Biology of BDSM 2020
Biology of BDSM 2020
Biology of BDSM 2020
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Abstract:
Introduction
BDSM is an abbreviation used to reference the concepts of bondage and discipline, dominance
and submission, sadism and masochism, enacted by power exchanges between consensual
partners. In recent years, attention has shifted from the idea of BDSM as a pathological and
tabooed niche practice towards viewing BDSM as a healthy form of intimacy.
Aim
This systematic review brings together all existing literature on the biology of BDSM and places
it in a broader biological context.
Method
A systematic search was conducted on Pubmed, Web of Science and PsycARTICLES, of which
ten articles are included and discussed in this systematic review.
Results
There is evidence for cortisol changes in submissives as a result of a BDSM interaction,
suggesting involvement of the physiological stress system. Endocannabinoid changes implicate
the pleasure and reward system. In dominants, this biologically measured pleasure seemed to
be dependent on power play rather than pain play. Testosterone and oxytocin are also implicated
in BDSM, though their role is less evident. Research into brain region activity patterns related
to BDSM interest suggests a role for the parietal operculum and ventral striatum in the context
of the pleasure and reward system, the primary and secondary somatosensory cortex in the
context of pain perception, empathy-related circuits such as the anterior insula (AI), anterior
midcingulate cortex (ACC) and sensorimotor cortex and the left frontal cortex in the context of
social and sexual interactions. Pain thresholds are shown to be higher in submissive individuals
and a BDSM interaction may cause pain thresholds to rise in submissives as well.
Conclusion
BDSM interactions are complex and influenced by several psychological, social and biological
processes. Though research is limited, there is emerging evidence for an interaction between
several biological systems involved in these types of interests and activities. This means there
is an important role for future research to replicate and supplement current results.
Keywords:
BDSM; sexuality; submissive; biological assessment; pain threshold; functional brain imaging
Introduction
BDSM is an acronym used to describe the concepts of bondage & discipline, dominance &
submission and sadism & masochism. It encompasses the psychological and physical roleplay
between two or more consenting partners, often involving a power exchange [1] between a
submissive party, (also referred to as “bottom” or “masochist”) and a dominant party (also
referred to as “top” or “sadist”). These interactions will often revolve around elements of pain
and power imbalance [2]. The BDSM practices referenced in this review all meet the
fundamental principle of safe, sane and consensual, which is a widely accepted cornerstone of
the BDSM community [3]. Coercive sexual sadism (i.e. sadistic practices with a non-consenting
partner) by its very definition is very different to consensual BDSM, even though certain
behaviour might seem similar on the surface [4]. Consequently, studies focusing on coercive
sexual sadism fall outside the scope of this review. For an overview of the current literature on
coercive sexual sadism, we refer to the systematic review of Mokros and colleagues [4].
In recent years, attention has shifted from the idea of BDSM as a pathological and tabooed
niche practice towards viewing BDSM as a healthy form of intimacy [5]. BDSM has shown to
be quite prevalent in society, with a large-scale survey study conducted by our group indicating
that 46.8% of the Flemish population had engaged in a BDSM-related activity at least once [6].
In the same study population, 7.8% identified as BDSM practitioners. Of these, 85.9% solely
practices at home, while 14.1% will also perform in a public setting. The practitioners identified
as follows: 28% as dominant, 36% as submissive, 27% as switch (i.e. persons who switch
between the dominant and submissive role) and 9% as other. Although more people are
becoming aware of what BDSM is and what it entails, much about the underlying psychological
and especially biological processes driving these interests and fantasies have yet to be revealed.
Are certain baseline biological processes related to an interest in BDSM? Do BDSM
interactions trigger biological changes that reinforce these interests? What changes might we
expect during a BDSM-themed interaction or “play” and how do these changes explain what
BDSM practitioners report?
We will begin by exploring several known aspects of the BDSM interaction and their biological
basis.
Sexuality
While sexual activity isn’t necessarily a part of the BDSM interaction, a play is more often than
not conducted within an erotic context [1]. In this line, a survey of Fetlife participants conducted
by our group in 2017 (n=364) indicated that 87% of the respondents experience BDSM as being
erotic and that 70% combined BDSM with sex at least regularly (unpublished data). This is
corroborated by an interview-based study in which practitioners elaborate upon the sexual
nature of their BDSM experiences [15].
Sexual motivation is closely linked to the pleasure and reward system, and the sexual pleasure
cycle depends on dopaminergic neurons of the reward system and the interacting opioid-
endocannabinoid system [16]. A recent functional magnetic resonance imaging (fMRI) study
showed that sexual cues activate the reward system in the brain in both men and women [17].
Beta-endorphin and dopamine are both linked to male sexual arousal [18]. Equally,
endocannabinoids are also known to influence sexual motivation [19] whereas another study
found the endocannabinoid 2-AG to significantly increase after orgasm [20].
The hypothalamus, and more specifically the paraventricular nucleus, has been implicated in
sexual activity and orgasm [21], most likely through the secretion of oxytocin and vasopressin
[22]. Both of these hormones have been linked to sexuality, though their interaction pathway is
not yet fully understood [23]. Nonetheless, oxytocin has been shown to increase VTA activation
in women as a result of sexual stimuli [24].
Sexual hormones, namely testosterone and oestrogens, are also implicated in sexual arousal by
ensuring cerebral integration between autonomic and somatic sexual systems [16]. Testosterone
plays an important part in the male sexual functioning. It modulates almost all the components
of sexual behaviour, and sexual behaviour will in turn influence testosterone concentrations
[25]. While baseline levels of testosterone are not correlated with the intensity of sexual arousal,
extremely low levels have been clearly linked to decreased sexual interest in both women and
men [26]. There is also growing evidence that testosterone therapy can be effective in increasing
sexual desire in men with sexual dysfunction and low testosterone levels as well as
postmenopausal women with low sexual desire [27, 28]. In women, the level of oestradiol also
seems to be positively correlated with sexual motivation [29].
As such, the dopaminergic driven reward system appears to play a crucial role in sexual pleasure
with several hormones such as oxytocin, vasopressin, oestrogens and testosterone to moderate
the interaction between relational connection, sexual motivation and reward.
Power dynamics
Power imbalance is a key element in the BDSM interaction, which usually includes a dominant
and submissive party or variations thereof [1]. This is reminiscent of general societal hierarchy
and status-relevant behaviour, which can be broadly divided into dominance (through induction
of fear) and prestige (through admiration and respect) [39]. Social dominance especially has
been shown to have a strong biological basis, with aggression as a common manifestation [40].
For instance the sexual hormone testosterone has been linked to both aggression [41] and social
dominance [42]. The relationship between testosterone and behaviour is complex, with no real
evidence for a correlation between baseline testosterone levels and trait aggression [41].
However, acute changes in testosterone levels in a competition context may explain differences
in aggressive reactions, both in men and women [43]. Interestingly, this correlation seems to be
mediated by trait dominance as well [44]. Recently, the importance of the stress hormone
cortisol in this dynamic has gained ground with the dual hormone hypothesis, which states that
testosterone mainly influences power dynamics when cortisol levels are low [45]. However, not
all studies have been able to replicate these results and more research will be needed to confirm
this hypothesis [41]. High levels of cortisol have also been correlated with social
submissiveness [42]. In line with this, facial dominance (i.e. the degree of dominance
interpreted from facial expression) in women has been associated with lower cortisol levels
[46].
Vasopressin and oxytocin are likewise not only involved in sexual arousal, but also in
dominance and aggression [47, 48]. In males, vasopressin tends to stimulate aggression and
sexual motivation, while it has a more inhibitory effect in females [48]. Oxytocin is widely
regarded as a prosocial hormone, being implicated in empathy, pair bonding, maternal care,
though depending on context it may also elicit antisocial effects [47].
To summarize, the dynamic between testosterone and cortisol has been shown to play an
important role in social dominance, as has the dynamic between vasopressin and oxytocin.
These hormones are also implicated in sexual motivation and sexual behaviour.
Research objective
This systematic review will summarize all peer-reviewed literature surrounding the biology of
consensual BDSM in order to assess the current state of the art and suggest directions for future
research. Because literature on this topic is limited as of yet, it is important to then place these
results in a broader biological context.
Methodology
A systematic literature search was conducted by the authors using the following inclusion and
exclusion criteria:
1) Inclusion criteria
a. Human studies including BDSM participants
b. Using a definition of BDSM that fits in the safe, sane and consensual paradigm
c. At least one biomarker assessed in the study
2) Exclusion criteria
a. Case reports, opinion articles, comment letters and essays without original data
b. Animal studies
c. Studies with a forensic population or sadomasochism in a coercive setting
These criteria were driven by the generally accepted scientific hierarchy of evidence [49]. No
time-limitation was used in the search. A systematic search was done in August 2021 on three
databases: Pubmed, Web of Science and PsycARTICLES. The search stringwas comprised of
two parts. The first part includes all terminology referencing BDSM, while the second part
includes all relevant biomarkers related to brain activity and hormones involved in pain, stress,
sexuality and pleasure as described in the introduction. This resulted in the following:
1) BDSM, masochi*, sadism, sadomasochi*
2) biolog*, biomarker, serum, plasma, blood, hormones, corticosteroid, glucocorticoid,
cortisol, endorphin, endocannabinoid, AEA, 2-AG, testosterone, oxytocin, estrogen,
vasopressin, pain threshold, brain imaging, functional magnetic resonance imaging,
MRI, magnetoencephalography, MEG, electroencephalography, EEG, event-related
potential, ERP
This search strategy resulted in a total of 10 articles which could be included from Pubmed.
The two additional databases yielded no additional results. A summary of the included articles
can be found in table 1.
Results
Research on peripheral hormones
Sagarin and colleagues were the first to investigate the impact of BDSM interactions on
peripheral cortisol and testosterone levels [37]. They found that cortisol rose significantly
during the scene (i.e. the BDSM interaction) for the submissive counterparts (n=7) but not for
the dominant participants (n=6). When the submissive subjects were female (n=6), a rise in
testosterone levels was also observed. When the couple had a positive feeling about the scene,
significant reductions in cortisol levels could be seen afterward, together with a reported
increase in relationship closeness. These results were less clear in couples reporting the play to
have been of poor quality. Because of the small sample sizes, however, statistical power
remains in question. Additionally, a control group was not included to compare the levels of
cortisol and testosterone.
A later study by Klement and colleagues [38] found similar increases in cortisol levels before
and during a non-sexual BDSM ritual called ‘Dance of Souls’ which includes temporary
weighted or hooked piercings while dancing to rhythmic drums. The participants (n=67) also
reported a subjective decrease in psychological stress.
Notably, Ambler and colleagues were unable to duplicate the cortisol and testosterone effects
in their study, which included 7 switch couples who were randomly assigned a top or bottom
role [50]. Since this is the only study that did not replicate the cortisol effects, it pays to examine
the differences in study design. Firstly, it must be noted that the study contains a very small
sample size, which brings statistical power into question. Secondly, the study chose to focus on
switches . A person identifying as a switch has a greater level of BDSM role fluidity, which
allows them to switch between roles [51]. This could mean that the biological changes
associated with either a dominant or submissive role are less pronounced, although this
hypothesis hasn’t been tested as of yet.
A more recent large-scale study, conducted in the Flemish BDSM community by our group,
found several relevant changes in hormone levels when comparing the blood results of 35
BDSM couples with those of 27 non-BDSM-interested control individuals [52]. It must be
mentioned that this is not an ideal comparison, since the relationship between the dominant and
submissive party may be a confounding factor that is not accounted for in the non-dyadic
control group. Blood samples were taken at three points in time: firstly right before play,
secondly right after play and thirdly fifteen to thirty minutes after play to account for aftercare
(i.e. the period of time after play for intimate contact and reflection). ELISA analyses assessed
the plasma concentrations of beta-endorphin, endocannabinoids (AEA, 2-AG), cortisol,
testosterone, oestrogen, vasopressin and oxytocin in each of the subjects. Results showed that
both endocannabinoids and cortisol levels significantly increased in submissives during the
BDSM interaction and that these increases were intercorrelated, which suggests that the
submissives indeed experienced the BDSM interaction as rewarding and pleasurable, and that
this experience was related to the stress levels invoked during play. The type of play seemed to
impact hormones related to reward differently in submissives and dominants. Whereas
increases in endocannabinoids were mainly related to impact play (i.e. pain play) in
submissives, significant increases in endocannabinoid levels in dominants were only found in
those focusing on power play in their interaction. Oxytocin was found to be largely unchanged
in the total group. However, when looking into the dominant group, a significant difference
between men and women could be found, with female dominants having higher oxytocin levels
after the play, which was not found in their male peers (unpublished data). This seems to suggest
that BDSM interactions lead to more feelings of attachment and closeness in female dominants.
No significant changes were found in levels of beta-endorphin, testosterone, oestrogen or
vasopressin.
Taken together, there is clear evidence for cortisol changes in submissives linked to a BDSM
interaction, which suggests involvement of the physiological stress system. As our study also
showed, endocannabinoid changes in submissives suggest that the pleasure and reward system
is likewise involved, mainly driven by pain play. In dominants, this biologically measured
pleasure seemed to be dependent on power play rather than pain play. The role of testosterone
and oxytocin is less evident and should ideally be explored in further research to see if the
above-mentioned results can be replicated.
Research on pain thresholds
The study conducted by our group described above [53] also collected pain threshold data
before and after interaction, using both a pressure and temperature stimulus. These findings
suggest that both the dominant and submissive group have an overall higher heat pain threshold
than the control group. These differences in the submissive group seemed to be driven by
minimalizing assumptions and cognitions about pain in general. Additionally, submissives
showed a trend towards a temporary additional increase in their heat pain threshold directly
after a BDSM interaction.
Defrin and colleagues [54] confirmed the presence of higher pressure pain thresholds in
masochistic individuals (n=17) compared to controls (n=17). This study would have also
benefited from the inclusion of other BDSM identities to compare pain thresholds and pain
cognitions. Pollok et al. also found that their masochistic group (n=10) consistently rated
painful sensations as more pleasant than the control group, indicating a different approach to
pain even outside the BDSM context [55].
These are controversial findings, since other literature suggests that a decreased pain sensitivity
is only present in submissives within the context of the BDSM interaction [1, 56]. This pain
threshold literature suggests, however, that submissives respond differently to painful stimuli
regardless of context as well.
Limitations
There are several limitations to this review that need to be addressed.
Firstly, the lack of consensus regarding the definition of BDSM poses some challenges. This
results for instance in a difference of terminology used in the included studies. Some studies
will reference the submissive party as “bottoms”, others as “masochists” or “submissives”. The
same is true for the dominant party. Another difficulty in this heterogeneous terminology is the
sexual component. While BDSM is often linked with sexual activity, not all BDSM
practitioners agree with this [91]. The role of sexuality remains a topic of discussion in the
scientific community [1].
Another important bias to address is the WEIRD bias. This states that most studies still focus
on western, educated, industrialized, rich, and democratic societies [92]. When we review the
ten studies included in this review, we must conclude that this is the case for all but two (see
table 1). This has of course potential implications for the generalizability of the study results.
International studies are needed to assess what cultural and societal differences may arise.
What must also be mentioned is the distinct lack of studies in this particular field, which means
that most of the results have not as of yet been replicated in other research. This means that it
is difficult to draw conclusions on both trait and state findings, and that causal implications
cannot be made. Small sample sizes also diminish the statistical power of the results.
Clinical implications
As our understanding of the biology of BDSM grows, so does the opportunity to help in the
destigmatization of BDSM in general. Historically, it has been pathologized by its inclusion in
for instance the Diagnostic and Statistical Manuel of Mental Disorders (DSM) and the
International Classification of Diseases (ICD). Though there has been some progress, it is still
included in the 5th edition (DSM-5) today as “sexual sadism”, “sexual masochism” and
“fetishism” [93]. On a more promising note, those diagnoses have been eliminated from the
most recent 11th edition of the ICD, replaced instead by “coercive sexual sadism disorder” [94].
By normalizing the biological processes that underlie BDSM activities, we hope to strengthen
the argument that it does not belong in the psychiatric or forensic field and needs to be firmly
distinguished from paraphilias as described in the DSM or ICD.
Conclusion
BDSM refers to a broad set of behavioural, relational and sexual interactions and is influenced
by several psychological, social and biological processes. Because it is not easily defined and
encompasses many aspects of pain, pleasure, sexuality and power structures, the biological
mechanisms associated with BDSM will be equally broad.
As for the important aspect of pain within the BDSM interaction, Dunkley and colleagues have
made an integrative model of how pain may be processed as pleasurable in the context of BDSM
[95]. This model draws on the existing psychological processes known to be involved in BDSM,
such as the altered states of consciousness (e.g. “sub-space”), sexual arousal, social bonding,
the importance of control and volition, etc. They use these to theorize on the process of
experiencing pain as a welcome sensation. The model also encompasses several biological
factors which are discussed in this review as well. They implicate the importance of the pleasure
and reward system to modulate painful sensations through dopamine and endocannabinoids, as
well as sexual arousal through oxytocin. Lastly, they also link cortisol increases to the
involvement of the stress system.
We have endeavoured to summarize the known biological processes in a model, by drawing on
these different aspects, as well power structures (see figure 2). The pain and power dynamics
which are so often present in a BDSM interaction will translate biologically in the activation of
several hormones such as cortisol, testosterone and vasopressin. Of these hormones, cortisol
has been most strongly implicated in BDSM interactions, with several studies finding evidence
for a physical stress reaction in the body during a BDSM play. Testosterone is likewise
implicated in female submissives [37], though this has yet to be replicated. Meanwhile,
experience of pleasure and sexuality, regulated by different hormones such as
endocannabinoids, beta-endorphin, oxytocin and sex hormones, will colour and direct the
BDSM experience and influence the experience of pain and power dynamics as well. Of these,
the endocannabinoids have been found to change because of a BDSM interaction [52],
suggesting a clear involvement of the pleasure and reward system. Oxytocin was implicated in
female dominants in the same study, though this has not been investigated further by other
research. Future scientific research will help to shed further light on these biological processes
and hopefully contribute to reducing the stigma that BDSM practitioners still endure in our
society.
-- INSERT FIGURE 2 ABOUT HERE --
Table 1: included studies on biology of BDSM