Introduction BDSM (bondage and discipline, dominance and submission, and sadism and masochism) increasingly receives attention from the scientific community. Where earlier research efforts mainly focused on epidemiologic characteristics, psychological and biologic factors driving BDSM preferences have recently gained interest as well. Aim To bring together all the existing scientific literature on BDSM from a biopsychosocial perspective. Methods Based on the PRISMA guidelines, the current systematic review brings together all the existing literature on BDSM from a biopsychosocial perspective. Main Outcome Measure Prevalence rates of BDSM interests were investigated in the literature, as well as the associations between BDSM interests on one hand and personality traits, adverse childhood experiences, education levels, sexual orientations and biological markers on the other. Results Biologic factors such as gender identity, sex hormone levels, and the neurologic constitution of the brain’s pain and reward systems influence BDSM orientation. With regard to psychological factors, both personality traits (eg, higher levels of openness or extraversion) and the presence of a personality disorder have been associated with a heightened interest in BDSM, although only limited supporting evidence is available. Additionally, sensation-seeking levels and impulsivity seem to contribute, because they presumably guide one’s drive to explore new or more-intense kinks. Whereas attachment styles impact couple dynamics, they also influence willingness to explore limits in a BDSM context. Lastly, education levels impact relational and sexual dynamics. Strengths and Limitations The limitations of the current review reflect those of the topical scientific literature. Although the number of studies focused on all aspects of BDSM is exponentially growing, most of these are only descriptive, and very few focus on underlying driving processes. Conclusion From this biopsychosocial perspective, we offer a dimensional approach while integrating the factors driving the onset and evolution of BDSM interests. De Neef N, Coppens V, Huys W, et al. Bondage-Discipline, Dominance-Submission and Sadomasochism (BDSM) From an Integrative Biopsychosocial Perspective: A Systematic Review. Sex Med 2019;7:129–144.

Introduction: Previous research has shown rather high prevalence rates of BDSM-related activities in the Belgian population. Nevertheless, BDSM is still being stigmatized and pathologized. Yet very few studies have focused on these phenomena among BDSM practitioners and in the general population. The current two-part study investigated a) stigmatizing attitudes and beliefs about BDSM in the general population, and b) self-reported stigma in members of the BDSM community. Methods and results: In study 1, a crosssectional survey questionnaire, containing the Big Five Inventory and a self-developed stigma-questionnaire, was completed by 300 members of the general population lacking any interest in BDSM (135 males, 158 women, 4 gender fluid, 3 genderless). Three dimensions of stigmatizing attitudes and beliefs about BDSM were identified, being prejudices, discrimination and incomprehension. About 86% maintained stigmatizing beliefs about these sexual interests and practices. Higher age, higher levels of conscientiousness, and lower levels of openness and agreeableness were found to be predictors for stigmatization. Study 2 involved 256 BDSM practitioners (110 males, 135 women, 7 gender fluid, 2 genderless) who completed a questionnaire with items concerning experienced stigmatization or discrimination because of their BDSM interests. About 28% reported not feeling comfortable to share their interests with the outside-world. Conclusion: These results suggest that people who do not conform to the current social standards of our society may not be explicitly excluded, but often seem to remain the subject of stigmatization and discrimination. Proper education about the concept of BDSM could be a first step in stigma-reduction.

Background BDSM is an acronym describing bondage and discipline, dominance and submission, and sadism and masochism. Afflicting or receiving pain is usually an important part of the BDSM interaction. Aim This research will focus on better understanding the aspect of pain within a BDSM interaction. Methods Submissive and dominant counterparts of 35 couples were recruited to participate in a BDSM interaction, of which 34 dominants and 33 submissives were included in the analyses. A non-BDSM interested control group (n = 27) was included to control for social interaction, of which 24 were included in the analyses. Outcomes This research investigates the differences in (i) baseline pain thresholds, (ii) the impact of a BDSM interaction on those thresholds, and (iii) threshold moderating factors like pain cognition between submissive and dominant BDSM participants and control individuals. RESULTS BDSM practitioners have a higher pain threshold overall and a BSDM interaction will result in a temporary elevation of pain thresholds for submissives. Additionally, pain thresholds in dominants will be dependent upon their fear of pain and tendency to catastrophize pain and submissives will experience less fear of pain than the control group. Clinical Implications By further enhancing our understanding of the mechanisms behind a BDSM interaction in this way, we aspire to relieve the stigma these practitioners still endure. Strengths & Limitations This is one of the first studies of its kind with a large sample size compared to similar research, which makes it a significant contribution to the field. It must be mentioned that there is a possible selection bias because recruitment was only done through the Flemish BDSM community and specifically those who visit clubs. Additionally, pain threshold remains a subjective measurement, which must be taken into account. CONCLUSION This study helps shed further light on the biological processes behind a BDSM interaction through pain threshold measurements.

Background 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. Aim To shed light upon the rewarding biological mechanisms associated with BDSM interactions. Methods A group of 35 BDSM couples (dominant and submissive counterparts) were recruited and tested during a BDSM interaction, with an additional control group of 27 non-BDSM interested people tested in a normal social interaction. Outcomes We compared the evolution of the stress and reward hormone levels of cortisol, beta-endorphins, and endocannabinoids (2AG and anandamide) in a group of BDSM practitioners before and after an active BDSM interaction with the levels in control individuals. Results We showed that submissives showed increases in cortisol and endocannabinoid levels due to the BDSM interaction, with dominants only showing increased endocannabinoid levels when the BDSM interaction was associated with power play. Clinical Implications This study effectively provides a link between behavior that many think of as aberrant on one hand, and biological pleasure experience on the other, in the hope that it may relieve some of the stigma these practitioners still endure. Strengths & Limitations It is one of the first and largest studies of its kind, but is still limited in sample size and only represents a specific population of Flemish BDSM practitioners. Conclusion Even though this is one of the first studies of its kind, we can conclude that there is a clear indication for increased pleasure in submissives when looking at biological effects of a BDSM interaction, which was related to the increases in experienced stress.