Sex Therapy with Survivors of Sexual Abuse

"She wanted to have sex, so she began to do oral sex on me," Tony explained. "I got an erection and then lost it and couldn't get it back." "Did you want to be having sex?" I asked him. "No, I really wasn't interested then," he replied. "So your body was saying no for you," I remarked. "Yeah, I guess so," he said somewhat proudly. "Wow, do you realize what's happening?" I declared, "You're becoming congruent! For all these years, your genitals have operated separately from how you really felt. Now your head, heart, and genitals are lining up congruently. Good for you!"

That day in therapy with Tony was a turning point for me as a sex therapist. l was amazed that I was actually congratulating him on his temporary sexual dysfunction. It felt appropriate. Instead of functioning, the goal of treatment shifted to self-awareness, self-care, trust, and intimacy-building. Insight and authenticity became more important than behavioral functioning.

While healthy sexual functioning is a desirable long-term goal, conveying the idea that all dysfunctions are bad and must be immediately cured is too simplistic. In working with survivors and others, sex therapists need to see sexual problems in context and we need to find out how people feel about a symptom before attempting to treat it. Therapists must respect dysfunctions, learn from them, work with them, and resist the urge to automatically try to change them.

Tenet 2: All Consensual Sex Is Good

In general, traditional sex therapy didn't make distinctions between different types of sex as long as sex was consensual and did not cause physical harm. That way of thinking does not hold up considering the sexual addictions and compulsions that are by products of sexual abuse. Little distinction was given to the type of sex that fostered addictive and compulsive behavior. The lack of distinction between the more specific nature of sexual interaction has left some people, including survivors, fearful of all sex. From working with survivors we have learned that sexual addictions and compulsions develop to a type of sex that incorporates or mimics the dynamics of sexual abuse.

On business trips Mark, a married man with two children, could not stop himself from cruising strange neighborhoods looking for pretty women whom he could watch from inside his car while masturbating.  He knew all the video parlors in a four-state area and could not pass one without stopping to masturbate.  He sought counseling because his wife had caught him in bed with his secretary.  She threatened to leave him unless he got help.

When Mark entered therapy he described himself as being addicted to sex.  I asked him to describe sex.  He used terms like, "out-of-control, impulsive, exciting and degrading."

Mark's preoccupation and addiction was to a type of sex that was fueled by secrecy and shame.  It was undertaken in a high state of dissociation; filled with anxiety; focused on stimulation and release; and lacking in true caring, emotional intimacy, and social responsibility. This type of sex was associated with power, control, dominance, humiliation, fear, and treating people as objects.  It was the same type of sex that he was exposed to as a young man when his mother's best friend would pull down his pants, molest him, and laugh at him.

Helping Mark recover involved helping him make connections between what happened to him in the past and his present behavior.  He needed to learn the difference between abusive and healthy sex.  Sex, per se, was not the problem.  It was the type of sex he had learned and developed arousal patterns to that had to change.  Healthy sex, like healthy laughter, incorporates choice and self-respect.  It is not addictive.

To help people overcome fears of sex, sex therapy involves teaching conditions for healthy sexuality.  These include consent, equality, respect, safety, responsibility, emotional trust, and intimacy.  While abstinence can be an important part of recovery from sexual addictions, it won't be enough unless new concepts and approaches to sex are also learned.

Tenet 3: Fantasy and Pornography Are Benign

In traditional sex therapy, therapeutic use of sexual fantasy and pornography was generally viewed as benign and often even encouraged.  Because the goal of therapy was functioning, fantasy and pornography were seen as therapeutically beneficial: giving permission, offering new ideas, and stimulating arousal and interest.  Books on becoming orgasmic frequently recommended that women read something juicy, like Nancy Friday's collection of sexual fantasies, to "get them over the hump" and be able to climax.

In the early years of my practice, like other sex therapists I knew, I kept a collection of pornography in my office to lend out.  While most pornography was degrading to women and contained descriptions of sexual abuse and irresponsible sex, the common attitude in the field was that "thinking it" is not "doing it." The implication was that sexual thoughts and images are harmless; as long as you don't act out a perversion, it's not damaging.

Through working with survivors, sex therapists have learned that sexual fantasies and pornography can be very harmful.  Reliance on them is often a symptom of unresolved issues from early sexual trauma.

Joann and her husband, Tim, came to see me for marital sexual counseling.  On the very rare occasions when Joann was interested in sex with Tim, she would manipulate the lovemaking in such a way as to encourage Tim to have forceful anal sex with her.  Sexual contact invariably concluded with Joann curled in a ball on the bed sobbing and feeling isolated.  Tim had some difficulty understanding why he went along with this scenario, but what I found equally curious was Joann's response when I asked her why she did it.  Joann shared that ever since she was about 10 years old, she had been masturbating to fantasies of anal rape.  They turned her on more than anything she knew.

In the beginning of their marriage, Joann was able to have sex without the fantasies; but as stresses with Tim increased, she found herself more and more drawn to them.  Often the fantasies would intrude during sex.  She felt controlled by them, filled with shame and disgust.

Joann's behavior had its roots in early abuse by her father.  He would spank her in a sexual manner or penetrate her anally with his finger as he masturbated himself.  The sexual fantasies Joann developed were not harmless or enhancing her sexuality.  They were upsetting and unwanted, symptoms of unresolved guilt and shame from the abuse she had experienced in childhood.  Her fantasies were reinforcing abuse dynamics, reenacting the trauma, punishing her unjustly, and expressing deep emotional pain at the betrayal and abandonment by her parents.

For survivors, using pornography and experiencing certain sexual fantasies are often part of the problem, not part of the solution.  Rather than condemn certain sexual behaviors, I encourage people to evaluate their sexual activities according to the following criteria:

• Does this behavior increase or decrease your self-esteem?

• Does it trigger abusive or compulsive sex?

• Does it emotionally or physically harm you or others?

• Does it get in the way of emotional intimacy?

Sex therapists can help people understand the origins of their negative sexual behaviors by showing compassion and not condemning.  Survivors benefit from learning ways to gain control over unwanted reactions and behaviors.² They can develop new ways of increasing arousal and enhancing sexual pleasure such as staying emotionally present during sex, focusing on body sensations, and creating healthy sexual fantasies.

Last updated: 8/05

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