Reproductive health

October 2012

Up front

Sexual diversity in patients

The importance of being nonjudgemental

Volume 41, No.10, October 2012 Pages 745-745

DJ Williams

It is important for health professionals to remember that despite narrow social scripts that define ‘normal’ sexuality, there remains tremendous sexual diversity across history and cultures.1

‘BDSM’ is an abbreviation that refers to a broad range of consensual activities and/or lifestyles that may involve bondage and discipline, dominance and submission, and/or sadomasochism. Activities may include spanking, whipping, caning, restraints, sensory stimulation or deprivation, piercings, role play scenarios, the use of sex toys, and many other possibilities and is practised for the erotic enjoyment of consensual participants. Despite common misperceptions, research shows that in general, BDSM (bondage/domination/sadomasochism) participants are healthy, asymptomatic individuals.2–4 Indeed, there is no empirical evidence suggesting that participation in BDSM is harmful to those who practise it or that it leads to neglectful or abusive parenting. The BDSM community promotes high levels of awareness of the importance of physical and psychological safety and participation is predicated on mutual consent and effective communication.

BDSM is practised across all sexual orientations. A national survey among Australian people found that nearly 2% reported being involved in BDSM within the past year, however, the proportion is higher among gay, lesbian and bisexual people.4 Nevertheless, there remains a lack of awareness among physicians concerning BDSM practices.5 Despite the fact that BDSM is not inherently harmful, recent research suggests that people who regularly practise BDSM have faced discrimination from their doctor.6

Because some erotic activities can carry specific elevated physical and psychological risks, it is important that patients can freely and openly discuss their sexual interests with their general practitioner without fear of judgement and discrimination. General practitioners can guide patients to help reduce the risks associated with some BDSM activities, such as preventing transmission of disease through blood and other body fluids. Also, some patients with particular medical conditions (ie. cardiovascular disease) may need to modify specific, intense BDSM practices, at least for a time. (The AIDS Committee of Toronto provides recommendations regarding safer sex at

New research suggests that much of BDSM may be better understood as a serious leisure pursuit, rather than exclusively relying on interpretation through sexuality discourses.7 Leisure pursuits are freely chosen, intrinsically motivated and produce important personal benefits. In other words, despite appearances and common assumptions, BDSM is not necessarily centred directly on sex for many who practise it. For some, BDSM offers a safe space to enjoy creative, embodied experiences and to express important aspects of identity that are not often realised or performed. Participation yends to require good communication skills, respect, trust and openness to intimacy.

Training that helps GPs to become more comfortable discussing a wide range of erotic activities and lifestyle practices with patients may be helpful. Emphasis should be placed on the recognition that there can be considerable diversity in personal meaning and motivation around people’s engagement in various erotic practices. Primary issues of safety and mutual consent should also be emphasised. The Community-Academic Consortium for Research on Alternative Sexuality (CARAS) is an excellent resource for health professionals and is available at

Effective GPs listen closely and nonjudge-mentally to their patients, thus creating a safe clinical space for patients to discuss many important aspects of their health. For patients who enjoy consensual BDSM, increased opportunities for such open and safe communication would be helpful and appreciated.

Conflict of interest: none declared.


  1. Popovic M. Psychosocial diversity as the best representation of human sexuality across cultures. Sex Relation Ther 2006;21:171–86.
  2. Sandnabba NK, Santilla P, Alison L, Nordling N. Demographics, sexual behaviour, family background and abuse experiences of practitioners of sadomasochistic sex: a review of recent research. Sex Relation Ther 2002;17:39–55.
  3. Connolly PH. Psychological functioning of bondage/domination/sadomasochism (BDSM) practitioners. J Psychol Human Sex 2006;18:79–120.
  4. Richters J, de Visser RO, Rissel CE, Grulich AE, Smith AMA. Demographic and psychosocial features of participants in bondage and discipline, ‘sadomasochism’ or dominance and submission (BDSM): data from a national survey. J Sex Med 2008;5:1660–8.
  5. Moser C. Demystifying alternative sexual behaviors. Sex Reprod Menopause 2006;4:86–90.
  6. Wright S. Survey of violence and discrimination against sexual minorities. Baltimore: MD: National Coalition for Sexual Freedom, 2009.                
  7. Newmahr S. Rethinking kink: sadomasochism as serious leisure. Qual Sociol 2010;33:313–31.


Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No






Competing Interests: 

Your comment is being submitted, please wait


Download citation in RIS format (EndNote, Zotero, RefMan, RefWorks)

Download citation in BIBTEX format (RefMan)

Download citation in REFER format (EndNote, Zotero, RefMan, RefWorks)

For more information see Wikipedia: Comparison of reference management software