(Un)desirable approaches in therapy with Swedish individuals practicing BDSM: client’s perspectives and recommendations for affirmative clinical practices

ABSTRACT

This transformative study aimed to explore how people who practice BDSM (bondage, discipline, dominance, submission, sadism, masochism) experience therapy; specifically, what sort of therapist responses and qualities they described as problematic and desirable in relation to addressing BDSM in therapy. Semi-structured interviews were conducted with 27 Swedish BDSM practitioners with experiences of psychotherapy. The interviews were analysed using inductive thematic analysis. Three themes were identified: ‘A professional stance’, relating to how therapists handled their professional roles when BDSM was addressed, ‘Therapists’ approaches towards BDSM’, regarding therapists’ opinions and attitudes towards BDSM, and ‘Conversations about BDSM’, regarding how therapists handled conversation about the topic. Participants reported negative experiences where therapists expressed prejudice, judgment or pathologizing attitudes, failed to contain their own emotions, questioned their clients about BDSM, used their clients to inform themselves about BDSM, avoided or focused excessively on the topic. Positive experiences were characterised by non-judgement, asking client-centred questions, and stimulating a collaborative exploration of matters relevant to the client. BDSM practitioners’ experiences of therapy were related to those documented in the literature on other minoritized identities. This study contributes to the growing literature on kink-aware therapy, which makes psychotherapy more affirmative, accessible, and rewarding to BDSM practitioners.

KEYWORDS:

• BDSM
• psychotherapy
• kink affirmative therapy
• kink-awareness
• LGBTQ+
• transformative research

Introduction

Evidence-based practice for psychologists calls for the integration of research evidence, clinical expertise and consideration of the patients’ sociocultural context and preferences (American Psychological Association, 2005). However, studies suggest that psychologists fall short regarding issues pertaining to sexuality, sexual identity or sexual practice (Dyer & Das Nair, 2013; Træen & Schaller, 2013). Unfortunately, clinicians appear to find it particularly challenging to encounter individuals with minoritized sexual identities and experiences in their professional roles (Berke et al., 2016; Shelton & Delgado-Romero, 2011). Research, such as a study by Ford and Hendrick (2003), suggests that this is also true when clients practice bondage, discipline, dominance and submission, and/or sadism and masochism (BDSM).

Critical perspectives urge psychologists to turn their gaze towards their discipline and psychotherapeutic practices and ask why psychologists are ill-equipped to address these issues (Parker, 2007). One explanation is that psychology, including psychotherapy, build on heterosexist and normative understandings of sexuality and have psychologised and pathologized gender and sexual identities and practices deemed non-normative for decades (see e.g. Kitzinger, 1999; Ruti & Cocking, 2015). Kitzinger (1999) effectively shows that psychotherapists need to address the kind of social oppression that psychological and psychotherapeutic theories reify, as well as the individual suffering caused by that oppression. This calls for critical approaches, deconstructing the normative understandings underpinning psychological and psychotherapeutic theories and practices, and affirmative approaches that can transform theories and practices. Building on critical psychology, this study takes a transformative perspective (Mertens & Ginsberg, 2008) in addressing BDSM practitioners’ experiences of psychotherapy.

What is BDSM?

BDSM practices are commonly referred to as play by practitioners (Lawrence & Love-Crowell, 2008) and are often, but not always, carried out with sexual intent or considered part of someone’s sexuality (Carlström, 2016). Bondage is about restricting someone’s physical ability to move (Dunkley & Brotto, 2018), for example, by tying them up in ropes, handcuffing them or locking them up in a cage. Discipline revolves around control, obedience, and the implementation of rules, rewards and punishments for acceptable and unacceptable behaviour (Moser & Kleinplatz, 2013). Dominance and submission are related but broader terms, referring to a power exchange dynamic where the submissive is giving up power and initiative to the dominant (Dunkley & Brotto, 2018; Pillai-Friedman et al., 2015). This can be acted out physically or psychologically, e.g. by physically subduing someone or using verbal commands, body language, tone of voice, or even giving someone certain looks (Carlström, 2016). Sadism and masochism, or sadomasochism, is about inflicting (for the sadist) or receiving (for the masochist) various sensations, commonly revolving around physical pain (Pillai-Friedman et al., 2015) or psychological dimensions (Dunkley & Brotto, 2018) of e.g. humiliation or fear. In BDSM practice, consent is key; individuals who choose to engage in play together do so within the framework of mutual pleasure, sexual or otherwise (Barker et al., 2007).

BDSM is often conceptualised as having subversive potential and may be construed as a queer practice, at least to the extent that it breaks social heteronorms concerning sexuality (Barker et al., 2007; Bauer, 2014). However, commentators do not agree whether it is meaningful or useful to connect BDSM to other minoritized identities, practices and categorisations, such as lesbian, gay, bisexual, transgender, queer and others (LGBTQ+) that concern gender, sexuality and/or relationships (Taylor et al., 2018). Although fantasising about BDSM-related themes or engaging in some form of BDSM practice might be much more common than stereotypic beliefs (Ansara, 2019; Shahbaz & Chirinos, 2017), BDSM is often described as a minoritized practice in research (Dunkley & Brotto, 2018; Nichols, 2006). This supports the idea of considering BDSM to be encompassed by the ‘+’ in the LGBTQ+ umbrella term. The present article makes no attempt to argue for a certain degree of queerness in BDSM practice per se, recognising that BDSM may be practiced in myriad ways, involving various specific activities, circumstances and meanings for the individuals engaged. The authors also acknowledge that LGBTQ+ identities may intersect for queer, transgender and/or pansexual BDSM practitioners, for instance, (see Bauer, 2014; Hammers, 2019; Speciale & Khambatta, 2020). Whether or not one regards BDSM as a queer practice, this article considers BDSM practitioners to have affinities with other minoritized LGBTQ+ groups, assuming certain shared conditions and experiences as an effect of living in a society where BDSM practice is socially stigmatised (Shahbaz & Chirinos, 2017). Concerns related to BDSM and therapy will thus be discussed and compared with the LGBTQ+ literature throughout this article.

Notably, conceptualising BDSM as a minoritized sexual practice is not unproblematic, in part because continued use of minoritizing language around a group could risk reifying marginalisation of that group (McDermott & Roen, 2016; Petchesky, 2009). Also, BDSM is not an inherently sexual practice (Barker et al., 2007). BDSM practices may be carried out without sexual intention some of the time, or may never be sexual at all, for people everywhere on the spectrum of a/sexuality (Ansara, 2019). BDSM practices can be about other forms of pleasure for the practitioners, for instance, a sense of enjoyment associated with altered states of consciousness, with a sense of power or loss of power, or being fully engulfed by sensory experiences. They may also be about a sense of safety, a release of emotions or tensions, or a creative outlet, for instance, (Carlström, 2016; Shahbaz & Chirinos, 2017). As such, individuals practicing BDSM may not self-identify with a sexual minority label.

However, BDSM practitioners have a long history of being pathologized within psychology and psychiatry, similar to other minoritized sexualities as well as gender identities (Moser & Kleinplatz, 2005). In the DSM-IV-TR, the diagnoses ‘Sexual Masochism’ and ‘Sexual Sadism’ were listed for sexual impulses, fantasies or behaviours involving one’s own or someone else’s suffering or humiliation (American Psychiatric Association, 2000). In the DSM-5, the diagnoses were renamed ‘Sexual Masochism Disorder’ and ‘Sexual Sadism Disorder’. It was emphasised that if the sadomasochistic activities reported by the individual were not associated with distress or impairment within important areas of life, then the individual should not be diagnosed with either of these disorders. It was made clear that the majority of those engaged in networks where sadomasochism is practiced, should not receive these diagnoses (APA, 2013).

Notably, even with these recent developments, BDSM practitioners may still be wrongfully diagnosed in some cases. Social stigma surrounding BDSM interests and discrimination against BDSM practitioners are established occurrences (Barker et al., 2007; Brown, 2010; Klein & Moser, 2006) which may render distress for the individual. This might erroneously prompt clinicians to pathologize BDSM practice (Barker et al., 2007; Kleinplatz & Moser, 2013), misattributing their clients’ suffering to their BDSM practice per se instead of the stigma and discrimination that BDSM practitioners experience. This risk might arguably be greater if the clinician has no knowledge of BDSM beyond what is written in the DSM-5.

Research on BDSM and therapy and kink-aware recommendations

Lack of knowledge and understanding of BDSM appears to be a widespread problem among psychotherapists. In one large study, 76% of the participating therapists reported that they had treated at least one client who practiced BDSM, but only 48% felt that they were competent concerning BDSM (Kelsey et al., 2013). In another study, therapists reported feeling more uncomfortable with treating BDSM practitioners than gay and lesbian clients (Ford & Hendrick, 2003). Furthermore, a recent literature review states that many clinically active therapists lack knowledge of BDSM or are even misinformed, remain unaware that BDSM practice in itself is no longer listed as a disorder in the DSM, and conduct therapy in unhelpful or unethical manners with BDSM practitioners (Dunkley & Brotto, 2018).

Recommendations for so called ‘kink-aware’ therapy (Ansara, 2019; Dunkley & Brotto, 2018; Pillai-Friedman et al., 2015; Shahbaz & Chirinos, 2017) include neither ignoring nor over-focusing on the topic of BDSM, to be mindful of one’s own reactions and strive towards a non-judgemental and openminded stance, and to seek out knowledge of specific practices, values and norms in BDSM culture, such as how consent and boundaries are negotiated (Dunkley & Brotto, 2018). The importance of being able to distinguish consensual BDSM practice from abusive relationship dynamics is also noted in several recommendations (Ansara, 2019; Dunkley & Brotto, 2018; Pillai-Friedman et al., 2015; Shahbaz & Chirinos, 2017).

While acquiring knowledge is one important aspect of moving from pathological understandings to providing professional services to people with minoritized experiences, proponents of affirmative therapies have effectively argued that knowledge is not enough in order to be non-discriminatory. Langdridge (2007) describes, for example, that the ideal of therapists’ being non-judgemental and neutral in humanistic and existential psychotherapies often fails to acknowledge the impact of social forces on the individual’s experiences and, thus, might reify heterosexist norms. In addition, Ansara (2019) refers to therapists who are seemingly non-judgemental to BDSM, but actively avoid talking about it in therapy. What is needed in order to transform psychological theories and practices related to BDSM is, thus, not only research on therapists’ competence in, knowledge of, or attitudes to, BDSM, but how therapists might become more kink affirmative (cf. LGB affirmative in Langdridge, 2007) and humble (Tervalon & Murray-García, 1998). In summary, kink-awareness and kink-affirmation can be thought of as crucial, complementary perspectives to make for helpful, rewarding therapy with BDSM-practicing clients, with therapists informing themselves of issues relevant to their clients and affirming the relevance and importance of BDSM in clients’ lives, supporting their well-being.

In order for recommendations for kink-aware and -affirmative therapy to be effective, they need to be tailored to the specific therapy-related needs and concerns that BDSM practitioners themselves express. However, few studies have explored BDSM practitioners’ firsthand accounts of their own experiences of psychotherapy in order to understand their lived experiences of helpful and unhelpful therapy. One exception is a questionnaire study from the USA where both therapists and BDSM practitioners were asked about therapy experiences (Kolmes et al., 2006). Another is an American-German study combining qualitative questionnaires and interviews with couples practicing BDSM together (Hoff & Sprott, 2009). In both studies, BDSM practitioners describe a number of negative, prejudiced responses from therapists, where BDSM is considered to be pathological, unhealthy, a form of abuse or self-harm, or a sign of other underlying pathology, past abuse or trauma. In some cases, therapists have even demanded that the individuals stop practicing BDSM as a condition for therapy (Kolmes et al., 2006), or have at least tried to get them to stop (Hoff & Sprott, 2009). Similar experiences have been noted in a recent study on LGBTQ+ identified BDSM practitioners (Speciale & Khambatta, 2020).

Results from these studies suggests that providing professional services to BDSM practitioners requires transformations in two steps. First, to document and stop adverse clinical practices that pathologize and minoritize BDSM-practices (cf. stopping conversion therapies, see e.g. Langdridge, 2007). Second, to systematise helpful therapy experiences from the point of view of BDSM practitioners, in order to provide well-grounded recommendations for therapists wishing to work professionally with BDSM-practicing clients. This study sets out to complement the existing international research and is the first Swedish study exploring how BDSM practitioners experience therapy. The specific research question is: What therapist responses and qualities do Swedish BDSM practitioners describe as problematic and desirable in relation to addressing BDSM in therapy? The authors hope that this study can contribute to the growing literature on kink-aware and kink affirmative therapy, in order to make psychotherapy more available, appropriate, and rewarding to BDSM practitioners.

Materials and methods

Ethical considerations

The study was approved by the Swedish Ethical Review Authority (Reg. No. 2019-02571). Participants were informed about the study, their rights, how data would be stored and how results would be presented. Informed consent was obtained from all participants prior to engaging in the interviews. Because of the historical pathologizing of BDSM practitioners in psychology, the advertisement of the study also emphasised that the study did not examine whether BDSM practitioners were in particular need of therapy, but rather how they had experienced therapy irrespective of why they had sought help. In accordance with transformative research (Mertens & Ginsberg, 2008), the researchers have been transparent about their positive and affirmative positioning regarding BDSM practice in information sheets and during interviews.

Participants and procedure

Eligible participants were at least 18 years old, had some experience of practicing BDSM and had experience of some form of psychotherapy in Sweden. They should also have started to practice or relate to BDSM prior to or during their involvement in therapy. Participants were recruited via an advertisement on Darkside, which is the biggest online forum for BDSM practitioners in Sweden.

In total, 27 individuals participated in the study. Participants were between 27–65 years old (M_age = 37 years). All participants lived in Sweden and spoke Swedish. The researchers did not explicitly ask participants about their ethnic background or experiences of racialisation, but participants were predominantly White. Professions varied from technical or practical professions to working with healthcare, research, social work, teaching or holding office jobs. Some were students, others were retired or in early retirement due to illness. Most participants were cisgender women, others identified as non-binary, genderqueer, genderfluid or femme, a few identified as men or queer cisgender men, and some stated that gender was not personally relevant to their identity. Many participants defined their sexuality as bisexual or pansexual, some as heterosexual, mostly heterosexual, or experimental but primarily heterosexual, and some as queer. Others described BDSM as the most important aspect of their sexuality and reported their play preferences, such as submissive, dominant, sadist, switch. Some said that they were polyamorous, relationship anarchists or approached relationships in ways that differed from the monogamous norm. Some participants had only just started relating to BDSM in thought during the last few years, while others had actively practiced BDSM for over ten years.

Semi-structured interviews were done face-to-face or over the telephone. The guide included questions concerning experiences of talking about BDSM in therapy, therapists’ responses, participants’ wishes and what they would not like to experience in therapy, and participants’ opinions on what therapists should know about BDSM in order to provide professional and affirmative therapy. The interviews lasted between 30 and 100 minutes (M_time = 47 minutes) and were audio recorded. Ten of the interviews were transcribed, elected chronologically and based on their sound quality. The rest were analysed as audio files due to limited time to complete transcribing of all data. All 27 interviews have been included in the analysis.

Data analysis

A thematic analysis, building on a critical realist epistemology, was used for this study (Braun & Clarke, 2006). The inductive process of analysis largely followed the steps outlined by Braun and Clarke (2006), complemented by inspiration from Halcomb and Davidson (2006) for the analysis of the auditory material.

During step one and two (Braun & Clarke, 2006), the first author familiarised themselves with the data and coded the data. The material was coded systematically, one transcription after another, in an effort to include as many meaningful units of information as possible. For the audio files, this step meant re-listening more carefully to the recordings, with frequent pauses to take notes of meaningful information to code.

During step three and four (Braun & Clarke, 2006), preliminary themes were first identified for the transcribed interviews. The preliminary themes were reviewed and refined for coherency and distinction, first by rereading the transcribed material and second, by comparing the non-transcribed interviews with the preliminary themes. The revision process sometimes necessitated rereading or relistening to parts of the interview material. Step five and six involved re-examining the themes and writing them up.

Results

Participants’ descriptions of problematic and ideal therapeutic qualities are summarised in three themes (see Table 1). These include how therapists handle their professional role when BDSM is addressed (‘A professional stance’), therapists’ opinions and attitudes towards BDSM (‘Therapists’ approaches towards BDSM’) and how the therapist handle conversations about the topic (‘Conversations about BDSM’). Participants highlighted many examples of what they understood as negative and positive responses by therapists. These are presented as contrasting clusters in each sub-theme.

Table 1. Themes and subthemes.

Main theme	Sub-theme
A professional stance	Therapists’ personal values: making them evident versus concealing them Therapists’ emotional reactions: exposing them versus holding space for the client Therapists’ agendas regarding BDSM: trying to change the client versus affirming them Informing oneself about BDSM: using the client versus taking own responsibility
Therapists’ approaches towards BDSM	Prejudice versus open-mindedness and humility Negative judgment versus non-judgemental acceptance Critically questioning versus proper curiosity and interest Pathologizing versus normalising Uncomfortable versus relaxed
Conversations about BDSM	Avoiding versus asking questions Over-focusing versus exploring collaboratively

A professional stance

Therapists’ professional stance was a prominent theme. One participant explicitly described the sense of being ‘less worthy of a good and professional approach’ when BDSM had been addressed in therapy, ‘as if, [… the therapists] forget that we are […] patients […] instead, suddenly you become some sort of object to be scrutinised’ (P21). Many participants discussed matters related to professionalism, including therapists’ values, emotional reactions and underlying agenda, which are described next.

Therapists’ personal values: making them evident versus concealing them

Many testified that therapists sometimes made their own values evident when BDSM was brought up in therapy. One participant said that she had felt that her therapist was worried that BDSM would complicate her life. Some understood their therapists as very normative, ‘standard vanilla people’ (P27) with strong opinions on what relationships and sex should be like. One participant described this as a ‘sense’ that was hard to pinpoint:

Participant: Many say that “oh I am so open-minded”, but […] they are actually very norm-y […] Norm-followers. […] I think I sense that quite easily. Is this, like, an open-minded person?

Interviewer: Mm. Do you know what you are reacting to, then? […]

Participant: I don’t quite know. […] [That therapist] was like, an ordinary Swedish middle-class woman. And that was palpable instantly. […] That she had experiences completely different from mine, completely different values. (P25)

When bringing up the issue of therapists’ personal values, participants maintained that therapists should not show their own opinions and values in therapy. This was emphasised in cases where the values of the therapist differed from those of the BDSM practitioner.

Therapists’ emotional reactions: exposing them versus holding space for the client

Participants described being exposed to therapists’ emotional reactions. Some had experienced therapists being shocked, frightened or making wide eyes when BDSM was mentioned. One participant said that the therapist shared private information about her own relationship to BDSM. The therapist’s personal interest thus directed the conversations in a way that ‘became very interesting to her’ (P10), breaching professional boundaries. The same participant emphasised the importance of therapists maintaining a ‘professional cool’ (P10), keeping their emotions to themselves and sticking to their role of guiding the client. Several participants stated that the therapist ought to stay focused on and hold space for the client.

Therapists’ agendas regarding BDSM: trying to change the client versus affirming them

Participants discussed therapists being guided by their own agendas. Many said they had feared that their therapists would want to try to make them stop their BDSM practice, as in conversion therapy, and one participant had, in fact, been encouraged to stop. Another said that her therapist had had a ‘hidden agenda’ (P04) during therapy. In hindsight, the participant felt this was positive for her, but pointed out that it would have been problematic had the agenda been different:

I think it can be both good and bad [to have a hidden agenda]. I think it can be good in the sense of, like helping this person out of an incredibly toxic and negative relationship […] But I also think that if you have a hidden agenda […] Concerning BDSM for example, […] “you will stop your BDSM interest because it is negative for you”, or “you will stop practicing certain forms … ” Or “we must find your underlying trauma that causes your submissive tendencies”. If you have that agenda, I think it can turn out very wrong. (P04)

In contrast, an agenda where therapists strengthen and affirm clients was understood as valuable. This could include helping people who had been through abuse and sexual assault within BDSM relationships to identify what had not been okay. It could also be about encouraging BDSM practice, e.g. by conveying statements such as ‘if you feel good – continue’ (P24) or ‘as long as everyone involved are consenting, it sounds good!’ (P01), and encouraging the individual to explore and find a community. One participant described how liberating it had been when her therapist had encouraged her to ‘embrace […] your lust’ (P02) rather than problematise BDSM, which helped her start viewing BDSM as a sexual orientation that she did not want to be without. Another participant also received support from a therapist to strengthen her self-appraisal and view BDSM as a positive part of her identity.

Informing oneself about BDSM: using the client versus taking own responsibility

Many described negative experiences where the client needed to educate their therapist. Some therapists had asked the client to explain BDSM to them, and others came to therapy sessions time and time again just as ignorant as the time before, without educating themselves. This led participants to dedicate several therapy sessions to teaching their therapists basic knowledge about BDSM in order to contextualise their experiences or ‘justify […] [their] sexual identity’ (P06). It was also a strategy to try to get something out of therapy without being met with prejudice and negativity. One participant understood this educating role as being exploited and described having to constantly explain things concerning BDSM as exhausting. Others did not mind being used as a source of knowledge by their therapists. Voluntariness thus seems to be key.

Many wanted their therapist to take professional responsibility by honestly admitting to their lack of knowledge about BDSM, their willingness to seek knowledge about it, and then doing that until the next therapy session. Some described therapists doing exactly that: ‘We interrupted that meeting, and … Then she said, “but then I will read up on this, and we will get back to it next time.” Very good. Very good and wise.’ (P10). These responses contributed to a sense of trust in their therapists.

Therapists’ approaches towards BDSM

Participants had many thoughts about therapists’ actual and anticipated approaches and attitudes towards BDSM. The descriptions of undesirable approaches were typically related to the desired ones, and are presented in clustered contrasts next.

Prejudice versus open-mindedness and humility

Most participants expressed that it is problematic if the therapist is prejudiced against BDSM. However, many had met therapists who equated BDSM with abuse or self-harm, viewed it as a coercive activity, or presumed BDSM to cause relationship problems. Some therapists had assumed that an attraction to BDSM was caused by a development gone awry, a childhood trauma or poor self-esteem:

Participant: After two or three meetings he started talking about self-harm in connection to BDSM. Versus my life experiences as a child and youth. […]

Interviewer: Mm. With prejudice, sort of.

Participant: Exactly, it was prejudice. (P08)

This participant went on to explain how a correct approach would have been:

Participant: [I]f he had treated me correctly, then I would have never been offended. […] It might have been a way of asking a question, to sort of, ‘can we explore this? I want to know if this could have something to do with you, and if it does, then I can help you.’

Interviewer: Right. So a bit more open and well-meaning?

Participant: Exactly, exactly. It would have made a world of difference. (P08)

Many participants agreed that therapists should take an open-minded and humble approach: ‘being open in the way you ask the question […] “I know nothing about this, would you like to tell me more?”’ (P06). Open-mindedness and humility were understood to make a big difference to participants.

Negative judgment versus non-judgemental acceptance

Feeling judged by a therapist was understood as negative. This could happen if the therapist suggested that BDSM was bad, weird, or abnormal. Some also said that experiencing general negative attitudes, coldness, ‘distancing or a reluctance to meet [the client]’ (P04) would be problematic. This could happen if the therapists were appalled, crossed their arms or pursed their lips. Some would also feel judged if the therapist had moralised or made negative comments, including bantering, mocking, ridiculing, laughing at or shaming the individual; ‘The major point is: don’t shame [the client]. […] [C]hoose your words’ (P06).

In contrast, many suggested that therapists should be non-judgemental, accepting, and respectful. One participant explained how important it had been to her that her therapist had shown acceptance when they had discussed an abusive relationship which was also characterised by BDSM dynamics:

To me, a lot came down to the fact that I could actually be brutally honest, and say “no, I don’t think there’s anything wrong with me being a masochist. I don’t think there’s anything wrong with me being submissive.” […] “I don’t think there’s anything wrong with the fact that I might choose to engage in a power exchange relationship again in the future.” […] And that she accepted that. We didn’t need to agree that it was necessarily the best option. But it was still accepted. It was still okay. (P04).

Participants provided examples of how therapists could convey acceptance non-verbally, by leaning forward, having an open body language, and making eye-contact. In addition, the participants hoped that therapists would show positive attitudes towards BDSM and that they could understand it as a rewarding experience that could add to the client’s quality of life.

Critically questioning versus proper curiosity and interest

Several participants described having their BDSM practice questioned, problematised or treated with suspicion, by therapists. Experiences included therapists asking questions about why someone would engage in BDSM or viewing it as a problem to be solved:

[I]f I had just said that “well I like vanilla sex, hetero”, well, no one would have questioned that or thought that it needed to be problematized at all, […] Not something that needs to be examined from all angles. But if I say that I like dominating men, well then it’s, “yes this was interesting!” [laughter] “We should talk more about that.” And then I feel like “no, I don’t think I want to if you are going to be in that way.” (P05)

Another participant reported feeling ambivalent regarding their BDSM practice at times, and feared that the therapist would detect that and interpret it as if the practice was problematic in a way:

[S]ometimes I am more critical and sometimes less critical, when viewing BDSM practice from a larger perspective concerning structures and so. But right now, I guess I don’t feel as critical toward my own practice as I did before. […] But the fact that it … That this ambivalence might be interpreted as if I had an unhealthy … That my practice was actually not good for me, I guess that’s a suspicion of mine. (P12)

The participants rather desired therapists to approach their BDSM practice with curiosity and interest in order ‘to understand and sort of tease out what BDSM does for us’ (P09). The therapists should ask the clients to tell them more about it because they genuinely wanted insight into their experiences. One participant stated: ‘I think the most important thing has been, not necessarily what they have said but how they have said it. You get very far with genuine curiosity’ (P04), illustrating that the intention of the therapist is the most important aspect here.

Pathologizing versus normalising

Many participants also addressed the tendency of some therapists to label BDSM practice as pathological in one way or another. A lot of participants described a fear of being pathologized. Some had not dared to mention BDSM with their therapists at all before the declassification in Sweden in 2009, but stated that their fear still remained. Some sensed current pathologizing tendencies in some therapists. One participant said that her therapist wanted to diagnose her with various conditions when she told the therapist about her BDSM-practice. Other therapists had stated that they still understood BDSM as sick, despite being aware that the diagnoses had been removed. One participant had seen ‘the wrong [version of the DSM] in the bookshelf, at the healthcare department that [they] had visited, where it still says that [BDSM practitioners] are mentally ill’ (P26). Several participants addressed that many therapists who are clinically active today received their training when BDSM was viewed as pathological, and thus may still carry those views if they have not kept themselves up to date on the matter.

Some maintained that therapists should normalise BDSM if it was brought up in therapy. Some said they wanted therapists to say that ‘people like different things’ (P27) or to approach BDSM as something given, nothing special, as anything else. One participant even suggested that therapists should normalise BDSM even if they knew nothing about it – she would rather see that the therapist would first say that it was normal and then read up on it to form an opinion, than make the client feel abnormal.

Uncomfortable versus relaxed

Several participants thought it would feel weird if the therapist was uncomfortable talking about BDSM. They gave several examples of responses they felt would be indicative of that. This included therapists asking brief questions staying on the surface, having a hard time responding or finding sensible formulations, or bluntly saying ‘I don’t want to talk about that. Let’s finish here, go find yourself another therapist’ (P10). One participant had experienced that a therapist felt awkward and was ashamed of talking about BDSM. Participants with such testimonies suggested that these therapists probably felt uncomfortable talking about sex in general as well, but sometimes they had the feeling that BDSM meant an additional layer of discomfort.

In contrast, participants wanted there to be a relaxed atmosphere in the therapeutic setting. The therapist should seem ‘chill’ (P01) and approach the topic in a relaxed way. One participant gave an example of a therapist embodying this ideal: ‘With [that therapist], you could talk about anything. And you wouldn’t scare him away by mentioning BDSM or poly or anything like that. So that was a relief.’ (P16).

Conversations about BDSM

The participants also shared reflections about how therapists could handle conversations about BDSM. Problematic and ideal scenarios are described next.

Avoiding versus asking questions

Several participants found it problematic if therapists tried to avoid talking about BDSM. Hypothetical scenarios were if the therapist would ignore any mention of BDSM, cut off the client, redirect the conversation, or under-value the importance of BDSM. Some had experienced therapists not giving much of a response. Such behaviours could signal that the topic was not okay to address or did not belong in therapy, like a taboo. One participant speculated that therapists had a ‘fear of touching upon’ the topic in therapy (P15), not necessarily out of personal discomfort but out of fear that they might accidentally pathologize BDSM if the topic were to be more deeply discussed and connected to the matters that the client sought therapy for. No matter the reason, avoiding the topic was undesirable to participants.

Instead, participants wanted therapists to ask questions about BDSM, as long as these centred the individual’s experiences. Broad and open questions were desired to stimulate conversation and help the individual describe meanings and feelings in depth. Such questions could include how the individual defined and regarded their BDSM practice, ‘“what aspects [of BDSM] do you usually practice?” […] what it does for us, how [we] are feeling [with our practice]’ (P09), what it means to their identity and health, and whether it might be relevant to address in therapy. Some wished to be asked whether they practiced BDSM and suggested this could be included as a standard question on intake questionnaires. Others said that general questions about sexuality, sex life or relationships could naturally lead to conversations about BDSM.

Over-focusing versus exploring collaboratively

Participants also pointed out, however, that focusing too much on BDSM could be problematic. If the therapist payed too much attention to BDSM, it could be understood as making it ‘a bigger deal than it is’ (P12). One participant stated that they would feel uncomfortable if ‘[BDSM would] sort of [take] up too much space if I don’t want it to take up much space. Or if I’d be asked too intimate questions that I don’t want to answer’ (P11). Some had experienced therapists that magnified BDSM when it had just been mentioned in passing.

In contrast, participants wanted therapists to keep a balanced focus and be accommodative to the individual, letting them direct the conversation and letting go of the topic if the individual did not find it relevant. Many highlighted the importance of exchange and collaborative exploration in therapy. One participant noted: ‘I want to meet my psychologist, not just sit there and talk’ (P07). Some said that their therapists had adequately asked questions to stimulate such joint exploration.

Discussion

This article sets out to explore Swedish BDSM practitioners’ experiences of therapy, investigating what responses and qualities they considered problematic versus desirable for therapists in relation to addressing BDSM in therapy. When it comes to documenting negative experiences, the participants in this study had often been met with prejudice, judgment, and negative values and attitudes from their therapists, which has also been reported in previous studies on this topic (Hoff & Sprott, 2009; Kolmes et al., 2006; Speciale & Khambatta, 2020). Prejudice that BDSM would be destructive or pathological (Hoff & Sprott, 2009; Speciale & Khambatta, 2020), a form of abuse or a sign of having been through some form of trauma in the past (Kolmes et al., 2006) is echoed in the present study. Further, this study reports several cases where therapists have failed to contain their own negative emotional reactions to the topic of BDSM. This is an acknowledged problem in the existing literature on conducting therapy with BDSM practitioners (Dunkley & Brotto, 2018), as well as with other minoritized sexualities and gender identities (American Psychological Association, 2011, 2015; The British Psychological Society, 2012). The present article speaks to the remaining problems of psychologisation and pathologizing of BDSM practices among psychotherapists today, despite changes in the diagnostic manual DSM-5. Continuous work to stop such adverse therapy practices are needed in order to ascertain professional and ethical services to BDSM practitioners.

In addition, some participants in the present study felt that their therapists did not give much of a response when BDSM was mentioned in therapy (as previously reported by e.g. Ansara, 2019), while others had experienced the opposite with therapists placing an exaggerated focus on BDSM. The phenomena of avoidance of, or under-focusing, and over-focusing on important aspects in therapy are established in research on other minoritized sexualities and gender identities (Mizock & Lundquist, 2016; Shelton & Delgado-Romero, 2011). The participants also reported needing to educate their therapists about BDSM, sometimes over several therapy sessions, before they got the opportunity to address what they actually wanted to talk about. This phenomenon is recognised in a recent study on LGBTQ+ BDSM practitioners’ experiences in therapy (Speciale & Khambatta, 2020). The current study further clarifies that this is not only an issue of therapists inquiring about BDSM; it is also problematic for therapists to repeatedly return to the therapy room without having informed themselves about BDSM in between sessions. In the present study as well as the one by Kolmes et al. (2006), BDSM practitioners regard it as a positive thing when therapists read up on the topic on their own. Out of consideration for the working alliance between therapist and client, out of respect for the client’s time in therapy, and out of care not to exploit clients who are dependent on their therapists, therapists ought to inform themselves about BDSM generally on their own and not primarily from their clients. If a client wishes to explain something related to BDSM, this should happen on the client’s own terms, and should not substitute seeking knowledge elsewhere on the therapist’s part. Independent knowledge-seeking is the responsibility of every therapist facing matters they are unfamiliar with (American Psychological Association, 2017). The results show clearly that efforts are needed to make Swedish therapists more knowledgeable of BDSM as an important first step to transform the services provided to BDSM practitioners.

While the negative accounts of therapy in this study were many, participants also described positive experiences of therapy and outlined desirable approaches, that can be used to further transform and ground recommendations for kink-aware and kink affirmative practices. Some participants described therapists that appeared relaxed and comfortable in conversations about BDSM (also described by e.g. Kolmes et al., 2006). Some participants described therapists as non-judgemental, accepting, open-minded and humble in relation to BDSM. In these cases, the non-judgemental approach was not described as a principle-based attitude (see discussion in e.g. McGeough & Aguilera, 2020) nor an acceptance where the therapist could be read as indifferent to or as avoiding the topic of BDSM (see e.g. Ansara, 2019). Rather, the participants’ accounts of their therapists’ approaches can be interpreted as being relation-oriented, client-centred and affirmative, as recommended by several commentators (Dunkley & Brotto, 2018; see discussion in e.g. McGeough & Aguilera, 2020). Such therapists were described as being interested and curious about the participants’ experiences and what BDSM meant to them and affirming participants’ BDSM practices, while also strengthening clients’ identities and self-images. This kind of relational and supportive approach has been illustrated in the study by Hoff and Sprott (2009). Parallels may also be drawn to participants in Speciale and Khambatta (2020) study, favouring that the therapist conveys allyship with their clients’ BDSM and queer communities. In sum, BDSM practitioners prefer therapists to take responsibility for their professional stance, showing a client-centred, collaborative and relaxed approach with proper curiosity, open-mindedness, encouragement, humility and acceptance.

The descriptions of undesirable and desirable approaches of therapists documented in this study, tap directly into larger discussions on how to provide tailored and professional services to clients with marginalised experiences. As suggested in the literature on affirming therapies (e.g Ansara, 2019; Langdridge, 2007) as well as cultural humility (see e.g. Tervalon & Murray-García, 1998), reading up on a certain group’s conditions will not be enough to ensure good practices. However, when ignorance and pathologizing tendencies are prevalent among therapists, having more knowledge is an important first step to transform services offered to BDSM practitioners. This is something that the participants mentioned several times. Notably, though, several commentators warn about the notion of understanding affirmative therapy as a certain ‘competence’ that can be acquired once and for all (e.g. Ansara, 2019; Tervalon & Murray-García, 1998). This insight is supported by the results in this study. Several participants advocated that therapists show a stance of humility, openness and collaboration, focusing on the clients’ concerns that are always unique. However, as Langdridge (2007) as well as Kitzinger (1999) point out, such a stance always requires consideration of the ever-changing sociocultural context, including subcultures and hegemonic normativities, that frame clients’ living conditions. Therapists’ commitments to lifelong learning and self-evaluation (Tervalon & Murray-García, 1998) could arguably mitigate the risk that they feel they have gained ‘full competency’ of a finite body of BDSM-related knowledge, helping them keep sight of relevant topics, experiences, and personalised meanings for the individual. Similarly, the authors understand that what should constitute kink-aware and/or kink affirmative therapy can differ between contexts, such as geographical locations, and times. Continuous discussions on this topic are needed in order for therapists to provide professional services to BDSM practitioners.

Limitations

This study is based on a convenience sample from one community, which affects transferability. The lived experiences of other Swedish BDSM practitioners are likely influenced by their own circumstances and intersections, of which the authors are unaware. The recruitment material, advocating increased BDSM-competency among therapists, might have particularly engaged persons who have experienced undesirable responses in therapy. Participants may also have been influenced to emphasise negative experiences in interviews, wanting to deliver what they thought the researchers were interested in, while the researchers allowed them to steer the conversations to a high degree.

Conclusions

This study provides qualitative information about what sort of responses BDSM practitioners have experienced from their therapists when BDSM has been addressed in therapy. Many negative experiences were described by the participants, including therapists expressing prejudice, negative values and judgements regarding BDSM, pathologizing BDSM and trying to change the client as well as avoiding or over-focusing on BDSM in therapy. Positive descriptions included therapists’ taking responsibility and a client-centred, collaborative and relaxed approach as well as being open-minded, affirming, humble, accepting, and showing proper curiosity. Current findings on (un)helpful therapeutic responses largely parallel the existing literature on affirmative therapy. Drawing on the results of this study, two major steps are required in order to transform services provided to BDSM practitioners. First, efforts are needed to make Swedish therapists more knowledgeable of BDSM. Second, reflexive work, by therapists as well as academically, should continue to make sure that therapists provide kink-aware and kink affirmative therapy that is accessible, ethical and rewarding to BDSM practitioners.

Acknowledgments

This study has not been supported by any funding. The authors would like to thank the participants for sharing their experiences.

Disclosure statement

The authors have no financial or other conflicts of interest to declare.

Additional information

Notes on contributors

Reid Lantto

Reid Lantto has an MSc in Psychology and is in training to become a licensed clinical psychologist. Reid has worked as a research assistant for five years, within the fields of clinical psychology and psychiatry.

Tove Lundberg

Tove Lundberg, PhD, is a clinical psychologist and works as a senior lecturer at the Department of Psychology, Lund University. Tove’s research focuses on topic areas related to sexuality and gender, LGBTQI, wellbeing and experiences of health care.