Every therapist encounters, at least occasionally, a client seeking help with sexual issues of one ilk or another. Typically, these individuals are either overtly or covertly worried about too much sex, not enough sex, no sex, strange sex, addictive sex, cheating sex, bad sex (whatever “bad” means), etc. Sometimes these concerns are their primary presenting issue, but usually not. More often, sexual issues lurk in the background, hiding behind depression, anxiety, fear of rejection, shame, and similar problems. In such cases, a client’s sexual concerns might only come to light while exploring the client’s self-esteem, failed relationships, substance abuse, unresolved early-life trauma, mood disorders, etc.
Recognizing this, I find it useful to incorporate a few very basic sex-related questions into the initial assessment with every client. Unfortunately, many therapists and clients are uncomfortable discussing sexual issues. As such, it is important for any initial queries to sound as neutral as possible. A few non-threatening questions I typically ask are:
- Do you have any concerns about your current or past sexual or romantic behaviors?
- Has anyone ever expressed concern about your sexual or romantic behaviors?
- Is there anything about your sexual or romantic life that feels shameful to you or that you work to keep secret?
Asking these simple, straightforward questions generally ensures that a client’s important sexual concerns (issues that might underlie and drive more obvious problems like depression and anxiety) aren’t overlooked. By posing queries and nonjudgmentally following up as indicated, we give clients permission to talk about their sex life and the ways in which it might be affecting them. We let them know that it’s OK (safe) to discuss their sexual life in treatment, however much shame they may be feeling about it.
Among the sexual issues commonly encountered is a client’s desire for (and shame/anxiety about) non-traditional forms of sex, including kinks, fetishes, and paraphilias. At this point, some readers may be wondering exactly what I mean when I use the words kink, fetish, and paraphilia. And with good reason, because if you search the internet you’ll find a wide variety of definitions with quite a lot of overlap.
In my work, I tend to define kinks as nontraditional sexual behaviors that people sometimes use to spice things up, but that they can take or leave depending on their partner, their mood, etc. Fetishes are nontraditional sexual interests or behaviors (kinks) that are, for a particular individual, a deep and abiding (and possibly even necessary) element of sexual arousal and activity. Paraphilias are fetishes that have escalated in ways that have resulted in negative life consequences.
A kink, a fetish, and a paraphilia can involve the same behavior, but the role that behavior plays and the effects it has can be very different depending on the person. Consider as an analogy the difference between a casual drinker, a heavy drinker, and an alcoholic. The basic behavior, consuming alcohol, is the same, but the underpinnings, impact, and long-term effects are quite different depending on the person. Moreover, it is only when the behavior is taken to an extreme that results in negative life consequences that it’s viewed as a disorder. For instance, the DSM-5 says that for a kink or fetish to qualify as a paraphilic disorder, the arousal pattern/behavior must create “significant distress or impairment in social, occupational, or other important areas of functioning.”
Consider the following client:
Kevin, a 29-year-old attorney, enters therapy for severe anxiety. When asked a few basic questions about his sex life, he says that for the last several years he has been hiring a dominatrix a few times per month, paying her to physically and verbally humiliate him. He says he does not become physically aroused while this is occurring, but after the dominatrix leaves he masturbates furiously. He also says that he has recently started dating a woman he met through another attorney, and he is afraid that if they have sex she will notice the many marks and bruises that he nearly always has on various parts of his body. He says he wants to continue dating this woman, but he also wants to continue with the dominatrix. He is unwilling to tell his new girlfriend about his sexual arousal patterns, and this is creating a great deal of stress and anxiety. He also says that twice in the past year he has started dating a woman he liked, only to break up with her because the stress of his compartmentalized sexual life felt overwhelming to him. He also feels like his performance at work is suffering because of his anxiety. He feels torn between the woman he would like to love and possibly marry, and his need/desire for sexual fulfillment through BDSM.
If BDSM was something Kevin engaged in occasionally with his partner(s) for a little bit of extra fun during sex, we would say he’s got a kink. However, the behavior is clearly a primary element of Kevin’s sexual life, elevating BDSM the level of a fetish. Moreover, it is causing significant and ongoing stress and anxiety, affecting both his social and work life. Thus, for Kevin, BDSM is also a paraphilia.
Notably, it is not the behavior itself that is pathologized. Rather, it is the way in which it affects Kevin that is pathologized. Again, I will use alcohol as an analogy. We do not say that drinking alcohol is inherently pathological (because plenty of people do it without any problems at all). In the same way, we do not say that BDSM is pathological. If, for instance, Kevin was perfectly at ease with his dominatrix sessions and did not feel as if they were interfering with his dating and work life, and instead was coming to therapy about to his desire to change professions, his sexual fetish would be a clinical non-issue.
In case you’re wondering, BDSM is far from the only kink/fetish/paraphilia out there. Sure, it’s the one that gets the most attention, especially with the “Fifty Shades” books and movies, but it’s hardly a lone sexual outlier. The DSM-5 specifically lists eight potential paraphilic disorders:
- Voyeuristic disorder (sexualized spying)
- Exhibitionistic disorder (exposing the genitals)
- Frotteuristic disorder (rubbing up against a nonconsenting person)
- Sexual masochism disorder (undergoing humiliation, bondage, or suffering)
- Sexual sadism disorder (inflicting humiliation, bondage, or suffering)
- Pedophilic disorder (sexual focus on prepubescent children)
- Fetishistic disorder (sexual focus on nonliving objects or nonsexual body parts)
- Transvestic disorder (cross-dressing for sexual arousal).
Once again, the APA very clearly states that a specific behavior does not become a paraphilic disorder (a pathology) unless and until it causes clinically significant distress or impairment. The organization also states that the eight listed disorders do not exhaust the list of kink/fetish/paraphilia possibilities. And they could not be more right. In his book, Forensic and Medico-Legal Aspects of Sexual Crimes and Unusual Sexual Practices, Anil Aggrawal lists 547 possible kink/fetish/paraphilic behaviors, ranging from Abasiophilia (sexualizing people with impaired mobility) to Zoosadism (inflicting pain on or seeing animals in pain). Other somewhat outré possibilities include:
- Anthropophagy: Ingesting human flesh
- Chremastistophilia: Being robbed or held up
- Eproctophilia: Flatulence
- Formicophilia: Being crawled on by insects
- Lactophilia: Breast milk
- Oculolinctus: Licking the eyeballs
- Symphorophilia: Witnessing or staging disasters, such as fires and car accidents
- Teratophilia: Deformed or monstrous people
Just so you know, if there’s a psychological term for it, at least a few people are into it. So even though eyeball licking might not be your cup of tea, it’s a legitimate turn on for somebody. And it’s not the job of any therapist to pathologize this or any other non-harmful, non-offending sexual kinks and fetishes. If a specific sexual desire or behavior is not causing harm to the client or others, as therapists we should neither judge it nor try to put a stop to it (no matter how weird we might think it is).
Moreover, as with sexual orientation and gender identity, kink/fetish/paraphilic interests are relatively immutable. No matter how ego-dystonic, it is unlikely that any type or amount of therapy will make these interests disappear. Thus, our job as therapists is to help a struggling client explore his or her fears, shame, and misunderstandings about his or her arousal template, and to eventually reduce the negative impact that is having.
When a client’s sexual interests and behaviors are non-harmful (to self and/or others), the proper course of action is to help the client accept what he or she is feeling and desiring as a natural and healthy part of who he or she is, regardless of the client’s current desire to change. If the client wishes to incorporate the kink/fetish into his or her life more fully, therapeutic help may be needed with spouses/partners to ensure mutual acceptance. For instance, we might try to help Kevin “come out” to the woman he is currently dating to see if she might support his fetish in a healthy and life-affirming way. And if she is not interested, we might work to help him find a woman who will.
Unfortunately, many clinicians are not trained to deal with complex sexual issues, such as kinks, fetishes, and paraphilias. Plus, some therapists are just plain not comfortable talking about nontraditional sexual topics. This does not make them bad therapists; it simply means they should give referrals if/when they feel out of their element. In fact, one of the most basic tenets of our profession is that when we feel unsure or insecure with a client’s issues, we consult with and/or refer that client to an appropriate specialist.
If you, as a therapist, choose to seek consultation with or to make a referral to another clinician regarding sexual concerns, you will most likely be looking for a therapist who is certified and/or trained in one of the following three areas:
- Human Sexology
- Sexual and Behavioral Addictions
- Gender Identity/Sexual Orientation
The best referral sources are listed below. Many of these organizations also provide trainings and certifications should you wish to learn more about a specific treatment specialty.
- IITAP: The International Institute for Trauma and Addiction Professionals. IITAP trains and certifies therapists to deal with the full gamut of sexual issues, including sexual addiction. They are a great referral source.
- SASH: The Society for the Advancement of Sexual Health. SASH is dedicated to sexual health and overcoming problem sexual behaviors, including sexual addiction. SASH offers both training and referrals.
- AASECT: The American Association of Sexuality Educators, Counselors, and Therapists. This organization provides referrals for counselors who can help with non-addiction, non-offending sexual issues, along with training and certification for treatment of non-addiction, non-offending sexual issues.
- ATSA: The Association for the Treatment of Sexual Abusers. ATSA promotes evidence-based practice, public policy, and community strategies that lead to the effective assessment, treatment, and management of individuals who have sexually abused/offended or are at risk to do so. ATSA provides referrals to qualified therapists.
- Safer Society Foundation: The Safer Society Foundation is dedicated to ending sexual abuse and offending through effective prevention and best-practice treatment for sexual abusers/offenders and their victims. The foundation provides a great deal of useful information on its website.
- SSSS: The Society for the Scientific Study of Sexuality. SSSS is dedicated to the study of human sexuality. This is a great organization to contact if you’ve got a client who is ego dystonic about non-pathological sex-related issues (such as sexual orientation, non-harming fetishes, and the like).
- WPATH: World Professional Association for Transgender Health. WPATH is a professional organization dedicated to transgender health. The organization promotes evidenced-based care, education, research, advocacy, public policy, and respect.