Dr. Michael Bettinger's patients do things that might make you gasp, like whipping and binding their partners in search of sexual pleasure.
They're not at this therapist's office looking for a cure for their behaviors. But should they be?
Bettinger specializes in kinky sex lives. Think leather, fetishized body parts and pain. But his mission is not what you might think; he doesn't rid patients of their unusual preferences. Bettinger is one of many therapists who doesn't treat a preference for kinky sex as a disease.
And he's not alone: There are more than 150 listings on the Kink-Aware Professionals Web site. People seeking "no judgments" therapy are more comfortable being totally open with a guy like Bettinger.
Besides, all they really want to talk to him about is the garden-variety stuff.
"Their problems have to do with anxiety, depression, family, work," he said, "nothing to do with their kinkiness."
The world of kinky sex has no firm boundaries, but it encompasses physical activities like BDSM (bondage, discipline, sadism and masochism), sexual role playing games, and every imaginable fetish. Some of these variances have long been labeled as signs of mental illness by the therapist's bible, the Diagnostic and Statistical Manual of Mental Disorders.
"Certain types of sexual behaviors are considered to be deviant and representative of mental disorders," says Dr. Michael First of Columbia University, editor of the latest version, DSM-IV.
And how do the high priests of psychiatry decide what constitutes a paraphilia, or perverted sexual desire?
"Most of the paraphilias are in there for historical reasons," says Frist. In 1968, when DSM-I came out, "it reflected what health professionals saw as a pathology." Of course, the DSM also once contained a category for homosexuality, which was removed from the listing amid much controversy in 1973.
Behaviors that currently reside in the "deviant" column include exhibitionism, voyeurism, frotteurism (rubbing one's genitals against unsuspecting strangers) — and transvestism, sadism, masochism and fetishism.
Bettinger's clients may think they're OK, but some see their behavior as a sickness in need of treatment. Indeed, many therapists see fetishes and kinks as the direct symptom of larger psychological problems.
For example, if a man came to Dr. Concelor Davis, a Christian therapist from Chicago, complaining of depression, and he found his patient was also into sado-masochism, would he treat the depression or the kink?
"I would try to start a discussion of the fetish, and bring him to see how those behaviors are associated with the very symptoms he's having problems with," says Davis. He sees fetishes as a symptom of abuse, not an inconsequential proclivity.
"We address the underlying issues that have precipitated the [fetish] disorder," Davis says. "I'm not sure if fetishes are curable, but they're treatable."
The kink-friendly therapists' response? They say treating fetishes as diseases is outmoded, obsolete and rooted in America's puritanical attitudes toward sex.
"Somebody comes in for depression and says, 'By the way, I like to spank my wife.' Then the therapist only wants to talk about spanking — even if the guy says, 'No, she likes being spanked," said Dr. William Henkin, a sex therapist and psychologist working in San Francisco.
But what if the fetish involves really hurting another person? Isn't there a point where behavior should be discouraged, even if it is consensual?
"If you smoke cigarettes and drink whiskey sometimes, that's self-destructive," Henkin answered. "But how would you like it if a therapist said you have a disorder and need serious psychiatric intervention?"