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In 1886, German psychiatrist Richard Freiherr von Krafft-Ebing published Psychopathia Sexualis, one of the first clinical works which described, labeled, and diagnosed unusual sexual behaviors. The book was one of the first to clinically describe male homosexuality and is the origin of terms such as masochism and sadism. Von Krafft-Ebing presented three categories of sexual disturbance, including pathologically exaggerated sexual instincts, absence of sexual instinct, and perversions of sexual instinct. He based these categories on 238 case studies, presenting sexual deviance as a form of mental pathology, which could be treated and cured. This view has shaped clinical approaches to any sexual behaviors which may be considered outside the norm, whatever we think the norm is.
In 2016, Quebec psychologist and researcher Christian Joyal published remarkable research, based on a randomized sample survey of Quebec’s general population. The study found that nearly half of the sample reported interest in at least one or more sexual behaviors which von Krafft-Ebing would have described as deviant and pathological. Around one-third of the sample had pursued these behaviors at least once, and many so-called deviant interests, such as voyeurism, fetishism, masochism were reported by participants at levels above what could be considered statistically unusual. In many of these sexual interests, there were no differences between men and women, and interest in sexual masochism was significantly linked with higher levels of life satisfaction. Joyal’s remarkable research turns von Krafft-Ebing's theories on their head and shatters many clinical assumptions about sexuality.
How can it be that nearly half of the general population have sexual interests once considered deviant? And how can it be that clinicians and therapists view these sexual interests as unusual, uncommon, and usually unhealthy, when anonymous research finds that these sexual interests may in fact represent the norm? Research by Keely Kolmes suggests that it is clinician bias, our assumptions of deviance, disturbance, and pathology, which lead to people keeping their sexual interests secret from their therapists.
Kolmes’ research, as well as further research by many other clinicians, has revealed that people experience sad, dismaying, and harmful responses from therapists when they share their sexual interests with therapists who are poorly trained on sexual diversity. Patients report being "fired" from therapy for being kinky, having Adult Protective Services called for engaging in consensual sexual behaviors, losing custody of their children, and generally being shamed and told that they are sick by therapists who believe, as von Krafft-Ebing did, that these sexual interests represent mental disturbance.
Sadly, good training and information on kinky sexual behaviors for therapists has been remarkably hard to find. Many therapists are ignorant. Many dominant clinical approaches, from sex addiction to attachment therapies, view interest in sexual kink as signs of pathology and trauma. Patrick Carnes, the founder of modern sexual addiction treatment, wrote that sadomasochism was sexually addictive behavior, where “victims may perceive their feelings towards their torturer as loving, but there is no genuine trust or intimacy when a relationship is based on hurting one another.” Therapist ignorance, bias, and lack of training has led to harmful, shaming practices which have forced patients to shamefully hide their sexual interests from everyone, including the professionals who are supposed to be nonjudgmental and healing.
Luckily, things have changed. Starting in 2010, a group of clinicians who work closely with these sexually stigmatized groups have been developing a set of guidelines for therapists who want to work from a place of knowledge and health, as opposed to ignorance and shaming. At an annual clinical conference, now known as The Multiplicity of the Erotic, in 2012, the first steps towards defining these clinical guidelines were outlined. A research and clinical group was formed, with the goal of summarizing and documenting research and best practices, and a second group was created to solicit information from stakeholders in the process, including people who have kinky sexual interests and have sought clinical services. After nearly a decade’s work, these comprehensive guidelines are now available. They may be found at www.kinkguidelines.com (A Safe For Work website!).
The 62-page document is thorough, comprehensive, and informative. Twenty-three clinical guidelines are laid out, with explanations, justifications, tips, and suggestions. They start with educating clinicians about the term “kink” itself, as an umbrella term which encapsulates a wide, evolving range of consensual sexual behaviors, fantasies, and interests, and go on to set forth the critical importance that clinicians must recognize their competence (or lack thereof) when it comes to working with these sexual issues.
The guidelines underscore the important fact that von Krafft-Ebing, and a century of clinical assumptions, were wrong. These sexual interests are not unusual, not uncommon, not caused by trauma, and not a sign of mental illness. Consensual kinky sexual interests don’t predict bad parenting or disturbed sexuality; ultimately, they can be healthy. Guideline 15 directs therapists to understand that their attempts to change or alter a person’s kinky sexuality may be unethical, ill-informed, and harmful to their patient. Guideline 17 highlights the very real damage and harm caused to patients by unexamined biases in the clinician themselves, directing therapists to do their own work, confronting and examining their moral and sexual values, and holding therapists ethically responsible for the impact of these biases in their clinical work.
Given the sad history of the field of mental health’s approach to sexuality, I believe that many therapists can’t truly be blamed for their ignorance. Social stigma forced sexual interests into dark closets, where clinicians' biased ignorance was either confirmed or unchallenged. Because clinical research and writing on these topics was inaccessible, or biased as well, ethical and concerned therapists had few resources on which to base an affirmative, health-focused, and accepting clinical approach to sexual diversity. This is no longer the case.
In my view, these guidelines should be read by EVERY mental health clinician. They should not be relegated to only the clinicians who work with sexual populations or those who identify as kinky. Remember—half the general population has these interests, and they express across the age range, and across social and demographic groups. Every clinician IS most likely working with kinky people, whether they know it or not.
It is every clinician’s ethical responsibility to correct their ignorance, confront their biases, reject outdated and stigmatizing clinical beliefs, and serve their patients in an accurate, ethical and empirically-grounded manner. The Clinical Practice Guidelines for Working with People with Kink Interests lay the foundation for a new era of clinical work, where our patients should no longer feel forced to keep parts of themselves secret from us, or fear being shamed.
