Development of The Bondage and

DEVELOPMENT OF THE BONDAGE AND DISCIPLINE, DOMINANCE AND
SUBMISSION, SADISM AND MASOCHISM HUMILITY SCALE (BDSMHS)
Dissertation presented to the Faculty of the

California School of Professional Psychology
Alliant International University
Sacramento
In partial fulfillment of the requirements for the degree of
Doctor of Psychology
by
Marjha A. Hunt M.A.
2022
Approved by:
Tatiana Glebova, PhD., Chairperson
Alex Hsieh, Ph.D.
Kristee Haggins, Ph.D.
DEVELOPMENT OF THE BDSMHS ii
©Marjha A. Hunt, 2022

DEVELOPMENT OF THE BDSMHS iii
Dedication
I dedicate this work, and the completion of this chapter in my journey, to so many.
Ubuntu reminds me that I could not have done this without the support of my ancestors and
family.
First & foremost, my why, Si & Key. You are, and have always been, my motivation
throughout this journey and what has kept me from quitting so many times. I hope this has been
a reminder that you can do anything, even when navigating a world that often tries to convince
us otherwise.
To my mom, dad, & little sister. Your support through this process & faith in my ability
to achieve more has been such a guiding force. Mom, you have given me the gift of creativity
that shows up in all my work & a voice that will speak up through fear, anxiety, & others’
attempt to minimize, erase, & oppress. Dad, you have given me the gift of compassion for myself
& others. You have also taught me the value of hard work & giving 110% in the things I am so
passionate about. Niya, you have been the ear that I could vent to & the safe place to laugh about
any & everything. Through our shared experiences & drive for #blackexcellence, you continue to
encourage & support who I am & what I live & fight for.
To my partner, Dar. The past seven years have been such a journey. You have
consistently shown up, believing in me & this dream; & have stood beside me in the advocacy
work for these communities. I appreciate you & your support & look forward to our future & the
impact we will continue to make on mental wellness in our communities. #blacklove
Other feelings of gratitude to a few others in my family, both blood & chosen. To my
cousin Sean, who is always there to celebrate & encourage continued excellence & connection.
To my sister-friend Tamara, who has supported (and inspired) me immensely in so many ways
through this entire 13-year journey. To my girl Heather, who walks beside me on this journey
and has encouraged me through life, relationships, & dissertation. And last, but certainly not
least, to my Egun, upon whose shoulders I stand, that have paved the way for me to do what I
have and show up in the ways that I do. I honor and give thanks.
Thank you for being such an integral part of my journey. I am humbled and filled with so much
gratitude. I love & appreciate all of you. I am because you all are!
Àṣẹ!
DEVELOPMENT OF THE BDSMHS iv
Acknowledgments
I’d first like to express my deepest thanks to THE BEST and most amazingly diverse
dissertation committee.
To my committee chair, Dr. Glebova. I appreciate your sacrifice, patience, dedication,
wisdom, and support during this process. Even during the most frustrating times, you continued
to teach, challenge, and encourage me. You have taught me so much about the research process
(that I will use for my next project), and I am so very grateful for you!
Dr. Hsieh, I have always felt your genuine support for me to succeed. Your openness (in
sharing your experiences), knowledge, and curiosity (which felt like challenges at times), pushed
me to be better; and your down-to-earth spirit and humor made the journey easier and more
worthwhile. Thank you for saying yes to being a part of this process (even though you failed
your mission of seeing me cry during the process). I appreciate you!
Dr. Haggins, I would have never imagined having a Black woman on my committee. You
are someone I deeply admire within the community and in academia. Your work and activism
inspire me and my passion for working with marginalized communities. Thank you for all you
do, for saying yes to this process, and for your continued support of (and Zola for) me and my
journey. I honor and appreciate you! Àṣẹ
I also want to honor and thank the BDSM/kink community and the experts in this study.
This would not have been possible without you, and your voice, feedback, and willingness to
give of your time is what allowed this to be possible. I hope this work makes you proud and
helps create more kink-affirming spaces and experiences.
DEVELOPMENT OF THE BDSMHS v
Abstract
This study aimed to create a BDSM Humility Scale (BDSMHS). The BDSMHS is an assessment
tool developed to measure a clinician’s ability to work with the BDSM/kink community from a
culturally humble lens. Delphi Method was used, as it is an appropriate methodology for
exploring agreement/disagreement and gaining consensus of experts on a specific topic area. The
researcher developed preliminary items to be used in Phase 1 of this study. The BDSMHS’s 31
preliminary items span four categories that align with the principles of cultural humility. These
categories include Knowledge, Attitude/Beliefs, Openness, and Acknowledgement of Power
Imbalances. A sample of 19 expert participants, 12 BDSM practitioners, and seven kink-
affirming, licensed mental health clinicians were recruited via the snowball method to rate each
item's relevance and importance using two 5-point Likert scales. This study included two rounds.
Data analysis included using Median and Interquartile Range for each item and analyzing
experts’ feedback on the instrument and its items. After data analysis for round 1, 10 items were
removed, 10 new items were created, and four items were modified. Consensus was reached
after round 2 analysis. No items were removed or added, and three items were modified for
clarity. The final BDSMHS consists of 31-items spanning four categories of cultural humility.
This scale may be useful in assessing and further developing graduate school curriculum that will
help cultivate clinicians who are more kink-aware when working with the BDSM/kink
community from a culturally humble lens.

DEVELOPMENT OF THE BDSMHS vi
Table of Contents
Dedication iii
Acknowledgements iv
Abstract v
List of Tables ix
CHAPTER I. Introduction and Literature Review 1
Statement of the Problem 1
BDSM Defined 6
BDSM and Abuse 7
BDSM and Pathology 9
Sexual Masochism Disorder 302.83 10
Sexual Sadism Disorder 302.84 10
Fetishistic Disorder 302.81 11
Nomenclature 11
Prevalence of BDSM Participants 13
BDSM Practitioners and Therapy 14
Kink-Aware Therapy 16
Competency and Humility 17
Literature Review Summary 18
Self of the Researcher 19
CHAPTER II. Method 21
Delphi Method 21
Development of Preliminary BDSMHS Items 23
Participants 24
Inclusion Criteria 24
Recruitment 25
Preventing Dual Relationships and Coercion 26
Procedures 26
DEVELOPMENT OF THE BDSMHS vii
Participant Rights 26
Data Collection 27
Demographics 27
Expert Licensed Clinician Data 27
Expert BDSM Practitioner Data 28
Phase 1 28
Phase 2 28
Phase 3 29
Phase 4 30
Instrumentation 30
Preliminary BDSM Likert-scale Questionnaire 30

CHAPTER III. Results 32
Preliminary Analysis 32
Sample 32
Description of Expert BDSM Practitioners 34
Description of Expert Licensed Clinicians 36
Delphi Analysis Round 1 37
Item Relevance 39
Item Importance 39
Item Removal 39
Item Modification 40
New Item Additions 41
Qualitative Data Themes 42
Feedback Outlier 44
Delphi Analysis Round 2 45
Item Relevance 46
Item Importance 47
Item Removal 47
DEVELOPMENT OF THE BDSMHS viii
Item Modification 47
Qualitative Data Themes 48
Comparison Data between Expert Groups 49
Self of the Researcher Reflections 50
CHAPTER IV. Discussion and Conclusion 52
Summary of Interpretation and Findings 52
Final BDSMHS Items 55
Contributions and Clinical Implications 56
Limitations 57
Recommendations for Future Research 58
References 59
APPENDIX A. Preliminary BDSMHS Questionnaire 64
APPENDIX B. Revised BDSMHS Items 70
APPENDIX C. BDSM Practitioner and Licensed Clinician Flyers 74
APPENDIX D. Inclusion Criteria, Informed Consent, and Attestation 77
APPENDIX E. Demographics 82
APPENDIX F. Final BDSMHS Items 87
DEVELOPMENT OF THE BDSMHS ix
List of Tables
Table 1. Expert Participant Demographics 33
Table 2. Description of Expert BDSM Practitioners 35
Table 3. Description of Expert Licensed Clinicians 36
Table 4. BDSMHS Questionnaire Descriptive Statistics: Round 1 37
Table 5. Preliminary BDSMHS Items Eliminated 40
Table 6. Preliminary BDSMHS Items Modified 41
Table 7. Revised BDSMHS Item Additions 42
Table 8. Qualitative Themes 44
Table 9. BDSMHS Questionnaire Descriptive Statistics: Round 2 45
Table 10. Revised BDSMHS Items Modified 48
DEVELOPMENT OF THE BDSMHS 1
CHAPTER I
Introduction and Literature Review
Practitioners of Bondage and Discipline, Dominance and Submission, and Sadism and
Masochism (BDSM) are rising. For this study, a “practitioner” is defined as one who identifies
as engaging in one or more of the various BDSM practices and self-identifies as being a part of
this community or population.
Statement of the Problem
Since the Fifty Shades trilogy release in 2012, websites, including Amazon, are selling
more BDSM-related novelties such as blindfolds, handcuffs, and whips, demonstrating the
increasing desire of individuals to explore kinkier sex (Gray, 2012) potentially. Holvoet, Huys,
and Coppens (2017) report that 46% of their sample (n=1027), from the general population,
engaged at least once in specific BDSM practices, although only 7.6% of those identified as
BDSM practitioners. They also conclude that BDSM fantasies are reported by 69% of the
sample. “Fetlife” (https://www.fetlife.com), a social networking site for the BDSM, fetish, and
kink community, now has more than nine million members than the one million in 2010, before
the Fifty Shades of Gray release.
When researching the prevalence of individuals who admit to participating in consensual
BDSM practices (not necessarily identifying as a BDSM practitioner), the numbers show them as
more prevalent than the numbers of individuals who identify as lesbian, gay, bisexual, and
transgender (LGBT). UCLA William Institute School of Law reports that 4.5% of the population
identifies as LGBT (LGBT Demographic Data Interactive, 2019). In comparing the rate of
BDSM practitioners and LGBT individuals, the researcher may conclude that clinicians have a
higher probability of working with those who engage in BDSM practices than those who identify
as LGBT. Despite this occurrence, the curriculum in graduate programs is more likely to include
information regarding working with same-sex and or transgender clients than those engaging in
BDSM practices. In the most extensive international sex research survey done by Durex (2005),
it was reported that 10% of study participants in the United States report engaging in
sadomasochism, while 36% report using masks, and blindfolds, or other forms of bondage.
Lodro Rinsler (2015) reported in Marie Claire magazine’s article that 85% of those engaged in
some form of light BDSM. An increase in overall practitioners suggests increasing individuals
and/or partnerships engaging in therapy. With the increasing participation rates in BDSM
engagement, clinicians should have a greater sense of knowledge regarding this community and
its practices. Phillai-Friedman et al. (2015) suggest when working with the BDSM community,
simply being “open-minded” is not enough. They state that it takes specified training that will
allow the clinician to work with the intricacies of this culture.
In an article geared toward clinicians working with this community, the authors speak to
those that “choose” to work with BDSM practitioners (Kleinplatz & Moser, 2004). This may
create the assumption that there are low practitioner rates in therapy, suggesting that such an
occurrence would not likely happen to the “average” clinician; thus, negating the importance of
becoming culturally humble working with the BDSM community and/or including more
education about this community in academic curriculum.
In one study that focused on BDSM competency in mental health clinicians, 100% of the
clinicians interviewed reported participation in the lifestyle (Rodemaker, 2011). This may
suggest that most BDSM competent therapists are so because of their knowledge from being
active in the lifestyle or their personal interest in working with this population instead of
becoming competent because of their required professional training. How prepared are clinicians
(who are not active in the lifestyle) entering the mental health field to work with this population?
According to Lawrence and Love-Crowell (2008), clinicians likely have minimal knowledge
about the culture of BDSM, hold harmful or inaccurate beliefs, or may inappropriately
pathologize practitioners of BDSM. In a study of 314 licensed marriage and family therapists
(LMFT) conducted by Ford and Hendrick (2003), results indicated that clinicians express more
discomfort when working with BDSM practitioners than with same-sex partnerships, despite the
rate of BDSM practitioners being more prevalent. Results also indicated that when dealing with
discomfort, 40% of clinicians would refer out compared to the 4% that would use self-
examination to deal with discomfort, 4% would seek out additional training and education about
the topic, and 2% that would seek their therapy for their own discomfort.
In a more recent publication, Stockwell, Hopkins, and Walker (2017) explore some of the
challenges of finding a clinician that is competent when working with BDSM culture. They
suggest it may be difficult because we are part of a culture that “frowns upon explicit attitudes
that indicate any degree of discrimination against any population” (p. 436). This suggests that if
a clinician was feeling some bias against this population, because of the stigma, they might not
feel comfortable enough to admit it, seek consultation around it, or obtain training to expand
their knowledge, thus potentially causing harm within the therapeutic relationship. California
Association of Marriage and Family Therapists (CAMFT) Code of Ethics explicitly states that
therapists do not perpetuate social prejudices when treating and diagnosing clients (CAMFT,
2019). Therapists in California make up over half the nation’s total. Because of this code,
clinicians may fail to speak up when they feel negatively biased toward a client’s beliefs,
lifestyle, or practices, for fear of being viewed as unethical. It is also suggested that a lack of
speaking up may be due to a lack of awareness of one’s own bias.

According to Kelsey’s study (2013) that included 766 licensed psychotherapists, 76%
reported having at least one client that engaged in BDSM, and over 50% reported having seen 10
or more BDSM clients. In the same study, 64% of the participants reported receiving no graduate
training in BDSM. Of those that received training, the study did not report whether the “training”
only included BDSM paraphilias discussed within the Diagnostic and Statistical Manual of
Mental Disorders. The study also reported that 52% of participants sought out additional training
on their own after graduation but did not report whether these trainings were BDSM specific or
just topics that included alternative sexual practices. Of all participants in the study, less than
half reported feeling competent in working with BDSM practitioners. These results suggest that
while there is a high prevalence rate of BDSM practitioners that attend therapy, most clinicians
do not receive adequate training regarding BDSM, and most do not feel competent in working
with them (even after seeking their own training).
Another study (Jutterbock, 2012) with four heterosexual married couples who
participated in BDSM showed a constant theme of feeling a lack of understanding from mental
health professionals regarding their marriage and BDSM. Kolmes and Weitzman (2010) suggest
that a Kink-aware therapist can distinguish between healthy BDSM and non-consensual abuse
and recognize BDSM as a normal part of the sexual spectrum. With the growing number of
BDSM participants, this researcher believes being Kink-aware should be expected from all
clinicians and not just those who also happen to be practitioners or those interested in gaining a
greater understanding of this population.
Lawrence and Love-Crowell (2008) interviewed 14 kink-aware therapists. The most
common theme amongst all therapists was cultural competence being essential for effective
therapy with BDSM practitioners. This theme includes two key factors. The first is therapists
having an open, accepting, and non-judgmental attitude toward BDSM practitioners and their
activities. The second is therapists know BDSM practices and cultural values. If many graduate
programs claim to produce culturally competent clinicians, why is this lack of competence a
common problem that BDSM practitioners are having with therapists? This leads this researcher
to believe that clinicians’ level of competency when working with the BDSM/kink community is
insufficient, and there is a gap in the academic curriculum when preparing clinicians.
A few of the therapists reported in the latter study (Lawrence and Love-Crowell, 2008)
that they had clients report being alienated or traumatized by previous therapists. What caused
this feeling for them? Was it a lack of knowledge? Is it that therapists were trained during a time
when BDSM was more pathologized than it is currently? Was this the norm for BDSM
practitioners? Is it the common language used amongst clinicians in the mental health field
perpetuating the stigma associated with this culture?
Based on previous research, there is a lack of competence among clinicians who do not
have specialized training in working with the BDSM community or have a personal affiliation to
the BDSM community. Furthermore, no instrument can assess whether a clinician is culturally
humble enough to work with this community. Having an instrument to assess this could be used
to show the effectiveness of master’s/doctoral level-specific curricula (such as sex therapy,
relational therapy, cultural diversity, etc.) in preparing clinicians to work with individuals and
partnerships with various relational dynamics and alternative sex practices within the
BDSM/kink community. This instrument will also allow trainers, educators, and supervisors to
assess levels of humility in this area and assess the general preparedness of new clinicians
entering the field when working with this population.

BDSM Defined
According to Newmahr (2010), BDSM is an overlapping acronym referring to the
consensual practices of bondage and discipline (BD), dominance and submission (D/S), and
sadism and masochism (SM). It is important to note that alternative relational dynamics are
included in the BDSM acronyms: Dominant and submissive and Master and slave (D/s and M/s).
These labeled pairings are ever-expanding within the community. They are now inclusive of
many other relational identities such as Daddy (a lover taking on a quasi-paternal role of
nurturing caregiver and disciplinarian), little (an age player that centers child-like playfulness
and wonder in their relational dynamic), brat (often a partner in the submissive role who
struggles against or challenges to dominant), and many more. This study will use “BDSM” for
general reference and any of the above combinations of acronyms for specific references.
Bondage and discipline encompass using physical or psychological restraints. Dominance
and submission encompass the exchange of power and control, and sadism and masochism
encompass taking pleasure in one’s own or another’s pain and/or humiliation. Fetishism is also
included in the BDSM community and includes a practitioner’s strong preference for certain
activities, areas of the body, tools, fabrics, or clothing (Nichols, 2006). Lighter forms of BDSM
may include, but are not limited to, things like spanking, biting or scratching, and more extreme
practices may include but are not limited to asphyxiation, blood play, severe whipping, or needle
torture. BDSM can be a healthy relationship dynamic, is rooted in mutual consensual by all
participants, and is not the same as abuse. It is important to distinguish that although BDSM is
not abuse, abuse can occur within BDSM relationships, just as it can with any relationship.
“Vanilla” is another term widely used that may be referenced in this study, likely by
experts and/or participants. According to an article published in Psychology Today, vanilla sex
refers to “conventional sex that conforms to the very basic expectations within a culture.
Classically, in heterosexual sex, it refers to sex in the missionary position, and broadly speaking,
excludes fetishes such as S&M” (Pillay, 2015, p.1).
BDSM and Abuse
According to Masters (2008), BDSM is often confused with acts of domestic violence
and/or abuse. Masters also states that actions such as physical force, hitting, yelling, humiliation,
using fear as coercion, and degradation can be viewed by clinicians as abuse; however, often, to
achieve BDSM satisfaction, many (or all) of these actions above must be employed. Masters,
therefore, suggests that within the context of BDSM, abuse should not be labeled solely on the
specific practices but also include an exploration of consent and the context of the relationship
dynamic being practiced.
While the spectrum of practices and roles within the BDSM community can vary widely,
one distinction separates healthy sex practice from unhealthy abuse - consent. Consent is one of
the most significant distinctions between BDSM and abuse. BDSM begins with negotiation, and
all parties can, at any time, terminate activities. It happens in a controlled environment with
individuals who share mutual respect and trust in one another. Abuse is typically unnegotiable,
single-sided, and in part, lacking in respect. BDSM practitioners often align with one of many of
the community’s different philosophies around safety and practices. The most notable include,
Safe, Sane, and Consensual (SSC), Risk-Aware Consensual Kink (RACK), Personal
Responsibility, Informed, Consensual Kink (PRICK), and Freely-given, Reversible, Informed,
Enthusiastic, and Specific (FRIES). Although each one speaks differently to practitioner style
and approach to protocol, they all include the same basic rule- consent. Consent is the
foundational structure of BDSM culture. Because of the importance of this practice in the BDSM
community, this researcher assessed knowledge of this framework when identifying participants
for this study.
There is a common myth when attempting to understand the “why’s” of BDSM. It
assumes a positive correlation between BDSM and childhood abuse (Santtila, Sandnabba &
Nordling, 2006; Taylor & Usher, 2001). Although this is consistently the misconception,
research has shown no correlation between childhood abuse and sexual interest in BDSM
(Moser, 2001; Santtila, Sandnabba & Nordling, 2006). Some studies have shown that by the age
of 18, 25% of women and a little over 16% of men will have experienced sexual abuse (National
Sexual Violence Resource Center, 2015). Studies were conducted with 186 BDSM practitioners,
and results indicated that 23% of women and 8% of men had experienced sexual abuse
(Nordling, Sandnabba, & Santtila, 2000). This suggests that regarding BDSM practitioners, there
are about the same percentage of women and a smaller percentage of men that have experienced
sexual abuse compared to the national average.
According to Warren and Warren (2008), there are indeed couples that gravitate toward
BDSM because of their experience with trauma. As stated earlier, by Lawrence and Love-
Crowell (2008), regarding the evidence of clinicians holding harmful or inaccurate beliefs
regarding BDSM culture and practices, this becomes problematic in its potential for creating the
idea that the use of BDSM as a means of coping with trauma is also harmful. Some individuals
are drawn to meditation to deal with trauma; however, it is almost always associated with being a
positive and healthy way of coping. According to Yaniv (2012), when an individual consciously
reenacts a traumatic situation in a controlled and safe environment, it is considered a therapeutic
technique called psychodrama. Based on many scenes experienced by those in the BDSM
community who have experienced trauma, this could also be recognized as an example of this
therapeutic technique.
BDSM and Pathology
Paraphilia is defined as “any intense and persistent sexual interest other than sexual
interest in genital stimulation or preparatory fondling with phenotypically normal, physically
mature, consenting human partners (American Psychiatric Association, 2013, p. 685). On the
other hand, a paraphilic disorder is “a paraphilia that is currently causing distress or impairment
to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to
others” (APA, 2013, pp. 685-686).
There are eight classifications under Paraphilic Disorders in the Diagnostic and Statistical
Manual of Mental Health Disorders (5th ed.; DSM-5; American Psychiatric Association [APA],
2013). These classifications include Voyeuristic Disorder, Exhibitionistic Disorder, Frotteuristic
Disorder, Sexual Masochism Disorder, Sexual Sadism Disorder, Pedophilic Disorder, Fetishistic
Disorder, and Transvestic Disorder. These classifications are then divided into two groups.
Group one includes those based on anomalous activity preferences. This group is then divided
into two subgroups. These include courtship disorders (voyeuristic disorder, exhibitionistic
disorder, and frotteuristic disorder) and algolagnic disorders (sexual masochism disorder and
sexual sadism disorder). The second group includes those based on anomalous target preferences
(Pedophilic disorder, fetishistic disorder, and transvestic disorder). (APA, 2013)
The APA (2013) also distinguishes paraphilic disorder from a diagnosis. A diagnosis
would be considered when a paraphilic disorder is present, along with negative consequences
that are the immediate and/or ultimate result of the paraphilia (i.e., distress, impairment, and/or
harm to others).
For this study, this researcher will focus on those that fall specifically within the BDSM
acronyms, which, for the DSM-5, include Sexual Masochism Disorder, Sexual Sadism Disorder,
and Fetishistic Disorder.
For each of the following disorders, diagnosis can be used for individuals who freely
admit to having these interests and those who deny them when contradictory evidence is present.
Two additional criteria must be met to consider diagnosis. Criterion A is that these symptoms
“must have been present for at least six months of recurrent and intense sexual arousal…” (p.
686) (this timeframe should be used as a general guideline and not a threshold for diagnosis).
Criterion B is that the “fantasies, sexual urges, or behaviors cause clinically significant distress
or impairment in social occupational, or other important areas of functioning” (p. 686). (APA,
2013)
Sexual Masochism Disorder 302.83
The DSM-5 (2013) describes Sexual Masochism Disorder as “recurrent and intense
sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer as
manifested by fantasies, urges, or behaviors” (p. 694). Specifiers for this disorder include: With
asphyxiation, being in a controlled environment (institution or other settings where opportunities
to engage in this behavior are restricted) or being in complete remission (no distress for at least
five years when in an uncontrolled environment. (APA, 2013)
Sexual Sadism Disorder 302.84
The DSM-V describes Sexual Sadism Disorder as “recurrent and intense sexual arousal
from physical or psychological suffering of another person as manifested by fantasies, urges, or
behaviors” (p. 695). In lieu of previous information for Criterion B, the individual may have
acted with a nonconsenting person. Specifiers include “a controlled environment or in full
remission” (p. 695). (APA, 2013)
Fetishistic Disorder 302.81
The DSM-V describes Fetishistic Disorder as “the use of non-living objects or a
particular focus on a non-genital body part(s), as manifested by fantasies, urges, or behaviors”
(p.700). Criterion C includes: “Fetish objects are not limited to articles of clothing used in cross-
dressing (as in Transvestic disorder) or devices specifically designed for tactile genital
stimulation (e.g., vibrator)” (p. 700). Specifiers include a controlled environment or are in
complete remission. (APA, 2013)
It is important to note that although there may be pathologizing stigmas attached to the
BDSM community, in a research study spanning three decades, empirical research suggested that
BDSM practitioners are psychologically and socially well adjusted (Weinberg, 2006).
Nomenclature
The problem with diagnosis, discussion of these issues, and teachings is that some of
these terms hold different meanings cross-culturally, and the continued use of specific terms and
the classification of problems perpetuate stereotypes against those within the BDSM/kink
community. This includes, but is not limited to, words and general classifications such as
addiction, perverse, abnormal, paraphilia, deviant, and more. According to Birchard (2011),
It should be noted that terms like “deviant” and “perverse” have been used to
disenfranchise and marginalize sexual minorities and the continued use of such terms by
offender treatment programs and therapeutic practitioners contributes to stereotyping and
discrimination. This runs against the spirit of the ethical guidelines of most academic and
professional associations and, as such, should be avoided. (p. 162)

Unfortunately, even today, academic articles refer to fetish and other non-conventional sex
practices as “perversion.” In 2012, the American Journal of Psychology published an article
titled, “Pleasure Seeking and the Aspect of Longing for an Object in Perversion: A
Neuropsychoanalytical Perspective,” and throughout the entire article, various practices are
referred to as “perverse.” Even addiction articles that reflect on the growth in research and
treatment continue using words like perversion when describing fetishistic behaviors (Keller,
1992). These exercises of power through “knowledge” continue oppressing those within the
community. Information like this is held with such high regard by the writers, who happen to be
older white males (also part of the population that masters oppression), which contributes to
maintaining the negative stigma attached to oppressed and marginalized communities.
According to Giugliano (2009), “sex addict” can be used to describe a spouse with a
hyper sex drive, a pedophile, or even a serial rapist. Can the first really be classified in the same
category as the latter two? Unfortunately, when reading the categories under Paraphilia, this
researcher had a similar reaction and wondered, what type of stigma are we putting on those in
the BDSM community that if they are pathologized with one of the three paraphilias above, they
are placed in the same classification as someone conducting illegal and harmful actions towards
children or other non-consenting victims? Even in scholarly articles such as “Sexual Addiction
and the Paraphilias” (Birchard, 2011), it is stated that, for their research and paper (to talk about
sexual deviance and behavior), they limit the definition of paraphilic behaviors to consensual
unconventional sex practices.
The existing literature suggests that a lack of knowledge regarding BDSM culture may
lead a clinician to pathologize various practitioners. For example, “age play” and “rape play” are
part of the safe edging in BDSM; however, a clinician hearing details of either may gravitate
toward pathologizing practitioners. Giugliano (2009) suggests separating various terms and
meanings is essential to assessing and researching this culture. While deconstructing the terms
and definitions with the DSM-5, this researcher found that classifying some of these disorders
and diagnoses as “paraphilias” is contradictory. The definition of paraphilia that APA gives
includes “consensual behavior” with a “physically mature human adult,” which would
immediately exclude pedophilic disorder, frotteuristic disorder, and part of Criterion B for sexual
sadism disorder.
Prevalence of BDSM Participants
There are various reported rates when exploring the research on self-reported prevalence
rates of BDSM. Comprehensive reports are broken down into a few categories, including 1)
Individuals that report having BDSM fantasies, 2) Individuals that report only “engaging in
behavior” that would, in fact, fit into BDSM categories, such as using whips and/or handcuffs,
being tied up, and unequal control dynamics sexually, and 3) Individuals that self-identify as
being a part of the kink community or BDSM community. It is important to note that there are
limitations with these statistics in that the latter, within mainstream society, is more stigmatized
than someone stating they have “fantasies of” or “engage in specific acts.” Because of this, the
report rates of the latter may be minimized. A study describing the prevalence of various
autoerotic sex and kink practices (Richters, Grulich, & de Visser, 2003) reported that in
Australia, 2.2% of men and 1.3% of women (ages 16-59) had engaged in BDSM in 2002. In
another study conducted in Europe (Jozifkova, 2018), it is reported that about half the
population, 45.9% (n=673), become aroused from and prefer unequal power dynamics in the
bedroom. These vast variations are consistent with this researcher’s findings across the board.
BDSM Practitioners and Therapy
A quantitative study by Kolmes et al., (2006) conducted a survey of 175 BDSM
practitioners, in the United States, regarding their experiences in therapy. Of the 175 participants,
77% identified as female, 18% as male, 2% as other, and 1% as intersex. Over 87% of
participants identified as Caucasian, with less than 1% African American, and less than 1%
Asian. Several themes emerged from participant responses regarding their interaction with
therapists. These themes included the therapist:
(1) Considering BDSM to be unhealthy, (2) requiring a client to give up BDSM activity
to continue in treatment, (3) confusing BDSM with abuse, (4) having to be educated
by the client about BDSM, (five) assuming that BDSM interests are indicative of past
family/spousal abuse, and (six) misrepresenting their expertise by stating that they are
BDSM-positive when they were not actually knowledgeable about BDSM practices.
(p. 314)
Some limitations of the study include the lack of inclusion of a higher percentage of
ethnic minorities as this may shift the experience between participant and therapist. In addition,
since the study, there has been a massive increase of BDSM practitioners, as discussed earlier,
and as such, there may be a shift in the level of therapist humility in working with them.
In the study above by Kelsey et al., (2013), the authors report that most therapists could
not differentiate between clients participating in BDSM practices and abuse, resulting in the
requirement of abstinence from BDSM practices in order for clients to continue receiving care.
Hoff and Sprott (2009) conducted a study with 32 United States couples practicing
BDSM. Five main categories of what emerged from the interviews. The first, labeled
Termination, highlighted reports of action taken by clinicians or clients, whereby disclosure of

BDSM participation resulted in the termination of therapy. The second category, labeled
Prejudice, highlighted reports about clinicians expressing negative comments in the beginning
and/or throughout treatment (termination did not happen in these cases). The third category,
labeled Neutral, highlighted reports of clinician responses that were not explicitly negative, and
they treated disclosure the same as other disclosures while therapy continued. The fourth
category, labeled Knowledgeable/Supportive, highlights reports involving acceptance and
informed responses by clinicians who supported ongoing therapy. The fifth, labeled Non-
disclosure, included participants who discussed the impact of not disclosing their participation in
BDSM practices to the clinician. In addition, participants were asked what advice they would
give clinicians working with clients who practice BDSM. Hoff and Sprott report two recurrent
themes. The first is that clinicians should consider BDSM as one of many factors in therapy and
treat each equally. The second is to discern when practices are “safe, sane, and consensual
(SSC)” and when they are not.
Although the above study reported both positive and negative experiences with clinicians,
it concluded that there was no way to determine or predict what type of experience one would
have based on what emerged. They also suppose that it mirrored the concern that stigma causes
clinicians to narrow the focus of the interaction. This study also supports a Nichols (2006)
clinical paper that outlines stigma-related clinical issues. Nichols highlights challenges that may
come up in the therapeutic room with BDSM practitioners. The first challenge explores the
negative impacts of countertransference from the therapist. Therapists often have feelings of
shock, fear, anxiety, disgust, and revulsion. These feelings will often be translated into a
pathologizing view of the client. She also describes the non-disclosure of participation as a
response to internalized stigma from the client. Clients may not realize how sabotaging secrecy
in the therapy room can be. They may prefer not to include certain parts of their life to avoid
anticipated negative judgment.
Berry and Lezos (2017) report in their study on sex therapy with diverse populations that
there are four main principles for inclusive sex therapy practices. These include a nonjudgmental
stance, understanding of diversity, appreciation of fluidity, and a reflective and self-critical
approach to practice. In addition, they report the data suggests a high level of literacy and
knowledge about sexual diversity is a crucial attribute when dealing with clients in general.
Kink-Aware Therapy
Kink-Aware therapy is defined and explained by Phillai-Friedman et al., (2015). They
report that a kink-aware therapist can detect and identify a healthy BDSM dynamic instead of
one that may include abuse and/or non-consensual agreements. They can also view BDSM as a
normal part of the sexuality spectrum. They highlight in their article the importance of therapists
being kink-aware/kink-friendly and how this will allow clinicians to work with individuals from
various sexual minorities and have an openness, acceptance of, and some knowledge regarding
BDSM culture, allowing clients to feel more comfortable discussing their sexual practices,
identities, without feeling judged or pathologized.
When exploring some of the implications of non-kink-friendly/non-kink-aware therapists,
in the study by Kolmes et al., (2006), they suggest that:
Until BDSM practices and lifestyles are included routinely as part of the human sexuality
component of training for all practitioners, and until the mental health profession begins
to recognize BDSM individuals as a subculture requiring special knowledge, skills, and
sensitivity, there remains the risk that therapists may be providing services to BDSM
individuals without ever having received appropriate study, training, or supervision (p.
306).
Competency and Humility
No instrument exists to assess a clinician’s humility (or competency) when working
specifically with BDSM practitioners. Although AAMFT includes “cultural norms” and
“culture” in both its code of ethics and core competencies, this researcher was unable to find a
definition of “cultural competence” or “cultural humility” as defined by the organization.
According to HumanServicesEDU.org (n.d.), an organization created to help students and
professionals navigate the start or advancement of a career in human services, cultural
competency refers to the ability to engage effectively with people across cultures. It comprises
four key components: Awareness, attitude, knowledge, and skills.
The Council for Accreditation of Counseling and Related Educational Programs
(CACREP, 2016) set eight common core areas in the curriculum for counselor-based
accreditation programs. One of the eight is social and cultural diversity. Sue et al., (1982) outline
a conceptual model for culturally competent therapy. This includes three main categories: belief
/attitude, knowledge, and skills. Belief and attitude encompass recognizing, owning, and
sensitivity toward differences in belief systems and/or practices. In addition to the basic
counseling knowledge, knowledge includes information about specific groups a clinician is
working with. Skills include communicating cross-culturally (accurately and appropriately) and
exercising appropriate intervention.
Over time, the terms used to describe levels of cultural openness and expectations have
evolved from “cultural awareness” to “cultural sensitivity” and then to “cultural competency.”
Currently, “cultural competency” is undergoing another shift into “cultural humility.” Cultural
humility, a term coined by Dr. Melanie Tervalon and Jann Murray-Garcia (1998), is an approach
that allows even more room for curious, subjective, accepting, and lifelong learning experiences
that place the client in the role of the expert regarding whichever cultures they identify with.
While previous research used concepts of competence and knowledge such as “cultural
sensitivity” or “cultural competency,” many professionals currently use the cultural humility
approach. In this study, the researcher replaces the less evolved terms to align with those of
cultural humility. Tervalon and Murray-Garcia (1998) state that humility can be differentiated
from competency by its inclusion of a) practicing “lifelong commitment to self-evaluation and
critique;” b) addressing power imbalances with clients, and c) developing “mutually beneficial
and non-paternalistic partnerships with communities on behalf of individuals and defined
populations” (p. 123). As such, cultural humility encompasses cultural competency.
Moving from a culturally competent approach to a culturally humble approach will also
allow even kink-aware therapists to move into a more kink-affirming role by creating space for
new norms and identities for this ever-growing population and allowing the culmination of this
knowledge to broaden their understanding and beliefs.
Literature Review Summary
Research regarding the BDSM community is beginning to appear more frequently.
Despite this, there seems to be a gap between the increasing number of practitioners and
culturally competent clinicians that work with this population. There appears to be an
underrepresentation of research for this subculture of therapy and a lack of information included
in curriculum when training clinicians. Research has shown that a lack of humility in any area
can create ethical barriers when working with any specific community by causing harm. When
going through curriculum topics from several accredited institutions and inquiring with other
licensed clinicians, it has been this researchers’ experience that the result is almost always an
absence of teaching or reports of very little general information regarding the paraphilias in the
DSM. The research leans toward the importance of competence through knowledge, attitudes,
and skills. Research also highlights ongoing pathologizing stigma regarding practitioner
experiences.
This study aims to create a BDSM Humility Scale (BDSMHS). For this scale, the researcher has
defined BDSM Humility as the knowledge about, acceptance toward, and openness in exploring
BDSM/kink relational dynamics and practices. This process must also include the
acknowledgment of power imbalances that may be present during the exploration process and a
lifelong commitment to self-exploration regarding one’s attitudes, bias, and engagement with
others regarding this topic.
Self of the Researcher
The primary investigator is an African American, cisgender female in her late 30s who
identifies as queer. The researcher is a Licensed Marriage and Family Therapist that specializes
in relationship therapy, alternative sex practices, and alternative relationship dynamics. The
researcher is also a certified sexologist who identifies as a kink-affirming therapist and BDSM
practitioner. The researcher has developed a Cultural Humility training for various local
businesses that are offered to their employees and/or incorporated into their new hire training.
She also teaches cultural humility and sex therapy to masters’ level Marital and Family Therapy
students at a local university. The researcher acknowledges that due to her social location and
bias, she may unintentionally omit or over endorse something or not consider certain factors
based on her level of knowledge. Some of the researcher’s biases are only including identities
and labels that she is familiar with, thus potentially excluding other important identities and
perspectives; unintentionally neglecting issues around blind spots due to her privileged position
(able-bodied, educated, and cis-gendered); and accessing recruitment participants through her
network (different representation of that which represents the community). Recognized biases
were addressed and corrected (if possible) during and after the study phases.
CHAPTER II
Methods
Delphi Method
The Delphi Method was developed to explore agreement on a specific topic, gain group
consensus and expert opinion, forecast certain areas or fields of study, and view trends over time.
This approach allows the insight of “experts” in the field to contribute more knowledge about the
subject to that field. Delphi Method posits that truth is everchanging as things evolve and that we
must evaluate and consider these changes in our applications based on new knowledge. As a
methodology aimed at understanding a complex problem within a field through the means of
gaining consensus of experts in a particular area, the Delphi method is appropriate for answering
research questions regarding the best ways to engage and treat clients within the mental health
field, more specifically, when working with specific populations.
According to Linestone and Turoff (1975), the Delphi Method begins with selecting
experts. This is perhaps the most critical aspect as the study’s validity is related to this selection
process. The input from the experts determines what is outcome contributed to the field. Unlike
other research, the need for randomization is not necessary. According to Jenkins and Smith
(1994), criteria for expertise can include things like publication, years of teaching/supervision,
and clinical experience. The researcher also had personal experience and active participation in
the BDSM/kink community for this study.
Typically, after determining the expert participants, Delphi has four phases. Phase 1 is the
initial exploration of the subject in question that allows the experts to contribute information they
deem pertinent to the study. This usually consists of open-ended questions, then coded using
quantitative analysis (Linstone & Turoff, 1975). For this study, Phase 1 was eliminated as the
researcher created an initial scale to be used for Round 1 of the survey. The Preliminary
BDSMHS Questionnaire can be found in Appendix A.
Phase 2 aims to explore and determine the experts’ opinions on the subject matter
included in the Round 1 Questionnaire. The experts survey the Preliminary BDSMHS items, and
the open-ended responses are analyzed. Close attention is paid to using much of the same
verbiage used in the expert responses. Usually, this is completed using a Likert-type scale
(Linstone & Turoff, 1975) and open-ended feedback. Each item in the preliminary 31-item scale
consisted of two 5-point Likert-scale questions for this study. Participants were asked to rate the
Relevancy and Importance of each item on the initial scale. Each item, along with the overall
scale, allowed open-ended feedback to be used during the analysis (see Appendix A).
Phase 3 consists of evaluating the areas of disagreement in responses from the experts.
This can be in the form of Likert scale items and/or feedback. This phase also includes revising
the survey, sending it out to participants, and asking them to consider previous results and rerate
their responses while reminding them of their last responses. Updates can include deleting, re-
wording, or adding new items based on expert responses. The Revised BDSMHS items can be
found in Appendix B.
Phase 4 includes analysis of the revised questionnaire and, if needed, repeating the
rounds of revision and resurveying the participants. This phase can be repeated until the
researcher believes that either a consensus has been reached or that a consensus will not be
reached (Jenkins & Smith, 1994).
After the preliminary BDSMHS items were created, the study proposal was submitted to
and approved by the International Review Board (IRB). The IRB approval number is #
2109220585.
Development of Preliminary BDSMHS Items
The preliminary BDSMHS items were created by the researcher, who is
considered an expert in the field and meets the criteria for both expert groups. There is also
substantial research on therapeutic engagement with BDSM practitioners, the impacts of this
engagement, and suggestions on what is needed to decrease adverse effects such as feeling
alienated, inaccurately pathologized, or traumatized. The researcher used this information to
compose the scale items. The researcher also included some of the frameworks from the
modified Cultural Awareness Scale (Kumlien et al., 2020) to assist in creating this scale.
Items were also created based on the categories included in the cultural humility
definition. These categories include Knowledge, Attitude/Beliefs, Openness, and
Acknowledgement of Power Imbalances. The ideals of cultural humility were selected as its
categories are inclusive of previous studies’ suggested responses to culturally appropriate clinical
work with the BDSM/kink community. These studies summarized the need for minimal harm
toward BDSM practitioners and what was needed for clinicians to be Kink-Aware. The themes
included the ability to treat BDSM/kink community individuals/partnerships like any other
relationship despite their participation in BDSM, discernment between healthy and unhealthy
BDSM practices (Hoff & Sprott, 2009), attitudes and beliefs that lead to pathologizing, comfort
from the client to disclose participation (Nichols, 2006), and nonjudgmental stance, knowledge,
and reflective and self-critical approach (Berry & Lezos 2017). Phillai-Friedman, Pollitt, and
Castaldo (2015) report that being a Kink-aware therapist includes the ability to detect and
identify a healthy dynamic, view BDSM as a normal part of the sexuality spectrum, have
knowledge about the community and its practices, and create a space for clients to feel
comfortable sharing without feeling judged or pathologized.

Also used in developing this preliminary scale were Clinical Practice Guidelines for
Working with People with Kink Interests (Kink Clinical Practice Guidelines Project, 2019). This
guideline, shared and utilized by the National Coalition of Sexual Freedom’s (NCSF) Kink
Aware Professionals, includes 23 guidelines, to which many of these items were centered
around, such as a) Clinicians understand that kink fantasies, interests, behaviors, relationships
and/or identities, by themselves, do not indicate the presence of psychopathology, a mental
disorder or the inability of individuals to control their behavior; b) Clinicians understand that
kink is not necessarily a response to trauma, including abuse; and, c) Clinicians understand the
centrality of consent and how it is managed in kink interactions and power-exchange
relationships.
The preliminary BDSMHS included 31 items across four components of cultural
humility, with specific regard to BDSM/kink.
Participants
There were two identified groups of expert participants: BDSM Practitioners and
Licensed Mental Health Professionals. The desired number of participants for each group was
between seven and nine (Linstone and Turoff, 1975).
Inclusion Criteria
Inclusion Criteria for all expert participants were as follows: (1) 20 years old or over, and
(2) able to read, write, and understand English.
The additional inclusion criteria for the BDSM Practitioner were as follows: (1) Self
identifies as an active member in the BDSM community for a minimum of two years, (2) Able to
identify their role in the BDSM community via self-report, and (3) Aware of and practices
foundational agreements (consent and safety) of the BDSM community.

Additional inclusion criteria for Kink-Affirming Licensed Clinicians were as follows: (1)
Licensed mental health clinician (this may include but is not limited to LMFT, LCSW, LPCC,
Clinical Psychologists, and Psychiatrists), (2a) meets criteria for a BDSM practitioner, or (b) is
American Association of Sexuality Educators, Counselors and Therapists (AASECT) Certified, a
Certified Sexologist, or a Certified Love Coach or (c) has obtained additional training
specifically on alternative sexual practices, and has worked majority with this population for no
less than one year, and identifies as “kink-aware” or “kink-affirming.”
Recruitment
Expert participants were recruited via the snowball method and through ads placed within
online kink community forums, including Fetlife, BDSM groups on Facebook, and various
clinician groups on Facebook (e.g., Clinicians of Color; Clinicians in Private Practice, Therapists
in Private Practice, etc.). The researcher also contacted experts through her professional network.
The experts were asked to contact other experts they knew and provide them with the flyer if
interested. The flyer for both expert groups included a link those interested could click or copy
and paste to take them directly to the Qualtrics survey. Both flyers can be found in Appendix C.
Once in the survey, participants were given inclusion criteria and asked to select one of
two boxes to confirm if they did/or did not meet the criteria. Those that checked the box
indicating they did meet the criteria were then taken to an informed consent and attestation page.
This page included inclusion criteria for each expert group and asked them to attest to meeting
the criteria for participation. Those who selected that they did not meet the criteria, or did not
attest, were taken to a page that thanked them for their interest in the study and informed them
they were not eligible to participate. The Informed Consent and Attestation can be found in
Appendix D.
Preventing Dual Relationships and Coercion
To protect against dual relationships, the researcher did not solicit anyone she knew
personally to be a BDSM Practitioner expert participant. Also, to minimize dual relationships,
the researcher developed the initial scale and attached the Qualtrics survey link directly to the
flyers (see Appendix C), which allowed expert participant responses to be separate from
demographic information. Other attempts to minimize dual relationships included no questions
inquiring about participant names or participants being assigned an identification number paired
with their email. Participants were informed of this on the informed consent and attestation page.
To protect against coercion, participants were informed that participation in the study was
voluntary, and they could withdraw at any time before submitting their responses. (See Appendix
D)
Procedures
Participant Rights
Participants were presented with informed consent (see Appendix D) regarding their
participation in the research. The informed consent page included: researcher and supervisor
contact information, school information, the aim of the study, participant anonymity, the
inclusion of demographic questions, estimated time to complete the survey, participant rights to
withdraw without penalty, type of survey questions, and feedback options, inclusion criteria,
confidentiality, compensation, potential risks, and optional resources, IRB contact information
for questions about their rights as participants, and a request to download and/or print the
informed consent for their reference.

Data Collection
Demographics. The demographics included participants’ age, gender identity,
race/ethnicity, sexual orientation, and the highest level of education. Each of these options
allowed participants to select more than one response, the option to choose “other” and type in a
response, and/or the option to choose “prefer not to say.” The Demographics Forms can be found
in Appendix E.
Expert Licensed Clinician Data. The data collected specifically for licensed clinicians
included questions regarding the training and curriculum around BDSM/kink they received during
and/or after their graduate program (yes/no options) and if they believed their program prepared
them to work with this population. The questions included the following options: a) I received
training as part of the curriculum, in my graduate program, specifically on kink and/or BDSM sex
practices (note: this does not include paraphilias included in the DSM); b) I received training
outside of the mandatory curriculum included during my graduate program (fellow student
presentation, continuing education, workshops, in-services, e-courses, and/or seminars); c) I
sought out and obtained post-graduate training specifically on kink and/or BDSM sex practices
(note: this does not include paraphilias included in the DSM); and, d) I believe my graduate
program prepared me to work specifically with the BDSM community upon graduating. This
question allowed them to select more than one answer as well. Also included were questions
(yes/no options) about their professional license type (LMFT, LCSW, LPCC, Clinical
Psychologist, Psychiatrist, and Other Mental Health Clinician License), additional certifications
(AASECT Certified, Certified Sexologist, Certified Love Coach, Other BDSM Specific Training(s),
and None), identities within their clinical practice (Kink- Affirming, Kink-Aware, Other, and None),
and whether they also identify as an active BDSM practitioner. Each allowed participants to select
more than one response except for the latter. (See Appendix E)
Expert BDSM Practitioner Data. Data explicitly collected for BDSM practitioners
included questions about relationship status (e.g., single, partnered, married, divorced, etc.),
relationship type (e.g., dating, monogamous, poly, swinger, etc.), active number of years as a
practitioner, current BDSM identity (e.g., Dom, sub, switch, top, etc.), and BDSM level of
participation (i.e., bedroom/munch only, 24-7/Lifestyle, or other). Each of these questions
allowed participants to select more than one response. Relationship status, type, and identity
allowed an “other” and/or “prefer not to say” response, with the ability to type in a reply. (See
Appendix E)
Phase 1
This phase was eliminated because the researcher developed a preliminary scale to be
used as the survey questionnaire instead of exploring this topic and gathering information for
Round 1 of the questionnaire.
Phase 2
Participants accessed the survey through a link included on the flyer. This link contains
Round 1 of the questionnaire. The participants were invited to respond to two 5-point Likert
scale questions for each item. Their answers responded to whether they believed each item to be
relevant to the category the scale was attempting to assess and whether the item was important
enough to be included on the scale. This phase aimed to assess experts’ agreement and beliefs
about each item and the survey overall.
For each round of this study, the researcher calculated the median and interquartile range
(IQR) of participant ratings for each of the 31 items to assess levels of agreement and consensus.
Since this researcher used a 5-point Likert scale, ratings four and five falls under “somewhat
relevant/somewhat important” or “strongly relevant/strongly important” regarding importance
and relevance. Likert-scale three ratings identify neutral responses, and Likert-scale ratings one
and two identify disagreement regarding importance and relevance. A median threshold set by
the researcher indicates that 50% of responses were at or above the median and are considered
the most significant by the panelists. The IQR used in this study allowed the researcher to
identify variability among scores. Therefore, the lower IQR indicated less variability among
panelist scores. This study used a median of 4.00 and an IQR of 1.50 or below to demonstrate a
strong level of agreement, consensus, and limited variability among scores. All items whose
medians were below four or IQRs were above 1.5 were eliminated for each Round. The IQR was
calculated by subtracting the 25th percentile scores from the 75th percentile scores, which
provided the researcher with a range of scores representing the middle 50% of the scores. A high
level of consensus and agreement was set in accordance with Binning, Cochran, and Donatelli
(1972) to ensure that items that became part of the final BDSMHS were those considered most
important and relevant by the expert participants.
Phase 3
Phase 3 began with this researcher evaluating the responses from Round 1 of the
questionnaire and looking for disagreement and additional item/overall feedback. The statistics
were computed using the method mentioned above. The questionnaire was revised with the
addition of new scale items, the modification of some existing scale items, and the elimination of
some existing scale items. Revised items were created (see Appendix B), and Round 2 of the
survey was emailed with a new link, participant identification number, and time allotted to
complete the survey. The email and instructions also included more clarification on the
completion of the survey to avoid confusion. This time, the survey included attestation, informed
consent, instructions, and results from the previous survey. The results page included a brief
report regarding the previous round's results, changes, and the number of experts that
participated. Expert participants were reminded of their initial rating and asked to consider expert
feedback. They were invited to rerate the items using two 5-point Likert scales. They were also
invited to give optional feedback via open-ended comment boxes, just as they were in the first
round of questions.
Phase 4
For this Phase 4, the researcher believed to have reached a consensus on Round 2 of the
survey by running statistical analysis including the median and interquartile range and reviewing
qualitative feedback from participants. The final items for the BDSMHS were created, and
expert participants were emailed the final version of the scale and thanked again for their
participation. They were also given the contact information of the primary researcher in case
they wanted to submit optional feedback on the final scale.
Instrumentation
Preliminary BDSMHS Likert-scale Questionnaire
BDSMHS items can be found in Appendix A. The items assessing Knowledge include
statements about basic knowledge around BDSM/kink identities and practices. Items assessing
Attitudes/Beliefs include statements reflecting potential judgment, bias, and believed myths
regarding BDSM/kink dynamics and practices. Items assessing Openness include comments
about a clinician’s ability to discuss and explore the basics of BDSM/kink and the willingness to
be inclusive in their therapeutic space and with their questions. The item assessing
Acknowledgement of Power includes a statement about intentionally acknowledging the power
dynamic between them and their client(s).
Each item is rated on two 5-point Likert scales. The first Likert scale for each item
inquires about how relevant the item is at assessing the specific category it falls under
(Knowledge, Attitude/Beliefs, Openness, and Acknowledgement of Power Imbalance). The
response options for Relevance were as follows: Not at all Relevant, Somewhat Irrelevant,
Neutral, Somewhat Relevant, and Strongly Relevant. The second Likert scale inquires about
whether the item was important enough to be included on the scale. The response options for
Importance were as follows: Not at all Important, Somewhat Unimportant, Neutral, Somewhat
Important, and Strongly Important. Two scales were used as an item that may be important but
not relevant to what the researcher is attempting to assess, and it may be relevant but not
important to inquire about. BDSMHS Questionnaire from Round 1 can be found in Appendix A,
and Revised BDSMHS Items from Round 2 can be found in Appendix B.
The questionnaire also allows participants to give feedback in an open-ended comment
window for each item and the overall scale. There was a designated column for comments for
each item and one for overall scale feedback at the end of all items. There was no character limit
for the optional feedback.

CHAPTER III
Results
Preliminary Analysis
46 people responded to Round 1 of the survey. Data cleaning eliminated 27 responses for
the following reasons: duplicate responses and IP addresses (2), incomplete data (20 respondents
completed between one and 47% of the questionnaire), and misunderstanding of survey prompt
(five). The misinterpretation of the survey prompt resulted in participants responding to the
survey as if they were being assessed to work with this community. Only participants who
completed 97% or more of the surveys were included in the study’s sample. Those who did not
respond with their email were reported as 97% completed. Three items did not get a response
from one participant.
Sample
Descriptive statistics for demographics were calculated for the sample of 19 expert
participants using IBM SPSS Version 27. Round 1 sample size was 19, including 12 expert
BDSM Practitioners and seven Licensed Mental Health Clinicians. Three of the 19 (two BDSM
Practitioners and one Licensed Clinician) did not include their email to participate in Round 2 of
the study. Of the seven Licensed Mental Health Clinicians, six reported being active participants
in the BDSM/kink community. This means that all but one of this study’s experts participate
actively in the BDSM/kink community. 88% (14 of 16) of those contacted for Round 2
responded, with 81% (13) completing the revised questionnaire. Of the 13 who completed Round
2, seven (54%) were expert BDSM Practitioners, and six (46%) were expert Licensed Clinicians.
The participant ages ranged from 24 and 69 years, with a mean age of 42. One participant
left the age field blank but attested they were at least 20 years of age. Most participants identified
as female (15, 79%), with a few identifying as male (three, 16%) (see Table 1). There was a wide
range of diversity in sexual orientation as about (seven, 37%) identified as straight, and an equal
amount of bisexual and pansexual (five, 26%). For race/ethnicity, most participants self-
identified as White (12, 63%) or Black (six, 32%). The participants had college experience, with
5% obtaining certification and an equal distribution of those with undergraduate and graduate
degrees (43%). Sample demographics can be found in Table 1.
Table 1
Participant Demographics
Characteristic n %
Expert Type
BDSM Practitioner 12 63.2
Licensed Mental Health Clinician 7 36.8
Age
21-30 3 15.8
31-40 7 36.8
41-50 4 21.1
51-60 2 10.5
61> 2 10.5
Gender Identity
Female 15 78.9
Male 3 15.8
Gender Fluid 1 5.3
Gender Non-Binary/Neutral 1 5.3
Two-Spirit 0 0
Trans Male/AFAB 1 5.3
Trans Female/AMAB 0 0
Other 0 0
Prefer not to say 0 0
Sexual Orientation
Heterosexual/Straight 7 36.8
Lesbian/Gay 2 10.5
Bisexual 5 26.3
Pansexual 5 26.3
Asexual 1 5.3
Demisexual 0 0
Other 0 0
Table 1 Continued
Characteristic n %
Race/Ethnicity
White/Caucasian 12 63.2
Black/AA 6 31.6
Hispanic 0 0
Latin 0 0
Asian 0 0
Indian 0 0
Hawaiian Native or Other Pacific Islander 0 0
American Indian or Alaskan Native 0 0
Multiracial 2 10.5
Other 0 0
Highest Level of Education
High School 0 0
Some College 2 10.5
Associates 2 10.5
Bachelors 6 31.6
Masters 6 31.6
Doctorate 2 10.5
Certification 1 5.3
Other 0 0
Participants who are also BDSM Practitioners
Yes 18 94.7
No 1 5.3
Description of Expert BDSM Practitioners
12 (63%) of this study’s (Round 1) sample were expert BDSM Practitioners. Most of
them (eight, 67%) reported being partnered or married. Relationship types included an equal
number, four (33%) of monogamous, dating, and poly identities. one participant reported being
both engaged and monogamous. Six (50%) reported being active in the BDSM lifestyle for eight
or more years. These participants were able to have multiple BDSM identities; however, the
majority identified as submissive (seven, 58%), followed by an equal number of those
identifying as dominant and switch (three, 25%). Most reported engaging in the lifestyle in the
bedroom and munch/kink events. See Table 2 for a description of BDSM Practitioners.
Table 2
Description of Expert BDSM Practitioners
Description n %
Relationship Status
Single 1 8.3
Partnered 6 50.0
Married 2 16.7
Separated 0 0.0
Divorced 1 8.3
Widowed 1 8.3
Other 1 8.3
Prefer not to say 0 0.0
Relationship Type
Dating 2 16.7
Monogamous 4 33.3
Swinger 0 0.0
Poly 4 33.3
Open 1 8.3
Other - Engaged 1 8.3
Prefer not to say 1 8.3
Active # of BDSM Years
2-4 4 33.3
5-7 2 16.7
8-10 3 25.0
11-20 3 25.0
20> 0 0.0
BDSM Identity
Dominant/Domme/Dom 3 25.0
submissive/sub 7 58.3
Switch 3 25.0
Top 1 8.3
Bottom 2 16.7
Master/Mistress 0 0.0
Slave 1 8.3
Little 2 16.7
Middle 2 16.7
Daddy 1 8.3
Mommy 0 0.0
Pro-Domme 0 0.0
Brat 1 8.3
Other(s) – Rope Bunny 1 8.3
BDSM Participation
Bedroom/Munch/Kink Event Only 6 50.0
24/7 4 33.3
Other – Fluid 2 16.7
Description of Expert Licensed Clinicians
Seven (35%) of the sample experts were licensed clinicians. Of the seven licensed
clinician experts, one (14%) reported receiving BDSM-focused training as part of their graduate
program curriculum, three (43%) reported receiving training outside of their mandatory
curriculum during their degree program, and six (86%) reported seeking out training post-
graduate degree. None reported believing their graduate program prepared them to work with the
BDSM/kink community. The largest portion of license types was Licensed Professional Clinical
Counselor (LPCC) (29%), followed by an equal distribution (14%) of the others (LMFT, LCSW,
Clinical Psychologist, LMHC, and other). License information can be found in Table 3. Other
certifications include Certified Sexologist (two, 29%). All seven (100%) identify as “Kink-
Affirming” within their practice. Most also identified as active BDSM practitioners (six, 86%).
Description information for licensed clinicians can be found in Table 3.
Table 3
Description of Expert Licensed Clinicians
Description n %
Training & Curriculum
I received training as part of the curriculum 1 14.3
I received training outside of the mandatory curriculum 3 42.9
I sought out and obtained post-graduate training 6 85.7
I believe my graduate program prepared me 0 0.0
Professional License Type
LMFT 1 14.3
LCSW 1 14.3
LPCC 2 28.6
Clinical Psychologist 1 14.3
Psychiatrist 0 0.0
Other Mental Health Clinician - LHMC 2 28.6
Additional Certification
AASECT Certified 0 0.0
Certified Sexologist 2 28.6
Certified Love Coach 0 0.0
Table 3 Continued
Description n %
Other BDSM Specific Training(s) 2 28.6
None 3 42.9
Clinical Practice Identity
Kink-Affirming 7 100.0
Kink-Aware 3 42.9
Other 0 0.0
None 0 0.0
Licensed Clinicians who also Identify as BDSM Practitioners
Yes 6 85.7
No 1 14.3
Delphi Analysis Round 1
The median and interquartile range of the 31 preliminary items on the questionnaire were
computed using IBM SPSS Version 27. See Table 4 for Round 1 data analysis.
Table 4
BDSMHS Questionnaire Descriptive Statistics: Round 1

Item Number Mean Median Standard Deviation Interquartile
1a. 4.61 5.00 .778 1
1b. 4.78 5.00 .548 0
2a. 4.5 5.00 .618 1
2b. 4.44 5.00 .784 1
3a. 4.61 5.00 .698 1
3b. 4.50 5.00 .924 1
4a. 4.72 5.00 .575 0
4b. 4.67 5.00 .686 0
5a. 4.56 5.00 .616 1
5b. 4.56 5.00 .616 1
6a. 4.33 4.00 .686 1
6b. 4.33 4.00 .767 1
7a. 4.61 5.00 .502 1
7b. 4.56 5.00 .511 1
8a. 4.94 5.00 .236 0
8b. 4.94 5.00 .236 0
9a. 4.22 5.00 .943 2*
9b. 4.00 4.00 1.029 2*
10a. 4.89 5.00 .471 0
10b. 4.83 5.00 .514 0
Table 4 Continued

11a. 4.61 5.00 .608 1
11b. 4.72 5.00 .461 1
12a. 2.89 3.00* 1.745 4*
12b. 3.28 4.00 1.674 4*
13a. 3.11 3.50* 1.811 4*
13b. 3.50 4.00 1.689 3*
14a. 4.56 5.00 .784 1
14b. 4.72 5.00 .669 0
15a. 3.94 4.00 1.162 2*
15b. 4.17 4.50 .985 2*
16a. 4.11 4.00 1.079 1
16b. 4.22 5.00 1.114 1
17a. 3.28 4.00 1.638 3*
17b. 3.67 4.00 1.534 2*
18a. 2.78 2.00* 1.896 4*
18b. 3.33 3.50* 1.749 4*
19a. 3.33 4.00 1.815 4*
19b. 3.50 4.00 1.724 4*
20a. 2.78 1.00 2.045 4*
20b. 3.22 5.00 2.045 4*
21a. 3.33 3.50* 1.749 4*
21b. 3.78 5.00 1.592 2*
22a. 4.78 5.00 .647 0
22b. 4.78 5.00 .647 0
23a. 4.44 5.00 1.149 1
23b. 4.67 5.00 .970 0
24a. 4.78 5.00 .428 0
24b. 4.83 5.00 .383 0
25a. 3.72 4.00 1.227 2*
25b. 3.83 4.00 1.150 2*
26a. 4.94 5.00 .236 0
26b. 4.94 5.00 .236 0
27a. 4.72 5.00 .752 0
27b. 4.89 5.00 .323 0
28a. 4.44 5.00 .922 1
28b. 4.61 5.00 .698 1
29a. 4.67 5.00 .594 1
29b. 4.67 5.00 .594 1
30a. 4.89 5.00 .323 0
30b. 4.78 5.00 .732 0
31a. 4.50 5.00 1.043 1
31b. 4.94 5.00 .236 0
*Items that did not fall within Median and IQR threshold
Note. Item descriptions that correlate to the item numbers can be found in Appendix A.
Item Relevance
The 31 items in the questionnaire were assessed for relevance. Median and IQR were
used to determine whether an item on the preliminary BDSMHS was relevant in assessing one of
the four categories. Items with median scores of less than four and/or IQR greater than 1.5 were
eliminated for not meeting the median and/or IQR threshold. Items that fell within the median
and IQR threshold for item relevance remained on the scale.
Item means ranged from 2.78 to 4.94; the median ranged from one to five, and IQRs were
between zero and four. Of the 31 items, 21 met the median and IQR threshold for item relevance.
Item results can be found in Table 4.
Item Importance
The 31 items in the questionnaire were also assessed for importance. Both median and
IRQ were used to determine whether an item on the preliminary BDSMHS scale was important
when assessing clinician humility when working with the BDSM/kink community. Items with a
median score of less than four and/or an IQR greater than 1.5 were eliminated. Items that fell
within the median and IQR threshold parameters (median score of four and higher and
interquartile range of 1.5 and below) for item relevance and importance remained on the scale.
Item means ranged from 3.22 to 4.94; medians ranged from one to 5, and interquartile
ranges were between zero and four. Of the 31 items, 21 met the median and IQR threshold for
item importance (see Table 4).
Item Removal
The preliminary questionnaire included 31 items, each with two- 5-point Likert scale
assessments. Of the 31 items, 10 were removed from the revised questionnaire for not meeting
median and IQR threshold parameters. These items had mean scores below four and/or IQRs
greater than 1.5. Items removed can be found in Table 5.
Table 5
Preliminary BDSMHS Items Eliminated
Item # Item Description

9 I know at least 6 acronyms for BDSM
12 I sometimes feel disgusted and/or grossed out by a client’s description that

involves BDSM sex practices and/or practitioner roles
13 I sometimes have strong or aversive internal (or external) responses to a client’s

description that involved BDSM sex practices and/or practitioner roles. (not
including “squicked”)
15 I believe that most BDSM practitioners that come to therapy will have some
issues/challenges relating to their sexual practices
17 During a session, a client reports fantasizing/acting out role play rape fantasies.
This client likely has unresolved sexual trauma
18 Because of my training/education I believe I know more than my client

regarding what is right/wrong and good/bad regarding their sex practices
19 I do not believe BDSM should be practiced with children living in the home
20 I do not believe BDSM can be a therapeutic coping skill
21 If a client disclosed shame in fantasizing about inflicting pain on their partner

during sex, I would never normalize that type of behavior
25 If a client references a sexual practice that I am unsure of, I will not inquire
about it unless I feel it is important to the work we are doing
Item Modifications
When modifying for clarity and content, there were four items in which content was
changed (i.e., removing one of two terms in an item, changing from assessing knowledge about
to the ability to differentiate between two diagnostic terms, changing item content to align with
scale demographics, and changing subject matter). See Table 6 for items modified.
Table 6
Preliminary BDSMHS Items Modified
Item # Modified Item Description

5 I understand the difference between “having a fetish” and a “fetishistic disorder”
11 I am knowledgeable about basic safety practices in consensual spanking (i.e.,

Areas of the body to aware of)
14 I have intentionally created a kink-aware space (inclusive literature, art, and/or

explorative questions using tones of acceptance)
27 I am ok talking with clients about the basics of consent in BDSM/kink practices
One of the most endorsed themes was the request for clarity with item and term
meanings, definitions, and sentence structure. Because of this, the researcher chose to: a) add in
the word “consensual” anytime BDSM/kink relationship dynamics and practices were
referenced; b) replace “working with” with “regarding the basics of/around” when referring to
knowledge about BDSM/kink relationship dynamics and practices; c) includes definitions of
BDSM practice acronyms (i.e., bondage, discipline, sadism; and masochism); and d) remove the
word “comfortably” or “comfortable” when referencing clinician engagement. Because these
overall modifications did not change the item’s content, these items are not included in the Items
Modified in Table 6.
Also, due to a few of the respondent’s misunderstandings of the survey prompt, the
researcher gave more explicit instructions on completing the survey.
New Item Additions
Based on the provided qualitative feedback, the researcher added 10it new items to the
revised BDSMHS. This included the addition of one item attempting to assess Knowledge, eight
items attempting to assess Attitude/Beliefs, and one item attempting to assess Openness. Item
additions can be found in Table 7.
Table 7
Revised BDSMHS Item Additions
Item # Item Description

9 I can differentiate between consensual BDSM (Bondage/Discipline,
Dominance/submission, and Sadism/Masochism) and paraphilic disorders
12 I believe that consensual BDSM/kink fantasies, interests, behaviors, and relationship

dynamics, by themselves, do not indicate the presence of psychopathology, or a
mental disorder
13 I believe that consensual BDSM/kink fantasies, interests, behaviors, and relationship

dynamics, by themselves, do not indicate the inability for one to control their
behavior
15 I do not assume when working with clients that engage in BDSM/kink that any
concern arising in therapy is caused by BDSM/kink practices
17 I understand that BDSM/kink is not necessarily a response to trauma, including

abuse
18 I evaluate my own biases, attitudes, and feelings about BDSM/kink and their impact
on my engagement with clients
19 I do not assume that involvement in BDSM/kink has a negative impact on parenting
20 I believe that consensual BDSM/kink experiences can lead to healing, personal

growth, and empowerment
21 I believe that distress about BDSM/kink may reflect internalized stigma, oppression,
and shame rather than evidence of a disorder
25 I am aware of my scope of practice when working with the BDSM/kink community

and will consult, obtain supervision, and/or refer as appropriate to best serve them
Qualitative Data Themes
Each item on the questionnaire included space for optional open-ended feedback from
participants. Feedback for themes was used to inform which items may need to be modified or
added. The researcher determined that major themes would be identified by 20 or more
comments reported by at least three participants, and minor themes would be identified by less
than 20 comments by at least three participants.
Three major themes came from the comments. Each of these themes had 20 or more total
comments and was reported by at least three participants. The researcher identified major
themes as a) the sharing of personal beliefs/practices (e.g., “consent is the utmost important
factor “this is a bad thing if clinicians do this!”, “we practice RACK”); b) recommendations for
sentence clarity/structure “this sentence reads like clinicians are condoning sex with children,”
“maybe separate into 2 questions;” and, c) request for clarification or definition of specific terms
“how are you defining this,” “what specifically is meant by this?” When determining how best to
respond to feedback regarding these three themes, the researcher decided that: a) theme a was
either incorporated in the addition of new items or deemed irrelevant (e.g., “We practice
RACK”) in the modification of BDSMHS items; b) the researcher would modify these items for
clarity if more than one person provided feedback; c) the researcher would fix all identified
incorrect sentence structure, and d)the researcher would provide definitions for several of the
basic terms used.
There were two minor themes present. These themes had between three and five total
comments reported by three to five participants. These themes included: Item
irrelevance/unimportance (each of these coincided with items that were eliminated for not
meeting median and IQR threshold parameters); and inclusion of new content (these were
considered and/or incorporated when adding new and modifying existing items). Table 8
includes both major and minor themes for Round 1 and Round 2.
Table 8
Qualitative Themes
Description # of # Unique
Comments Participants
Round 1
Major Themes
Statement of Personal Beliefs/Practices 20> 3>
Recommendations for sentence structure/clarity 20> 3>
Request for clarification/definition of specific terms 20> 3>
Minor Themes
Statement of item irrelevance/unimportance 3-5 3>
Inclusion of new content 3-5 3>
Round 2
Major Themes
Statement confirming importance for item/scale 20> 3>
Minor Themes
Statement confirming importance & recommendation for 3-5 3>
. modification
Feedback Outlier. The researcher notes that one expert participant (BDSM Practitioner)
made several comments about items that were “prejudice, bias, or stigmatizing.” They also stated
how problematic these beliefs were and that this researcher and any clinician who shares these
beliefs should not be working with this community. This participant believed this meant the
researcher was biased or prejudiced against the BDSM/kink community. This participant did not
submit their email to participate in Round 2 of the survey. Unfortunately, due to anonymity, the
researcher was unable to clarify to this participant that several questions on the BDSMHS were
intentionally designed to reflect many of the common myths, biases, and stigmatizing beliefs
reported in several research studies (many of which were referenced previously). The researcher
decided to include this outlier’s responses as the Delphi method’s philosophy is gaining expert
feedback based on various perspectives. The researcher also computed the data with and without
this participant’s responses and found that none of the items eliminated, modified, or added
would have been different.
Delphi Analysis Round 2
Data cleaning eliminated one response due to incomplete data (2% complete), resulting in
a sample of 13. The median and interquartile range for the 31 Revised BDSMHS items were
analyzed using IBM SPSS Version 27. See Table 9 for Round 2 data analysis.
Table 9
Revised BDSMHS Questionnaire Descriptive Statistics: Round 2

1a. 4.85 5.00 .376 0
1b. 4.92 5.00 .277 0
2a. 4.77 5.00 .439 .5
2b. 4.69 5.00 .630 .5
3a. 4.85 5.00 .555 0
3b. 4.85 5.00 .555 0
4a. 4.85 5.00 .555 0
4b. 4.85 5.00 .555 0
5a. 4.62 5.00 .650 1
5b. 4.54 5.00 .660 1
6a. 4.46 5.00 .660 1
6b. 4.62 5.00 .506 1
7a. 4.54 5.00 .660 1
7b. 4.62 5.00 .650 1
8a. 5.00 5.00 .000 0
8b. 5.00 5.00 .000 0
9a. 4.85 5.00 .376 0
9b. 4.85 5.00 .376 0
10a. 4.92 5.00 .277 0
10b. 4.92 5.00 .277 0
11a. 4.77 5.00 .599 0
11b. 4.62 5.00 .650 1
12a. 4.92 5.00 .277 0
12b. 4.92 5.00 .277 0
13a. 4.77 5.00 .599 0
13b. 4.77 5.00 .599 0
14a. 4.38 5.00 .961 1
14b. 4.31 5.00 .947 1
Table 9 Continued
15a. 4.54 5.00 .967 .5
15b. 4.62 5.00 .961 0
16a. 4.54 5.00 .660 1
16b. 4.54 5.00 .776 1
17a. 4.92 5.00 .277 0
17b. 4.92 5.00 .277 0
18a. 4.85 5.00 .555 0
18b. 4.85 5.00 .555 0
19a. 4.69 5.00 .855 0
19b. 4.77 5.00 .832 0
20a. 4.62 5.00 .768 .5
20b. 4.46 5.00 .967 1
21a. 4.46 5.00 1.198 .5
21b. 4.31 5.00 1.251 1.5
22a. 5.00 5.00 .000 0
22b. 5.00 5.00 .000 0
23a. 4.85 5.00 .376 0
23b. 4.92 5.00 .277 0
24a. 4.92 5.00 .277 0
24b. 4.92 5.00 .277 0
25a. 4.92 5.00 .277 0
25b. 4.92 5.00 .277 0
26a. 5.00 5.00 .000 0
26b. 5.00 5.00 .000 0
27a. 4.85 5.00 .555 0
27b. 4.92 5.00 .277 0
28a. 4.77 5.00 .599 0
28b. 4.85 5.00 .555 0
29a. 4.92 5.00 .277 0
29b. 4.85 5.00 .376 0
30a. 5.00 5.00 .000 0
30b. 5.00 5.00 .000 0
31a. 4.77 5.00 .599 0
31b. 5.00 5.00 .000 0
Note. Item descriptions that correlate to the item numbers can be found in Appendix B.
Item Relevance
The revised questionnaire included 31 items regarding relevance. Just as the researcher
did in the initial round, median and IQR were used to determine whether an item on the revised
BDSMHS was relevant in assessing a specific category. Items with a median score of less than
four and/or an IQR greater than 1.5 were eliminated. Items that fell within the median and IQR
threshold parameters for item relevance remained on the scale.
Item means ranged from 4.38 to 5.00. The median for each item was 5, and IQR ranges
were between zero and 1.5. All 31 items met statistically significant criteria for item relevance.
No items were removed from the scale. Item results can be found in Table 9.
Item Importance
The questionnaire included 31 items regarding importance. Both median and IQR were
used to determine whether an item on the revised BDSMHS was important when assessing
clinician humility when working with the BDSM/kink community. Items with median scores of
less than four and/or IQRs greater than 1.5 were eliminated. Items that fell within the median and
IQR threshold parameters for item relevance and importance remained on the scale.
Item means ranged from 4.31 to 5.00. The median for each item was 5, and interquartile
ranges were between zero and 1.5. All 31 items met median and IQR threshold parameters for
item importance. No items were removed from the scale. Item results can be found in Table 9.
Item Removal
The Revised BDSMHS Questionnaire included 31 items that met the criteria for
importance and relevance. None of the items were removed from the revised BDSMHS for
falling outside the median and IQR threshold parameters.
Item Modification
Based on the feedback theme, there were three items in which content was modified.
These included: specifying an item to align with the BDSM community, generalizing an item to
a broader context within the community, and eliminating the “need to know” specifics regarding
safety protocol. Each of these items was within the category of knowledge. Modified items for
the final scale can be found in Table 10.
Table 10
Revised BDSMHS Items Modified
Item # Modified Item Description

6 I feel knowledgeable regarding the basics of consensual BDSM/kink Group Events
(e.g., Munch)
7 I understand there are different types, each with varying degrees, of power dynamic
relationships in BDSM and that no two are exactly alike
11 I understand that there are safety protocols for consensual BDSM practices and will
refer to a specialist if there are areas of concern
Qualitative Data Themes
Like Round 2, each item on the questionnaire included space for optional open-ended
feedback from participants. Using the same parameters as Round 1, the researcher looked again
at feedback for themes to inform which items may need to be modified. There was one major
theme that came from the comments. Comments about how important both the items and scale
were, “this is really important,” “a must,” and “this is needed.” This confirmed the researcher’s
assumptions about the need for an instrument that measures clinicians’ ability to work from a
culturally humble approach with the BDSM/kink community (see Table 10).
Following the same theme determinants as Round 1, one minor theme was present. This
theme confirmed the importance of an item, paired with the recommendation for a modification.
Statements like, “this is important, but is it necessary a clinician know this to give care;” and,
“good question, maybe changing to reflect specific BDSM/kink event instead of alternative sex
practices,” etc. Relevant suggestions were incorporated when modifying existing items (see
Table 10). Final BDSMHS items can be seen in Appendix F.

Comparison Data between Expert Groups
The researcher ran all the same analyses on each of the expert groups independently to
see what the differences would be between responses. For Round 1, when removing data for
expert Licensed Clinicians, each of the same items (see Table 5) would have been eliminated,
along with item 16 (When thinking of some healthy relationship patterns, practitioners of BDSM
come to mind), resulting in 11 items eliminated. This item would not have fallen within median
and IQR threshold parameters for relevance and importance. When removing data for expert
BDSM Practitioners, each of the same items (see Table 5) would have been eliminated, except
item 21 (If a client disclosed shame in fantasizing about inflicting pain on their partner during
sex, I would never normalize that type of behavior), resulting in nine items eliminated. This item
would have fallen within median and IQR threshold parameters for relevance and importance.
For Round 2, removing data for expert licensed clinicians would have resulted in one
item being eliminated (20. I believe that consensual BDSM/kink experiences can lead to healing,
personal growth, and empowerment). This item would not have fallen within median and IQR
threshold parameters for relevance and importance. When removing data for expert BDSM
practitioners, results would have eliminated item 21 (I believe that distress about BDSM/kink
may reflect internalized stigma, oppression, and shame rather than evidence of a disorder). This
item would not have fallen within median and IQR threshold parameters for relevance and
importance.
The difference in each was either an additional item removed or one less item removed.
Based on comparison data, this researcher concludes that there is no significant difference
between the perspectives of the two different types of experts.

Self of the Researcher Reflections
After receiving the initial feedback, I was shocked at a few of the responses. For a
moment, I wanted to walk away from the survey altogether. I reflected on why the research was
done the way it was and appreciated how anonymity allows others to be open and honest in
feedback, which I may have not otherwise received. It was also humbling to be shown my own
bias in the process and recognize the importance of the more traditional Phase 1 of the Delphi
method. While creating the initial items, I based them on data from previous literature; however,
in customizing them to the BDSM/kink community, bias in being a sexual person came up, as I
failed to include questions that considered Asexual people that engage in BDSM/kink. An expert
participant in their feedback noted this.
This process was also a great reminder that what is very clear to me may not be to others.
Some participants did not complete the survey because they believed they, themselves, were
being assessed and, as BDSM practitioners, did not feel qualified to respond to some of the
items. A few licensed experts also responded to the survey as if they were being assessed
themselves.
When first researching this subject, the idea of a person being negatively impacted by my
survey seemed innocuous. In my mind, I was very clear about my intentions, and I assumed
others would understand them as well, especially experts on this subject matter. While creating
the initial scale items, I could not help but reflect on my own experience as a client seeing a
therapist and the responses I read, during my research, of others that had experienced negative
impacts from seeing clinicians that were not Kink-Aware or Affirming. Some of the items were
stated in ways that reflected the approaches of those “unskilled clinicians.” These items
expressed a clinician’s disgust with topics brought up in therapy or even pathologizing responses
to healthy coping behaviors. It appeared that most expert participants (both BDSM practitioners
and licensed clinicians) were able to see this and even responded with feedback that this was
important to address. However, one expert (BDSM practitioner) assumed that this was my
personal bias due to item content. They expressed their disappointment and commented that I
should never work with this community. While slightly offended at first, I imagined they may
have felt very similar to how I and others have felt when seeking mental health treatment and
then was able to see how some could still be negatively impacted by participating in these types
of studies. This led me to want to do even more research and be much more explicit in my
explanation and intention. I also realize that it should not be assumed that everyone understands
the style of academic approaches to surveys and questionnaires. Yet another reminder that
offense can happen regardless of intent.
Overall, this process has been very humbling. I am even more motivated to expand my
knowledge to decrease my bias, do further and deeper research that is intentionally more
inclusive of folks from my blind spots, and dedicate more effort toward the education of this
topic to clinicians, with the hopes of decreasing the shame and negative impacts folks in this
community may experience when seeking out help for their mental wellness.
CHAPTER IV
Discussion and Conclusions
Summary of Interpretation and Findings
This study aimed to create a scale to assess a clinician’s cultural humility working with
the BDSM/kink community and its practices. Cultural humility includes knowledge,
attitude/beliefs, openness, and acknowledging power imbalances within the therapeutic
relationship. There is no instrument to measure this, so this study fulfills the existing gap.
As Stone Fish & Busby (2005) state, a researcher may employ the use of the Delphi
method if they “perceive discrepancies in ideas that are fueling theory or practice” (pp. 238).
Many graduate programs attempt to prepare clinicians to be culturally competent; however, this
study and previous research indicate that training for cultural humility when working with the
BDSM/kink community is lacking. The researcher utilized the Delphi method as it is appropriate
for gaining consensus regarding a potential solution to a problem. The researcher sees a possible
solution to this problem, beginning with acquiring agreement between experts on what items are
needed to assess the clinician's ability to work with BDSM/kink community from a culturally
humble lens. These needs align with previous research that reports the need for clinicians to be
Kink-aware/Kink-affirming (Phillai-Friedman et al., 2015, Kolmes et al., 2006, and Kink
Clinical Practice Guidelines Project, 2019).
After two survey rounds, analysis, and item revisions, the final BDSMHS includes 31
items. Of the 31 items, 11 aim to measure clinician Knowledge around various BDSM/kink
relationship dynamics and practices, 11 items attempt to measure the Attitudes/Beliefs held by
clinicians regarding BDSM/kink relationship dynamics and practices, eight attempt to measure
clinician Openness when engaging with the BSDM/Kink community, and one is attempting to
measure their ability to Acknowledge Power Imbalances within the therapeutic relationships.
These items reflect the construct of cultural humility, specifically regarding the BDSM/kink
community.
Of the total sample of 19, all but one expert participant identified as being currently
active in the BDSM community. This aligns with previous research reporting that in their
sample, 100% of BDSM competent clinicians also participated in the lifestyle (Rodemaker,
2011), suggesting that when humility is present, it is rooted in community participation instead
of academic curriculum.
All expert clinicians reported not feeling their graduate program prepared them to work
with the BDSM community and its practices adequately. All expert clinicians also reported
gaining additional training on their own, either during or after their graduate program. This
finding is in accordance with Castaldo’s (2015) study which suggested that it takes specific
training for a clinician to work with this community adequately. Additionally, these parallel both
Lawrence and Love-Crowell (2008) and Kelsey’s (2013) reports of most clinicians having
minimal knowledge about BDSM culture. Knowledge is one of the categories experts find both
relevant and important.
Lawrence and Love-Crowell (2008) report on the harmful or inaccurate beliefs and
tendency to inaccurately pathologize BDSM practices. The newly developed scale would allow
clinicians to be assessed on their propensity to pathologize behaviors that might otherwise be
seen as healthy. This could create an opportunity for conversation in educational and supervision
settings about how lack of knowledge, and/or personal attitudes/beliefs, and/or lack of openness
in a specific area can contribute to inaccurate pathology. In addition, ratings that met the median
and IQR threshold parameters within the Knowledge category on the BDHSHS signify the
importance and relevance of having accurate knowledge and the ability to differentiate between
diagnosis, disorder, abuse, and healthy and consensual BDSM relationship dynamics and
practices (See Appendix F for specific items relating to Knowledge). This was also highlighted
in Kolmes and Weitzman’s (2010) report on what being Kink-aware provides to the community,
suggesting that all clinicians should be Kink-aware at a minimum. Hoff and Sprott (2009) also
report the need for more kink-aware clinicians as a primary and recurrent theme in interviews of
couples practicing BDSM) on what advice they would give to clinicians working with the BDSM
community. Until now, the field has had no way of measuring if the “problems” of clinicians
being ill-prepared to work with this population are still problems or if the curriculum in graduate
programs has evolved in preparing clinicians to be more culturally humble when working with
this community.
Considering major themes determined with open-ended feedback, 10 new items (most
within the category of Attitude/Beliefs) were added to the BDSMHS after Round 1. The
researcher assumes that many of these items were speaking more to a clinician’s personal sexual
preference (things they view as “disgusting” as opposed to their attitude/beliefs about behaviors
practiced within the community (pathology based on practice). This suggests that there may be a
fine line between personal preference and attitude/beliefs regarding its impact on clinicians’
ability to treat BDSM practitioners. This researcher believes that there may be a conflict
between the notion that we can just “check our beliefs and attitudes” so they do not negatively
impact our ability to treat and our ability to do this without specific training and being more
Kink-aware.
The differences in expert responses (eliminating one additional item per round or one less
item per round) suggest that even experts may be impacted by the stigma held by mainstream
society, resulting in internalizing it or directing the stigma and bias toward others.
Final BDSMHS Items
The final BDSMHS items (Appendix F) resulted in all 31 items being identified as
relevant and important to include in such an assessment by the expert BDSM practitioners and
licensed clinicians who participated in the study. These results align with Berry and Lezos’
(2017) report on skills needed when providing inclusive therapy around sex practices. They
report a nonjudgmental stance (this study’s assessment of attitude/beliefs), understanding of
diversity (this study’s assessment of knowledge), appreciation of fluidity (this study’s assessment
of openness), and self-critical approach to practice (acknowledgment of power imbalances), are
the four main principles for this type of work. They also report that data suggests a high level of
literacy and knowledge about sexual diversity is crucial when dealing with clients. With all the
data from previous research (Phillai-Friedman et al., 2015; Lawrence and Love-Crowell, 2008;
Stockwell et al., 2017; Kelsey, 2013; Jutterbock, 2012; Kolmes and Weitzman, 2010; Masters,
2008; Santtila et al., 2006; Taylor & Usher, 2001; Birchard, 2011; Kolmes et al., 2006; Hoff and
Sprott, 2009; Berry and Lezos, 2017; Kink Clinical Practice Guidelines Project, 2019), that
shows a lack of humility as well as the negative impact that happens when clinicians are not
affirming; one would assume graduate programs would make improving curriculum a priority.
This instrument provides the ability to assess if clinicians are indeed more kink-aware.
While conducting the study, I wondered if one of the areas held more weight than the
other regarding humility. If a clinician lacked knowledge but had high levels of openness, what
difference would it make compared to someone lower on openness with much more knowledge?
The researcher assumes that openness weighs the most and increases the potential for affirming
care above the other categories.
Contributions and Clinical Implications
This scale was created to be used as a tool to measure clinician humility when working
with the BDSM/kink community. This instrument could also assess the curriculum used in
specialty programs specifically focusing on this population to ensure clinicians gain more
knowledge about the community. Evaluators of curriculum, training programs, and specific
classes within mental health graduate programs can assess how well content and approach
prepare clinicians to be more affirming, thus potentially decreasing so many of the negative
impacts from clinicians toward practitioners of the BDSM community.
Ultimately, this scale could be a valid and reliable instrument in academia for assessing
and evaluating curriculum and clinical approaches when working with the BDSM/kink
community. The evaluation and assessment process would cultivate conversation and dialogue
around a stigmatized topic that clinicians are taught very little about within their graduate degree
program on the individual, course-specific, and program levels. This researcher hopes that these
conversations widen the breadth of knowledge about BDSM/kink, create a higher level of
openness, and allows for more self-exploration of how attitude and beliefs can negatively impact
care; thus, decreasing stigma and the negative impacts experienced by participants, reducing the
amount of clinician discomfort when working with this population, and increasing the number of
kink-affirming clinicians, which allows more access to affirming care for practitioners.
The categories used in the BDSMHS can be used by professors and facilitators of mental
health graduate programs to guide them toward a more intentional approach to teaching about
various sexual practices, openness, acknowledging power imbalances, and how attitude and
beliefs can affect their impact on treatment.
In addition to its contribution to research regarding BDSM, maybe this scale will prove to
be foundational and inspire someone else to modify it and create a scale of humility regarding
another topic or population to help prepare clinicians to be more culturally humble and provide
more awareness around other subjects.
Limitations
One limitation of this study is restricted racial/ethnic and sexual diversity among experts.
While there was a wide range in age, most participants self-identified either as White or African
American/Black. Due to the convenient sampling, the researcher could not ensure participants
met each of the BDSM identity categories. This means that other identities might have included
feedback not reported here but is likely still important and relevant. Another limitation is that the
study was only accessible by those with social media and the internet (as the flyers were
distributed via social media, and then interested individuals had to access the survey via the
internet, with Qualtrics). Also, all results came from self-reported data. This means the
researcher has no way of knowing if self-reports on experience were factual.
Other possible limitations of this study were that the researcher created the initial pool of
items, and the category of Acknowledging Power Imbalance only has one item. When future
research moves forward with factor analysis, having only one item in any category will be
problematic. In addition, having a more traditional Phase 1 of the Delphi Method (creating initial
items from expert feedback) would have resulted in a wider variety of items and topics within
this subject.
Recommendations for Future Research
The BDSMHS was developed to assess a clinician’s level of cultural humility when
working with the BDSM/kink community. To utilize this scale in academic and other
professional settings, it is recommended to test the scale for validity and psychometric
properties. Future studies can investigate correlations between the BDSMHS and the Sexual
Attitude Reassessment (SAR) scale, cultural competency scales, or other scales specific to one of
the four categories intended to be measured by the scale. To confirm the structure of the
BDSMHS, a factor analysis of the scale needs to be done.
It may also be beneficial to conduct this study again using a larger sample and include
Phase 1 in gaining a modified, revised scale that provides alternative perspectives and areas of
importance in measuring clinician humility.
Another potential area for research may be exploring some of the item’s statements,
specifically regarding BDSM practitioners. Some items may represent internalized beliefs or
stigma that may lead a BDSM practitioner to feel an increased sense of shame regarding what
may otherwise be viewed as healthy behaviors. A clinician could then pathologize this shame as
a disorder without further exploring its root cause. Using this instrument (BDSMHS) can solve a
significant problem with clinicians’ lack of preparedness when working with the BDSM/kink
community.
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Appendix A
Preliminary BDSMHS Questionnaire
Appendix B
Revised BDSMHS Items
Appendix C
BDSM Practitioner and Licensed Clinician Flyers
Appendix D
Inclusion Criteria, Informed Consent, and Attestation
Appendix E
Demographics
Appendix F
Final BDSMHS Items
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DEVELOPMENT OF THE BONDAGE AND DISCIPLINE, DOMINANCE AND

SUBMISSION, SADISM AND MASOCHISM HUMILITY SCALE (BDSMHS)

Dissertation presented to the Faculty of the

©Marjha A. Hunt, 2022

categories include Knowledge, Attitude/Beliefs, Openness, and Acknowledgement of Power

Imbalances. A sample of 19 expert participants, 12 BDSM practitioners, and seven kink-

community from a culturally humble lens.

Preliminary BDSM Likert-scale Questionnaire 30

Introduction and Literature Review

this community or population.

Statement of the Problem

the Fifty Shades of Gray release.

When researching the prevalence of individuals who admit to participating in consensual

allow the clinician to work with the intricacies of this culture.

education about this community in academic curriculum.

speaking up may be due to a lack of awareness of one’s own bias.

with them (even after seeking their own training).

greater understanding of this population.

Lawrence and Love-Crowell (2008) interviewed 14 kink-aware therapists. The most

perpetuating the stigma associated with this culture?

to show the effectiveness of master’s/doctoral level-specific curricula (such as sex therapy,

entering the field when working with this population.

According to Newmahr (2010), BDSM is an overlapping acronym referring to the

Bondage and discipline encompass using physical or psychological restraints. Dominance

excludes fetishes such as S&M” (Pillay, 2015, p.1).

BDSM and Abuse

dynamic being practiced.

Responsibility, Informed, Consensual Kink (PRICK), and Freely-given, Reversible, Informed,

for this study.

There is a common myth when attempting to understand the “why’s” of BDSM. It

sexual abuse compared to the national average.

reenacts a traumatic situation in a controlled and safe environment, it is considered a therapeutic

BDSM and Pathology

interest in genital stimulation or preparatory fondling with phenotypically normal, physically

others” (APA, 2013, pp. 685-686).

2013). These classifications include Voyeuristic Disorder, Exhibitionistic Disorder, Frotteuristic

(Pedophilic disorder, fetishistic disorder, and transvestic disorder). (APA, 2013)

and Fetishistic Disorder.

Sexual Masochism Disorder 302.83

asphyxiation, being in a controlled environment (institution or other settings where opportunities

five years when in an uncontrolled environment. (APA, 2013)

Sexual Sadism Disorder 302.84

from physical or psychological suffering of another person as manifested by fantasies, urges, or

acted with a nonconsenting person. Specifiers include “a controlled environment or in full

remission” (p. 695). (APA, 2013)

Fetishistic Disorder 302.81

The DSM-V describes Fetishistic Disorder as “the use of non-living objects or a

particular focus on a non-genital body part(s), as manifested by fantasies, urges, or behaviors”

complete remission. (APA, 2013)

offender treatment programs and therapeutic practitioners contributes to stereotyping and

professional associations and, as such, should be avoided. (p. 162)

practices as “perversion.” In 2012, the American Journal of Psychology published an article

maintaining the negative stigma attached to oppressed and marginalized communities.

unconventional sex practices.

Prevalence of BDSM Participants

BDSM Practitioners and Therapy

A quantitative study by Kolmes et al., (2006) conducted a survey of 175 BDSM

therapists. These themes included the therapist:

Termination, highlighted reports of action taken by clinicians or clients, whereby disclosure of

category, labeled Knowledgeable/Supportive, highlights reports involving acceptance and

(SSC)” and when they are not.

anticipated negative judgment.