Frotteuristic disorder (rubbing up against a nonconsenting person).Exhibitionistic disorder (exposing the genitals).Voyeuristic disorder (sexualized spying).The DSM-5 specifically lists eight potential paraphilic disorders: Sure, its the one that gets the most attention, especially with the Fifty Shades books and movies, but its hardly a lone sexual outlier. In case youre wondering, BDSM is far from the only kink/fetish/paraphilia out there. If, for instance, Kevin was perfectly at ease with his dominatrix sessions and did not feel as if they were interfering with his dating and work life, and instead was coming to therapy about to his desire to change professions, his sexual fetish would be a clinical non-issue. In the same way, we do not say that BDSM is pathological. We do not say that drinking alcohol is inherently pathological (because plenty of people do it without any problems at all). Rather, it is the way in which it affects Kevin that is pathologized. Notably, it is not the behavior itself that is pathologized. Thus, for Kevin, BDSM is also a paraphilia. Moreover, it is causing significant and ongoing stress and anxiety, affecting both his social and work life. However, the behavior is clearly a primary element of Kevins sexual life, elevating BDSM the level of a fetish.

If BDSM was something Kevin engaged in occasionally with his partner(s) for a little bit of extra fun during sex, we would say hes got a kink. He feels torn between the woman he would like to love and possibly marry, and his need/desire for sexual fulfillment through BDSM. He also feels like his performance at work is suffering because of his anxiety. He also says that twice in the past year he has started dating a woman he liked, only to break up with her because the stress of his compartmentalized sexual life felt overwhelming to him. He is unwilling to tell his new girlfriend about his sexual arousal patterns, and this is creating a great deal of stress and anxiety. He says he wants to continue dating this woman, but he also wants to continue with the dominatrix. He also says that he has recently started dating a woman he met through another attorney, and he is afraid that if they have sex she will notice the many marks and bruises that he nearly always has on various parts of his body. He says he does not become physically aroused while this is occurring, but after the dominatrix leaves he masturbates furiously. When asked a few basic questions about his sex life, he says that for the last several years he has been hiring a dominatrix a few times per month, paying her to physically and verbally humiliate him. Kevin, a 29-year-old attorney, enters therapy for severe anxiety. Paraphilias are fetishes that have escalated in ways that have resulted in negative life consequences. Fetishes are nontraditional sexual interests or behaviors (kinks) that are, for a particular individual, a deep and abiding (and possibly even necessary) element of sexual arousal and activity. In my work, I tend to define kinks as nontraditional sexual behaviors that people sometimes use to spice things up, but that they can take or leave depending on their partner, their mood, etc. And with good reason, because if you search the internet youll find a wide variety of definitions with quite a lot of overlap. At this point, some readers may be wondering exactly what I mean when I use the words kink, fetish, and paraphilia. We let them know that its OK (safe) to discuss their sexual life in treatment, however much shame they may be feeling about it.Īmong the sexual issues commonly encountered is a clients desire for (and shame/anxiety about) non-traditional forms of sex, including kinks, fetishes, and paraphilias. By posing queries and nonjudgmentally following up as indicated, we give clients permission to talk about their sex life and the ways in which it might be affecting them.

Is there anything about your sexual or romantic life that feels shameful to you or that you work to keep secret?Īsking these simple, straightforward questions generally ensures that a clients important sexual concerns (issues that might underlie and drive more obvious problems like depression and anxiety) arent overlooked.Has anyone ever expressed concern about your sexual or romantic behaviors?.Do you have any concerns about your current or past sexual or romantic behaviors?.A few non-threatening questions I typically ask are: As such, it is important for any initial queries to sound as neutral as possible. Unfortunately, many therapists and clients are uncomfortable discussing sexual issues. Recognizing this, I find it useful to incorporate a few very basic sex-related questions into the initial assessment with every client.

Kink and fetish checklist