Sex Therapy With Survivors of Sexual Abuse

I became a sex therapist in the mid-1970s because I was impressed with how well standard sex therapy techniques were able to help people overcome embarrassing problems such as difficulty having an orgasm, painful intercourse, premature ejaculation, and impotence. The use of sex education, self-awareness exercises, and a series of behavioral techniques could cure many of these problems within a matter of only several months. I noticed that as people learned more about the sexual workings of their bodies and gained confidence with their sexual expressions, they would also feel better about themselves in other areas of their lives.

But there were always a number of people in my practice who had difficulty with sex therapy and the specific techniques I gave them as "homework." They would procrastinate and avoid doing the exercises, would do them incorrectly, or, if they could manage some exercises, would report getting nothing out of them. Upon further exploration I discovered that those clients had one major factor in common: a history of childhood sexual abuse.

Besides how they reacted to standard techniques, I noticed other differences between my survivor and nonsurvivor clients. Many survivors seemed ambivalent or neutral about the sexual problems they were experiencing. Gone was the usual sense of frustration that could fuel a client's motivation to change. Survivors often entered counseling because of a partner's frustration with the sexual problems, and they seemed more disturbed by the consequences of sexual problems than by their existence. Margaret, an incest survivor, tearfully confided during her first session, "I'm afraid my husband will leave me if I don't become more interested in sex. Can you help me be the sexual partner he wants me to be?"

Many of the survivors I talked with had been to sex therapists before, with no success. They had histories of persistent problems that seemed immune to standard treatments. What was even more revealing was that survivors kept sharing with me a set of symptoms, in addition to sexual functioning problems, that challenged my skills as a sex therapist. These included --

Avoiding or being afraid of sex. Approaching sex as an obligation. Feeling intense negative emotions when touched, such as fear, guilt, or nausea. Having difficulty with arousal and feeling sensation. Feeling emotionally distant or not present during sex. Having disturbing and intrusive sexual thoughts and fantasies. Engaging in compulsive or inappropriate sexual behaviors. Having difficulty establishing or maintaining an intimate relationship. Considering their sexual histories, touch problems, and responses to counseling, I quickly realized that traditional sex therapy was horribly missing the mark for survivors. Standard treatments such as those described in the early works of William Masters, Virginia Johnson, Lonnie Barbach, Bernie Zilbergeld, and Helen Singer Kaplan often left survivors feeling discouraged, disempowered, and in some cases, retraumatized. Survivors approached sex therapy from an entirely different angle than other clients did. Thus they required an entirely different style and program of sex therapy. Over the course of the last 20 years, the practice of sex therapy has changed considerably. I believe many of these changes were the results of adjustments other sex therapists and I made to be more effective in treating sexual abuse survivors. To illustrate, I will show how sex therapists have challenged and changed six old tenets of traditional sex therapy through treating survivors.

Tenet 1: All Sexual Dysfunctions Are "Bad"

In general, traditional sex therapy viewed all sexual dysfunctions as bad; the goal of treatment being to cure them right away. Techniques were directed toward this goal, and therapeutic success was determined by it. But the sexual dysfunctions of some survivors were, in fact, both functional and important. Their sexual problems helped them avoid feelings and memories associated with past sexual abuse.

When Donna entered therapy for difficulty achieving orgasm, she seemed most concerned with the effect her problem was having on her marriage. She had read many articles and a few books on how to increase orgasmic potential but had never followed through with any suggested exercises. For several months, I worked unsuccessfully with her, trying to help her stick with a sexual enrichment program.

Then we decided to shift the focus of her treatment. I asked Donna about her childhood. She reported some information that hinted at the possibility of childhood sexual abuse. Donna said that during her upbringing her father was an alcoholic whose personality changed when he was drunk. She disliked it whenever he touched her, she pleaded with her mom for a dead-bolt lock on her bedroom door when she was 11 years old, and she had few memories of her childhood in general. After several sessions during which we discussed dynamics in her family of origin, Donna told me she had a very upsetting dream [that included a graphic description of sexual abuse by her father that the client felt was historically true].

No wonder Donna had been unable to climax. The physical experience of orgasm had been intimately associated with her past abuse. Her sexual dysfunction had been protecting her from the memory of her father's assault.

In numerous other cases, I encountered a similar process. Steve, a 25-year-old recovering alcoholic, had a chronic problem with premature ejaculation. As we explored his inner psychological experience in therapy, he was able to identify that when he allowed himself to delay ejaculation, he would start to feel an urge to rape his partner. Premature ejaculation was protecting him from this very upsetting feeling. It wasn't until he connected this urge to rape with his intense rage at his mother for sexually abusing him as a child that he was able to resolve the internal conflict and comfortably prolong gratification.

Impressing upon Donna or Steve the idea that their sexual dysfunctions were bad would have done them a disservice. Their dysfunctions were powerful coping techniques. I also encountered another type of situation that challenged the old tenet that sexual dysfunctions are bad. For some survivors who had experienced little difficulty with sexual functioning, the onset of sexual dysfunction signaled a new level of recovery from sexual abuse.

Tony was a 35-year-old single man who had been in and out of abusive relationships for years. His partners were often sexually demanding and generally critical. Tony's father had raped him repeatedly when he was young, and his mother had molested him in his teens. As Tony resolved issues related to his past abuse, his choice of partners improved. One day he told me that he had been unable to function sexually with his new girlfriend. This was extremely unusual for him.

"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, the 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.

Tenet 4: Use Standardized Techniques In a Fixed Sequence

Another tenet of traditional sex therapy was the importance of using a fixed series of behavioral techniques. Sex therapists relied heavily on "sensate focus" exercises that were developed by William Masters and Virginia Johnson. Versions of these techniques exist in the standard treatments for low sex desire, pre-orgasmia, premature ejaculation, and impotence. These structured step-by-step behavioral exercises were designed to improve self-awareness, sexual stimulation, and partner communication. Through working with survivors, however, we have learned that sex therapy techniques need to be expanded, modified, and individualized. Time must be spent teaching appropriate developmental skills and pacing therapy to prevent retraumatization.

One day in 1980, the bulb on my little projector broke and I could not show Fred and Lucy the tape on the first level of sensate focus exercises. Instead I gave them a handout and complete verbal instructions. They were to take turns lying down and massaging each other in the nude. The next week they came back and reported on how it went. Lucy said the exercise was all right, but Fred's belt buckle kept hurting her as she passed over it. Even though they had been given specific instructions to take their clothes off, Lucy, an incest survivor, said she never heard them. Instead, she adapted the technique to make it less threatening.

Standardized techniques performed in a fixed sequence generally don't work for survivors because these techniques fail to respect the important needs survivors have for creating safety, pacing experiences, and being in control of what's happening. Just being able to sit, breathe, feel relaxed, and stay present while touching one's own body can be a challenge.

Survivors need a lot of options for exercises that offer opportunities to heal without being overwhelmed. I rely on the techniques for relearning touch described in my book The Sexual Healing Journey. These techniques can easily be modified, adapted, and rearranged in different sequences by survivors themselves.

It is essential that sex therapists assess a client's readiness before suggesting a particular sex therapy exercise. I often find that a client's curiosity about an exercise is a good indicator of readiness to try it. Starting, stopping, and shifting among different techniques. Nudity, genital exploration and exchanging sexual touch with a partner are often advanced challenges, generally not appropriate to suggest in the early stages of therapy.

Sexual healing is generally an advanced type of healing work for survivors, less important than issues such as overcoming depression, improving self-esteem, resolving family-of-origin issues, and securing physical safety and health to name a few. Any sex therapy, therefore, needs to take a back seat to general recovery issues that might arise. Sex therapy needs to be integrated with other aspects of resolving sexual abuse.

Tenet 5: More Sex Is Better

In traditional sex therapy, the main criteria by which we judged success was how regularly and frequently clients were having sex. I used to ask lots of questions about frequency and evaluated success by how much a couple conformed to the national average of engaging in sexual activity once or twice a week. This focus on quantity often ignored issues of quality. Working with survivors taught me that with physical and sexual interaction, high quality is more important than large quantity.

Jeannie¹, a 35-year-old survivor of childhood molestation, and her boyfriend, Dan, sought therapy to address sexual intimacy problems. They planned to marry in the next year. It was concerning both of them that Jeannie would "check out" during sex. "I feel like I'm making love to a rag doll," Dan lamented. She agreed to sex to please him, fearing he would end the relationship if she declined too often.

For Jeannie, more sex brought on more problems of dissociation. The sexual contact she was having was getting in the way of her recovery from sexual abuse and her ability to create an honest intimacy with Dan. In therapy, as the reality of what was going on emerged, the couple decided to take a vacation from sex for awhile. Jeannie needed time and permission to validate her inner experience. The break from sex enabled her to honor her real feelings, learn new skills, and eventually be able to say yes to it without anxiety. Jeannie also learned that Dan loved her for herself, supported her getting in touch with her inner feelings, and viewed sexual interaction as less important than emotional intimacy and honesty.

When survivors progress in healing and start having sexual relations more regularly, it's not uncommon for the frequency of their sexual interactions to vary. To ensure positive sexual experiences, survivors often need to give themselves a safe, comforting envirornment and plenty of time for intimate relating. Sex emerges from mutual good feelings and a sense of emotional connection between partners. The high quality and specialness of sexual encounters become more significant than how often they occur.

Tenet 6: An Authoritative Behavioral Goal-Focused Style Works Best

In traditional sex therapy, the therapist's role was primarily to present a program of exercises and help clients follow that program to achieve functioning. Therapists offered sex education and worked to improve couples' communication. The therapist was the authority, suggesting techniques, pacing interventions, and monitoring progress. Little attention was paid to how a therapist's style might be influencing the progress of therapy. Working with survivors has taught many sex therapists that their therapeutic style is as important as any intervention.

For many survivors, sex is one of the most difficult areas to address in recovery Just hearing the word "sex," or saying it can bring on a minor panic attack. Survivors can easily unconsciously project feelings toward the offender and the abuse onto the therapist and the sexual counseling. After all, therapists seem invested in survivors being sexual, and the process of therapy strains a survivor's sense of control and protection. This high potential for negative transference needs to be addressed if sex therapy with survivors is to be successful.

To minimize negative transference, I suggest therapists adopt the following premise: Do the opposite of what happened in the abuse. For instance, because the victim was dominated and disempowered in abuse, it makes sense that therapy should focus on empowering the client and respecting his or her reactions to it. Therapists need to explain techniques and interventions, encouraging clients to exercise choice at all times. Suggestions, not directions or prescriptions, should be given. Rather than admonish clients for their resistances and relapses, therapists should reframe these as inevitable, seek to understand, and work with them.

Because sexual abuse involved a traumatic violation of boundaries, it's important that sex therapists be extremely good at maintaining clear emotional and physical boundaries. Talking about sex can stir up sexual feelings. It's inappropriate to combine sex-focused sessions with touch.

Several years ago, I was appalled when a prominent sex therapist told me how she held and rubbed her female client's hand during a session to demonstrate different stroking techniques for masturbation. Therapy needs to be a safe place physically and psychologically for everyone, at all times.

It's also important for sex therapists not to dominate the content and course of therapy. Personally, I find I'm most effective when I establish a therapeutic relationship with the client in which we're working together. The client sets the pace and direction and presents the content; I provide encouragement, support, guidance, creative ideas, insight, information and resources.

The Value of Change

There is no question that the challenge of treating survivors of sexual abuse has revolutionized and improved the practice of sex therapy Personally, I know that the changes I have made in how I perceive and practice sex therapy have made me a better therapist with all of my clients, regardless of whether they were abused. Other sex therapists seem to agree that the practice of sex therapy has become more client-centered and respectful of individual needs and differences. Learning about the dynamics of sexual trauma has helped therapists become more aware of the conditions necessary for sex to be positive and life-affirming for everyone.

Endnotes

¹ This is a pseudonym, as are all names in this article.

² For more information on techniques, see The Sexual Healing Journey, HarperCollins, 1991.

³ For a description of these techniques, see William Masters et al., Masters and Johnson on Sex and Human Loving, Little Brown and Co., 1986.

Wendy Maltz, M.S.W., is clinical director of Maltz Counseling Associates. She is the author of the Sexual Healing Journey: A Guide for Survivors of Sexual Abuse and Caution: Treating Sexual Abuse Can Be Hazardous to Your Love Life.