Health Risks

10.25.14 10:45 AM ET

Coming Out Kinky to Your Doctor, in Black and Blue

As more people embrace their inner kinkster, doctors need to know the details to provide quality health care. This… can be complicated.

Recently, Claire Conrad, 36, found herself trussed up in stirrups—and not in a fun way. Conrad was at the ob-gyn to check to see if, as the Maryland resident likes to put it, “My cervix is trying to kill me.”

She’d had an abnormal pap smear, and was getting a colposcopy to make sure it wasn’t cancer. In the process, Conrad, who asked that her real name not be used, was coming out to her ob-gyn as kinky. It was plain as the purple and black caning marks on her legs.

Conrad, you see, is in an open marriage and enjoys a little submission and a little pain with her sex.

When her doctor blurted out, “Oh! You are bruised,” Conrad figured it could have been worse. Still, she left the appointment with the clear sense that the staff would be gossiping about her after she’d gone. If she ever had a caning session that broke the skin and became infected, she said she’d think twice about going back to her doctor.

“That’s a tough one,” she said. “If I had been injured, I don’t think I would be comfortable with talking to my doctor about it. Even if I did, I don’t know if I would be honest about what happened.”

Conrad’s not alone. Preliminary research finds that fewer than half of all kinksters are out to their healthcare providers about their kinks—and that’s in the San Francisco Bay Area, a notoriously kink-friendly place. Among those that are out, almost everyone anticipated being stigmatized, prompting them to hide aspects of their behavior that could impact their health. And while the medical field has gotten better about understanding sexual minorities, there’s still a distance to go before kinksters like Conrad feel comfortable in medical offices around the country.

“Up until now, it’s been a don’t-ask-don’t-tell kind of situation,” said Dr. Jess Waldura, lead investigator of The Alternative Sexualities Health Research Alliance (TASHRA), which plans to conduct a nationwide survey in 2015. “We need to destigmatize kink so providers can think straight when we’re confronted by it.”

The New Don’t-Ask-Don’t Tell

In the past year, Dr. Mike Lesniak has noticed a trend: His urgent care clinic in rural Pennsylvania was the go-to place for kinksters to get their wounds treated. He figured that was because the clinic wasn’t set up to document injuries in a way that would be admissible in court. And because he wasn’t their primary care doctor, they wouldn’t have to worry about looking him in the eye next time they needed to have a sinus infection checked out.

The experience left Lesniak in a quandary. He wanted to make sure the wounds were consensual. And he’d want to make sure that, if they were, they were being made safely.

“Sometimes, they’d say, ‘Everything’s OK,’ and you could tell it was. Other times, the response would be, ‘Everything’s OK,’ but you would get the vibe that there’s no way that everything is OK,” he said. “I try to delve into what they are doing so that I can assure myself that they are acting safely. And if not, then I can help them adjust some things to be safer.”

Kinksters’ reticence makes sense. Before 2013, people interested in bondage and discipline or sado-masochism (BDSM)—that is, getting an erotic thrill from being tied up or tying someone else up, or hurting someone or being hurt by someone—were treated in the Diagnostic and Statistical Manual (DSM), the bible of psychiatric care, as a mental disorder that could then be used in court to remove children from kinkster parents, among other things. Today, the DSM defines BDSM as a kink that only becomes a disorder if it’s causing distress or dysfunction.

The problem, said Dr. Charles Moser, a San Francisco-based internal medicine physician and perhaps the leading researcher on kink in healthcare, is that it’s up to a doctor to determine if a kink is causing distress. If the doctor is biased, he may still classify it as a disorder that can lead to legal repercussions.

Shame-Free Care

It’s a shame because, though because the majority of the 120 self-identified Bay Area kinksters Waldura recruited for the initial study said it’s important to be open with one’s providers about one’s kink, fewer than half actually were. And many said they had physical and mental health needs associated with their kinks.

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Those needs varied depending on where respondents were in the kink universe. You’d expect submissives and masochists to sustain more injuries than dominants and sadists—but neither tend to bring their concerns to physicians, said Moser.

Moser had made a practice of treating the kinky. Sometimes this means talking about hepatitis A and B vaccines and risk for hepatitis C infection with someone participating in blood play, or talking about how to reduce risk of infection if someone is playing with needles. More often, thought, it’s high blood pressure, diabetes and other typical health needs that go unaddressed when kinksters delay care to avoid provider bias.

“I always say that people have more accidents on the way to and from the play party than at the party,” said Moser, author of Healthcare Without Shame.

Avoiding care can lead to the same kind of health disparities experienced by anyone who delays care: unchecked diabetes, for instance, or undiagnosed high blood pressure, which put people at higher risk for major health problems like kidney failure or heart attack.

And while other research indicates that kinksters may be more mentally healthy than their vanilla counterparts, the TASHRA participants said they experienced fears around talking to therapists about their kinks.

Keely Kolmes, a San Francisco-based psychologist, mostly sees people who don’t come to talk about their kinks. But their kinks do come up. For instance, when a couple is having trouble, the tension and hostility can bleed into BDSM scenes. Or, power dynamics from sexual scenes can bleed through to non-kink interactions when that’s not what the couple wants. Sometimes novices to the scene have abusive experiences with new play partners and want help working through the trauma so they can engage in their kink in a healthy way. Longtime kinksters can need help working through feelings of inadequacy when a bottom leaves an encounter unsatisfied, either sexually or emotionally.

Sometimes she sees clients who are ambivalent about their kink identities. She treats them the way she would treat someone who’s coming out as gay, helping them accept themselves and their sexuality as a normal, healthy part of their lives and connects them to community support.

Not everyone is so understanding. In a study Kolmes did as part of her doctoral dissertation, she found that some kinksters had therapists who hammered on the idea that BDSM was a sign of childhood trauma. Some of these therapists required them to give up their kink to continue in therapy.

Kolmes hopes the TASHRA research will start more discussions among providers.

“I’m a strong believer that the world is not broken up into kinky people and not-kinky people,” she said. “Like many aspects of sexuality, I view kink behaviors and fantasies on a continuum. I’d love to see research on people whose sexual behavior varies based on partners. People who don’t think they’re kinky fall in love with people who want to be spanked or want to role-play. Our sexual behavior shifts so much. Things become erotic that weren’t before because it’s exciting to our partners and it becomes exciting to us.”

Opening Up

One could hardly get more out than Eric Paul Leue. Leue, the reigning Mr. LA Leather and director of sexual health and policy for San Francisco-based BDSM, bondage and fetish site, Kink.com, has shared his pup name and his role in the leather community with his parents.

When he goes to the doctor, he sees another leatherman—former International Mr. Leather, Dr. Tony Mills.

“If I need a cardiologist, for example, I would reach out to people in the community,” he said, “because who knows what my doctor is doing outside the office? I want to trust her or him, and know that I am understood, not judged, not side-eyed.”

Leue’s not alone. The Kink-Aware Professionals Directory lists doctors, therapists, chiropractors, dentists, and others who affirm kink identities. Still, Leue knows it’s easier for him. He splits his time between LA and San Francisco.

Openness might be a function of sexuality and gender, as well. When Waldura put out the call for kinksters to participate in research via social networks, she noticed that it was shared mostly by straight people using pseudonyms on the kink website FetLife and openly, under real names by leather men like Leue on Facebook.

Some of this, she suspects, is because gay men have been emboldened by their sexual outsider status. But some of it could be providers’ judgment of women’s sexuality in general.

For instance, one woman she interviewed for the study was kinky, obese and had multiple partners. It wasn’t her kink that tripped up her doctors. “Her providers couldn’t believe she was having sex at all because she was fat,” said Waldura. “A lot of women I talked to were highly sexually active. For some providers, that’s the problem.”

Conrad can relate. Though she’s been married for a decade, Conrad’s marriage has gone through periods of being open and periods of being closed. Right now, it’s open and she’s been enjoying multiple partners for the last year. So, when she asked for a pap and sexually transmitted infection screening, her nurse was confused. When she outed herself as having multiple partners, her nurse’s reaction was, in Conrad’s words, “judgy.”

Ironically, Conrad, who is getting a degree in public health, has worked with the two other doctors in her ob-gyn’s practice. On the one hand, she was anxious about her colleagues knowing about her kink. On the other, as a public health expert, she regretted that discomfort meant they’d missed a chance to provide better healthcare.

“It would have been a perfect opportunity to have a conversation,” she said. “Kink needs to be normalized. If someone says, ‘I practice x, y, or z,’ or ‘These are rope burns,’ it needs to be a conversation about what the realistic risks are that people are facing, physically and emotionally. These are all opening the door for a conversation that could help negate any negative impact.”