For most of the twentieth century, an interest in consensual power exchange was treated as a symptom in search of a diagnosis. Over the past decade the empirical picture has shifted substantially — and in a direction that surprises most clinicians who have not read the data.

This article is presented by Dr. Saeed Behckam, clinical psychologist and sex therapist practicing in Iran (Tehran) and Canada (Toronto, Richmond Hill & Vancouver), for the readers of Behckam.com.

What did the largest personality study actually find?

A study published in The Journal of Sexual Medicine compared 902 practitioners of consensual bondage-discipline, dominance-submission and sadism-masochism with 434 controls, using established instruments for the Big Five personality dimensions, attachment style, rejection sensitivity and subjective wellbeing. Practitioners scored as less neurotic, more extraverted, more open to new experiences, more conscientious and less rejection sensitive, with higher subjective wellbeing. They also scored as less agreeable — the one dimension running the other way.

Where differences appeared between roles, scores were generally more favourable for those in a dominant than a submissive role, with control participants scoring least favourably of the three groups. The authors concluded that these practices may be understood as a recreational leisure activity rather than as the expression of psychopathological processes.

The finding is not that kink makes people well. It is that the assumption of illness was never supported to begin with.

Does the biology tell a different story?

A systematic review published in the same journal gathered the ten existing studies on the biology of these interactions. Cortisol changes were observed in submissive participants following an interaction, indicating involvement of the physiological stress system. Endocannabinoid changes implicated the pleasure and reward system. In dominant participants, the biologically measurable pleasure appeared to depend on the power exchange rather than on pain — a distinction that overturns the common assumption about what is being sought.

Testosterone and oxytocin were also implicated, though the evidence for their role was weaker. The authors are explicit that the literature is small and requires replication, so these findings should be read as an emerging picture rather than a settled one.

Why pain thresholds and empathy circuits matter

Two further findings from that review are clinically useful. First, pain thresholds were found to be higher in submissive individuals, and an interaction may raise them further — meaning the subjective experience is not the one an outside observer assumes. Second, imaging work implicated empathy-related circuitry, including the anterior insula and the anterior midcingulate cortex, alongside the parietal operculum and ventral striatum in the reward pathway and the somatosensory cortices in pain perception.

The involvement of empathy circuitry is the detail worth sitting with. It is difficult to reconcile with the folk model of these practices as an absence of attunement between partners; it suggests something closer to the opposite.

Freud got there first — and was then misread

In Three Essays on the Theory of Sexuality (1905), Freud treated sadism and masochism as component instincts present in ordinary sexual life, not as discrete diseases confined to a deviant minority. He argued that a degree of aggression belongs to normal sexuality and becomes pathological only at the point where it becomes exclusive and replaces every other route to satisfaction. Much of the twentieth-century clinical tradition kept his terminology while discarding precisely this proportionality — and pathologised the ordinary variant along with the rare one.

What kink aware practice actually means

It does not mean endorsement, and it does not mean expertise in any particular practice. It means three specific things. The clinician does not convert the presenting problem into the interest when the client came about anxiety, a marriage or a bereavement. The clinician can distinguish consensual negotiated exchange from coercion, and takes the second seriously. And the clinician understands that anticipating a pathologising reaction is itself a common reason clients withhold information — which quietly degrades the quality of everything else in the assessment.

Read more: How to rebuild intimacy after conflict with your partner — and Anxiety chest pain or heart attack: how to tell the difference

Frequently Asked Questions — Behckam.com

Is an interest in kink a sign of psychopathology?

The largest personality study to date, comparing 902 practitioners with 434 controls, found the opposite pattern. Practitioners scored lower on neuroticism and rejection sensitivity and higher on extraversion, openness, conscientiousness and subjective wellbeing. The authors concluded such interests are better understood as recreational leisure than as an expression of psychopathological processes.

Does this mean kink is always healthy?

No, and that claim would go beyond the data. The study was cross-sectional with a self-selected online sample, so it cannot establish direction of effect. What it does undermine is the default clinical assumption that the interest itself is a symptom requiring explanation.

What is the difference between consensual kink and abuse?

Consent, negotiation and the ability to stop. Abuse removes choice; consensual power exchange is built on an agreement that either person can end. A clinician who cannot hold this distinction will misread both the healthy version and the genuinely dangerous one.

What does a kink aware therapist actually do differently?

Chiefly, they do not spend the session treating the interest as the presenting problem when the client came about something else. Research suggests fear of a pathologising reaction is itself a barrier to disclosure, which means the interest can absorb clinical attention that the actual difficulty needs.

Conclusion

Two independent lines of evidence — one on personality and wellbeing in over nine hundred practitioners, one on the underlying physiology — point away from the pathology model that dominated the last century. Both come with real limitations: self-selected samples, cross-sectional designs and a small biological literature that has not yet been replicated. What can be said with reasonable confidence is narrower but still consequential: the interest itself is a poor diagnostic signal, and treating it as the problem is more likely to obscure the actual clinical picture than to reveal it.

Looking for professional support with your relationship or mental health?

For evidence-based, confidential guidance on your sexual, emotional and mental wellbeing, you can book a private consultation with Dr. Saeed Behckam, Iranian clinical psychologist and sex therapist serving clients in Tehran, Toronto, Vancouver and worldwide online.

References

Retrieved from PubMed, U.S. National Library of Medicine: