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Topics in Human Sexuality: Sexuality and Childhood Sexual Abuse

Case Vignette

Maria is a happily married 27-year-old woman. She and her husband, Jeff, share many common interests and values. They would like to begin their family, however, this presents a problem. Maria is a survivor of childhood incest. Her grandfather, who is now deceased, was the person responsible. Although Maria would like to be sexual with Jeff and tries to do so, he is acutely aware of her discomfort during lovemaking. He has stopped trying to initiate sexual intimacy because he feels like “a perpetrator.” Maria is upset and unhappy about the situation.

Child sexual abuse is the involvement of children or adolescents in sexual activities that they do not fully understand and can include exhibitionism, fondling, oral- genital contact, and rectal or vaginal penetration. Most mental health professionals are acutely aware of the profound effects of child sexual abuse. Childhood sexual abuse and incest have become increasing areas of concern for clinicians. This is in part due to the prevalence rates of abuse: By adulthood, 26% of girls and 5% of boys experience sexual abuse (Melmer & Gutovitz, 2017). Females between the ages of 12 to 24 have been shown to be the demographic at highest risk of becoming victims of sexual assault and rape. Greater than 50% of the rapes targeting women happen during childhood, and between 5% and 25% of adults report being victims of child sexual abuse. Fewer than half of all sexual assaults are ever reported to the police (Melmer & Gutovitz, 2017). It is believed that many statistics on child sexual abuse and neglect vastly underestimate its incidence. This is particularly true for men, who often remain silent about their abuse.

Childhood sexual abuse presents many therapeutic challenges. Childhood sexual abuse is a betrayal of intimacy. As such, relational problems of many types may result from past abuse. One of the primary areas in which this is seen are within sexual relationships. Childhood sexual abuse often prevents survivors from achieving satisfying sexual relationships.

Understanding the impact of childhood sexual abuse and its effects on sexuality will help mental health professionals to better counsel individuals and couples.

Objectives:

• Define sexual abuse ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

• Discuss the non-sexual effects of abuse • Describe myths of male victimization • Discuss effects of trauma and sexual abuse connected to adult sexuality • Describe techniques that can be used in counseling abuse survivors • Define counseling techniques including use of sexual genograms/sensate focus

Definition of Childhood Sexual Abuse, Incest and Teen Dating Violence

Case Vignette

Karen is a 35-year-old woman who reports a long history of childhood sexual abuse, first by her grandfather beginning at age 6, and later with a series of abusive boyfriends and men. Most recently she has been involved with Rick, who she describes as sexually adventurous. He often demands that she try sexual acts that she does not wish to undertake, such as anal sex. Karen is seeking to leave this relationship, but feels hopeless that any relationship can be loving or truly consensual.

The American Medical Association defines child sexual abuse as "the engagement of a child in sexual activities for which the child is developmentally unprepared and cannot give informed consent” (American Medical Association, 1992). The most significant feature of child sexual abuse is that the dominant position of an adult allows him or her to coerce the child into sexual activity (American Psychological Association, 2001). Child sexual abuse may include fondling a child's genitals, masturbation, oral-genital contact, digital penetration, or vaginal and anal intercourse. Child sexual abuse is not solely restricted to physical contact; such abuse could include noncontact abuse, such as making a child watch pornography or look at an adult’s genitals. Sexual abuse may also include abuse by a child’s peer, especially when there is a significant incongruity in age, development, or size.

Although all forms of sexual abuse are damaging, incest, sexual abuse perpetrated by a family member is particularly destructive and painful. Incest is defined as any sexual activity between close blood relatives who are forbidden by law to marry (Kellog, 2005). Among the various types of incest, father-daughter incest is the most common, followed by the other types like brother-sister, sister-sister, and mother- son incest (Soron, 2016). Incest is frequently underreported, due to the stigma surrounding it. The results of incest and other forms of sexual abuse may not be evident until the survivor reaches adulthood and seeks his or her own relationships Herrenkohl et al., 2013, Kim-Cohen et al., 2006).

Teen dating violence, another common experience included within the realm of childhood sexual abuse, is defined as abuse, harassment, or stalking of an adolescent between 12 years and 18 years of age in the context of a past or present romantic or consensual relationship (Mulford & Blachman-Demner, 2013). Studies demonstrate ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

3 that approximately one in five female adolescents suffer physical and/or sexual violence by her partner during a dating relationship (Rizzo et al., 2010).

Risk Factors for Child Sexual Abuse

Many factors increase the risk of child abuse, including individual, family, environmental, and social factors. Children that have a physical disability, mental disability, or other behavioral disorders are also at higher risk for abuse, especially if the family lacks the socio-economic resources to assist them.

The following factors may increase the risk of abuse:

• Abused as children • Attachment problems • Chronic behavior problems • Divorce • Frequent moving • Hostile environment • Isolation from friends and family • Low self-esteem • Medical problems • Mental or physical disability • Mental health problems • Nonbiological relationships • Poor social network • Poverty • Prematurity • Punitive child-rearing styles • Substance abuse • Unemployment • Unrealistic expectations • Young parents

Situational Triggers: • Acute environmental problems • Argument • Substance abuse • Perceived need for discipline/punishment

Effects of Trauma and Sexual Abuse

Case Vignette

Kathy, a 29-year-old sexual abuse survivor has been in an out of treatment for a severe eating disorder since childhood. The bulimia began as a teen and after disclosing that ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

4 her older brother had molested her. Kathy’s psychological problems have prevented her from holding down a consistent job, and her social network is quite limited as she is often seen as “draining” and “needy” in relationships. Her sexual relationships mirror her problems with food — she is restrictive and not interested in sexual relationships sometimes, and has other times when she is promiscuous, “binging” on sex.

Childhood sexual abuse is damaging. The effects of sexual abuse include those related to emotional/psychological health and physical health. A brief discussion of these effects is included because it is important to see the survivor holistically and not to focus only on relational and sexual problems. Although many of the things described below are not immediately related to adult sexuality they have less direct effects.

Sexual abuse impacts the survivor’s sense of safety and well being. As a result, those who have been sexually victimized are more likely to develop psychological problems. The most common of these are disorders along the depressive spectrum, including major depressive disorder and dysthymia (Molnar, Buka & Kessler, 2001; Williams et al., 2015), suicidality (Chatzittofis, et. al, 2017), intimate partner violence (Williams et al., 2015), Post Traumatic Stress Disorder (PTSD) (Afifi et. al, 2008) and anxiety disorders (Levitan, et al., 2003). Memories of childhood sexual abuse can be highly distressing to the patients and are associated with a broad spectrum of aversive emotions that include anxiety, helplessness, anger, and sadness (Kleim, Graham, Bryant, & Ehlers, 2013).

Victims of child sexual abuse are also at higher risk for developing addictive behaviors including substance abuse problems (Day, Thurlow, & Woolliscroft, 2003; Clum et al., 2012)) such as tobacco, alcohol, and illicit drugs (Melmer & Gutovitz, 2017) and eating disorders (Kimber et al., 2017; Afifi et al., 2017). There are many reasons for this. Substance abuse combined with eating disorder symptoms results in emotional numbing and may be a way to modulate emotions or to decrease painful feelings. People who develop eating disorders often describe similar functions of the disorder. Survivors are often uncomfortable with their bodies and do not want others to see them. This certainly impacts their abilities to be sexual with partners and those with eating disorders may eschew sexual experiences due to these body image concerns (Potki et al., 2017).

Cook et al. (2016) describe what they term avoidant coping behaviors as common sequalae of sexual abuse. Avoidant behaviors include dissociation, binge–purge eating, substance use, self-mutilation, suicide attempt, and risky sexual behavior. The researchers state that although tension-reducing behaviors such as sexual activity and substance use can have immediate stress-diminishing benefits, risky sexual practices with multiple partners and inconsistent condom use can have negative long-term effects such as increased risk of sexually transmitted infections.

Researchers have established that there are elevated rates of childhood sexual abuse in borderline personality disorder patients (Menon et al., 2016) and such research ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

5 suggests a role of childhood trauma in the form of sexual abuse in developing borderline symptoms in adulthood. In the Menon et al. (2016) study, 44.44% of the patients had some form of sexual abuse in their childhood and the connections between child sexual abuse in earlier years of life was specifically associated with borderline personality disorder compared to child sexual abuse in later years. Merza et al. (2017) also found an association between childhood adversity, including sexual abuse, and non-suicidal self-injury, common in individuals with borderline personality disorder.

Some abuse survivors also exhibit somatic concerns such as migraine headaches, other aches and pains, asthma, and gastrointestinal upsets. Some gastrointestinal and respiratory problems may symbolically relate to the abuse, such as nausea being related to forced oral sex. Other physical symptoms include tension, heart palpitations, trembling, poor sleep, sweating and loss of appetite. Fibromyalgia and Chron’s disease are also found more frequently in trauma survivors (Miller, 2005). When physical problems occur, survivors are less likely to show interest in sexual intimacy. It is difficult to want to be sexual, for example, when a person is experiencing a flare up of Chron’s disease.

In addition to the research cited above, another major source of data is the Behavioral Risk Factor Surveillance System survey, which looks at adverse childhood experiences (ACEs) among a large sampling of US adults. The data were analyzed on 48,526 U.S. adults from five states. Exposures included psychological, physical, and sexual forms of abuse as well as household dysfunction such as substance abuse, mental illness, violence, and incarceration. Main outcome measures included risky behaviors and morbidity measures, including binge drinking, heavy drinking, current smoking, high-risk HIV behavior, obesity, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability due to poor health, and use of special equipment due to disability (Campbell, Walker& Egede, 2016).

Male Survivors

Case Vignette

Curt, a 22-year-old man who is currently involved in a drug and alcohol treatment program, recently disclosed a history of sexual abuse, occurring between himself at age 10, and a female babysitter who was 16. While he initially insists that the “relationship” was consensual and not damaging in any way, since becoming substance-free Curt has begun to better understand the far-reaching effects of the abuse, and how it as impacted his current relationships. In particular, Curt has a history of seeking sexual encounters with women much older than him, and who are generally unavailable. This has not proven to be successful, and he feels that he cannot have a “normal” (i.e., age-appropriate) relationship.

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National Crime Victimization Survey reports that 9% of men have experienced sexual assault. This study suggests that men encounter assault by women and men relatively equally: about 43% of sexual assaults against men were perpetrated by women, and 51% by men (Weiss, 2010).

Although many of the issues described in the section above are pertinent to male and female survivors of sexual abuse, there are some special issues to consider when working with male survivors.

While male survivors of sexual abuse do not receive the same degree of attention as female survivors it is important to note the detrimental effects of sexual abuse on men. Williams et al. (2016) posits that male sexual abuse victims are often almost invisible. Johanek (as cited in Renken, 2000) describes three myths of male victimization:

1. “Real men” would fight or resist the abuse 2. Sexual response to abusive behaviors “shouldn’t happen.” 3. Offenders are homosexual and forever “taint” the victim.

Males, especially those that abused by other men, tend to struggle with issues of homophobia and vulnerability and to engage in sexually risky/acting out behaviors. They may direct feelings of anger about the abuse outwardly or engage in sexual acting-out behaviors. While female perpetrators are often viewed as less detrimental than male perpetrators this is a myth. Sexual abuse of men by women, is equally damaging.

Effects of Trauma and Sexual Abuse Connected to Adult Sexuality

Case Vignette

Joe is a married father of two. He describes a history of sexual molestation by a male clergyman when he was 9. Joe is vocal in his homophobia and expression of hatred for gays and lesbians. It came as a shock to everyone when Joe was arrested for soliciting an uncover officer posing as a male prostitute. Joe is ashamed of his behavior and fearful that he will continue to act out in this compulsive way.

Marianne is a newly married women in her mid-twenties who has a history of sexual abuse (coercive fondling) by an older male cousin. While she has tried to put this behind her, she is struggling. Marianne describes herself as “asexual,” and while she knows that her lack of interest in sex is hurtful to her husband, she feels that she cannot change this. When pressed, she states that she feels “dirty” when she engages in sexual intimacy with him, and she has secretly begun purging to allow herself to tolerate sexual relations. In exploring her sexual self-concept, Marianne’s descriptors further include: cold, negative, and disgusting. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

It is no surprise that childhood sexual abuse has an impact on adult sexuality. Just as survivors of childhood sexual abuse exhibit many different types of concerns that relate to the abuse, there is no single presentation with regard to adult sexuality.

In looking at the proceeding discussion, an interesting lens through which to look at sexuality in adult survivors is the idea of sexual self-concept, the core of sexuality (Potki et al., 2017; Deutsch, Hoffman &, Wilcox, 2014). Mental and emotional aspects of sexual wellbeing are the important aspects of sexual health. Sexual self-concept is defined as the cognitive perspective concerning the sexual aspects of ‘self’ and refers to the individual’s self-perception as a sexual being. Sexual self-concept is multi- dimensional and dynamic, and is developed based on the individual’s understanding of his/her personal sexuality (Deutsch, Hoffman &, Wilcox, 2014). Sexual self- concept originates from past experiences to present sexual experiences.

The development of sexual self-concept is influenced by multiple events in individuals’ lives including biological, psychological and social factors. In the psychological category, the impact of body image, sexual abuse in childhood and mental health history are present. Individuals with a history of childhood sexual abuse, may have a more negative sexual self-concept (including sexual anxiety, monitoring sexuality, the fear of sexual relationships and sexual depression). This is in contrast with positive aspects of sexual self-concept, including sexual self-efficacy, sexual consciousness, sexual optimism, motivation to avoid high-risk sexual relationships, self-blame in case of sexual problems, management of sexual affairs, sexual self-esteem, sexual satisfaction, prevention of sexual problems, use of contraception, avoidance of high-risk sexual behavior and internal control of sexual problems (Potki et al., 2017). Survivors of childhood sexual abuse may develop maladaptive beliefs and attitudes towards sexuality, which cause survivors to process sex-related information through a threatening lens (Lorenz & Meston, 2012).

Meston, Rellini & Heiman (2006) looked at female survivors of child sexual abuse using measures of adult sexual function, psychological function (i.e., depression and anxiety), and sexual self-schemas. The primary purpose of the study was to examine whether differences existed between women with and without a history of sexual abuse in the way that they viewed themselves as a sexual person and, if so, whether such differences mediated the link between early unwanted sexual experiences and later adult sexuality. Survivors were found to view themselves as less romantic and passionate than women who were not abused. In particular, survivors showed an inverse relationship between romantic/passionate sexual self-schemas and negative sexual affect during sexual arousal. The relationship between abuse and negative sexual affect was independent from symptoms of depression and anxiety, suggesting that the impact of sexual abuse on sexual self-schemas may be independent from the impact that the abuse may have in other areas of the survivor's life.

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In looking more broadly at some more of the specific effects of sexual abuse on sexuality in the adult survivor, the effects of sexual abuse on adult sexuality fall into one of the following categories:

• Difficulty establishing intimate relationships • Avoidance behaviors • Intense emotional reactions or numbing • Physical problems related to sexuality • Body image disturbance that impacts sexuality • Intrusive thoughts or fantasies • Sexually risky behaviors • Hypersexual behaviors

Establishing Intimacy

In addition to problems with sexual intimacy, survivors of sexual abuse also experience difficulties in close relationships. Bass & Davis (2015) define intimacy as a “bonding between two people based on trust, respect, love, and the ability to share deeply.” It is no question that sexual abuse damages a person’s ability to trust others. Many see trust as an all-or-nothing experience, rather than being able to develop trust in another person. In relationships, trauma survivors may be hypervigilant to any sign that the person is not trustworthy. Child sexual abuse can result in insecure or disoriented/disorganized attachment patterns (Menon et al., 2016). Although some of these factors can be partially protective, especially hypervigilance, it also impedes the ability to establish a relationship, especially one that will be sexual (Gardner, McCutcheon, & Fedoruk, 2017; Martinson et. al, 2013). . Another common impediment to establishing intimacy is confusing the past with the present (Nasim & Nadam, 2013). Although a partner may loosely share some characteristics with an abuser - which does that mean that he or she is abusive. A survivor may react by distancing, or by merging — creating a state of dependency. Neither of these extremes is solid ground for an intimate or a sexual relationship.

An interesting take on intimacy can be found in a study by Lorenz and Meston (2012). These researchers sought to better understand the link between childhood sexual abuse and adult sexual functioning and satisfaction by examining the cognitive differences between women with and without sexual abuse histories. They used the Linguistic Inquiry Word Count, a computerized text analysis program, to investigate language differences between women with and without abuse histories when writing about their daily life (neutral essay) and their beliefs about sexuality and their sexual experiences (sexual essay). In comparing these groups, the researchers found that women who reported sexual abuse used more intimacy words and more language consistent with psychological distancing in the sexual essay than did non abused women.

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Additionally, survivors of childhood sexual abuse report significantly lower satisfaction with their sexuality (Rellini & Meston, 2007), which in turn is associated with lower marital or relationship satisfaction (DiLillo, Peugh, Walsh, Panuzio, Trask, & Evans, 2009) and higher rates of divorce (Nelson, et al., 2002).

Avoidance Behaviors

Sexual abuse survivors may also go to lengths to avoid sexual expression and intimacy. This may manifest in lack of sexual interest or inhibited sexual desire. Maltz (2001) identifies this as the most common sexual problem in this population. Sometimes sexual avoidance behaviors are hidden by other, more overt behaviors, such as an abuse survivor who self-injures or overeats with the intention of making herself unattractive to a potential partner (Merza et al., 2017). This may be due to fears about sexual intimacy which developed in childhood. There may also be strong negative reactions when touched. Some abuse survivors approach sex only as an obligation.

Vaillancourt-Morel et al. (2015) looked at avoidant and compulsive sexual behaviors in male and female survivors of childhood sexual abuse. They studied 686 adults currently in a close relationship. Prevalence of childhood sexual abuse was 20% in women and 19% in men. The researchers found that childhood sexual abuse was associated with more sexual avoidance and sexual compulsivity, which, in turn, predicted lower couple adjustment.

Intense Emotional Reactions Or Numbing

Another common sexual problem for abuse survivors is the intensity of emotional reactions when engaging in sexual behaviors (Rellini et al., 2012). Survivors often report negative reactions, such as fear, guilt, anger or disgust. These feelings are generally rooted in the past rather than the present and are one of the most challenging things for couples to work on. Other abuse survivors describe a sense of emotional numbing, such as in the first vignette presented in this material, or a feeling of being dissociated or distant during sexual activities. Another difficult experience is that of having a flashback during sexual experiences.

Physical Problems Related To Sexuality

With the close connection between mind and body, it makes sense that those with a history of abuse may experience physical problems related to sexuality. Adult abuse survivors often report difficulties with sexual arousal (in women, lack of lubrication, in men, inability to develop or maintain an erection), difficulty with intercourse (muscle pain, spasm, fear of penetration, vaginismus), difficulty experiencing orgasm (anorgasmia), or difficulty averting orgasm (premature ejaculation in men, rapid orgasm in women). Some of these problems, such as lack of ability to achieve orgasm, may be related to messages that trauma survivors received from their ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

10 abusers, such as that they are somehow sexually inadequate (Reissing, et al., 2003). Women with histories of childhood sexual abuse also reported lower sexual desire, inhibited sexual arousal and orgasm, and higher sexual pain than women without such histories in both clinical and community samples (Najman et al., 2005).

Body Image

Body image is the attitude and perception one’s own body. Body image includes many components: thoughts and beliefs one holds, understanding of how others view us, feelings about the body, kinesthetic awareness and responsiveness. While these components may be related to physical appearance, this relationship may be indirect, especially for a person that has been through sexual abuse. For all of us the goal of body image treatment is finding a place of acceptance and ownership of the body. Childhood sexual abuse robs the person of that ability and negatively affects body image (Castellini et al., 2016; Kravvariti & Gonidakis, 2016).

Ackard, Kearney-Cooke & Peterson (2000) studied the connection between body image and sexuality. The reseachers found that women more satisfied with body image reported more sexual activity, orgasm, and initiating sex, greater comfort undressing in front of their partner, having sex with the lights on, trying new sexual behaviors, and pleasing their partner sexually than those dissatisfied. Women with better body image reported less self-consciousness, less focus on physical attractiveness, and more positive relationships with others and overall satisfaction. Body image was also predictive only of one's comfort undressing in front of partner and having sex with lights on. Other things associated with healthier body image was frequency of sex and orgasm, initiating sex, trying new sexual behaviors, and confidence in giving partner sexual pleasure.

Thus the study described above shows that a person’s evaluation of body image can affect interests and experiences of the person during sexual activities (Potki et al., 2017). Dissatisfaction with body image hinders sexual behavior and interferes in the quality of sexual experiences and sexual performance is related to better sexual self- concept and less anxiety and worries about body image (Cash, Maikkula & Yamamiya, 2004). Thus there is a relationship between body image and sexual self- concept.

Dyer, Feldmann & Borgmann (2015) conducted a study to assess the association between traumatic experiences and emotions such as anxiety, shame, guilt, disgust, and anger. For patients who have experienced child sexual abuse, these emotions might be triggered by perceptions of their own body. Results suggested that specific areas of the body are associated with trauma and linked to highly aversive emotions. In post-traumatic stress disorder patients, the areas associated with highly negative emotions were the pubic region and inner thighs. Thus, the patient's body may act as a trigger for traumatic memories. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Intrusive Thoughts Or Fantasies

Post-traumatic stress disorder (PTSD) is characterized by symptoms that include intrusive or distressing thoughts, nightmares, and flashbacks derived from past exposure to traumatic events. While not every sexual abuse survivor has PTSD, many describe intrusive thoughts or fantasies about sex, such as fantasies or the reality of sexual pleasure being linked to pain. They may also fantasize about being in power or control during sex or other types of aggressive sexual behavior. Intrusive thoughts and fantasies are defenses, and require delicacy on the part of the counselor.

Sexually intrusive thoughts create somewhat of a diagnostic conundrum as they are a component of obsessive compulsive disorder (OCD) with sexual obsessions affecting 13% to 21% of individuals with OCD at any given time (Pinto et al., 2008). While not every person with obsessive compulsive disorder has OCD, studies have demonstrated some connection. For example, Caspi et al. (2008) found that in a small scale sample of patient with OCD, 53.3% had a history of childhood sexual abuse. It is important during treatment to differentiate between sexual obsessions and other unacceptable thoughts, as well as other thematic variations may help guide cognitive-behavior therapy. It may also clarify important potential treatment targets, such as when conducting exposure and response prevention or cognitive therapy. Furthermore, treatment outcome requires careful consideration of each patient's particular core fears, this is especially true of abuse survivors (Wetterneck et al., 2015).

Kuyken and Brewin (2014) looked at a sample of adult women with major depression who reported childhood sexual or physical abuse. The women completed a measure of the extent to which they were experiencing intrusive memories of the abuse and their efforts to avoid these memories. The majority of women in the sample reported high levels of disturbing intrusive memories, and high levels of avoidance. Those abused women with particularly high levels of intrusions and more avoidance were also more severely depressed than both non- abused women and abused women with low levels of intrusions and avoidance. Higher levels of intrusions and avoidance were also associated with repeated childhood abuse, sexual abuse involving intercourse and sexual abuse involving a primary caregiver.

Sexually Risky Behaviors

Some survivors of sexual abuse report risky or inappropriate sexual behaviors and research has confirmed that this is one factor in influencing sexual high-risk behaviors (Arabi-Mianrood et al., 2017). This may include sexual compulsivity, promiscuity, or acting-out behaviors. These indiscriminate sexual behaviors may actually be accompanied by a lack of physical pleasure. Another sequalae of sexual abuse may be sexual behaviors such as exotic dancing or prostitution. This is often ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

12 seen in situations in which a child was rewarded for sexual favors, and gained esteem and power through these rewards.

Many survivors have difficulty setting boundaries, especially those of a sexual nature, and may be unable to “say no” to sex, even when they do not desire it. Boundary-setting and communication are key targets of counseling.

In one study of men who have sex with men (Williams et al., 2015), researchers found that experiences of childhood sexual abuse were associated with sexual revictimization. They also reported negative sexual health outcomes, with men who have sex with men reporting higher childhood sexual abuse rates than the general male population. They were more likely than men without childhood sexual to engage in high-risk sexual behaviors, have more lifetime sexual partners, use condoms less frequently, have higher rates of sexually transmitted infections (including HIV) and to exchange sex for drugs or money. Researchers looking at straight men with a sexual abuse history have found similar evidence of sexually risky behaviors including higher rates of sexually transmitted infections including HIV (Greenberg, 2001), sex that results in pregnancy (Purcell, et al., 2004) and a higher number of sexual partners (Schraufnagel et al., 2010). Abused men are more likely to engage in condomless sex, to have earlier sexual debut and to exchange sex for drugs or money than men with no childhood sexual abuse history (Chandry et al., 2014).

Other studies (e.g., Pérez-Fuentes et al., 2013) have found a correlation between depression and sexual risk behaviors. Cook et al. (2016) also found evidence that there is a connection between sexually risky behaviors in a group of men who were forced to have sex by women. In this study the mean age of the abuse was 18.

Clum et al. (2009) looked at young women living with HIV who experienced physical and/or sexual abuse in childhood. They using the Life Story Interview with women recruited from HIV clinics. Interviews covered abuse experiences, cognitive and emotional consequences of abuse, coping strategies, and sexual behavior and relationships. Overall, these young women had complex abuse histories, often experiencing more than one type of abuse in the context of other difficult life events. Avoidance and substance use were frequently utilized as coping strategies for abuse- related distress. Young women reported sexual and relationship concerns, including avoidance of sex, sexual dysfunction, sex as a trigger for abuse memories, and difficulty establishing intimacy and trust.

Hypersexual Behaviors

Closely related to the problem of sexually risky behaviors is the connection between childhood sexual abuse and hypersexual behaviors (Chatzittofis et al., 2017; Montgomery-Graham, 2017). Hypersexual Disorder is conceptualized as primarily a nonparaphilic sexual desire disorder with an impulsivity component (Kafka, 2010). Such excesses of sexual behavior (i.e., hypersexual behaviors and disorders) can be ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

13 accompanied by both clinically significant personal distress and social and medical morbidity.

Estimates of the prevalence of compulsive sexual behaviors range from about 1.7% and 4.4% of individuals and include both men and women (Grant et al., 2005). Evaluating the prevalence of hypersexual behaviors is difficult, due to the embarrassment and shame frequently reported by those with sexual compulsivity. Compulsive sexual behavior can be divided into three elements: repeated sexual fantasies, repeated sexual urges and repeated sexual behaviors (Derbyshire, & Grant, 2015). All of these elements can be related to childhood trauma. People who engage in compulsive sexual behaviors report varying responses, including tension release, numbing, and the behaviors are often followed by guilt and remorse. Behaviors can be triggered by specific mood states depression, loneliness and may be comorbid with other addictive behaviors.

As with other forms of sexual risk taking, the effects of compulsive sexual behaviors can be troubling and can interfere with many different areas of an individual’s life. Due to these sexual behaviors, individuals with sexual compulsivity may experience medical problems including unwanted pregnancies, sexually transmitted infections, HIV/AIDS, and physical injuries due to repetitive sexual activities (for example, anal and vaginal trauma) (Miner & Coleman, 2015).

Other sexual problems may include:

• Low sexual desire • Tendency to dissociate from the body during sex • Compulsive masturbation • Sexualizing relationships and situations • Believing that sex is dirty or disgusting • Refraining from any sexual contact • Erection and orgasm problems • Confusion about sexual orientation • Lack of sexual knowledge

Sexuality Counseling

Counseling for couples in which one member has a history of abuse is challenging and requires specialized knowledge and skills. Long, Burnett, & Thomas (2006) describe a stage model that they term integrative couples counseling. They include the following interventions in their approach:

• Detailed history of sexual abuse experiences ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

• Reasons for seeking counseling • Use of sexual genograms • Exploration of feelings about abuse • Communication about sexual needs and desires • Exploration of guilt and shame issues • Journaling feelings about sexuality • Sensory exercises that include non-sexual touch • Initiation of sex/ability to decline sex • Relaxation techniques for anxiety • Direct feedback about likes and dislikes • Physical exercise as a way to increase control • Sensate focus activities and masturbation training

Sexual History and Genogram

An important part of sexuality counseling involves taking a thorough sexual history. Abuse experiences are one component of this history, and while this is important, past traumatic events are only one of the factors that counselors should consider. A thorough sexual history can be conducted as part of an interview or as a pictorial representation (sexual genograms). The sexual genogram combines aspects of the sex history with the genogram to examine the impact of the partners' family loyalties, secrets (such as sexual abuse), and scripts on their sexual functioning. The exploration process offers an opportunity to identify patterns and to target areas of needed change (Belous et al., 2012; McGoldrick, 2016).

Some of the areas to consider in a sexual questionnaire or to include in a sexual genograms are:

• Overt and covert messages regarding sexuality and intimacy • First memory of sex • Hopes/fears about sex • Sexual expectations • Extent of sexual openness now and in family of origin • Religious and spiritual influences, cultural influences on sexuality • Family secrets, including incest and abuse, unwanted pregnancies, extramarital affairs, sexual addiction, compulsive behaviors other safety issues • History with erotic material including pornography • Issues connected to sexual orientation/attraction, gender identity, non- conformance • Masturbation history • Body image history/feelings about ones body (self and close relatives, especially parents • Personal factors that affected development of selves as sexual beings • Previous sexual partners ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Journaling

For many survivors of childhood sexual abuse, journaling can be an important part of sexual healing. Many of the questions in the section above can also be used as prompts for journaling. There are also a number of commercially available resources, such as Your Surviving Spirit (Miller, 2003) and Courage to Heal Workbook (Davis, 1990).

Sensate Focus

Sensate focus exercises were originally introduced by Masters and Johnson. The goal is to increase awareness of each other's needs. One of the key components of this approach is the lack of outcome orientation — the goal is to become aware of responses and feelings rather than to reach orgasm.

The first stage of sensate focus involves non-genital touch. In this stage the couple is encouraged to touch each other’s bodies and to be aware of feelings and sensations. Should the survivor become scared, overwhelmed or dissociative, the experience is terminated. Couples are told that no intercourse is allowed, and that it is a way to gain appreciation of one another. Touching, talking, and hugging are encouraged. Use of techniques such as relaxation and breathing techniques and grounding are important to counteract anxiety.

The next stage of sensate focus increases focus on touch. Genital touch is still not allowed. Couples are taught during this stage to put their hand over the other’s hand to demonstrate what is pleasurable and what is not. The experience can be stopped at any time if the survivor needs to do so.

Touch is gradually increased at the pace the couple needs and to include genital contact and finally intercourse.

Summary

Sexual abuse has lingering effects on adult behavior, relationships and sexuality. Helping abuse survivors to recognize these effects and providing a caring supportive environment in which the individual and couple can heal is key to recovery.

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