewed. Medical boards with questions pertaining to paraphilias or paraphilic disorders were asked how many affirmative responses had been obtained in the prior 5 years and how they would treat an affirmative response. OUTCOMES: Eight medical boards inquired about paraphilias or paraphilic disorders, however there was no evidence of an affirmative response to these questions in the prior 5 years. RESULTS: Of the 51 applications reviewed, 8 (16%) inquired whether the applicant had, was diagnosed with, or had been treated for a paraphilia or paraphilic disorder. The wording of the questions was variable and often failed to distinguish between paraphilias and paraphilic disorders. All but one medical board responded to requests for further information. The medical board staff members stated that an affirmative response would result in case-by-case review, including request for further information and possibly an in-person appearance before the board. None of the medical boards were willing or able to provide a formal count of affirmative responses in the last 5 years. CLINICAL IMPLICATIONS: Medical boards may be contributing to the stigma experienced by both physicians and patients with diverse sexual interests. The benefit of retaining these questions is not clear. STRENGTHS AND LIMITATIONS: This study is the first to investigate the use of paraphilias and paraphilic disorders as screening questions for medical licensure. Data regarding the number of affirmative responses were limited by the medical boards' inability or unwillingness to respond to share the information. CONCLUSIONS: Eliminating or modifying physician licensing application questions pertaining to paraphilias and paraphilic disorders may decrease the stigma encountered by persons with diverse sexual interests. Removal also may diminish the barriers to accessing health care services for both physicians and patients with diverse sexualities. If the questions are retained, they should conform to the current DSM-5 nosology, which distinguishes between the mere presence of a paraphilia and a diagnosis of a paraphilic disorder. Cranstoun LM, Moser C. The Paraphilias and Medical Licensure in the United States. J Sex Med 2021;18:1130-1133.

Conceptualization, History, and Future of the Paraphilias.

There is no accepted definition of the term paraphilia despite its being listed as an essential feature of a class of mental disorders known as the paraphilic disorders. The origin of the term, history of its inclusion as a diagnosis, and logical flaws inherent in the various definitions are discussed in this review. We examine the basis for pathologizing individuals with paraphilias, consider what paraphilias can tell us about how humans develop their sexual interests, and question the usefulness of dividing sexual interests into paraphilias and normophilias. The construct of the paraphilias appears to be poorly conceived and has outlived its usefulness.

S/M (sadomasochistic) interests as an issue in a child custody proceeding.

This article describes a child custody case centered on the fitness of the mother, who was involved in an SM relationship with her live-in boyfriend. Although the investigation confirmed that no child abuse had occurred, that the child was unaware of the mother's sexual interests, that there were no incidents of inappropriate sexual activities in front of the minor, and that the child was doing well, the court severely limited the mother's visitation and custody arrangements and ended her alimony. Practitioners of alternative sexual lifestyles have not fared well in child custody hearings, and this case is no exception. The present case indicates how the family court system can be biased against sexual minorities in general and SM practitioners in particular. In addition, the present case demonstrates how the DSM diagnostic criteria can be misused in dealing with alternative lifestyle practitioners. Recommendations for further education of the court and for future research are made.

Investigating bias in psychotherapy with BDSM clients.

There is a concern among consensual BDSM participants that they will receive biased care from mental health professionals. Results are presented of an anonymous Internet-based survey administered to both BDSM-identified individuals who have received psychological care and to mental health professionals. The survey included socio-demographic data and invited participants to write narrative accounts of biased or culturally sensitive care, from which common themes were identified. Mental health providers (N=17) responded in fewer numbers than those who identified as BDSM-identified participants (N=175). Descriptive characteristics of the sample will be discussed. Themes from the qualitative data may be useful in informing the future development of guidelines for practitioners to work more responsibly with clients who identify as members of this sexual minority group.

24/7 SM slavery.

This study describes the nature of 24/7 SM slavery as practiced within the SM (sadomasochistic) community. These SM participants, who attempt to live full-time in owner-slave roles, represent a small proportion of those with SM interests. SM slaves have not been studied systematically to determine if and how they differ from other SM practitioners. An online questionnaire was used to obtain responses from individuals who self-identified as slaves. A total of 146 respondents participated, 53% female and 47% male, ranging in age from 18 to 72. We explored the depth of their relationships, how well they approximated "slavery," and how their relationships were structured to maintain distinct roles. Data showed that in long-term SM slave relationships, a power differential exists which extends beyond time-limited SM or sexual interactions. Owners and slaves often use common, daily life experiences or situations, such as the completion of household chores, money management, and morning or evening routines, to distinguish and maintain their respective roles. In addition, contrary to the perception of total submission, results revealed that slaves exercise free will when it is in their best interests to do so. These relationships were long-lasting and satisfying to the respondents.