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Bondage-Discipline, Dominance-Submission and Sadomasochism (BDSM) From an Integrative Biopsychosocial Perspective: A Systematic Review
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Nele De Neef, MD, Violette Coppens, PhD, [...], and Manuel Morrens, MD, PhD
BDSM (bondage and discipline, dominance and submission, and sadism and masochism) increasingly receives attention from the scientific community. Where earlier research efforts mainly focused on epidemiologic characteristics, psychological and biologic factors driving BDSM preferences have recently gained interest as well.
To bring together all the existing scientific literature on BDSM from a biopsychosocial perspective.
Based on the PRISMA guidelines, the current systematic review brings together all the existing literature on BDSM from a biopsychosocial perspective.
Prevalence rates of BDSM interests were investigated in the literature, as well as the associations between BDSM interests on one hand and personality traits, adverse childhood experiences, education levels, sexual orientations and biological markers on the other.
Biologic factors such as gender identity, sex hormone levels, and the neurologic constitution of the brain’s pain and reward systems influence BDSM orientation. With regard to psychological factors, both personality traits (eg, higher levels of openness or extraversion) and the presence of a personality disorder have been associated with a heightened interest in BDSM, although only limited supporting evidence is available. Additionally, sensation-seeking levels and impulsivity seem to contribute, because they presumably guide one’s drive to explore new or more-intense kinks. Whereas attachment styles impact couple dynamics, they also influence willingness to explore limits in a BDSM context. Lastly, education levels impact relational and sexual dynamics.
The limitations of the current review reflect those of the topical scientific literature. Although the number of studies focused on all aspects of BDSM is exponentially growing, most of these are only descriptive, and very few focus on underlying driving processes.
From this biopsychosocial perspective, we offer a dimensional approach while integrating the factors driving the onset and evolution of BDSM interests.
De Neef N, Coppens V, Huys W, et al. Bondage-Discipline, Dominance-Submission and Sadomasochism (BDSM) From an Integrative Biopsychosocial Perspective: A Systematic Review. Sex Med 2019;7:129–144.
Key Words: BDSM, Biopsychosocial, Kink, Masochism, Sadism, Sadomasochism
BDSM, previously known as sadomasochism (or SM), is an overarching abbreviation of bondage and discipline, dominance and submission, and sadism and masochism and refers to a physical, psychological, and sexual role-play involving power exchange between consensual participants.1, 2, 3 Historically, these practices and interests have been pathologized (for review, see reference 4); Krafft-Ebing5 pioneered in classifying sadism and masochism as pathologies in his Psychopathia Sexualis, a reference work of 19th century sexology. These views were later reflected in Freud’s6 theories on sexuality. The perception of BDSM as being pathologic influenced scientific articles from the 1970s and 1980s, which tended to focus on (non-consensual) sexual sadism from a forensic perspective and incidental SM-related fatalities.7, 8, 9 These historical views still have an impact on the most prominent contemporary psychiatric classification systems, the International Classification of Diseases (ICD; 10th edition: ICD-10) on one hand the Diagnostic and Statistical Manual of Mental Disorders (DSM; 5th edition DSM-5) on the other.10, 11, 12, 13 Ever since, the BDSM community is subjected to misconceptions and stigmatization.
The recent success of the Fifty Shades of Grey books and movies, among others, have led to an increased awareness of this expression of intimacy and sexuality. Contemporary mainstream interest in BDSM is mirrored in the exponential growth seen during the last decade of scientific research focusing on all kinds of BDSM aspects and, as such, has enriched the existing literature, thereby nuancing its initial pathologic classification.
This increased availability of BDSM-related scientific literature inspired us to bring together the existing literature on biopsychosocial aspects of BDSM in the current systematic review, the first in its kind. An integration of biologic, psychological, and social knowledge about BDSM may contribute to the understanding and destigmatization of this form of sexual expression, as well as challenge its place in psychopathological classifications.
The current systematic review was conducted according to PRISMA-P (preferred reporting items for systematic review and meta-analysis protocols) guidelines.14
Different sources may refer variously to individual parties involved in a BDSM interaction. In this review, solely the terms “dominant” and “submissive” are used to respectively refer to either participants providing stimulation, orders, or structure or those being physically constrained, receiving stimulation, or following orders. A “switch” is an individual who shifts between both the dominant and submissive roles, depending on the context and play partner.
A literature search was performed using the following inclusion and exclusion criteria: (i) research articles with a focus on BDSM generating original data were included; (ii) case reports on consensual sexual masochism and submission were included; (iii) opinion articles, (comment) letters, and essays without original data were excluded; (iv) given the focus on consensual sexual sadism or masochism, forensic articles on sexual offenders were excluded. These inclusion criteria were driven by the generally accepted scientific hierarchy of evidence.
A PubMed database search (1970–April 2018) for English-language articles was conducted using the following search terms: BDSM OR masochism OR sadomasochism OR sexual sadism OR bondage OR sexual submissive OR sexual submission OR sexual kink.
Titles and abstracts were screened to eliminate irrelevant articles. Full texts of potentially relevant articles were read and screened for further eligibility; the final selection was made in consensus by N.D.N. and M.M.. See Figure 1 for PRISMA Flow Diagram (based on reference15).
Preferred reporting items for systematic review and meta-analysis protocols flowchart. PRISMA = preferred reporting items for systematic review and meta-analysis protocols.
The Pubmed database search initially generated 1,593 records. Cross-referencing further led to inclusion of 9 additional articles and book chapters. Preliminary screening of titles and abstracts resulted in 98 remaining articles to be read in full. 10 articles were found irrelevant for the current review (studies including forensic patients, opinion articles, articles related to non-BDSM sexuality), resulting in a final selection of 87 articles to be included.
Studies reporting on the prevalence rates of BDSM interests and practices have yielded somewhat divergent results (Table 1). An Australian study18 found that 2.2% of men and 1.3% of women between ages 16–59 years had engaged in BDSM activity during the previous year. On the other end of the spectrum, Holvoet et al3 reported a BDSM interest in as much as 46.8% of the general population (n = 1,027), who have engaged in BDSM-themed activities at least once, although the same study indicated that only 7.6% of the general population self-identified as a BDSM practitioner. Studies reporting on individuals having BDSM fantasies reveal higher prevalence rates. Holvoet et al,3 for example, found that 69% of the general population had fantasies about BDSM-related activities. In line with these prevalence rates, another study in Canadian university students showed that 72% of the men and 59% of the women had had fantasies of being tied up, and 65% of the men and 58% of the women had fantasies of tying up a partner.16 In the same group, 60% of the men and 31% of the women indicated positive thoughts of whipping or spanking someone. Similarly, Jozifkova and Flegr21 demonstrated that about half of the general population preferred unequal power dynamics in their sexual relationship.
Prevalence rates of BDSM interests in the general population
This divergence might be explained by several factors. First, studies that surveyed participants on their interests using an overarching term such as “SM” or “BDSM” without specifying a definition18, 19, 24, 25 systematically yielded lower prevalence rates, compared with studies gauging interest or practices of specific activities and dynamics (eg, “tying up,” “blindfolding,” “whipping”).3, 16, 21, 22 This may indicate that, in general, the subjective interpretation of the definition of (BD)SM practice has a stricter connotation than when defining the practice through specific, individual acts, leading to lower prevalence rates when overarching terminology is used. This is illustrated by the fact that about half of the sample from Holvoet and colleagues3 indicated having engaged in BDSM activities, whereas, in the same sample, only 7.6% actually self-identified as a BDSM practitioner. It should be noted that no consensus exists on which activities are BDSM practices and which are not.3
A second source of divergence might stem from investigating different intensity levels of BDSM interest. As such, some studies assessed interest in or fantasies about BDSM, whereas others queried actual performance of such activities. As can be expected, the first type of studies demonstrated higher prevalence rates than the latter.
Third, the applied methodology could further account for some of the variance, because the surveys yielding higher prevalence rates3, 22, 23 were held via internet channels, whereas Richter et al18, 19 interviewed participants through less-anonymous telephone calls. A final explanation might come from the time span covered by the different questionnaires, because the prevalence of activities in the preceding month3, 22 was found to be much lower than lifetime experience (1.3–8.1% vs ≤32%).22
Although BDSM practitioners are often considered as a homogeneous subculture of the general population, in the current review, we applied a dimensional approach toward interest in and practices of BDSM. On one end of the spectrum, BDSM-related interests translate into unexplored fantasies and, on the other, an intensive, continuous implementation of these interests in all aspects of daily life. It has been suggested that a majority of the general population has BDSM-themed fantasies, and about half has engaged in BDSM-related activities at least once.3 Joyal and Carpentier23 found interest in voyeurism, fetishism, and masochism in half of their population sample and at least 1 experience with such an activity in one-third. Additionally, engaging in at least 1 BDSM-related activity on a regular basis is reported by 12.5% of the general population.3 The latter study also demonstrated that 1% of the general community explores these interests outdoors and visits dedicated BDSM-related clubs or events. Finally, an even smaller subgroup implements BDSM in their lives on a 24/7 basis, although specific prevalence rates of these practices are not known.26 Accordingly, BDSM is seen by some as a form of leisure,27 whereas others define it as a lifestyle, an identity, or even their “orientation(s)”.23 Santilla and colleagues28 showed that these interests also seem to evolve over time, from initial milder interactions toward more extreme forms later on. For example, a practitioner may start pain play interests by experimenting with mild spanking and evolve toward more intense stimuli, such as electrical stimulation or needle play.
Literature indicates that BDSM is an umbrella term that covers an array of interactions that can be present independently or in different clusterings. A dimensional angle of approach is therefore also applicable on the nature of the interaction and the acts implemented. Generally, a shift in power dynamics is at the core of BDSM play.1, 29 As such, in a more stereotypical setting, there is a dominant partner (D) in charge of the scene, and a submissive partner (s), who consents to being submitted to the actions of the dominant. The roles may switch, more parties may be involved, but, at each point, power exchange is at its essence. This power shift will translate in a wide range of role play possibilities, including specific rituals (kneeling, use of title to address partner), humiliation, movement restriction, or sensory deprivation. When looking at the specific nature of the activities, “softer” BDSM elements such as movement restriction or blindfolding are much more frequently implemented, compared with “harder” BDSM activities (eg, whipping).3 Based on the associations between specific BDSM activities, Alison and colleagues2 https://paperpile.com/c/ihzoih/Gpb1+egEC defined 4 clusters of BDSM-related behaviors: pain play (including spanking, caning, use of clothespins), humiliation (eg, verbal abasement, gagging), physical restriction (use of bondage, handcuffs, or chains), and hypermasculinity (eg, anilingus, use of dildo). This last category, however, presumably reflects the fact that more than half of their sample consisted of gay men and may not be representative for the broader BDSM community. Nevertheless, it demonstrates that different BDSM activities are not necessarily all present in each interaction and that certain clusterings can be established. In this line, Jozifkova et al30 suggested that D/s dynamics and affinity with bondage are 2 separate play strategies, although both may co-occur. Weierstall and Giebel31 recently developed a sadomasochism checklist containing a submission scale and a dominant scale, each containing 24 items with 6 different factors: domination, use of toys, soft play, beatings, breath play, and play involving bodily fluids. This, again, indicates that heterogeneous profiles of interest emerge within the BDSM community.
BDSM play is often perceived as a precursor to or part of sexual activities.1 Chivers et al32 demonstrated that exposing individuals with masochistic sexual interests to stories with masochistic and submissive themes elicited both subjective and genital sexual arousal responses, indicating the sexual nature of these experiences. In contrast, Newmahr33 argued that, to many practitioners, SM does not precede or replace sexual activities but is an end into itself. Both may be true, because a recent online survey of BDSM forum members (Fetlife; n = 363) conducted by our research group (unpublished results, 2019) showed that BDSM-related interests are sexual in nature in most, but not all, BDSM community members; 70% indicated they always or regularly combined BDSM play with sex, whereas 7% never combined the 2, and 23% do so only on occasion.
In the layman’s view, BDSM is subject to binary categorization, with participants being either dominant or submissive. More recently, however, more roles have been defined for BDSM community members to identify with: dominant, master/mistress, top, sadist, submissive, bottom, masochist and switch,34, 35 although a clear delineation between these roles does not always exist. In Martinez’s survey study,35 most of the participants (n = 185 of 202) identified with 1 BDSM identity, with 41.1% of the participants self-identifying as a submissive, slave, or bottom, 28.2% as dominant, master, or sadist, and 22.3% as switch. More than half of the population (52%) indicated maintaining the same role (dominant or submissive) throughout all interactions, whereas the other half tended to experiment with other roles as well, although men tended to be significantly less fluid in their role (43.4% of the men had at least some level of fluidity, whereas this was the case for 51.5% of the women). Nevertheless, almost all participants clearly preferred 1 role over others, because only 7.4% experienced both roles in equal amounts. In Alison’s study,2 these ratios were confirmed, with 27.0% of the subjects identifying themselves as mainly sadistic, 22.7% as both sadistic and masochistic, and 50.2% as mainly masochistic. However, it should be noted that the sample used in the latter study is far from representative for the general population, because 88% of the participants (n = 184) were male, and, additionally, more than half (51.6%) reported being homosexual.
To conclude, BDSM interests can be approached from a multidimensional perspective. In the general population, depending on the applied BDSM definition and methodology, 8–70% is BDSM-minded, with a smaller amount of practitioners seeking to take their interests outdoors. Practitioners play with varying degrees of intensity and frequency and are heterogenous in performing their activities in a sexual context. Roles adopted in the interaction occasionally are strictly dominant or submissive, but they are more flexible in the majority of the players.
There is a distinct stigma surrounding the spectrum of BDSM, resulting, among others, from the fact that it links sexuality to pain, power display, and humiliation, rather than to romance and tenderness, an association more commonly made by the general public. Nevertheless, it has been claimed that previous cultures (eg, ancient Egypt, ancient Rome) accepted the use of physical and mental pain play in a sexual context much more than is the case in our current western societies,1, 36, 37 but insufficient data exist to verify this hypothesis. International differences in BDSM practices have been suggested,38 but large-scale studies investigating this notion have yet to be conducted. Yost39 identified 4 categories of stigmatizing attitudes: (i) BDSM is socially and morally wrong, (ii) BDSM is associated with non-consensual violence, (iii) a general lack of tolerance toward SM practitioners, and, finally, (iv) the notion that submissive or dominant traits translate to other domains in everyday life (eg, behavior toward children). Although few studies looked into the characteristics and traits facilitating these stigmatizing attitudes, stigma was found to be higher in women who were less sexually emancipated.40 In a large sample of SM-identified women, half reported they had experienced some form of physical assault or discrimination because of their SM
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