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

Figures & data

Table 1. Database search terms

Database	Date Searched	Search Terms
Embase; MEDLINE; PsycARTICLES; PsycINFO (on Ovid)	February 26^th, 2019 Updated search on June 27^th, 2019	1. ((personality or mental health or anxiety or depression or individual differences or biological or neurodevelopment or genetic or hormones or neural or learning or modeling or conditioning or relationships or interpersonal or marriage or polyamor* or communication or sexual health or sexual risk or consent or sexual knowledge or sex education) not (offend* or forensic or criminal or medic*)).ab,ti. 2. ((bdsm or sadism or masochism or sadomasochism or kink* or bondage or leather or fetish* or domination or submission) not (offend* or forensic or criminal or medic*)).ab,ti. 3. limit 2 to english language 4. limit 3 to human 5. limit 4 to yr = “2000 -Current” 6. 1 and 6

Table 2. Methodology and outcome information for articles included in review

Author(s)	Pub. Year	Appears in Review Section	n	Sampling Strategy	Study Design/Data Collection Method	Primary Measures	Outcomes of Interest and Indicative Effect Sizes
Ahlers et al.	2011	Demographics; Incidence Rates*	367 men	Opportunistic sub-sample of a representative sample of Berlin men. This was a nested sample from a larger study.	Quantitative survey, in-person	Nested study in a larger survey (n = 6,000) that used multiple pre-existing measures of health and sexual functioning/interests	OR (95% CI), Those with at least one paraphilic associated arousal pattern compared to those with none were more likely to: Be single: 2.64 (1.05, 6.64), p = .040 Masturbate at least once per week: 4.40 (1.78–10.91), p = .001 Use pornography: 2.65 (1.54, 4.59), p < .001 Ever have an STD: 2.60 (2.24, 3.03), p < .001 Have HIV: 2.89 (1.49, 5.60) p = .001
Alison et al.	2001	Etiology; BDSM ID, Engagement, and Behaviors	184 (22 women, 162 men)	Opportunistic sampling from 2 BDSM clubs in Finland, via mail	Quantitative survey, via mail	Questionnaires from Nordling et al. (2000/2006), Sandnabba et al. (1999/2002), & Santtilla et al. (2001/2002) about BDSM and sexual experience, childhood background, and mental/physical health	Females engaged in more humiliation behaviors than males: d = 0.37, p < .05 Males engaged in more hypermasculine behaviors than females: d = 0.62, p < .01 Gay males preferred hypermasculine behaviors more than heterosexual males: d = 0.42, p < .01 Heterosexual males preferred humiliation behaviors more than gay males: d = 0.43, p < .01
Bailey et al.	2003	Incidence Rates	1,218 women	Purposive and snowball sampling of gay and bisexual women in England and Scotland	Quantitative survey, in-person	Questionnaire created for use in sexual health clinics	OR (95% CI), Women who had sex with both men and women (in the past 10 years) were more likely than women who only had sex with women to engage in sadomasochism: 3.66 (2.40, 5.58), p < .001
Baughman et al.	2014	Psychological Correlates	643 (190 men, 435 women)	Convenience sampling of undergraduate students in Canada	Quantitative survey, online during a proctored testing session	Pre-existing measures of the Dark Triad and sexual fantasies	Psychopathy was positively related to intimate ($r^2$= .040, p < .05), exploratory ($r^2$= .068, p < .05), impersonal ($r^2$= .168, p < .01), and sadomasochistic ($r^2$= .109, p < .01) sexual fantasies. Sadomasochistic fantasies were positively related to narcissism ($r^2$= .010, p < .05), but not Machiavellianism ($r^2$= .004, p > .05)
Botta et al.	2019	Demographics*; BDSM ID, Engagement, and Behaviors	266 (141 men, 125 women)	Snowball sampling online of Italian BDSM identified individuals	Quantitative survey, online	In addition to pre-existing measures of sexual complaints and sexual satisfaction, questions about demographics, BDSM role, and sexual behaviors were created for this study	Women were more likely than men to list physical pain as a favorite BDSM activity: ϕ = .241, p < .001 OR (95% CI): Men more likely than women to identify as dominant: 2.15 (1.28, 3.63), p = .006 Women more likely than men to identify as a submissive: 2.47 (1.50, 4.09), p < .001 Women not more likely than men to identify as a switch: 0.79 (0.45, 1.38), p = .488
Brown et al.	2017	Demographics; Psychological Correlates	576 (384 males, 173 females, 19 other)	Convenience sampling of BDSM identified individuals across online platforms	Quantitative survey, online	Demographic questionnaire about BDSM ID/involvement and pre-existing measures of suicide and pain tolerance	The total indirect effect of fearlessness about death and perceived pain tolerance as mediators for the relationship between BDSM engagement and suicide attempts was significant for men (95% CI [.046, .371], p < .05) but not for women (95% CI [−.007, .355], p > .05).
Chivers et al.	2014	BDSM ID, Engagement, and Behaviors*; Demographics	Study 1: 54 men Study 2: 46 women	Study 1: Community convenience sample of men in Canada Study 2: Community convenience sample of women in Canada	Study 1 & 2: Quantitative quasi-experimental and survey design, in-person	Study 1: measured both genital and sexual arousal to audio narratives, paraphilias scale Study 2: same as study 1, but with the addition of measures of sexual orientation and identity	Study 1: Men with masochistic sexual interest (MMI) had greater subjective arousal to masochistic sex than neutral stimuli: ${\eta }_p^2$ = .843, p < .001 MMI did not differ in subjective arousal to conventional and masochistic sex narratives: ${\eta }_p^2$ = .211, p = .060 MMI had sig. greater subjective response to masochistic sex stories than men with conventual sexual interest (MCI): d = 0.90, p = .015 MMI had sig. greater genital arousal to masochistic sex than neutral stimuli: ${\eta }_p^2$ = .739, p < .001 MMI did not differ in genital arousal to conventional and masochistic sex narratives: ${\eta }_p^2$ = .002, p = .865 MMI had sig. greater genital arousal to masochistic sex than MCI: d = 1.06, p < .001 Study 2: Women with masochistic interests (WMI) reported greater same-sex attraction than women without these interests: ${\eta }_p^2$ = .336, p < .001 WMI had sig greater subjective masochism index than women with conventional sexual interests (WCI): d = 1.83, p < .001 WMI had greater genital masochism index than WCI: d = 0.91, p = .014
Connolly	2006	Etiology; BDSM ID, Engagement, and Behaviors*; Demographics*; Interpersonal Factors; Psychological Correlates*	132 (73 males, 56 females, 3 transgender individuals)	Convenience sample of BDSM club/organization participants in California	Quantitative survey, in-person proctored testing sessions	Detailed demographic questionnaire and 7 pre-existing measures of psychopathology	BDSM participants had lower depression (${\eta }_p^2$ = .440, p < .001), anxiety (${\eta }_p^2$ = .847, p < .001), PTSD/trauma (${\eta }_p^2$ = .494, p < .001), and BPD (d = −1.24, p < .001) scores than population norms BDSM participants had higher dissociation scores than population norms:${\eta }_p^2$ = .127, p < .001 Higher submission scores were related to higher PTSD scores when compared to domination scores: β = −.22, p < .05 BDSM participants had slightly lower psychological sadism (${\eta }_p^2$ = .147, p < .001) and masochism (${\eta }_p^2$ = .207, p < .001) scores than population norms. More submissiveness predicted more paranoia symptoms (β = −.24, p < .05) and dependence (β = −.22, p < .05). More dominance predicted histrionic (β = .36, p < .01) and narcissistic personality disorder symptoms (β = .31, p < .01).
Cross & Matheson	2006	Etiology*; Psychological Correlates	Study 1: 154 (93 BDSM ID [24 females, 69 males], 61 control/non BDSM ID [15 females, 46 males])	Study 1: Online convenience sample of both BDSM and non BDSM identified participants	Study 1: Quantitative survey via email or mail	Study 1: Multiple pre-existing measures of mental health, sexual behaviors, and gender bias *Study 2 & 3: These studies were not included due to exclusion criteria	Study 1: Authoritarianism was significantly higher in control group compared to the BDSM group: ${\eta }_p^2$ = .039, p = .034. No significant differences in feminist beliefs between switches (d = 0.36, p = .115), masochists (d = 0.31, p = .086), or sadists (d = 0.13, p = .559) and controls. No significant differences between switches (d = 0.04, p = .861) or sadists (d = 0.17, p = .501) and masochists or switches and sadists (d = 0.14, p = .589). Males had significantly higher traditional gender role beliefs than females: ${\eta }_p^2$ = .080, p < .001. OR (95% CI), Sadists were not less likely to be employed than controls: 0.96 (0.38, 2.42), p = .862
Damon	2003	Etiology; Demographics	342 males	Online and in-person convenience sample of sadomasochistically identified males	Mixed methods survey via email or mail	Measures of SM experience created for the study, plus pre-existing measures of self-esteem and sexism	Submissives had lower self-esteem than dominants: ${\eta }_p^2$ = .046, p < .001 Submissives had higher benevolent (${\eta }_p^2$ = .115, p < .001) and hostile (${\eta }_p^2$ = .033, p = .004) sexism than dominants
Dancer et al.	2006	Interpersonal Factors	146 (66 males, 80 females)	Online convenience sample of self-identified 24/7 slaves	Quantitative survey, online	A measure created about the ‘24/7 slave’ experience	Not applicable/calculable for results presented in review
Dawson et al.	2016	Etiology; Incidence Rates; Psychological Correlates	1,226 (351 men, 785 women, 90 unidentified)	Opportunity sample of Canadian undergraduate students	Quantitative survey, online	A measure of paraphilic interest, plus pre-existing measures of sex drive, gender beliefs, personality, and neuro-developmental factors	Average level of arousal to fantasies for men compared to women: Fetishism: d = 0.48, p < .001 (more arousal for men) Sadism: d = 0.26, p < .001 (more arousal for men) Masochism: d = −0.01, p = .901 More arousal to masochism was related to more arousal from sadism: $r^2$ = .43, p < .001 OR (95% CI), Men report arousal to sadistic sexual interest more often than women: 2.11 (1.48, 3.00), p < .001 Men have a higher incidence rate of atypical sexual interests than women: d = 0.04 p < .001 No association between non-right handedness and paraphilic interest in men: $r^2$ = .006, p = .217 Non-right handedness weakly associated with paraphilic interest in women: $r^2$ = .007, p = .031 Total indirect effect of natal sex on paraphilic interests mediated by sex drive: β = −.24 95% CI [−.31, −.18] There were significant positive relationships between hypersexuality (men: $r^2$ = .063, p < .001, women: $r^2$ = .091, p < .001), sexual compulsivity (men: $r^2$ = .067, p < .001, women: $r^2$ = .057, p < .001), impulsivity (men: $r^2$ = .016, p < .05, women: $r^2$ = .009, p < .05), sensation seeking (men: $r^2$ = .009, p < .05, women: $r^2$ = .017, p < .001), and total paraphilia scores
Fuss et al.	2018	Interpersonal Factors	546 (347 women, 189 men, 10 unidentified)	Convenience and snowball sample of mental health professionals (via email) from Germany, Austria, or Switzerland	Randomized controlled trial, quantitative survey, online	Case vignettes created for the study, pre-existing measures of stigma and a measure of estimated psychopathology	Mental health practitioners (MHP) gave lower pathology scores to female subjects than male subjects in sexual sadism vignettes (${\eta }_p^2$ = .033, p < .001), but not in sexual masochism vignettes (${\eta }_p^2$ = .000, p = .964). MHP trained in psychoanalysis pathologized sexually sadistic behaviors more than people trained in CBT: ${\eta }_p^2$ = .013, p = .005. Males with sexual sadism were perceived as being more dangerous (${\eta }_p^2$ = .042, p < .001) and MHP indicated they wanted more social distance from males (${\eta }_p^2$ = .041, p < .001) than females. In the sexual sadism vignettes, female subjects were less likely to be diagnosed as mentally disordered than men: ϕ = .162, p < .001.
Hawley & Hensley	2009	Etiology*	470 (231 women, 239 men)	Opportunity sample of college students at a university in Kansas	Quantitative survey, online	Sexual fantasy vignettes created for use in this study, measures of social dominance/resource control, and short measure of neuroticism adapted from a pre-existing Big 5	Women preferred the male domination scenario more than men preferred the male domination scenario: ${\eta }_p^2$ = .368, p < .001
Hébert & Weaver	2014	Demographics*; Psychological Correlates*	270 (93 males, 168 females, 7 transgender/intersex individuals, 2 unidentified)	Convenience sample from BDSM related subreddits	Quantitative survey, online	BDSM related demographic questions and pre-existing measures of desire for control, personality, self-esteem, life satisfaction, and interpersonal reactivity	Submissives scored higher than dominants on emotionality: ${\eta }_p^2$ = .020, p = .020 Dominants scored higher than submissives on desire for control (${\eta }_p^2$ = .029, p = .006) and extraversion (${\eta }_p^2$ = .030, p = .005)
Hillier	2019	Eitiology; Psychological Correlates	68 (39 female, 23 male, 6 other)	Convenience sample from online kink identified individuals	Quantitative survey, online	Socio-demographic data, kink role identification and behaviors, preestablished measures of childhood trauma and the Big 5	Trauma scores did not significantly predict dominance (p = .064, $R^2$ not given) or submission (p = .935, $R^2$ = .00) scores Neither neuroticism or extraversion predicted dominance (p = .382, $R_{adj}^2$ = .001) or submission (p = .470, $R_{adj}^2$ = .007)
Holvoet et al.	2017	BDSM ID, Engagement, and Behaviors*; Incidence Rates; Interpersonal Factors	1,027 (459 men, 565 women, 3 other)	Representative sample of Belgian citizens	Quantitative survey, online	Measure created for the study of various BDSM interests and questions about BDSM involvement/identification	Positive relationship between dominance and submission sum scores: $r^2$ = .702, p < .001 Women had significantly higher submission sum scores than men: ${\eta }_p^2$ = .010, p < .001 Men had significantly higher domination sum scores than women: ${\eta }_p^2$ = .041, p < .001
Houngbedji & Gullem	2016	Incidence Rates	95 (62 men, 33 women)	Online convenience sample of French swingers	Quantitative survey, online	Socio-demographic data, questions about swinging and other sexual practices, self-report use of drugs, and a pre-existing measure of sensation seeking	Not applicable to/calculable for results presented in review
Joyal	2015	Demographics*; Incidence Rates*	1,516 (799 women, 717 men)	Online convenience community sample of US adults	Quantitative survey, online	A revised version of the Wilson Sex Fantasy Questionnaire	Not applicable to/calculable for results presented in review
Joyal & Carpentier	2017	Etiology; Demographics; Incidence Rates	1,040 (475 men, 565 women)	Semi-representative sample of adults in Quebec, via telephone and online	Quantitative, survey administered via telephone or online	Questionnaire created for this study that included demographic information, sexual behavior/experience, pornography consumption, paraphilic sexual arousal, and sexual satisfaction	OR (95% CI): Women had a higher desire to engage in masochism (1.7 [1.3–2.0], p = .001) and fetishism (1.4 [1.1–1.7], p = .015) than men, and men had a higher desire to engage in sadism (1.9 [1.2–3.1], p = .007) Women had higher lifetime engagement rates of masochism (2.0 [1.4, 2.5], p < .001) than men, and men had higher lifetime engagement rates of sadism (2.0 [1.1, 3.4], p = .014) and fetishism (1.4 [1.1, 1.9], p = .012)
Joyal et al.	2015	Etiology; Incidence Rates	1,516 (799 women, 717 men)	Community convenience/snowball sample of adults in Quebec advertised both online and in other media	Mixed methods survey, online or via telephone	A revised version of the Wilson Sex Fantasy Questionnaire, plus a qualitative section (not included in review) where participants described their sexual fantasies	OR (95% CI) for presence of fantasies for women compared to men: Women had a higher prevalence rate for the fantasy of being dominated (1.60, [1.30–1.97], p < .001) and being spanked or whipped (1.43 [1.15, 1.78], p = .001) than men Men had a higher prevalence rate of the fantasies of dominating others (0.60, [0.49, 0.73], p < .001) spanking or whipping others (0.41, [.33, .51], p < .001), and forcing someone to have sex (0.43, [0.32, 0.57], p < .001) Women reported more intense fantasies about being dominated (d = 0.29, p < .001) and being whipped or spanked (d = 0.19, p < .001) than men Men reported more intense fantasies about dominating someone else than women: d = 0.26, p < .001 More domination fantasies were linked to more submission fantasies: $r^2$ = .250, p < .001 Men’s overall ratings of sexual arousal to sexual fantasies were higher than women’s: ${\eta }_p^2$ = .106, p < .001
Jozifkova et al.	2012	Etiology	340 (157 men, 183 women)	Opportunity sample of last-year high school students from 15 high schools in Prague. This was a nested study.	Quantitative survey, in-person	A questionnaire designed for this and a larger study, focused on relationship partner preference and bondage/dominance/submission	For males, dominance scores significantly correlated with 7/8 items about desiring hierarchical disparity between partners ($r^2$ = .027-.098, p < .001 - < .05); for females only 2 items correlated with dominance scores ($r^2$ = .028-.102, p < .001 – < .05) Opportunism scores ns. with 8 items for males ($r^2$ = .002-.015, p > .05) or females ($r^2$ = .000-.016, p > .05).
Kelsey et al.	2013	Interpersonal Factors	766 (437 females, 329 males)	Convenience sample of licensed psychotherapists residing in the US via email	Quantitative survey, online	A questionnaire designed for this study including information on socio-demographics, professional information (e.g., degree type/therapy style), beliefs about treating BDSM identified clients, and attitudes toward BDSM	Therapists with experience treating BDSM identified patients reported more positive attitudes toward BDSM: $r^2$ = .023, p < .001 Therapists who felt competent to treat BDSM clients had significantly more positive attitudes than those who did not consider themselves to be competent: d = 0.82, p < .001 Therapists with no graduate training on BDSM had less accepting attitudes than those with some training: d = 0.29, p < .001
Kimberly et al.	2018	Interpersonal Factors*	238 women	Convenience sample of women online and through other media	Mixed methods survey, online	Pre-existing measures of physical satisfaction, sexual communication, and a measure (created for study) of basic BDSM behavior.	Engaging in BDSM related to an increase in comfort discussing sexual topics, controlling for relationship status: β = .25, p < .001. Engaging in BDSM not related to an increase in physical relationship satisfaction: β = .13, p = .060
Klement et al.	2017a	BDSM ID, Engagement, and Behaviors	67 (33 women, 26 men, 3 transgender individuals, 5 not specified)	Opportunity in-person sample of adults attending a BDSM event in Arizona	Mixed methods in-person, survey and behavioral observation	Survey created for study asked about BDSM role and experience, sexual arousal, psychological state both during and after event. Cortisol measured via saliva.	Sexual arousal increased from before to during the sadomasochistic (SM) event: d = 0.53, p = .037. Negative affect decreased from before to during SM event: d = 0.58, p = .014. Stress levels decreased from before to during SM event: d = 0.54, p = .022.
Klement et al.	2017b	Etiology	185 (111 women, 74 men)	Convenience sample from 3 groups: MTurk, college students, and the BDSM community	Quantitative survey, online	Pre-existing measures of sexism, rape myth acceptance, victim blaming, and expectation/acceptance of sexual aggression	No significant differences between the BDSM and two control samples on levels of hostile sexism (${\eta }_p^2$ = .019, p = .185) or expectation of sexual aggression (${\eta }_p^2$ = .015, p = .266) BDSM had significantly lower benevolent sexism (${\eta }_p^2$ = .154, p < .001) rape myth acceptance (${\eta }_p^2$ = .144, p < .001), victim blaming (${\eta }_p^2$ = .060, p = .004), and acceptance of sexual aggression (${\eta }_p^2$ = .043, p < .027) scores than control groups
Lammers & Imhoff	2016	Etiology; BDSM ID, Engagement, and Behaviors	14,306 (9,016 women, 5,290 men)	Opportunity/convenience sample from readers of two magazines in the Netherlands	Quantitative survey, online	Information of occupational hierarchy (position), and a pre-existing measure of sexual interest	Men were more strongly aroused to sadistic thoughts than women: d = 0.48, p < .001. Social power related to arousal to sadistic thoughts: B = .026, p = .011. Power increased arousal to sadistic thought for women (B = .032, p < .001), but not men (B = −.024, p = .146) Women were more aroused by masochistic thoughts than men: d = 0.21, p < .001 Social power increased men’s arousal to female masochism: B = .062, p < .001
Långström & Hanson	2006	Demographics	2,450 (1279 men, 1171 women)	Random sample of Swedish adults via mail	Quantitative survey, in-person interviews	Measures of impersonal sex, life/sexual satisfaction, sexual history, paraphilic sexual arousal, drug use, and other risk factors	OR (95% CI), Women (14.16 [3.02, 66.31], p < .001) and men (13.36 [4.12, 43.32], p < .001) who engaged in more sexual activities and reported hypersexuality more likely to deliberately use pain during sex compared to those with low sexual activity and low hypersexuality.
Lodi-Smith et al.	2014	Demographics*; Psychological Correlates	595 (244 males, 334 females, 17 gender fluid)	Convenience sample online	Quantitative survey, online	Pre-existing measures of the Big 5, the Dark Triad, and sexually deviant behavior	In multiple regression, only openness (β = .23, p < .01) was significant predictor of sadomasochistic activities in men. In the same regression for women, more openness (β = .14, p < .01), low conscientiousness (β = −.12, p < .05) and Machiavellianism (β = .20, p < .01) all significantly predicted sadomasochistic behaviors
Luo & Zhang	2018a	Etiology; Psychological Correlates	Study 1: 363 (283 BDSM ID [190 males, 97 females], 80 non BDSM ID/control [41 males, 39 females]) Study 2: 64 females	Study 1: Convenience online sample of Chinese BDSM and non-BDSM identified individuals Study 2: Convenience sample of 64 Chinese females that identified as submissive	Study 1: Quantitative quasi-experimental and survey design, online Study 2: Quantitative quasi-experimental and survey design, in-person	Study 1: Pre-existing measures of interpersonal reactivity, self-esteem, SES, life satisfaction, a relationship assessment, and 12 female face photographs rated for pain/enjoyment/arousal and relationship to BDSM Study 2: 48 digital pictures of female faces as stimuli and participants’ reactions measured by both EEG and subjective ratings	Study 1: Female submissive had lower trait empathy than switches and controls, but not dominants: ${\eta }_p^2$ = .210, p < .001. Female submissives had lower subjective empathetic responses than controls: ${\eta }_p^2$ = .447, p < .001. Study 2: Female submissives had lower subjective empathetic responses than controls: ${\eta }_p^2$ (average) = .665, p < .001.
Luo & Zhang	2018b	Etiology; Psychological Correlates	26 females	Opportunity sample of 26 Chinese female submissives, recruited from Luo and Zhang (2018a)	Quantitative quasi-experimental and survey design, in-person	48 digital pictures of female faces as stimuli and participants’ reactions measured by both EEG and subjective ratings of pain/enjoyment/arousal and the image’s relationship to BDSM	Female submissives’ responses in the N1, early LPP, and late LLP neural responses to other’s suffering inhibited in gag vs no gag condition: N1 (measured across 6 electrodes): ${\eta }_p^2$ = .120 - .280, p < .001 - < .05. Early LLP (6 electrodes): ${\eta }_p^2$ = .110 - .190, p = .006 - .049. Late LLP (8 electrodes): ${\eta }_p^2$ = .180 - .210, p = .003 - .007.
Martinez	2018	BDSM ID, Engagement, and Behaviors*	202 (102 women, 96 men, 2 genderqueer)	Convenience sampling online of adults (no geographical limitations)	Mixed methods survey, online	A questionnaire created for this study asked about demographics, BDSM experiences/identification, and body satisfaction information. The qualitative component was not included in this review.	There was a significant effect of both gender (${\eta }_p^2$ = .041, p = .024) and sexual identity (${\eta }_p^2$ = .081, p < .001) on BDSM role fluidity. Women had higher role fluidity than men: d = 0.39, p = .006. OR (95% CI), Men more likely than women to identify as being in the dominant category: 9.52 (4.62, 19.63), p < .001. Women more likely than men to identify as being in the submissive category: 5.94 (3.17, 11.11), p < .001. Switches were not less likely to be heterosexual than submissives: 0.66 (0.31, 1.38), p = .354. Switches were less likely to be heterosexual than dominants: 0.11 (0.05, 0.26), p < .001.
Moskowitz et al.	2011	Interpersonal Relationship Factors	2,209 men (665 BDSM identified, 1,554 non BDSM identified)	Convenience in-person sample of both BDSM Leathermen and non-Leathermen at two separate unrelated events	Quantitative, in person survey	A questionnaire created for this study and asked about Leatherman affiliation, HIV status, HIV testing, STI testing, number of partners, and condom use	OR (95% CI): Leather (BDSM) identified men were more likely than non-leather men to be HIV positive: 1.62 (1.19, 2.21), p < .01 Leather submissives were more likely to be HIV positive than non-leather men of any BDSM role identification: 2.19 (1.46, 3.26), p < .001
Nordling et al.	2000	Etiology*; Psychological Correlates	186 (164 males, 22 females)	Opportunistic sampling from 2 BDSM clubs in Finland via mail	Quantitative survey, via mail	Questionnaire from Alison et al. (2001), Nordling et al. (2006), Sandnabba et al. (1999), & Santtila et al. (2001) about BDSM and sexual experience, childhood background, and mental/physical health	OR (95% CI), Abused participants had more of the following than non-abused: Suicide attempts: 17.18 (4.92, 59.96), p < .001 Psychiatric in-patient visits: 8.83 (2.69, 28.98), p < .001 Out-patient psychological counseling: 11.71 (2.64, 51.95), p = .003 Visits to GP about BDSM-related injuries: 6.88 (1.07, 44.22), p < .010 Likelihood of abused vs non-abused BDSM participants to engage in BDSM club behaviors: r = .122, p = .003
Nordling et al.	2006	BDSM ID, Engagement, and Behaviors	186 (164 males, 22 females)	Opportunistic sampling from 2 BDSM clubs in Finland via mail	Quantitative survey, via mail	Questionnaire from Alison et al. (2001), Nordling et al. (2000), Sandnabba et al. (1999), & Santtila et al. (2001) about BDSM and sexual experience, childhood, mental/physical health	More heterosexuality was related to a preference for masochism in men (ρ = −.16, p = .042) and in women (ρ = −.66, p < .001)
Oliveira Júnior & Abdo	2010	Demographics*; Incidence Rates; Psychological Correlates	7,022 (3,188 women, 3,834 men)	Opportunistic, in-person sampling of adults in 18 cities in 13 Brazilian states	Quantitative survey, in-person	Questionnaire created for this study that measured demographics, general life habits, sexual behavior/history/orientation, general health, and sexual difficulties	OR (95% CI), Men more likely than women to participate in more than one usual sexual behavior (USB) compared to only one unusual sexual behavior: 2.15 (2.27, 2.77), p < .001. Men (1.75 [1.29, 2.37], p < .001) and women (1.50 [1.05, 2.14], p = .033) with at least one USB more likely than men without an USB to show PTSD symptoms. Men (4.74 [2.39, 9.42], p < .001) and women (3.39 [2.38, 4.83], p < .001) with at least one USB more likely than those without to have ever been a victim of sexual violence.
Pascoal et al.	2015	BDSM ID, Engagement, and Behaviors*; Demographics*	68 (22 women, 46 men)	Convenience/snowball sample of BDSM identified individuals in Portugal through local BDSM organizations	Quantitative survey, online	A BDSM questionnaire created for this study asking about age of first experience, most liked practices, self-report measures of sexual dysfunction, and a pre-existing measure of sexual satisfaction	Not applicable to/calculable for results presented in review
Rahman & Symeonides	2008	Etiology	200 men	Opportunistic/snowball in-person sampling from adult men in the London area	Quantitative survey, in-person	Pre-existing measures of sexual fantasy (WSFQ), handedness, sibling sex composition, digit ratios	Those with more paraphilic interest had more older brothers than those with low paraphilic interest: d = 0.49, p = .001. High paraphilics had trend toward having more non-right handedness than low paraphilics: d = 0.26, p .070
Rehor	2015	BDSM ID, Engagement, and Behaviors*; Demographics*	1,580 women	Opportunistic/convenience sampling through kink communities and online BDSM pages. There was no geographic limitation	Quantitative survey, online	Bespoke measure of interest/participation in a wide range of BDSM, role-play, erotic, exhibitionistic, fetishistic, and other sexual behaviors	Not applicable to/calculable for results presented in review
Richters et al.	2014	Demographics; Incidence Rates	20,094 (9,985 men, 9,730 women)	Representative sample of Australian men and women recruited via telephone	Quantitative survey, via telephone interview	Demographics, and bespoke questions about masturbation, pornography consumption, a range of sexual behaviors (e.g., BDSM, sex toy use, role-play, anal, etc.), and paying for sex.	OR (95% CI) for current study: Women participated less than men in BDSM (0.63 [0.43–0.92], p = .017) but not in role play (1.15 [0.89–1.49], p = .292). OR (95% CI) of percentage of sample indicating participation in following activities in Richters et al. (2003) compared to the percentage of the Richters et al. (2014): BDSM, men: 1.42 (0.94–2.14), p = .095 BDSM, women: 1.29 (0.70–2.38), p = .422 Role play, men: 2.18 (1.58–3.02), p < .001 (higher in 2014 cf. 2003) Role play, women: 2.62 (1.89–3.64), p < .001 (higher in 2014 cf. 2003)
Richters et al.	2008	Etiology; Demographics; Psychological Correlates	19,307 (10,173 men, 9,134 women)	Representative sample of Australian men and women recruited via telephone	Quantitative survey, via telephone interview, a nested study in Richters et al. (2003).	Survey from Richters et al. (2003) and further questions about participation in less common sexual activities (e.g., BDSM), history of sexual coercion, psychological wellbeing, and sexual difficulties	OR (95% CI) for the experience/engagement in the following among BDSM vs non-BDSM participants: Sexual coercion before 16: Men: 2.03 (0.75, 3.38), p = .228 Women: 0.99 (0.36, 3.03), p = .987 Psychological distress: Men: 0.33 (0.14, 0.80), p = .010 (BDSM group lower) Women: 2.20 (0.88, 6.26), p = .118 Masturbation (lifetime): Men: 1.46 (0.49, 4.34), p = .493 Women: 3.89 (1.37, 11.07), p = .011 (BDSM higher) Bisexual experience: Men: 4.44 (2.96, 9.33), p < .001 (BDSM higher) Women: 5.69 (1.97, 16.42), p = .001 (BDSM higher) More than 50 sexual partners: Men: 3.13 (1.28, 7.66), p = .012 (BDSM higher) Women: 6.76 (1.93, 23.69), p = .003 (BDSM higher) Sexual difficulties (8 were measured): Men: 0.57 (0.24, 1.33) - 2.93 (0.78, 11.00), p = .110 - .997 Women: 0.58 (0.22, 1.56) - 1.81 (0.73, 4.46), p = .198 - .897
Richters et al.	2003	Incidence Rates; Psychological Correlates	19,307 (10,173 men, 9,134 women)	Representative sample of Australian men and women recruited via telephone	Quantitative survey, via telephone interview	Bespoke survey asking about demographic information, autoerotic, esoteric, and other sexual behaviors (e.g., role playing, anal sex)	OR (95% CI): There were no differences between men and women in the engagement of BDSM (0.68 [0.36–1.29], p = .239) or role play (0.94 [0.64–1.37], p = .730)
Rogak & Connor	2017	Interpersonal Factors	163 (75 males, 84 females, 3 transgender individuals)	Convenience/snowball sample of BDSM participants in committed relationships from two BDSM related websites	Quantitative survey, online	An inventory of BDSM participation was created for this study, and was preceded by a pre-existing measure of dyadic adjustment	Dominants and submissives did not differ in overall dyadic adjustment/relationship satisfaction: d = 0.10, p = .603. BDSM participants scored above the criterion variable for dyadic adjustment indicating relationship distress: d = 0.32, p < .001.
Roush et al.	2017	Demographics; Interpersonal Factors; Psychological Correlates	321 (198 males, 108 females, 9 transgender individuals, 4 other identified)	Convenience sample of individuals who endorsed BDSM involvement from BDSM-related web forums	Quantitative survey, online	Demographics and pre-existing measures of suicidal ideation, depression, interpersonal needs, and other measures of well being	Thwarted belongingness and perceived burdensomeness mediated the relationship between shame and suicidal ideation in BDSM practitioners, $R^2$ = .57, p < .001
Rye et al.	2015	Interpersonal Factors; Psychological Correlates	94 females	Convenience sample of female students in an undergraduate research experience group	Quantitative survey, in-person survey during a larger testing session	Two newspaper-like articles about BDSM (stimuli) and accompanied by questions about perceptions of BDSM. Pre-existing measures of sexual communication and comfort, sexual anxiety and sexual liberalism	Erotophilia (via scores on 7 measures) was positively related to personal feelings about BDSM ($r^2$ = .109 - .462, p < .001) and to comfort in discussing BDSM ($r^2$ = .058 - .303, p < .001 - < .05). Personal feelings about discussing BDSM did not change based on whether participants received a positive or negative media portrayal passage, ${\eta }_p^2$ = .000, p = .863.
Sagarin et al.	2009	Interpersonal Factors*	Study 1: 13 (6 women, 7 men) Study 2: 45 (19 women, 26 men)	Study 1 & 2: Opportunistic in-person sample of attendees of a BDSM even in Arizona	Study 1 & 2: Quantitative, in-person survey, and hormone level testing	Study 1 & 2: Researchers created two surveys- one for before a scene took place, and one for after- that asked about BDSM roles, anticipation/result of the scene, and measures of their perception of scene partner. Salivary testosterone where samples taken before and after the scene occurred.	Study 1: Between baseline and 20 minutes after the BDSM scene, bottoms’ cortisol levels rose significantly (${\eta }_p^2$ = .326, p = .040), but tops levels did not (${\eta }_p^2$ = .000, p > .050). Study 2: Between baseline and 20 minutes after the BDSM scene, bottoms’ cortisol levels rose significantly (${\eta }_p^2$ = .236, p = .002), but tops levels did not (${\eta }_p^2$ = .000, p > .050). One measure of relationship satisfaction/closeness increased significantly from before to after the BDSM scene, regardless of how scene went (p < .001).
Sanchez et al.	2006	Etiology	36 females	Convenience, in-person sample of undergraduate females at the University of Michigan	Quantitative behavioral observation, quasi-experimental design	A lexical-decision task with eye tracking was created for use in this study with stimuli that were associated with sex or dominance/submission	Women responded faster to sex primed submissive words than neutral primed submissive words: ${\eta }_p^2$ = .110, p = .030. Women responded slower to sex primed dominant words than to neutral primed dominant words: ${\eta }_p^2$ = .360, p < .001. There was no difference in men’s response time to sex primed submissive and neutral primed submissive words: ${\eta }_p^2$ = .068, p = .190. Men responded slower to sex primed dominant words than neutral primed dominant words: ${\eta }_p^2$ = .508, p < .001.
Sandnabba et al.	1999	BDSM ID, Engagement, and Behaviors	164 males	Opportunistic sampling from 2 BDSM clubs in Finland via mail	Quantitative survey, via mail	Questionnaires from Alison et al. (2001), Nordling et al. (2000/2006), Sandnabba, Santtila, Nordling, Beetz, and Alison (2002), & Santtila et al. (2001) about BDSM and sexual experience, childhood background, and mental/physical health	Gay men were older than heterosexual men at age of first awareness of BDSM interest (${\eta }_p^2$ = .093, p = .004) and at age of first BDSM experience (${\eta }_p^2$ = .086, p = .006). There was a non-significant tendency for heterosexual men to be masochists and gay men to be sadists: A significant proportion of participants had lighter BDSM sessions than they wanted (ϕ = .647, p < .001) and believed they wanted heavier sessions than their partners (ϕ = .410, p < .001).
Sandnabba et al.	2002	BDSM ID, Engagement, and Behaviors	12 males	Opportunistic sampling from 2 BDSM clubs in Finland via mail This was a sub sample from a larger study	Quantitative survey, via mail	Questionnaires from Alison et al. (2001), Nordling et al. (2000), Sandnabba et al. (1999), & Santtila et al. (2001) about BDSM and sexual experience, childhood background, and mental/physical health	Zoophilic oriented participants were more likely to have participated in more sadomasochistic behaviors than matched non-zoophilic BDSM controls, including the use of knives (ϕ = .607, p < .01), skin branding (ϕ = .519, p < .05), face slapping (ϕ = .467, p < .05), and urologia (ϕ = .430, p < .05)
Santtila et al.	2002	BDSM ID, Engagement, and Behaviors*	186 (164 males, 22 females)	Opportunistic sampling from 2 BDSM clubs in Finland via mail	Quantitative survey, via mail	Questionnaires fromAlison et al. (2001), Nordling et al. (2006), Sandnabba et al. (1999), & Santtilla et al. (2001) about BDSM and sexual experience, childhood background, and mental/physical health	Not applicable to/calculable for results presented in review
Santtila et al.	2001	Etiology	164 males	Opportunistic sampling from 2 BDSM clubs in Finland via mail	Quantitative survey, via mail	Questionnaires from Alison et al. (2001), Nordling et al. (2006), Sandnabba et al. (1999), & Santtilla et al. (2002) about BDSM and sexual experience, childhood background, and mental/physical health	Likelihood of sadistic participants having more ambivalent and less secure attachment and masochists having more secure and less ambivalent attachment: Cramer’s V = .401, p = .006
Shulman & Home	2006	Etiology; Psychological Correlates	261 women	Convenience online sample of adult women residing in US	Quantitative survey, online	Pre-existing measures of sexual fantasy, experience, guilt, opinions, and feminist perspectives	Ns. relationship between feminist beliefs and forceful sexual fantasy ($r^2$ = .014, p = .053) or between CSA and sex guilt ($r^2$ = .002, p = .318). Lower sex guilt related to more erotophilia ($r^2$ = .645, p < .001) and forceful sexual fantasies ($r^2$ = .071, p < .001). Higher erotophilia was related to more forceful sexual fantasies: $r^2$ = .132, p < .001. Higher erotophilia was related to lower sex guilt: $r^2$ = .645, p < .001.
Tomassilli et al.	2009	Demographics; Incidence Rates	347 women	Convenience in-person sample of gay and lesbian women at two community events in New York City	Quantitative survey, in-person	A measure of demographics and engagement in bondage/domination, SM, photo/video exhibitionism, and asphyxiation/breath play was created for this study	OR (95% CI) for participation in kinky sexual behaviors for lesbian vs bisexual women: Sadomasochism: 0.66 (0.34, 1.27), p = .211 Bondage and domination: 0.65 (.37, 1.16), p = .144 Photo or video exhibitionism: 0.35 (0.19, 0.64), p < .001 (bisexual women more) Breath play: 1.00 (0.28, 3.58), p = .647 Women who engaged in the following sexual behaviors were younger at their age of first sexual behavior than women who did not engage in these: Bondage and domination: d = 0.35, p = .004 Sadomasochism: d = 0.34, p = .019
Watts et al.	2019	Psychological Correlates	608 (443 women, 165 men)	Convenience sample of undergraduate students from two universities in the Southeastern US	Quantitative survey, distribution/data collection method not specified	Measures of paraphilic interests and existing measures of personality disorder symptoms, erotophilia, psychopathy, and narcissism	Sexual sadism was significantly positively correlated with: Narcissistic entitlement and exploitativeness: $r^2$ = .032, p < .01 Four of five measures of psychopathy: $r^2$ = .058 - .194, p < .01 Schizotypal personality disorder symptoms: $r^2$ = .078, p < .01 Antisocial personality disorder symptoms: $r^2$ = .584, p < .01 Borderline personality disorder symptoms: $r^2$ = .260, p < .01
Williams et al.	2016	Etiology	935 (293 men, 561 women, 15 transgender individuals, 50 queer or gender fluid)	Convenience online sample of adults who regularly practiced BDSM	Quantitative survey, online	A measure of demographics, BDSM role identification, and both serious and casual leisure was developed for use in this study	Dominants were significantly more likely than submissives to indicate BDSM was serious (cf. casual) leisure on 4/6 serious leisure items: Cramer’s V, .055- .070, p < .001 - .034
Williams et al.	2009	Incidence Rates; Psychological Correlates	Study 1: 103 men Study 2: 88 men	Study 1 & 2: Convenience, in-person sample of undergraduate students from a large Western university	Study 1 & 2: Quantitative survey, in-person	Study 1: A demographic questionnaire including questions about pornography use, and a pre-existing measure of deviant fantasies and behaviors Study 2: In addition to the survey from study 1, participants completed Big 5 and Dark Triad measures	Study 1: Positive relationship between sum deviant behaviors and fantasies: $r^2$ = .504, p < .001 Study 2: Positive relationship between sum deviant behaviors and fantasies: $r^2$ = .518, p < .001 Sadistic sexual fantasies were positively related to narcissism ($r^2$ = .096, p = .003) and psychopathy ($r^2$ = .078, p = .008) Bondage fantasies were positively related to psychopathy ($r^2$ = .058, p = .024) Sadistic sexual behaviors were also positively related to narcissism ($r^2$ = .053, p = .031) and psychopathy ($r^2$ = .058, p = .024) Bondage sexual behaviors were positively related to psychopathy ($r^2$ = .058, p = .024)
Wismeijer & Van Assen	2013	Demographics; Psychological Correlates	902 (464 males, 438 females)	Convenience sample of BDSM respondents from a BDSM website in the Netherlands	Quantitative survey, online	Demographics and information about BDSM role, pre-existing measures of attachment, personality, rejection sensitivity, and subjective well-being	Submissives had more anxious attachment than dominants, neither differed significantly from switches: ${\eta }_p^2$ = .038, p = .038 Submissives, switches, and dominants did not differ in avoidant attachment: ${\eta }_p^2$ = .006, p = .543 Non-BDSM females had lower relationship confidence than BDSM females: ${\eta }_p^2$ = .016, p = .001 BDSM participants had higher scores of openness to experience (${\eta }_p^2$ = .045, p < .001), extraversion (${\eta }_p^2$ = .008, p < .05), and conscientiousness (${\eta }_p^2$ = .019, p < .001) and lower scores on rejection sensitivity (${\eta }_p^2$ = .022, p < .001), neuroticism (${\eta }_p^2$ = .033, p < .001), and agreeableness (${\eta }_p^2$ = .018, p < .001) than non-BDSM controls. Dominants and switches scored higher on openness to experiences than submissives: ${\eta }_p^2$ = .045, p < .001 Submissives scored higher on agreeableness than dominants: ${\eta }_p^2$ = .018, p < .001.
Yost	2010	Interpersonal Factors	Study 1: 213 (150 women, 63 men) Study 2: 258 (140 men, 118 women)	Study 1: Convenience in-person sample of undergraduate students from a US liberal arts university Study 2: Convenience in-person sample of undergraduate students from a large public US university	Study 1 & 2: Quantitative survey, online	Study 1: Measure of attitudes about sadomasochism and pre-existing measures of social desirability, authoritarianism, sexual conservatism, and rape myth acceptance Study 2: Validation of model in study 1 and existing measures of social desirability, authoritarianism, and sexual orientation attitudes The samples from study 1 & 2 were combined for the analyses presented in review	In a multiple regression, more homophobia (β = .21, p = .030), sexual conservatism (β = .38, p < .001), social conservatism, as measured by right wing authoritarianism (β = .18, p = .08), and more rape myth acceptance (β = −.15, p = .040) predicted more prejudice toward sadomasochism practitioners People who engaged in sadomasochism had less prejudice toward sadomasochism than those who did not: d = 1.2, p < .001 People who knew others that engaged in BDSM had less prejudicial attitudes than those who did not: d = 0.84, p < .001 As knowledge about sadomasochism increased, attitudes become more positive on all four sub-scales: $r^2$ = .010 - .032, p < .001 - < .05
Yost & Hunter	2012	Demographics	272 (144 women, 128 men)	Convenience sample of self-identified BDSM participants recruited online and in US based BDSM events/organizations	Quantitative survey, online	A bespoke measure that asked about BDSM self-identification, role, and participation	OR (95% CI): Women were significantly more likely than men to identify as submissive: 3.33 (2.02, 5.50), p < .001 Men were significantly more likely than women to identify as dominant: 3.85 (2.13, 6.94), p < .001 Women were not more likely than men to be switches: 0.79 (0.46, 1.35), p = .467
Zubriggen & Yost	2004	Etiology; Incidence Rates	162 (85 men, 77 women)	Convenience sample of adults from a midwestern US city via media advertisements/notices	Mixed methods survey, via mail	Responses to open-ended questions about sexual fantasies; pre-existing measures on rape myth acceptance, attitudes toward women, sexual beliefs, and social desirability. Fantasies were labeled categorically based on content (e.g., domination/submission)	Domination was more likely to appear in men’s sexual fantasies than in women’s: d = .38, p = .02 No difference in the frequency of appearance of submission in sexual fantasies between men and women d = .25, p = .11 Women were more likely to portray themselves as submissive in their fantasies and men were more likely to portray themselves as dominant: ${\eta }_p^2$ = .046, p = .006

*Effect sizes either could not be calculated for all outcomes of interest in this section or they were not applicable to results presented

Figure 1. PRISMA flow diagram for search. Please note that the search was updated on June 27th, 2019 and includes one additional article.

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