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Fifty 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, imagining the arrangement of his delicate organs in relation to her vicious heels.

Just an hour before, I had been 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 is characterized by 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 United States that promotes sexual liberation by holding classes, workshops, and social events around New York City.

There were people from all walks of life present — artists, educators, scientists — who ranged in age, ethnicity, sexual orientation and relationship dynamic. 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 a lone medical student who wanted to learn from this highly stigmatized group. How else can health care professionals come to speak frankly about sex and better care for our patients, of whom a significant number are kinky?

Although studies vary, an estimated 10 percent of the population has engaged in kink activities, and a much larger proportion expresses interest 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 announced that 9.3 percent 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 E.L. James’ erotic novel “Fifty Shades of Grey,” which sold over 100 million copies worldwide and was produced into a popular film adaptation, the nation’s growing interest in kink is no surprise. The series garnered unenthusiastic reviews of its literary merit as well as criticism for its inaccurate portrayal of a BDSM relationship — and it’s an all too accurate portrayal of an abusive one. However, it fostered one important change: brought kink into the light.


When it comes to discussing sex, medical professionals often become uncomfortable. I cannot 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 feels awkward and pointless to bring it up, but it is 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 move 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.”

Dr. Jess Waldura, a family physician and clinical researcher at the University of California, San Francisco, co-founded The Alternative Sexualities Health Research Alliance in 2012. She tells the story of one patient in attendance at a kink party who fainted during an emotionally intense scene. When she arrived at the emergency room, doctors wanted to know what she was doing when she fainted, 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 recounts. “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 also diminishes access to preventive health care. He had to seek sexually transmitted infection testing elsewhere. Lewis says that his doctor decided that, “because of my genital status and my sexual partners being female, I was at very low risk. He deemed taking the tests a waste of time.” Lewis’ doctor was unaware that some kink activities, such as needle play, increase patients’ risks for contracting STIs.

In medical school, we are trained to ask two questions. The first is, “Are you sexually active?” The second, “revolutionary” question, which emerged only after “decades of fighting for equality around sexual orientation,” said Waldura, is: “Do you have sex with men, women or both?” Yet Waldura sees a need for this revolution in sexual awareness to progress even further. 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 patients won’t be offended, this question still offers kink-oriented patients an opportunity to begin a dialogue.

Despite the increased presence of kink in popular culture, those who engage in it are marked by a “concealable, stigmatized identity.” The community feels marginalized, which Waldura calls “a deficit” on the part of the medical community. “We did not see the need because of our blinders and our own internalized stigma. 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. I explored 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. Upon arriving, I entered an unmarked door and descended into the 5,000 square-foot, multi-level dungeon, which was furnished with what appeared to be medieval torture devices, including cages, benches, and hooks. Dungeon monitors in neon orange traffic control vests patrolled the space, ensuring safety and enforcing rules. I watched kinksters — people participating in kink — as they negotiated scenes and observed which activities and toys were permitted. I learned that, along with sex, alcohol and drug use, cell phones and cameras were banned on the premises. Paddles also strictly prohibits touching others without their express consent. Verbal and nonverbal safety signals maintain limits and enable participants to withdraw consent during play.

The scenes themselves were intriguing. In one, a dominant top man meditatively bound two submissive bottom women with a beautiful configuration of rope and proceeded to tickle them until they dissolved into giggles. Kink isn’t just about pain, as with sadomasochists, but rather physical stimulation to produce new and exhilarating sensations. A 2009 study suggests that kink produces its own version of “runner’s high,” which occurs when oxytocin levels, the “bonding hormone,” soars and cortisol levels, the “stress hormone,” plummet.

In some ways, impact play is a recreational contact sport like football. Both have risks and techniques for playing safely — for example, tying ropes loosely enough to avoid nerve damage during bondage. Also, kinksters with specific health issues have unique considerations. For Lewis, thyroid and lung conditions often limit the intensity of play. Those who use pacemakers for heart problems should avoid electrical toys, and patients on anticoagulant medications 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 health care providers should provide that counseling. Waldura remembers 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 extensive knowledge about kink, said Waldura.


While making my rounds in the dungeon, I noticed a few kinksters featuring impressive bruises from consensual play. In the medical community, these marks would trigger additional questioning. While we have been trained to screen for abuse by noticing and investigating signs, we don’t know how to hold a particularly nuanced discussion of consent. I’ve learned that there’s a huge difference between consensual, negotiated kink relationships and abuse. Abuse entails a lack of explicit consent and includes situations in which someone is afraid to impose limits because of potential consequences.

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

As mandatory reporters, health care 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 United States, laws differ from state to state and may be difficult to interpret.

During the course of my training, I’ve learned that health care providers aren’t required to report suspected abuse between adults in most states, yet many are unaware of this. “Doctors have no idea what the law is. They just know that they’re supposed to report violence,” Waldura explains. “We have very little training in it. So what happens is a fear response.” Despite input from legal experts and other advisors about this issue, there is no definitive answer.

There are other significant challenges within the kink community. Ham Mason, a queer submissive activist and person of color who has been practicing kink for 20 years, argues that there needs to be more awareness of diversity. “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 said. Because of this stereotype, health care providers may assume that people of color are not 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.” Unfortunately, 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. Among these requests were 73 criminals, 33 child custody, and 15 discrimination cases.

Kink introduces unique challenges in providing legal and personal support. In addition to becoming more kink aware, providers should “assume the potential for abuse exists in all patients” said Lewis, regardless of their social identity or sexual behavior, and screened appropriately.  Just because some people are in a kinky relationships does not mean that they do not experience abuse. Providers need to watch out for abuse in people who have both non-kink and kink relationship styles.

Kolmes has worked with submissive bottom clients who have been in abusive kinky relationships and struggle with whether the root of the issue was the play or the partner. Kolmes also notes that the inverse is also true; dominant top clients express concerns about crossing boundaries and acting as a good partner. Despite these difficulties, she does not 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, 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 (DSM), the bible of psychiatry, which has had a long history of pathologizing sexual behavior such as homosexuality, masturbation, and promiscuity.

In a notable departure from earlier editions, the fifth edition of the DSM clarified that people with “atypical sexual interests” are not mentally ill. Rather, it is considered a disorder if the person experiences distress beyond what is expected from the social stigma surrounding kink. It is also considered a disorder if one’s action infringes on others, particularly those who are unwilling or unable to consent. Since the release of the DSM-V, there has been a 57.5% drop in requests for child custody legal assistance to the National Coalition for Sexual Freedom from 2012-2014.

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

Some studies suggest that kinksters show favorable psychological characteristics. Kinky individuals are less anxious and rejection-sensitive, and they tend to be 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. Further, kinksters are no more likely to be coerced into sexual activity or to experience sexual dysfunction.

For Mason, her three year dominance-submission relationship has affected her positively. In addition to leading her back to therapy, it has 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 will not be visiting Paddles anytime soon, I know this experience has radically transformed how I will 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 is not just about rattling off differential diagnoses or memorizing pathophysiology; it is about truly listening to our patients and connecting to them with open minds.

Author’s note: This article won the 2015 Trachtenberg Essay Contest. It originally appeared in Quartz, and later appeared on KevinMD.

Christy Duan Christy Duan (3 Posts)

Contributing Writer Emeritus

Albert Einstein College of Medicine


Christy Duan is a fourth-year medical student at Albert Einstein College of Medicine and a future psychiatrist. She is an award-winning writer who has published in The Detroit Free Press, Quartz, KevinMD.com, Abaton, and Autostraddle. In 2012, she graduated from the University of Michigan with a Bachelor of Science in Statistics. Christy is passionate about social justice and global health. Her work has spanned from the Usambara mountain range of Tanzania to the sprawling metropolis of Hong Kong, and from community HIV interventions to data mining. Read more of her work at http://www.christyduan.com.