50 SHADES OF CARE

Why doctors need to pay more attention to their kinky patients

On Valentine’s Day weekend last year I found myself at Paddles, the local dungeon in New York City’s Chelsea neighborhood, for the first time. I was perched at the alcohol-free bar when a man politely introduced himself as a human carpet. He asked that I tread on him and lay on the floor to demonstrate. A professional dominatrix-in-training stepped onto his chest and buried her stilettos deep into his belly. His eyes were closed and he looked calm—blissful, really. As a medical student, I winced, imaging the arrangement of his delicate organs in relation to her vicious heels.

Just an hour before, I was in a Hell’s Kitchen diner chatting with a group of people interested in kink or BDSM (bondage-discipline, dominance-submission, and sadism-masochism), which includes consensual yet unconventional sexual behaviors that allow participants to experience different roles and sensations.

The monthly novice “munch” was hosted by the Eulenspiegel Society, one of the oldest and largest BDSM organizations in the US that promotes sexual liberation by holding classes, workshops, and social events around New York City.

There were people from all walks of life—artists, educators, scientists—who ranged in age, ethnicity, sexual orientation, and relationship style. Some had been practicing kink privately for years, but were seeking to connect with the larger community. Others were curious and, after mustering up enough courage to attend the meeting, were ready to explore BDSM. I was the lone medical student who wanted to learn from this highly stigmatized group. How can healthcare professionals speak frankly about sex and better care for our patients, of whom a significant number are kinky?

Although studies vary, an estimated 10% of the population has engaged in kink activities, with a much larger proportion interested in it. Those who engage do so along a broad spectrum of activity type and intensity, from a one-time experience to a lifestyle. To bring those numbers into perspective, the 2014 National Diabetes Statistics Report (pdf) announced that 9.3% of the US population has diabetes. Think about how many people you’ve met who have diabetes. When you compare the two, kink-oriented people aren’t as rare as they seem.

With the popularity of Fifty Shades of Grey, the first novel in E.L. James’ erotic trilogy that has sold over 100 million copies worldwide, and the film adaptation opening on Feb. 13, interest in kink is no surprise. The series garnered mixed to negative reviews for its literary merit as well as criticism for its inaccurate portrayal of a BDSM relationship—and its all too accurate portrayal of an abusive one. However, it has accomplished one important change: brought kink into the light.

* * *

When it comes to conversing about sex, medical professionals are often uncomfortable. I can’t count the number of times that my peers and I have been chastised for failing to elicit a sexual history. When we think a medical issue is unrelated to sex, it can feel awkward and like a waste of time to bring it up. But it’s usually the medical professional who feels uncomfortable—not the patient. In my first year of medical school, I interviewed a patient with a spinal cord injury who used a motorized wheelchair to get around. When I finally asked about her sexual history, she thanked me: “I love it when I’m asked about sex. No one ever does because they think I don’t have sex. But it’s an important part of my life.”

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Dr. Jess Waldura (Genevieve Shiffrar)

Dr. Jess Waldura, a family physician and clinical researcher at University of California, San Francisco and The Alternative Sexualities Health Research Alliance, said that one patient was at a kink party and fainted during an emotionally intense scene. When she was brought into the emergency room, doctors wanted to know what she was doing when she fainted, which is an important part of the medical history. “She kept trying to explain that she was at this play party and they just didn’t understand,” Waldura said. “And finally she just had to make up another story because she couldn’t get through to them about what she was doing.”

Yoseñio V Lewis, a polyamorous dominant/top and transgender patient educator at Stanford University, said that this lack of awareness can also diminish preventative health care. He had to seek sexually transmitted infection testing elsewhere because my “doctor stated that, because of my genital status and my sexual partners being female, I was at very low risk,” Lewis told Quartz. “He deemed taking the tests a waste of time.” He was unaware that some kink activities (like needle play) could increase risks for STIs.

YVL - Headshot 2
Yoseñio V Lewis (bella)

At medical school, we’re trained to ask two questions. The first often is, “Are you sexually active?” And after “decades of fighting for equality around sexual orientation,” Waldura told Quartz, there is the second “revolutionary” question: “Do you have sex with men, women, or both?” She would like to see a third asked—“What would you like me to know about your sexuality so I can take the best possible care of you?” While being so open-ended that even grandma won’t be offended, it still gives kink-oriented patients an invitation to begin a dialogue.

Despite the increased presence of kink in popular culture, it’s still a “concealable stigmatized identity” and the community “doesn’t feel their voice is being heard—a deficit on our part. We did not see the need because of our blinders and our own internalized stigma,” Waldura said. “We as medical providers don’t know that it’s there and aren’t trained to look for it. Yet the people in the community feel that there’s a need for us to know.”

* * *

In preparation for the monthly novice munch, I spent some time educating myself about kink and exploring questions like, “How is kink related to physical and mental health?” and “What do medical providers need to know about kink versus abuse?” Of course, there were other questions like, “What does one even wear to a dungeon?”

I settled on an all-black ensemble, a simple dress with tights and sensible boots. I entered an unmarked door and descended into the 5,000 square-foot, multi-level dungeon furnished with what looked like medieval torture devices, cages, benches, and hooks. Dungeon monitors in neon orange traffic control vests patrolled the space, ensuring safety and enforcing rules. I observed as kinksters negotiated scenes, including what activities and toys are permitted or banned. At Paddles, there’s no sex/alcohol/drug use on the premises, no touching others without their express consent, and no cell phones or cameras. They also established verbal or nonverbal safety signals to maintain limits and withdraw consent during play.

In one scene, a dominant/top man meditatively bound two submissive/bottom women in a beautiful configuration of rope—and tickled them until they dissolved into giggles. Kink isn’t just about pain as with sadomasochists, but about stimulation to produce new sensations. A 2009 study suggests that kink produces its own runner’s high, which occurs when oxytocin “bonding hormone” levels soar and cortisol “stress hormone” levels plummet.

In some ways, impact play is a recreational contact sport like football—they both have risks and techniques for playing safely (like tying ropes loosely enough to avoid nerve damage during bondage). And, kinksters with specific health issues have unique considerations. For Lewis, his thyroid and lung problems often limit the intensity of play. Those who use pacemakers for heart problems should avoid electrical toys and those on anticoagulation medication should engage in impact play with utmost caution.

Kink-oriented patients have the same right to medical advice about their sexual practices as anyone else and healthcare providers can help with that. Waldura recounts the story of one of her research interviewees, “a woman who had been pregnant and was quite a hardcore masochist [who] went to seven different obstetricians to try and get some information on what she could do safely.” The patient “finally found someone who knew nothing about kink, but who was willing to sit down and say, ‘Hmm…electrical play. That seems like it’s probably not a good idea. Flogging? On the butt and legs? That seems fine.’” This practical and non-judgmental approach is more important than having extensive knowledge about kink, said Waldura.

* * *

While making my rounds in the dungeon, I noticed a few kinksters with some impressive bruises from consensual play. In the medical community, these marks would trigger additional questioning. While we’ve been trained to screen for abuse and spot the signs, we don’t know how to have a particularly nuanced discussion of consent.

I’ve learned that there’s a big difference between a consensual, negotiated kink relationship and abuse. It’s abuse if there is no explicit consent, which includes situations where someone is afraid to impose limits because of potential consequences.

Keely Kolmes
Dr. Keely Kolmes (Robin Andersen)

“If you’ve had no reason to familiarize yourself with kink…it can be very easy for healthcare providers to assume that they know what’s going on with a patient when they may have no idea,” Dr. Keely Kolmes, a San Francisco-based psychologist in private practice who works with kink-oriented clients, told Quartz. “Clinicians can do a great deal of harm if they’re misinformed.”

As mandatory reporters, healthcare providers are responsible for reporting injuries caused by specific weapons, such as guns and knives. They must also report suspected abuse of vulnerable patients, which can include children, the elderly, and people with disabilities. However, in the US laws differ from state to state, and can be difficult to interpret.

In my training, I learned that healthcare providers are not required to report suspected abuse between adults in most states. But many “doctors have no idea what the law is. They just know that they’re supposed to report violence,” Waldura said. “We have very little training in it. So what happens is a fear response.” Despite conferring with lawyers and risk management about this issue, Waldura said that no one has a definitive answer.

Ham Mason, a queer submissive activist and person of color who has been practicing kink for 20 years, said that there also needs to be more awareness of diversity in the community. “When you think about the face of BDSM, it’s usually either a gay man or straight people and usually the face is white,” she told Quartz. Because of this stereotype, healthcare providers may assume that people of color aren’t kinksters and think that disclosures of kink activity may be a “cover story” for abuse, Mason said. “It could be a matter of having your children taken away or not.”

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Ham Mason

Her concerns are not unfounded. The National Coalition for Sexual Freedom’s Incident Reporting and Response said it received 178 requests for legal assistance from kink-oriented clients in 2014. These requests involved 73 criminal, 33 child custody, and 15 discrimination issues.

In addition to becoming more kink aware, providers should “assume the potential for abuse exists in all patients” regardless of their social identity or sexual behavior, and screen appropriately, said Lewis.

Kolmes has worked with submissive/bottom clients who have been in abusive kinky relationships and struggle with whether it was the play or partner that was bad for them. Dominant/top clients also have concerns about crossing boundaries and being a good partner, Kolmes said. Despite these concerns, she doesn’t recommend avoiding kink altogether.

“We see a lot of clients who have been abused or sexually assaulted in the past. We don’t tell them to avoid love and romance and sexual relationships. We work with them on actually figuring out what their boundaries are, helping them stay present and not dissociate, and to learn how to have healthy, loving relationships,” Kolmes said. “Telling someone to avoid kink would be like telling a non-kinky person to avoid love and sex.”

* * *

In a 2006 study (pdf), Kolmes found that some mental health professionals considered kink to be unhealthy and required clients to give up on kinky activities in order to continue treatment. These stigmatized responses can be linked to the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatry, which has had a long history of pathologizing sexual behavior such as homosexuality, masturbation, and promiscuity.

When the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders came out in 2013, it clarified that people with “atypical sexual interests” are not mentally ill—a big departure from earlier editions. Rather, it’s considered a disorder if the person experiences distress beyond what’s expected from the social stigma surrounding kink. It’s also considered a disorder if it infringes on others, especially those who are unwilling or unable to consent. The clarification led to a 57.5% drop in requests for child custody legal assistance to the National Coalition for Sexual Freedom from 2012 to 2014.

Because kink has been pathologized for so long, kinksters must overcome a large degree of stigma. There is often an assumption that they were child sexual abuse victims or have psychiatric issues, compulsive behaviors, and low self-esteem.

Some studies suggest that kinksters show favorable psychological characteristics—they are less anxious and rejection sensitive, as well as more extroverted, open to new experiences, and conscientious. Other studies propose that the higher subjective sense of well-being in kinksters is linked to their improved communication and boundary negotiation skills. Kinksters are no more likely to be coerced into sexual activity or experience sexual dysfunction.

For Mason, her three year dominance-submission relationship has affected her positively. In addition to leading her back to therapy, it’s made her conscious of habits and improved her communication skills.

“It has impacted other places in my life, like work, where I feel like I’m more likely now to speak up for myself and say what my wants and needs are. And I think it’s also helped me set up better boundaries,” Mason said. “[BDSM is] always part of me and it’s who I am wherever I go. It’s not something that you turn on and off.”

* * *

While I won’t be visiting Paddles anytime soon, I know this experience has radically transformed how I’ll care for my patients in the future. When I first entered medical school, a wise doctor said that “the most important part of the stethoscope is what’s between the earpieces.” Now, almost three quarters of the way through medical school, these words have taken on new shades of meaning. Great medicine isn’t just about rattling off differential diagnoses or memorizing pathophysiology. It’s about truly listening to our patients and connecting to them with open minds.

Here is Christy’s website. We welcome your comments at ideas@qz.com.

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