17th Annual Symposium
in San Diego, California on Aug 27, 1999
I. Who we are... why we are doing this
Introductions of Dr. Ruth W., neurologist, and Susan Wright, Policy Director of NCSF
We are presenting on "SM Issues for Healthcare Providers" because the same issues which may lead to inadequate health care for patients with non-mainstream sexual orientations or gender identity affect those who participate in sexual minority practices.
There are many questions related to physical or psychological health which patients may feel unable to ask because of fear of discrimination or of breach of confidentiality. As health care providers, we have a responsibility to be able to address these concerns without passing judgment.
An understanding of the basic principles of SM play enables us to fulfill this responsibility. In addition, it is important that we be able to identify when someone is in an abusive, non-consensual situation, and to provide them with appropriate support. This workshop will address the physical and psychological aspects of SM practices and provide an understanding of common scenarios.
II. Examples of questions Doctors may get
A 50 y/o man defers consulting his family physician about lower abdominal cramping associated with bowel movements because he is afraid the doctor will be able to tell he is into anal sex play and enemas, and that this may be related to his problem.
A 30 y/o woman gets a vaginal tear from fisting, which is continuing to bleed, but doesn't want to consult her doctor or got to the ER.
A 45 y/o man is left in bondage by a professional dominatrix for too long and develops numbness and weakness of both arms which does not resolve after a couple of days.
A 25 y/o woman newly diagnosed with MS is scared to explore her new interest in SM with her girlfriend, because she doesn't know how to ask her neurologist about what might be safe or dangerous for her to do.
The same issues which may lead to inadequate healthcare for patients with non-mainstream sexual orientation or gender identity affect those who participate in sexual minority practices. This includes gays, lesbians, bisexuals, folks who enjoy SM, who have body modifications such as piercings, tattoos, who crossdress, who are sex workers, who have multiple partners, who are transgendered or engage in fetish behavior.
There are many questions related to physical or psychological health which patients may feel unable to ask because fear of discrimination or of breach of confidentiality. Simple problems fester or become chronic. Patients are afraid to tell their doctors about their alternative sexual expression - even doctors they know are kink-friendly.
We are all unused to discussing sexuality in a neutral atmosphere and we are not given training to do it. In the LGBT community we are at an advantage, because sexuality is often more to the forefront than in the heterosexual community, but this certainly doesn't make us immune to being judgmental about practices outside our realm of experience. But precisely because of this reason I would argue that we have more of a responsibility to address issues related to alternative sexual practices.
Everyone deserves adequate health care, whether they are kinky or straight. As a prerequisite to good health care, the patient must trust their physician.
As healthcare providers we have a responsibility to be able to address these concerns without passing judgment. An understanding of the basic principles of SM play enables us fulfill this responsibility. In addition it is important that we be able to identify when someone is in an abusive situation and to provide them with appropriate support.
III. What is SM?
SM includes a broad and complex group of behaviors between consenting adults that involves the consensual exchange of power. This includes the giving and receiving of intense erotic sensation and/or mental discipline and power games.
SM activity is often called "playing" or having a "scene" because that is the way the SM-Leather-Fetish community approaches our form of sexual expression. Our equipment is often referred to as "toys". Like any other kind of game, we have rules we play by.
Individuals negotiate their limits prior to having a scene. Negotiation is ongoing; before, during and after the scene (what's known as "aftercare") to make sure the bottom is fine with what occurred. In our community, it's considered polite to check in with a bottom the day after the scene (or to request that they call you). This is usually more for the psychological issues that may have arisen rather than physical concerns.
SM does not feel like what it looks like. SM rests on a firm foundation of ongoing communication because most of what's going on is in the participants head. I'll use the term top and bottom, but it's also called dominant and submissive, or master and slave. SM is sometimes called D/S or BDSM or the practitioner may not identify or label their activities at all.
Contrary to popular stereotypes, the bottom is in control of the scene and can stop the activity at any time. Often people use a predetermined "safeword". This is a word or gesture that will stop the scene. At community events, the established safeword is "safeword," but individuals often have their own personal safeword, or some simply use "no" to mean "no." Sometimes people who are very submissive have trouble saying no, so a word like "red" is easy for them to say. Or some bottoms like to resist and say no, when they really mean yes, so they choose to have a safeword.
This community-wide standard was codified more than ten years ago in the creed: "safe, sane, consensual."
1. Safe is being knowledgeable about the techniques and safety concerns involved in what you are doing, and acting in accordance with that knowledge.
This includes protection against HIV, STDs, and hepatitis. It also includes notifying your partner of any physical condition that may impact on the scene, like asthma, bad back, epilepsy, etc. It also includes psychological safety, such as you were abused as a child and don't like a particular part of your body touched.
The community concerns itself with safety issues by supporting hundreds of educational and social organizations that teach people the proper way to use their equipment. Such as: how to tie wrists without putting pressure on the insides; how to properly clean equipment; which areas on the body are unsafe to stimulate, such as the face, joints, spine, bottoms of the feet.
2. Sane is knowing the difference between fantasy and reality, and acting in accordance with that knowledge.
Since physical acts has so much power, there are many fantasies that can be acted out by only hinting at the physical conditions someone fantasizes about. That's why our language is so symbolic: dungeon, slave, words of humiliation, or affectionate ownership. You may have to break through the fantasy to make sure your patient likes and wants what is happening.
Sane includes being of clear mind, and the community strongly recommends that mind-altering substances should be avoided during a scene, including alcohol, illegal drugs, and prescription drugs that impair judgment.
3. Consensual is respecting the limits imposed by each participant at all times. One of the recognized ways to maintain limits is through the "safeword" I mentioned. If it's nonconsensual, then it's abuse or assault. SM must be consensual.
To determine if informed consent has been reached, you can ask the following questions:
a) Was informed consent expressly denied or withdrawn? (similar to rape standards, if one of the participants withdraws consent during the activity, that must be respected)
b) Were there factors that negated the informed consent? (alcohol impairment, drug use, underage participants)
c) What is the relationship of the participants? (first encounter or long-term partner?)
d) What was the nature of the activity? (did it cause permanent harm, was it unsafe, was it enjoyable?)
e) What was the intent of the accused abuser? (to cause pleasure, to gain dominance, to gain control, to hurt?)
IV. SM vs Abuse
The community standard of safe, sane and consensual emerged from the growing national concern with domestic violence. SM is not domestic violence, but increasingly as SM gains wider mainstream acceptance, there are abusers who take advantage of men and women who enjoy SM. This makes it difficult for you, as a doctor who is required to report abuse.
If there are physical signs, you can usually judge by the marks:
1. SM rarely results in facial marks or marks that are received on the forearms (defensive marks).
2. There is usually an even pattern of marks if it is SM, indicating the bottom held quite still during the stimulation.
3. The marks are often quite well-defined when inflicted by a toy like cane or whip, whereas in abuse there are blotches of soft-tissue bruising, randomly distributed.
4. The common areas for SM stimulation is on the buttocks, thighs, back, breasts, or the genitals. The fleshy parts of the body can be stimulated intensely and pleasurably.
Questions to ask to determine if it is abuse. Whether an individual's role is top/dominant or bottom/submissive, they could be suffering abuse if they answer no to any of the following questions:
1. Are your needs and limits respected?
2. Is your relationship built on honesty, trust, and respect?
3. Are you able to express feelings of guilt or jealousy or unhappiness?
4. Can you function in everyday life?
5. Can you refuse to do illegal activities?
6. Can you insist on safe sex practices?
7. Can you choose to interact freely with others outside of your relationship?
8. Can you leave the situation without fearing that you will be harmed, or fearing the other participant(s) will harm themselves?
9. Can you choose to exercise self-determination with money, employment, and life decisions?
10. Do you feel free to discuss your practices and feelings with anyone you choose?
V. Intersections of SM and Healthcare
The role of Health Care Providers is to educate the patient to understand the medical problem. Give the patient the info to help determine what is safe, and what to do if there is a problem. If they don't know already, they should know to educate play partner(s).
1. When SM causes health problem (least common). An accurate report of activity is essential and requires trust from patient:
a) Fainting or dizziness
b) Bondage-related - causing nerve damage, joint strain, numbness
c) problems releasing retained rectal objects
2. When the patient wants advice on what is safe (pretty common). Much of this we can figure out from common medical knowledge (eg how long can vascular supply be cut off), but you may need expert advice on this from scene-friendly physicians:
a) extreme bondage (breast, genital)
c) breath control
d) anal play
e) nipple piercing and breast-feeding
3. When health problem inhibits a patient from full expression of sexuality. This is more straightforward, and involves educating patient about their disease:
a) MS: fatigue, overheating, numbness, coordination, sexual dysfunction,
b) CAD: HTN level of exertion,
c) Diabetes: avoiding hypoglycemia,
d) Asthma: need quick-release restraints, no chest or breath restraint,
e) Epilepsy: awareness of aura, what to do if seizure occurs,
f) LBP, arthritis: avoid putting strain upon joints (shouldn't do this anyway).
VI. Talking to your Patients about SM
1. Who is involved in SM?
You have patients involved in SM practice and you don't know it. One out of every ten Americans engages in diverse sexual behavior, yet the stigma against these millions of people means that these people aren't talking about their sexuality as it impacts on their health concerns.
How does a patient come out about SM activities to a healthcare provider? It may be that the provider simply notices piercings or marks or shaved skin. Don't ignore these signs--ask questions to ensure it is consensual SM. That will encourage your patient in turn to ask their health care questions. As you ask questions, never assume you know the kinky activity by a person's appearance.
As an added bonus, Doctors can benefit from being kink-aware because the SM community constantly talks to each other. They belong to support groups, women's groups, special interest groups, and word gets around. You could find you're getting many referrals if it's known that you don't pass judgment on their lifestyle.
2. Don't discriminate against SM practitioners.
It is imperative for you to be nonjudgmental. As a prerequisite to good health care, the patient must trust their physician. To create that trust, the HCP must be receptive. Patients are often inhibited from going to HCP in the first place because of embarrassment/fear of being judged or discriminated against. Many practitioners don't even tell their therapists much less their doctors.
You must be aware that there is REAL discrimination and persecution going on against SM practitioners. The analysis of the NCSF Violence and Discrimination Survey indicates that 1/3 of the respondents have suffered discrimination because of their SM practice, and another 1/3 have suffered attacks and harassment because of their SM practice. People lose their kids, their jobs, their spouses, and even suffer estrangement from family members because of the stigma. NCSF has received complaints from people who have been lectured by their doctors to stop what they are doing, or they were made to feel like they were wrong.
Just because you treat and understand a kinky patient, that's not the end of the road. Often you have to make referrals, and you will have to educate other HCP. This includes making them comfortable enough and knowledgeable enough to give quality medical care to the patient.
3. How do you talk about SM with your patient?
You as the Health Care Provider may be embarrassed about expression of sexuality in patient. Most of us are uncomfortable with discussing sexuality. Medical school doesn't address this issue, and our society is taught to treat sexuality as a joke or something to be avoided.
4 out of 5 of the people who participate in the organized SM community are closeted at work or with their friends and family. Some don't even tell their primary partner about the SM activities they engage in. This can cause problems for the doctor when the patient hems and haws and doesn't ask their real question until your hand is on the door knob. It can take up extra time you don't have. So be sensitive to hints and tentative probes - it may be up to you to help them discuss their activities and how it might be adversely affecting their health.
Remember that your patients have had no experience talking about this in the way that you require. They may provide too much information about their personal desires and explain their sexual encounters in ways that are embarrassing to you. They aren't trying to shock you - they are simply sharing in the way they've learned through SM support and educational groups. You can gently help them stay on track by asking questions and keeping the dialogue moving.
We are here because we want to be able to address these needs of our patients, as they can have deep impact upon level of healthcare sought and given. Patients have a right to this. If we don't feel comfortable we should refer to someone else, and not at patient's emotional expense. As LGBT Health Care Providers, I feel we are better equipped to deal with these issues because our sexuality is a more prominent factor in our identity, and we should have more empathy for those who feel marginalized because of sexual practices.
We don't have all the info about what the patients' needs are, and they may not tell, or even anticipate all of their activities, and they don't have the medical information to make decisions about safety.
How we can appear non-judgmental:
a) Ask about sexual partners/activities when taking medical history
b) Be very careful about judgmental language and use open ended questions.
c) Ask patient to define terms used rather than making assumptions.
VIII. Open up for questions