This is a column about visiting health care professionals. I was going to concentrate only on psychotherapists, but when I asked on some of the lists I’m on for stories about therapists who handled clients into BDSM badly, I got nothing back but good comments about any therapist. This is a good sign that therapists are educating themselves about issues dealing with alternative sexualities. There is also a project by the Community-Academic Consortium for Research on Alternative Sexualities (CARAS) to educate therapists on us, which should also help, but there are still therapists out there who are not going to be sympathetic, so this article will be on the issues surrounding not just mental therapists, but how to work with healthcare professionals as well when the subject of BDSM comes up.

We are all at some time going to have to see a healthcare professional, or a mental health professional. Most of the visits to a doctor or a clinic are going to be routinecheck-ups, if your insurance allows for them. Visits to mental health professionals are never routine. You will be seeing one because you are not happy with a part of your life or you have things going on that distress you. In either case you need to know and understand some things if you are afraid that your BDSM practice will come up in the visit.

The first thing you have to understand is that most healthcare professionals are going to be very conservative in health and sexual matters, unless you found him or her on the Kink Aware Professionals list. (KAP site: ( www.ncsfreedom.org, click on Resources for the KAP search engine. Choose what kind of listing you want, and then write in a location and click search). This is for three reasons. First of all, the insurance companies who provide their fees are also very conservative, being the province of businessmen and lawyers and secondly, the insurance companies also provide their protection against malpractice actions, which means that many of these providers will be practicing defensive medicine.

Lastly, Physicians swear an oath to not do any harm and the other professions have extensive codes of ethics, which are pretty much aimed at the same goal. These are highly regulated industries and the providers have invested a great deal in expensive educations and internships in order to be able to get the licenses to practice.

On top of all this most, if not all, states have a statute that requires healthcare providers to report signs of abuse, child abuse, spousal abuse and elder abuse. There is even a standardized set of questions that many people use to detect this if they are suspicious.  This can cause all kinds of trouble if the provider wants to report you or your partner.

Lastly, and perhaps most importantly, Sadism and Masochism, in the general usage of that term, are considered pathological in the Diagnostic and Statistical Manual (DSM) produced by the American Psychiatric Association (the Psychiatrists) to standardize mental health issues. In spite of the fact that it is an antiquated document, which I have spoken about in this space before, it is the basis for the diagnosis that the therapist will use to get his or her money from the insurance company. What is worse, many general practitioners will also use the DSM without having a complete understanding of it. This is generally a problem in the over use of psychotropic drugs, but it can also have repercussions for us. So, in light of these risks in seeing a physician or therapists, I would like to offer some advice, first the physician.

First of all, remember, these professions have your interests in mind first. The problems generally come when a provider decides that he or she knows your interests better than you, which is rare. A physician or therapist, particularly the later, is going to try and stay on your good side, to be a little bit of a friend, if you will let him or her, because this makes the job of getting you to cooperate with unpleasant tasks in order to stay healthy easier. Quite a lot of medicine is a matter of getting patients to give up bad habits or pick up better ones. It is about getting them to take expensive and sometimes unpleasant medicines and to tell them things they don’t want to hear. It is easier to do this with someone whom you like and who likes you.

If the physician sees marks on your body that look dangerous or abusive he or she is going to inquire about them, as it looks like something they should be concerned with. If these marks are not a problem for you, they are really none of the physician’s business, except when they are required to report abuse. Still, marks that are bad enough are going to create questions, even if they are not a problem for you. The best way to deal with these questions is to tell the truth. Most physicians, particularly the young ones are very tolerant. More importantly, there are privacy laws that keep the physician from reporting these marks or how you got them, again, unless the physician feels that he or she has detected abuse. The physician is not supposed to out you, and if he does he could lose his license to practice.

If you are not comfortable discussing your sex practices, I would suggest that you can say something that will be both the truth and deflect the physician back to the thing you really came in for in the first place. Simply say that you got the marks during sex. Sex, being a word that always comes out in neon, makes a lot of people, physicians included, uncomfortable so the subject should change. If he or she attempts to get you to be more specific, simply change the subject back to the problem you were in the office to begin with. If it’s a routine check-up you can ask if the physician is done, that kind of thing. If he or she gets pushy then you can remind them that you did not come in because the marks were bothering you, so you don’t see as how they are the physician’s business. This should bring him or her back to the business at hand.

If the physician decides that you have been abused and reports it to the authorities then there are two things you have to remember. First of all, the authorities are looking for real problems, not problems that really aren’t there. While there is a dispute whether or not one can consent to assault, the social worker or police officer is not going to be aware of that. These disputes are the province of lawyers, not the police or social workers. That being said, I have found that the police are more sympathetic, particularly in big cities, to BDSM than are social workers. The police are more interested in busting predators than interfering with happy couples that have alternative sex practices. They have seen worse than cane marks. Social workers, on the other hand, particularly inexperience ones, might have a crusade going. Social work is boring, and frankly, underpaid. They have to deal with dysfunctional clients, live with a quota system of some kind and report to politician superiors who may or may not understand what it is like being a social worker. It is a nasty job, so if they see what looks like a clear-cut case of abuse they might just jump on it. Particularly the more inexperienced ones, who would have a not so sophisticated view of the world. The social worker’s job is bound by rules and procedures so it attracts people with a very rigid view of right and wrong, and to some of them BDSM is wrong.

Choosing a mental health provider can be either very easy but if you make a wrong turn it can go very wrong. The nice thing about mental health providers is that they understand that their services are voluntary, not mandatory. Most modern practitioners call the people they work with clients, not patients, so as not to imply that they are going to work with them as a physician would. Mental health treatment is not, in general, about the removal of symptoms, although the cognitive/behavioral schools aspire to just that. There is a division of practice in mental health because there is more than one kind of mental health practitioner. This divide breaks between counselors and psychotherapists. The best description of this divide is that while counselors are teachers and advisors, psychotherapists are detectives trying to find root causes of problems. That being said, this is not a bright line. A psychotherapist has a Ph.D. and needs a long internship to practice. Counselors generally have master’s degrees, Master of Family Therapy or Master’s of Social Work, in general, and have had to undergo a shorter, more focused internship. That being said, there is a new degree, the Doctor of Psychology, PSY-D, which is much the same as an MD, a more focused clinical approach to therapy, leaving out the extensive research requirements needed to get a Ph.D. While the PhD, which is aimed more at academics and research and the master’s level counseling.

The last person that I would see if I were not having problems with psychoses would be a psychiatrist. These are MDs who have specialized in behavioral problems. They are different from brain scientists, who generally are MDs, but are more oriented towards the mechanical, electrical and chemical aspects of the brain. Psychiatry is the oldest of the psychotherapeutic practices, Freud and others at the turn of the 20^th Century began it, and as such it is the most conservative of the practices. They tend to be psychoanalysts and hold to a lot of Freud’s ideas, which are very conservative about sexuality.

There is a lot of pill pushing in the psychiatric community and problems with general practitioners over prescribing psychotropic drugs are even worse. I would not go see a psychiatrist straight off, but would go to counselor or a psychologist first as only they can tell if your problem is severe enough to need the special skills of a psychiatrist. Above all, don’t fall for the ads that can make it look like everyone could use a psychotropic drug. A good example of what I am talking about is the recent issue of depression. Most people get depressed at some point in their life, but that depression has causes; generally it is about mourning a loss of some kind. Clinical Depression is pervasive. It is not caused by anything. Your life simply seems to be in the dumper, whether it is or not. This is what the drugs were invented to ameliorate. I use that term because long-term usage can be dangerous, as recent research has shown.

There are drugs used to treat sexual problems as well. They generally are used to reduce the sex drive. While most psychiatrists don’t know it, the idea that sexual hyperactivity is the cause for sexual problems can be traced directly back to the late Victorian forensic psychiatrist, Krafft-Ebbing who first wrote about sexual psychopathologies, and is the one directly responsible for Sadism and Masochism being diagnosable. Krafft-Ebbing believed that only vanilla sex was normal.

There are two things to understand when working with a mental health professional. First, if your sex life is not a behavioral problem for you, it is none of the therapist’s business. Second, BDSM is only a problem for you if it is a problem. If your “perversions” are a problem for you it is not the BDSM which is a fault, it is your perception of the BDSM. If you are obsessed with BDSM fantasies but will not do anything to fulfill them, where is the problem, in the fantasies or in your repression of them? It is this kind of conundrum that makes working with a therapists or counselor difficult. What makes it even more complex is the rock on which therapy that fails runs aground. There is nothing that the therapist can do for you beyond point out issues, suggest behaviors or make suggestions. You have to do the work yourself. As with physical medicine you are responsible for what goes on in your own life, the therapist is only a detective, to find the problem, and a teacher to show you how the problem expresses itself (and sometimes the causes of the problem) and to show you ways to change the behavior which is causing the problem. The rest is up to you.