BDSM and Kink: Essential Insights for Providers

A patient comes into your office, or a client climbs up on your massage table, with visible bruising on their arms and legs. How do you respond? Do you immediately screen for domestic violence? Are you prepared to ask open-ended questions that will allow them to disclose abuse, self-harm, combat sports, or participation on BDSM (bondage, discipline, domination, submission, sadism, masochism) with equal understanding and safety for their vulnerability?

Lilithfoxx, queer sexologist, AASECT-certified Sexuality Educator, and relationship & intimacy coach, tells me, “Most of all, I wish providers knew that kink isn’t rare. Studies consistently show that a significant percentage of adults have engaged in or fantasized about BDSM practices.” That percentage is even higher among LGBTQ+ people, yet many healthcare professionals lack the training to respond competently. The gap between prevalence and provider education creates real barriers to care—particularly for queer and trans patients who already face disproportionate healthcare avoidance.

“When professionals dismiss or stigmatize it,” Lilithfoxx says, “they’re dismissing a huge part of their patient population. Creating a culturally competent practice means including kink in intake forms, using neutral language, and being curious rather than critical.”

So what is BDSM and why does it matter in inclusive health and wellness spaces?

In Hurts So Good: The Science and Culture of Pain on Purpose, researcher and journalist Leigh Cowart writes that "at its core, masochism is about choosing pain on purpose, for a reason. And often, in my experience, that reason is to feel bad to feel better." Cowart explores various forms of deliberate pain—from freezing cold winter ocean plunges to last-person-standing multi-day ultramarathons to hottest-of-the-hot chile pepper eating contests—demonstrating that consensual pain-seeking exists across contexts far beyond sexuality.

While Cowart focuses specifically on pain, the underlying principle, the purposeful nature, the goal to “feel better” extends throughout kink and BDSM practice more broadly. The "feeling better" might come from endorphins, from the surrender or assumption of power, from sensory overwhelm or deprivation. But it's often also about something more fundamental: feeling like ourselves.

Understanding BDSM as Sexual Orientation and Practice

And for many, many people, who we are in our core are people who enjoy sex, who find kink pleasurable, who thrive in relationships where BDSM plays an integral role. Pain on purpose has a history as old as humanity, perhaps older. “People have long used this tactic, consenting to suffer so that they can enjoy the deliberately engineered biochemical relief that follows painful stimuli. It’s not weird. And it’s not rare.”

Hakima Tantrika, Sex Educator and Writer for Valm.com, frames this as existing, at least for some, as an innate orientation. “Just as some people are naturally inclined toward certain foods, art forms, or lifestyles, BDSM can be a fundamental part of how someone experiences intimacy, safety, or release. When professionals pathologize or dismiss it, they risk alienating patients who are looking for compassionate, non-judgmental care.”

And even if it isn’t an innate part of their sexuality, participation in BDSM can be clinically significant for a number of reasons. Mistress Mia Payne, owner of Payne With Purpose, a Self-Development Dungeon is Certified in Therapeutic BDSM™, a member of The Therapeutic BDSM™ Collaborative Network, and a Founding Member of The Kink Professional Standards Alliance. She says that providers need to understand how common this is and allow that to inform the ways they mark their practices as safe spaces. “[Providers] say ‘we are queer friendly, we are trans friendly.’ They also need to add ‘we are kink positive,’” she says.

Therapeutic BDSM: Health Benefits and Clinical Applications

Payne engages in Therapeutic BDSM™. Her work often offers mental health support to clients suffering from depression, anxiety, and other clinical issues, using the neurochemicals produced through BDSM practices to manipulate mood and create meaning. As a practitioner, she helps people to move through stuckness, to transform something about themselves or their experience of the world. She does this in tandem with licensed therapists through The Therapeutic BDSM™ Collaborative Network, creating needed experiences and sharing notes back with her clients’ therapists. 

“Therapeutic BDSM™ is not therapy,” she tells me, but rather a collaboration with therapists in order to “bring catharsis” through experiences of ordeal, or service, or vulnerability. The difference between Therapeutic BDSM™ and recreational BDSM is primarily the goal. “The end goal is not just to feel good,” Payne says. “The end goal is to accomplish some kind of processing.”

The other difference is that what Payne does involves no sexual contact. It is, in fact, quite the misconception that BDSM is inherently sexual—a position I find myself defending every year when the discourse about “kink at Pride” comes around again. Personally, I’ve used rope ties to help me focus on household chores, or to help calm an overstimulated nervous system, much in the same way I currently use my weighted blanket. While the word “kink” evokes sexuality, it is not so for everyone. I’ve known many sex-averse asexuals who love to engage in BDSM. And for good reason.

As Lilithfoxx tells me, “For some people, BDSM is a way to release stress, regulate emotions, or explore embodiment after trauma… Dominance and submission can allow someone to practice vulnerability or control in ways that feel deeply healing.” And there’s plenty of science to back this up, which Cowart explores in their book. One such study, Emotionally extreme life experiences are more meaningful, found that not only does it appear that emotional extremity drives meaning, rather than pleasure alone, but that “the events we find meaningful… determine how we see ourselves and our place in the world, and subsequently how meaningful we find our lives.”

Payne emphasizes the importance of building resilience through facing fears in controlled environments. "Nothing will build resilience faster than" telling someone, "I want to experience this thing I'm super afraid of, and I want you to help me walk through that." Emerging whole and deeply seen from that experience, with a seasoned professional guiding the way, creates transformation that talk therapy alone may not achieve. This kind of work, Payne says, can be beneficial to a large number of people in ways that talk therapy alone just cannot.

Sex educator GiGi Engle explains the appeal in terms providers might better understand: kink offers feelings of safety in a dangerous world that often “[strips] us of our power,” a world that may give us power over others that we don't deserve, or piles on responsibilities we struggle to handle. "So many people,” she notes, “have shame around their sexuality, and being able to explore it in this way can really help." Engle wishes "more health and well-being experts understood the mental health benefits that come with kink," explaining that "kink isn't therapy, but it can be therapeutic… a way to explore desire [and] the giving and taking of power."

Cowart echoes this sentiment, writing that “BDSM [isn’t] inherently therapeutic [but] some practitioners can exercise it as a tool for personal growth.”

“When people talk about pain on purpose,” Cowart writes, “they almost always talk about what comes next, how they feel after the pain. The dominion over self. The endorphin rush, that hit of homebrew morphine, the lactic acid that makes the muscles tense with a pleasing burn long after the workout has ended.”

Just like the ache after a hard workout, it can be the sign of real growth. It can also be a sign of trouble. So how do you tell the difference?

Distinguishing Consensual BDSM from Self-Harm and Abuse

Lilithfoxx describes a pattern many BDSM practitioners know intimately: "Too often, patients who disclose BDSM interests are met with judgment, unnecessary concern, or subtle shaming. This can push people into silence and prevent them from seeking care when they really need it."

This matters because the clinical literature doesn't support treating BDSM as inherently pathological. Cowart notes that "multiple studies have found that rates of mental illness are not higher in BDSM practitioners as compared to those of the general population." Yet practitioners still face assumptions about trauma, abuse, or psychological dysfunction.

Cowart draws a clear line: BDSM is not abuse, and abuse is not kink. Consent creates that boundary. And that same framework helps distinguish between "pain on purpose" that is pleasurable, therapeutic, or recreational, and clinical self-harming behavior. From personal experience with both, Cowart describes self-harm as often feeling "compulsive, unavoidable"—fundamentally different from chosen experiences with purpose. A healthy practice is something you can so no to, either to a partner or to yourself.

The questions Cowart poses for discernment focus on function rather than form: "Is it causing suffering? Is it harming you? What role does the action play in your life, and how do you feel about it?"

But here's the problem: as Cowart points out, "there are healthy ways to pursue pain on purpose, and there are unhealthy ways; being preoccupied with shame can make self-assessment difficult." When patients don't trust their providers, when they assume judgment or feel ashamed, their ability to discern between abuse, self-harm, and consensual BDSM becomes actively impaired. The provider's response doesn't just affect the current conversation—it shapes the patient's capacity for honest self-reflection.

Cowart's own experience with treatment providers during periods of severe self-harm illustrates this dynamic. Their healing was stifled by "treatment providers' inability to demonstrate sufficient curiosity about the motivations of [their] interior state." Those providers "assumed they knew why I was starving and cutting and what I was getting out of it and that their externally applied framework for healing was the only true and correct way out." The result? "Their assumptions made me feel unheard and unseen."

How to Screen for Harm Without Pathologizing BDSM

Holly Nelson, an LPC, NCC, and EMDR-certified counselor pursuing AASECT sex therapy certification, offers clear guidance: "I wish more health and wellness professionals knew that BDSM is not inherently pathological, abusive, or the result of trauma." Instead, she describes kink as potentially "a beautiful way for people to explore their own needs, desires, and boundaries," noting that "kink done correctly is playful, healing, deeply intimate, and transformative."

Her recommendation for providers is straightforward: "I'd love professionals to approach clients who practice BDSM with curiosity rather than judgment. Ask your clients/patients about negotiation, boundaries, consent, and aftercare practices rather than assuming harm or stigmatizing them."

Lilithfoxx provides more specific language: "When a patient mentions impact play, rope bondage, or power exchange, professionals shouldn't immediately jump to conclusions about abuse or trauma unless there are clear indicators that consent is missing." Instead, they suggest "asking open-ended, nonjudgmental questions like 'What does that practice mean for you?' or 'How does it make you feel?'" This approach, they note, "allows the patient to share their reality rather than defend it."

The distinction matters. Cowart reminds providers that "the existence of a pathological variant of pain on purpose does not encompass the diversity of all the other ways that people choose to engage in pain." Collapsing all deliberate pain-seeking into pathology doesn't protect patients—it drives them away from care and undermines the trust necessary for effective treatment.

Continuing Education on BDSM for Healthcare Professionals

Creating truly inclusive healthcare spaces requires building competency in distinguishing consensual practice from harm. It requires curiosity over judgment, open-ended questions over assumptions, and recognition that many patients already have sophisticated frameworks for consent, negotiation, and safety that providers could learn from.

The patient with bruising who walks into your office? They're already calculating risk, deciding how much to disclose, weighing whether this interaction will push them further from care or draw them toward it. Your response—grounded in education, curiosity, and respect—determines which direction they go.