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

Oct 312016
 

Comorbidity is a fancy sounding term, but it’s also important phenomenon. Researchers and clinicians historically noticed that some diseases and disorders tend to occur together. A person with one is likely to have the other. The disorders “clump”. That’s comorbidity. Depression and anxiety “clump” together, so they’re considered “co-morbid”. But the disorders or diseases don’t cause each other. They just tend to occur together, for whatever reason. This week’s article looked at two psychological disorders to see if they were potentially co-morbid: borderline personality disorder and sexual masochism disorder.

What is borderline personality disorder (BPD)?
Comorbidities of BPD

Comorbidities of BPD

BPD is a personality disorder. Personality disorders are specific group of disorders in psychology. They are life long patterns of interaction that cause dysfunction in everyday life. There is no treatment for most personality disorders. Personality disorders include narcissism, antisocial personality disorder, and paranoid personality disorder.

BPD specifically is defined in the DSM 5 as a “pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity”. People with BPD rarely have relationships that last for long. Their opinions of people may change drastically from moment to moment. Their opinion of themselves changes too. They fear abandonment. Resorting to suicide attempts or self injury to get others to stay is not uncommon. Their mood can also be very unstable. A constant feeling of hollowness inside is also common.

Most people with BPD are women. It’s one of the few personality disorders that does have a treatment. Dialectical behavior therapy, a modification of cognitive behavior therapy, is helpful.

What is sexual masochism disorder? How does it differ from masochism?

Sexual masochism disorder is not the same thing as masochism!

Masochism is the sexual or emotional enjoyment of receiving pain. Sadism is the opposite. It’s the enjoyment of giving pain. Many people safely practice sadism/masochism as part of their sexual life. Masochism and sadism by themselves are not psychiatric diagnoses. They are normal, healthy parts of human sexuality.

In contact, sexual masochism disorder (SMD) is masochism that causes distress, dysfunction, or nonconsensual harm. For example, deliberately putting yourself in a situation where you could be raped. Or asphyxiating yourself when you’re alone (because it can, and does, kill). Because those are likely to cause serious harm, they might be considered SMD rather than masochism.

The specifics of what counts as SMD vs masochism is, frankly, a hot topic. But key in that difference is whether the individual is distressed or having difficulties because of their interests…and whether they seek treatment. Unfortunately, there is no specific treatment for SMD.

All of which brings us to today’s study…

Frías et al tried to answer several questions, including: Are BPD women more likely to have SMD than women without BPD?

So they interviewed and surveyed 120 women. These women were referred to them by a local adult outpatient mental health center. All had personality disorders. 60 had BPD. 60 had other personality disorders. Frías et al verified those diagnoses and interviewed the participants. They diagnosed SMD based on those interviews.

The surveys asked about:

  • childhood traumas
  • attachment styles
  • self esteem
  • sensation (adventure) seeking
  • perfectionism
  • sexual fantasies
  • sexual satisfaction

And as always, there was a demographic questionnaire.

What did they find?

SMD was 10 times more likely in BPD women than in women without BPD. Which sounds impressive. 6 out of 60 women with BPD had SMD. That means 54 out of 60 women with BPD did not have SMD. None of the 60 control women had SMD.

BPD women with SMD, compared with BPD women without SMD, were more likely to…

  • Have experienced childhood sexual abuse
  • Be sensation seekers
  • Have a dismissing or hostile attachment style

There were no differences in…

  • Demographics
  • Non-sexual childhood trauma
  • Self-esteem
  • Perfectionism
  • Sexual satisfaction

Interesting comments came out of the interviews as well. Some of the SMD women reported that they had previously injured themselves for masochistic reasons. Others intentionally put themselves in places where they were nearly injured or raped. They didn’t tend to involve others in their SMD needs. Instead they preferred to masturbate, self-injure, or asphyxiate themselves. None were involved in the local BDSM community.

What are the limitations of this study?

As I’ve said many times before, no study is perfect. This study in particular ended up being very small. Only 6 women in the BPD group had SMD. It’s very difficult to make generalizations based on 6 people. A bigger study would help clarify the potential relationships. And can you really make a conclusion based on such a small sample size? I would take the conclusions here with a small grain of salt until they’re repeated with a larger sample size.

I also have my doubts about comparing women with BPD to women with other personality disorders. Research needs a “control” group. The control group is usually a group without the disorder. In fact, they’re usually completely healthy. The researchers then have a comparison group.

Comparing women with BPD to women with other personality disorders doesn’t seem like a clear control group to me. What bias was introduced? It’s difficult to say. I’d like to see a study like this done with a control group without psychiatric diagnoses.

Lastly, this study has the usual limitations. It’s not an experimental study. So the results are correlation, not causation. Since they asked participants to remember historical events, there’s a recall bias. As always, their results may not apply to other populations.

What do the results mean?

I find it interesting that none of the women with SMD were active in their local BDSM group. This is evidence that SMD and masochism are not the same thing. Definitely one of the tidbits from this study that we need to share.

The association between childhood sexual abuse, BPD, and SMD is interesting. There have been theories that sexual abuse and BPD may be related. Even theories that abuse may cause BPD. I would hesitate to go quite that far. However, it’d be worth doing more research to find out.

In summary — this is interesting investigational work, but certainly not the last word.

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

Citation: Frías, Á., González, L., Palma, C., & Farriols, N. (2016). Is There a Relationship Between Borderline Personality Disorder and Sexual Masochism in Women?. Archives of Sexual Behavior, 1-8.

Oct 032016
 

Pain is an interesting phenomenon. It is nearly a human universal. The vast majority of humans have experienced it. Some experience it daily. Yet we all have different relationships with pain. Pain can be the enemy. It can be something to run away from or something to be endured if running doesn’t work. Or it can be something to come to terms with, like an old friend. Physical pain can be a tool too, muting emotional pain. Lastly, pain can be embraced. Some people ride the pain like a wave and find enjoyment in the intensity. They are often called “masochists”.

Masochism is the enjoyment, often sexual in nature, of receiving and experiencing pain. Masochism is typically practiced in a consensual “session”, paired with sadism. Some masochists prefer pain to come with physical restriction (bondage) and/or power exchange (dominance/submission). Yes, this is the same thing as BDSM or “kink.”

Researchers wondered if there was anything different about masochists’ sensation of pain. After all, most people avoid pain. Pain is unpleasant. Why deliberately seek it out? Can the experience of masochists tell us about how humans experience pain? Most importantly — can we learn anything that might help alleviate the suffering associated with chronic pain?

To answer these questions, Defrin et al invited 34 people to participate in a study. Half of those people were masochists involved in the local BDSM scene. The other half was a control group who did not. Both groups filled out surveys about pain. They answered questions on…

  • how much they feared pain
  • their experiences of pain in everyday life
  • how much they catastrophize pain. How terrible is it when they do experience pain? And how do they cope with pain when they do experience it? Different aspects of catastrophizing include rumination on the pain, magnification of that pain, and a feeling of helplessness.
  • the masochists were also surveyed about their BDSM experiences

Defrin et al tested the pain threshold of both groups. They tested the pressure required for the participant to report feeling pain, while the participants were “seated on comfortable armchairs”. (No! Not the Comfy Chair!)

The comfy chair might be a torture beyond what masochists were expecting

The comfy chair might be a torture beyond what masochists were expecting

If you don’t get that reference, stop reading this article right now. Go watch the glory that is Monty Python. Then come back. Don’t worry, I’ll wait.

What did Defrin et al find?

First – what were masochists doing and enjoying? The majority enjoyed whipping on the buttocks. Other areas of the body were also involved. Generally, the more pain and the more areas of the body they experienced pain in, the more they enjoyed the experience. Masochists in this study had weekly to monthly sessions. 

What about everyday pain? When you stub your toe and go “ow!”? As groups, both masochists and non-masochists reported the same amount of pain. Both disliked that kind of sudden, unpredictable pain. However there were some differences. Among masochists, those who had more frequent sessions reported less pain in their every day lives. Interestingly, some people from both groups reported some enjoyment with everyday pain (65% of masochists and 24% controls).

When tested, masochists had a higher pain threshold than non-masochists. For both groups, the more frequently they encountered pain the higher their pain threshold was.

Masochists also reported lower levels of pain catastrophization. They ruminated and magnified pain less and had more of a sense of control surrounding pain than non-masochists did. And the more frequently they had sessions and the more parts of their bodies that were involved, the less fear of pain they had.

So in summary — compared with non-masochists, masochists were better able to cope with everyday pain and had a higher pain threshold. The more the masochist experienced pain in their sessions, the bigger this difference.

Why might there be this difference?

This was a correlational study. So it’s impossible to say for certain why there were these differences between masochists and controls. There are three possibilities:

  • Masochists naturally have a lower pain threshold
  • The experiences of being a masochist and having frequent exposures to pain increases their pain threshold
  • There is a third factor that wasn’t found in this study

To me, the second explanation is most likely. I would expect that if masochists naturally had a lower pain threshold then the number of sessions wouldn’t make a difference. But that wasn’t the case.

Masochistic sessions are highly pleasurable. Rather than attempting to reject or escape the pain, masochists embrace it in a positive, safe environment. That environment matters! The way that we approach pain absolutely affects how much pain we feel and how intense that pain is.

This study does have a number of holes. It has a small sample size. That always limits how applicable the study is. In addition the pain experiences used in the study were predictable, just like the pain in masochistic sessions. Predictable pain is a very different experience from unpredictable pain. If pain is predictable the brain can prepare. Neurotransmitter amounts can change and blunt the feeling of pain. So can we really extrapolate predictable pain thresholds to everyday, nonpredictable, pain thresholds?

I find it interesting too that some of the control group reported everyday pain to be enjoyable. Perhaps there are more people who would participate in masochistic activities given the chance and societal acceptance?

What does this mean for those who suffer with chronic pain?

Well, no one is going to suggest that they all start masochistic sessions. But perhaps borrowing the mindset of masochism would be helpful. Working to help those with chronic pain accept and work positively with their pain may be helpful. It’s hard to say.

What do you think?

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

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!