Mar 202017
 

The term “gender and sexual minorities” isn’t just sexual orientation and gender identity. It also includes relationship structures, like non-monogamy, and sexual practices. Perhaps the most common minority sexual practice is BDSM/kink. BDSM stands for bondage, dominance, submission/sadism, and masochism. The terms BDSM and kink are roughly interchangeable. For today’s article I’ll be using the term kink.

Kink is an activity between consenting adults for the purpose of creating intense physical and/or psychological experiences. The intense sensations can range from physical restraint (bondage) to tickling to pain. Psychological experiences can include role playing and voluntary power exchanges. Power exchange is where one person “takes control” for a period of time. Fetishes are common. Experiences are often called “play.” There can be significant overlap between kink, polyamory, sex positivity, and LGBT communities.

As many as 2-10% of people enjoy kink. Many more have thoughts of it. Some prefer kink activities over non-kink activities. Others identify as kink-oriented or kinky. Kink-oriented people see it as part of their identity, like being gay. Still others only enjoy it from time to time. They dabble but don’t feel strongly attached.

Unfortunately, kink is heavily stigmatized in the United States. As a result kink-oriented people are afraid of “coming out”. There is also minimal understanding or acceptance of kink in the medical community. In fact, it is often confused for abuse or intimate partner violence. Patients who practice kink may not be able to get the healthcare they need.

The Kink Health Project
Rope

Rope is commonly used in kink

So what about the study? Today’s study, the Kink Health Project, was a qualitative study. The researchers came together with community members and asked open ended questions. They collected the free-form information and found themes. Aside from the demographics, no statistics here, just concepts and idea.

The study was done in the San Francisco Bay Area in California. TASHRA played a huge role. The study was designed with input from 16 community members. Then there were large “town hall” meetings, small focus groups, and interviews. So participants could keep the level of privacy they wanted. Researchers asked about experiences and thoughts about health care and kink.

In total, 115 people participated. Although they were mostly non-heterosexual (79%) and white (81%), they were also diverse in terms of age, experience in kink, and gender identity. 19% were gender non-conforming. Preferred kink role (dominant, submissive, or switch) was evenly distributed across the participants.

Despite concerns of stigma, 44 participants had visited a health care provider for a kink-related concern. 38% were “out” to their provider about practicing kink.

Themes

When researchers analyzed the data, they saw five themes emerge:

  • Physical health
  • Sociocultural aspects
  • Stigma’s impact on interactions with physicians
  • Coming out to health care providers
  • Kink-aware medical care

Physical health is perhaps the easiest aspect to grasp. Many of the practices in kink can impact health. The most common injuries in this study include bruising and related trauma, broken skin, nerve damage, fainting, burns, and needle-sticks (and other blood exposure). Despite these risks, some participants reported better physical health because of kink. They felt better about themselves. So they took better care of themselves.

As part of taking care of themselves, they wanted specific testing. Participants wanted the ability to have more frequent or complete STD or blood-bourne disease testing. They wanted testing based on their own individual risks. Not testing based on the population at large. Population risks often simply didn’t apply. It’s like pregnancy testing a lesbian who’s never had sex with a man.

Most said they got health information from their communities, not physicians. Why? Certainly they did want good health information. They especially wanted individualized medical care so they could play safely. So why get information from the community? Because they had a lot of fear of stigma from medical professionals. And because healthcare professionals don’t often know about kink, they could get better knowledge from the community. Groups like the Society of Janus exist specifically to spread knowledge.

Participants interacted with healthcare professionals differently because of the fear of stigma. They hid their activities. Some even gave false information. Others delayed appointments until bruises faded, or tried to hide marks from their play.

One area of particular concern was the fear that kink would be confused for domestic violence. Health care providers are often taught that “Bruises = abuse”. This is not always the case. Women in particular were afraid of this confusion. Delays in seeking health care were commonly reported.

Those who did come out to their health care provider, and they did have good experiences. However they were also in the San Francisco Bay Area. San Francisco is well known for being an accepting place. So participants suspected their positive experiences were probably unusual.

How can health care providers do better?
Kink Pride Flag in San Francisco

Kink Pride Flag in San Francisco

Participants in the Kink Health Project brain stormed ways that the medical profession can serve their needs better. Here are some:

  • Differentiate between domestic violence and consensual activities
  • Ask open ended questions about sexual behavior
  • Individualize screenings for sexually transmitted infections and blood-bourne infections
  • Acknowledge alternate family structures, including multiple partners
  • Provide non-judgmental counseling on decreasing risks
What can a kinky patient do?

So what can a kink-oriented patient do to potentially improve their experience in health care?

  • Consider coming out to your provider. This is an incredibly individual decision, however. Only do so if you think you’ll be safe
  • If and when you come out, give that provider resources. TASHRA is probably the best resource to start with.
  • Emphasize your desire for safety and the consensual nature of your activities. A health care provider’s first concern should be your safety. They need to know that no one is truly causing you harm.
  • If you need to, ask for a referral or seek another opinion. Not all providers are going to be comfortable treating kinky patients. It is, however, their responsibility to refer you to another provider if they’re not able to provide the care you need.

And remember: You deserve to have a health care provider who treats you with respect.

Want to read the study for yourself? The abstract is publicly available

Jun 082015
 

A Thought BubbleBelieve it or not, psychological science has limited understanding of what “normal” sexuality is. Even “common” sexuality is not well understood. Most statistics are woefully incomplete, asking about penetration styles and little else (example). We need to know more! Why? Well how else are we going to develop acceptance and understanding of the diversity of human sexuality? And the definition and use of the term “paraphilia” likely would need to be changed with greater understanding.

Today’s study looked at the sexual fantasies of roughly 1500 Canadian (Quebec) people (1516, 52.7% female). Ages ranged from 18-77, though most were between 19 and 40 (mean 29.6 +/- 10.8). 85% of the participants identified as straight. 3.6% identified as gay, and 11.4% identified as bisexual. As far as I can tell, no questions were asked about transgender status and no one reported themselves to be trans.

The participants were recruited through advertisements interviews, word of mouth, and presentations. They then filled out a survey online. The survey was a modified version of a known sex fantasy and behavior survey. The sexual behavior questions of the survey were removed. Additional sexual fantasy questions were added based on the most frequently visited pornographic sites. A write-in “other” option was also included.

The researchers then separated the fantasies out into rare, unusual, common, and typical categories. A rare fantasy was one that less than 2.3% of the participants had. Unusual was below 15.9%. Common was 50% of the participants or more, and typical was over 85%. The authors did not give a group name for fantasies that 16-49% of the participants had — so I’m going to call that “uncommon.”

What did they find?

The only typical (>85%) fantasy for both men and women was having romantic feelings during sex.

Common (50-85%) fantasies include themes of oral sex, masturbation and having sex with multiple people of the opposite sex. Sex in unusual, public, and romantic places was also common. Some choices of partner were also common: having sex with a famous star, or with a person other than one’s spouse. Lastly, fantasies of being sexually dominated was also common to both men (53.5%) and women (64.6%).

Men generally had more common fantasies than women did. These included sexual acts with strangers or acquaintances, watching a stranger undress, and having a much younger partner or a female partner with very large or very small breasts. Men were also more interested in dominating a partner (59.6%) than women were (46.7). In contrast, women were more interested in being tied up than men were (52.1% vs 46.2%).

Uncommon (16-49%) fantasies for both sexes include tying another person up, spanking or whipping someone, being spanked or whipped, being forced to have sex, and having gay sex. Men also uncommonly had fantasies of forcing others to have sex and having sex with prostitutes. Those fantasies were unusual for women.

Unusual (2.4-15.9%) fantasies included cross-dressing, urinating on a partner, and being urinated on. Fantasizing about having sex with animals and pre-pubescent children fell into the rare (less than 2.5%) category.

Here are some of the interesting statistics I pulled from this study that I’ll be using in the future:

  • About 3% of the group identified as gay, and 11% as bisexual. However, one in three women and one in five men fantasize about gay sex.
  • Men have more specific features to their fantasies, such as the breast size of their female partners. They’re also more likely to fantasize about having sex with strangers or acquaintances (around 2/3 of the group).
  • Men are more interested in anal sex than women (64% vs 32.5%)
  • Half to 2/3 of the group fantasized about public sex.
  • Half to 2/3 of women and men fantasize about being sexually dominated. Slightly fewer fantasize about doing the dominating (47% of women, 60% of men). Fewer fantasize about actually being forced into sex (a little less than 30%) or forcing others into sex (10-20%)
  • Roughly half the group fantasized about being tied up.
  • 1/4 to 1/3 of the group fantasized about spanking or whipping.
  • Cross dressing and urination fantasies are rare (<10%)

As always, this study has its limitations. The people who chose to participate may be a only a small group of the larger population. They may be more open-minded than the population at large.

But what does it all mean??

I think one of the big messages here is this: Fantasies of varying natures are not at all rare. They appear to be part of the normal spectrum of human sexuality. As the study authors put it, “there are very few statistically
unusual sexual fantasies.”

Many of the features of these fantasies are things that have been called pathological. Sadism, masochism, voyeurism, exhibitionism…all were present in fantasies in at least one in five in the survey. But all are considered a “paraphilia” for which there is treatment. They are also rather neglected aspects of human sexuality. They’re not typically addressed in sexual education, nor are medical or psychological professionals often given information on them.

I hope the authors will do more analysis with their data and make a few more publications. I’d love to see if fantasies varied by sexual orientation, for example. I would also have liked to see data on sexual satisfaction and whether the participants did the things they fantasized about. From a health perspective, I’d also like to know if the participants were at higher health risk from things like substance use or STIs. But that’s why we have science — someone else will ask that question!

All in all, I’m really happy with this study. It’s an area that sorely needs more data. The study was thoughtful and allowed participants to detail their own experiences in an “other” box.

Interested in reading the study for yourself? The abstract is publicly available.

Mar 162015
 

170px-Rod_of_Asclepius2.svgBeing a gender or sexual minority (GSM) is not only difficulty and tricky for patients — it can also be a challenge for medical providers. Medicine can be a particularly conservative field, depending on location and specialty. Lives are, after all, often at stake.

Despite recent advances it appears that some 40% of lesbian, gay and bisexual medical students are hiding their sexual minority status in medical school. Among transgender medical students, 70% were hiding their identity. All because of fear of discrimination.

That fear has been, and still is, warranted. From medical providers transitioning and losing their practices, to medical students losing their residency slots, to LGBT health student organizations fighting to exist, LGBT providers face similar discrimination as our patients.  Similar happens for other gender and sexual minority health care providers, though we lack statistics. At a meeting of kink-identified mental health care providers, one attendee noted a high level of vulnerability for the clinicians. Being “outed” could lose them their jobs or even trigger legal action.

To some extent, discretion among health care providers is warranted. Most people don’t want to know about their clinician’s (or coworker’s) personal lives. And most GSM providers don’t actually want to share those most intimate details. It’s where the line is that can be distressing — how much information is too much? Can I discuss my wife when other women clinicians are discussing their husbands? How exactly do you notify your fellow clinicians or patients about a change in gender pronouns or name? How can a clinician use information gained from intimate encounters to help patients, without revealing too much? It’s a balance we constantly seek. Sometimes mentors are there and can help. Other times we figure it out as we go along.

Yet we bring a lot to the table, as minorities. Like many racial and ethnic minorities, there are pressures and issues that affect GSM people more than the majorities. We bring that knowledge with us to the research we choose to perform, the communities we participate in, and each and every patient encounter.

We as clinicians and future clinicians need to have the support in order to be appropriately open about our gender and sexual minority status. Our patients and clients must know they can be safe and honest with us so they can receive the most complete and respectful care possible.

Some progress has been made already. There’s an association for LGBT medical professionals. There’s an association for kink psychological research. There’s an association for transgender health. All of which allow student members and provide mentoring. Many other organizations exist too. Some US medical schools are working with their students to provide a safe and welcoming environment where these issues can be explored. The American Association of Medical Colleges recently launched a program to enhance education surrounding LGBT and intersex health care. The American Medical Association also has an LGBT Advisory committee.

I’m proud to say that my medical school has been accepting and supportive of its gender and sexual minority patients, and that clinics in the area of my medical school are seeking to expand their care to be more inclusive of LGBT patients. Support exists for both those seeking medical care, and those seeking to provide that care. It’s only the beginning.

Aug 152013
 

Rope (often used in BDSM ) smiley face - CC BY 3.0 Rose Lovell

A new psychological study of BDSM practitioners has just been published. This is the first such research to specifically examine the “Big Five” personality characteristics.

For those of you not interested in the nitty-gritty, here’s the digest: As a group, people who practice BDSM report a better sense of well-being and are more open to new experiences, extraverted, conscientious, and less sensitive to rejection than people who don’t practice BDSM. As with all correlations, this does not mean that BDSM activities caused these differences. Rather, people with these characteristics may be more likely to investigate BDSM.

Are you interested in the details? Cool! Let’s break this study down then.

First, some basics on BDSM. As some readers may remember, BDSM is an acronym standing for: Bondage, Dominance/Submission, SadoMasochism… and probably a few others besides. BDSM is considered an “alternative” sexuality and is highly stigmatized here in the United States. BDSM is often misrepresented as a purely sexual practice focused on pain. In truth, it’s often more sensual than sexual or painful. Many forms of BDSM “play” involve no sex or pain at all. Specific practices vary a lot depending on the people involved**.

Within BDSM, a person is typically in one of three roles: dominant (dom/domme), submissive (sub), or switch. The terms are fairly self explanatory. Dominant “has” control, submissive “gives” control, a switch is someone who switches roles*. Sometimes being a dom/sub/switch is referred to as an orientation, sometimes it’s a role for a particular activity (“scene”)***.

What about these personality characteristics? In personality psychology, there’s the concept of the “big five” personality characteristics, OCEAN: Openness, Conscientiousness, Extraversion, Agreeableness, and Neuroticism. Personality characteristics are thought to be innate. You’re born with a certain personality, and it’s relatively unchangeable. Each of the “big five” can be thought of as a line, and each person falls somewhere along that line. To wit….

  • Openness: How open to new experiences are you? Open vs cautious
  • Conscientiousness: How tidy, thorough and responsible are you? Organized vs careless
  • Extraversion: How much do you enjoy being around other people? Extravert vs introvert
  • Agreeableness: How trusting and cooperative are you? Friendly vs cold
  • Neuroticism: How easily do things tip you emotionally off balance? Easily upset vs steady

Some of these traits are associated with greater happiness and resiliency (e.g., Openness, Agreeableness and Extraversion) whereas others are associated with mental instability or illness (e.g., Neuroticism). There are nuances, overlaps, and arguments over these concepts that I won’t address here, but I hope that gives you a good starting place for understanding the study results. Let me know in the comments if it doesn’t and I’ll gladly expand. This study looked at more than just the “big five”. It also included measures of rejection sensitivity, attachment style, and subjective well being.

So why look at the “big five” and all those others in the context of BDSM? The arguments of the researchers make some sense. While BDSM and the “big five” have not been directly compared before, there is some evidence that the “big five” is associated with certain sexual attitudes. The more open you are, the more permissive your attitudes around sex. The more neurotic you are, the less stable your relationships, thus impacting your sexual life. And so on. Similarly, people with secure attachment styles are more likely to have a wide variety of sexual behaviors and better trust with partner(s) than people with insecure attachment styles.

So we have our variables: the “big five”, rejection sensitivity, attachment style, subjective well-being. What about our participants?

BDSM participants were 902 Dutch people, 464 male and 438 female (no mention of trans or genderqueer folks), recruited from one Dutch BDSM forum. Control participants were 434 Dutch people screened for BDSM behavior, 129 male and 305 female, recruited from magazine ads or websites having to do with “secrets”. Men in the study were older than women. I’m really not sure this control is an adequate control for this study because of the recruitment methods… but I’m not sure it’s not either. Differences between the groups? There certainly were some other than the practice of BDSM. There were significantly more women in the control group than the BDSM group. The control group was younger and less well educated than the BDSM group, although both were more well educated than the average Dutch citizen. Whether these differences affected the study results is unknown, but a possibility.

The researchers also note a gender difference between roles in the BDSM group. Men were 33.4% submissive, 18.3% switch, and 48.3% dominant identified. Women, on the other hand, were 75.6% submissive, 16.4% switch, and 8% dominant. This is certainly reflected in the stereotypes associated with BDSM activities.

Results included:

  • People who practice BDSM were more Open, Extraverted, and Conscientious than the control participants.
  • People who practice BDSM were less Neurotic and Agreeable than the control participants
  • People who practice BDSM were less sensitive to rejection than people who didn’t practice BDSM. Within the BDSM participants, submissives were more sensitive to rejection than dominants
  • People who practice BDSM had a greater sense of well-being than control participants. Dominants scored the highest on well-being.
  • Relatively few differences between BDSM participants and control participants was found when attachment styles were examined. When there was a difference, BDSM participants had a more secure attachment than control participants.

Effect sizes were small to medium. That is about average for a psychological study.

The OCEAN results make sense within the context of BDSM. In order to even try BDSM activities, you’d need to be open to new experiences. Conscientiousness is also valued, in order to be safe. Extraversion is helpful within a community setting. The rejection sensitivity results also make sense to me – a timid person may not continue to explore BDSM after one or two rejections. But this is all after-the-fact reasoning, and not particularly predictive or scientific.

The authors note that these results contradict the long-standing assumption that women who participate in BDSM so do because they were abused as children. But they didn’t ask directly about childhood sexual abuse. Rather, they draw this conclusion from the established relationship between attachment styles and abuse history. Childhood abuse is associated with insecure attachment. But in this study, BDSM folk were more likely to have a secure attachment than the control group. I think this logic is fairly sound, though a definitive answer will need to wait for a study where childhood abuse is specifically asked about.

The most obvious limitations to this study are the participants. The BDSM and control participants were not necessarily comparable, and there were significant known differences between the groups. Those differences could have affected the study’s results. Also, as usual, this study’s results may not be generalizable to BDSM communities in other countries (e.g., the United States).

Despite the limitations, these results are a delightful breath of fresh air, when so much of the literature treats BDSM as psychopathology. People who practice BDSM has long argued that there is nothing inherently “wrong”, “sick” or “dangerous” about their sexuality. These results absolutely support their assertion. The study authors state “We therefore conclude that these results favor the view […] that BDSM may be thought of as a recreational leisure, rather than the expression of psychopathological processes.” Yes, yes and yes.

The study was published in the Journal of Sexual Medicine. The abstract is publicly available.

* This is a highly simplified description. Power, and the exchange of power, is complex.

** It’s important to note, though, that for many people who participate in BDSM pain is very important, if not the central experience.

*** In addition to Dom/Sub/Switch, there’s also the idea of “topping” and “bottoming”. Topping and bottoming are much more transitory than Dom/Sub/Switch. In any particular activity, the Top is the “do-er” and the Bottom is the “do-ee”. But being Top or Bottom is activity specific and not as much of an orientation as Dom/Sub/Switch.

Jul 022013
 

CC BY-NC-ND 2.0 by flickr user aling_

Time for the last month’s news. Hope you all are having fun out there. This month’s image is the theoretical flower for the month: the rose.

Gender-related news…

  • A preliminary report presented at the Endocrine Society meeting in June appears to confirm that cross-sex hormone therapy is safe in the short term (12 months). Summary.
  • Finasteride, a commonly used anti-androgen used to prevent hair loss in both cisgender men and transgender women, has now been reported to reduce alcohol consumption. Summary.
  • GnRH agonists, also called “puberty blockers”, have been shown to be safe in one study. The prime concern for years has been about bone health. Previous studies had shown a drop in bone density while on the medication. This new study confirms that bone density returns to normal after going off GnRH agonists. Summary. This study will be covered more thoroughly in a later blog post.
  • The folks at Skepchick did a wonderful piece on a recent news article on an intersex person. Check it out!

Sexuality

  • In high doses, testosterone appears to help cisgender women retain their sex drive after hysterectomy/oophorectomy. The rub? Testosterone should be given either through the skin (creams, patches, etc) or by intramuscular injection. Summary.
  • Many cisgender men are now being treated for “low testosterone levels”… when their testosterone levels were never checked. This could be very risky. Summary.
  • Exodus International has apologized to gay people and closed down. Exodus was well known for its promotion of reparative therapy for gay people. Summary.
  • The American Medical Association has come forward arguing that the ban against blood donation by men who have had sex with men (the “gay blood ban”) should be lifted. Summary. The FDA recently reviewed their policy, but decided that the ban should stay. Currently in the United States, any man (male-bodied) who has had sex with a man since 1977 is ineligible to give blood. Additionally, any woman (female-bodied) who has sex with a man who had sex with a man since 1977 is ineligible to donate for the next 12 months. The FDA’s policy on trans folk is unclear, but some trans folk report being turned away because of their gender identity.
  • A case report of “foot orgasm syndrome” was reported in the literature. A woman reported having orgasms whenever her feet were stimulated. Summary.
  • A study found that people who practice BDSM (bondage, dominance/submission, sadomasochism) are not psychologically “sick”. Summary. I’ll be covering this study in a later post. It’s interesting and need a lot of breaking down.
  • A study by Durex reports that the vast majority of people enjoy sex most when they are emotionally attached to their partner(s). Summary. Because a sex study conducted by a condom maker is totally not biased.

And the biggest item of news? The US Supreme Court declared that Section 3 of the Defense of Marriage Act was unconstitutional. Federal and state governments are currently scrambling to figure out all the ramifications. And Proposition 8, here in California, was effectively reversed. Marriage equality now exists in my home state. Yipee!

Did I miss a piece of news? Let me know in the comments!