Therapy experiences of clients with BDSM sexualities: listening to a stigmatized sexuality.

Author:Hoff, Gabriele
Position:Report
 
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Introduction

In the field of mental health, one current cutting edge is the identification of appropriate and inappropriate therapeutic techniques with people with alternative sexualities. When topics of alternative sexuality arise in the context of therapy, misapplications of diagnostic criteria and a lack of familiarity about alternative sexualities can combine to foster disruptions or dysfunction in the therapeutic interaction (Nichols, 2006). As the field of mental health gains more information about the full range of human sexuality, the increase in knowledge can lead to more accurate diagnoses, effective interventions, and address public misconceptions about human behavior and mental health.

Clinical practice around issues of alternative sexuality and mental health is hindered by the difficulties in translating research and scholarship into clinical practice. In particular, assessing pathological from non-pathological expressions of alternative sexuality requires a close relation between research, clinical practice, and professional training. While there are many factors that lead to a noticeable hindrance of scholarship in how to translate sexuality research into practice and clinical practice into research, one factor that we explore in this study is the experience of stigma within therapeutic contexts.

Stigmatization of various forms of sexuality can cause significant difficulties in gaining information from and making observations about people with alternative sexualities. By stigma, we mean that a person is recognized or labeled as having an "undesired differentness from what we had anticipated" (Goffman, 1963; p.5)--and that this difference is seen as discrediting the person, making others suspect that the person is incapable, immoral or diseased. In several cases, the cues for stigma cannot be readily seen by the public, but must be inferred through the "labeling" of a person (Goffman, 1963; Major & O'Brien, 2005). Stigmatized identities based on characteristics unseen by the public can lead people to "pass" as not having that characteristic, or lead people to avoid interactions and conversations about the stigmatized characteristic with those who don't share that characteristic. The labeling of certain kinds of sexuality as a mental disorder or illness (whether justified by scientific evidence, or not) can instigate the experience of stigma. Stigma can be realized through the activation of stereotypes, prejudice and discrimination--and people with stigmatized sexualities can experience difficulties in accessing mental health services. Some of these difficulties may be caused by negative assumptions held by health care providers about the client's sexuality and others emerge from negative assumptions internalized by the client.

This paper will focus on the experience of people whose sexuality includes BDSM practice. BDSM stands for bondage/discipline, dominance/submission, and sadism/masochism. BDSM is a term that is used and recognized widely by the members of several alternative sexuality subcultures (Kleinplatz & Moser, 2006). Very few studies of BDSM currently exist, but those few extant studies indicate that it is an aspect that is present in approximately 23% of the population in terms of fantasy, at least on occasion (estimates range from 12-33% for women, 20-50% for men; Kinsey et al. 1953; Arndt et al, 1985) and expressed in behavior by 10% of the population (Masters et al. 1994).

This form and expression of sexuality may intersect with the diagnosis of Paraphilias as a mental disorder. According to the DSM-IV-TR:

A Paraphilia must be distinguished from the nonpathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement in individuals without a Paraphilia. Fantasies, behaviors, or objects are paraphilic only when they lead to a clinically significant distress or impairment ... (boldface in original) (APA 2000, p. 568)

Thus, both explicitly in the text of the DSM and inherent in the logical structure of current diagnostic criteria is a condition in which BDSM interests are present but are not clinically diagnosable as mental illness. Individual clinicians may make the mistake of assuming that all BDSM interests imply mental illness, but such an assumption is not inherent in the current DSM diagnostic guidelines. Diagnostic issues and controversies around appropriate application of these criteria can impact the therapeutic interaction, inviting the experience of stigma.

Moser & Levitt (1995), in a 1987 survey of 225 people who self-identified as practicing BDSM sexuality, found that 5% of their sample endorsed the statement "S/M may best be defined as a mental illness" and that 16.1% "sought help from a therapist regarding my S/M desires." This indicates a relatively low level of internalized stigma but also may indicate a low level of disclosure to a therapist (disclosure rates were not directly measured in the survey). Kolmes, Stock and Moser (2006) surveyed 175 participants who self-identified as practicing BDSM sexuality and who had therapy experience. Of these respondents, more than one-quarter did not disclose their BDSM sexuality to their therapists because they either felt their sexuality was unrelated to the reasons for entering therapy or they were afraid of the response of the therapist. Of those who disclosed, the respondents reported 118 incidents of biased or inadequate care in reaction to the disclosure, and 113 incidents of sensitive or culturally aware care by the therapist upon disclosure.

Nichols (2006) presents an overview of clinical issues that might come up in therapy with BDSM clients or patients, and discusses the impact of stigma in this particular setting from the point of view of the practitioner. In particular, she examines issues of counter transference where the therapist intellectualizes their fear, disgust or anxiety after disclosure of BDSM practice, and the phenomenon of non-disclosure of BDSM as a response to internalized stigma on the part of the client. Having a disclosure narrow the focus of therapeutic interaction against the will or desire of the client, or having BDSM ignored completely, are also discussed as possible impacts of stigma on therapy.

The current study is distinctive from previous research in this area by providing a qualitative analysis of the experiences of BDSM clients in therapy, which can complement the few previous quantitative surveys and the explorations of this topic from the point of view of the practitioner. A careful study of the experiences of people with alternative sexualities when they interact with therapists and counselors would help identify roadblocks and areas of difficulty. A study of this nature can also highlight the positive experiences that people with alternative sexualities have had in counseling, which can act as guidance for future encounters with therapists, as well as provide information for the training of therapists. In this study, we examine the questions "What are the experiences of clients who express BDSM sexuality when they are in therapy? Does stigma make a felt impact on their therapeutic relationships, whether they disclose or not?"

Method

The present investigation employed a content analysis approach to stories and reflections expressed by heterosexual couples who practice consensual erotic BDSM. Heterosexual couples were chosen to minimize the impact of an intersection with other sexual stigmas on the examined experiences of therapy. While couples were recruited as part of the protocol of the original study (Hoff, 2003), the unit of analysis for this study was the individual.

The type of sampling strategy for the study was criterion sampling (Miles & Huberman, 1994). All cases that met the following criteria were included: heterosexual couples who indicated a strong preference for BDSM sexuality in their relationships; committed couples who had been together for at least one year. Participants were recruited through the first author's personal contact with four BDSM social community organizations: Society of Janus in San Francisco, California USA; Bundesvereinigung...

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