Sexual Behavior and Therapy After Childhood Sexual Trauma

Central JSM Sexual Medicine Review Article *Corresponding author Mark Schwartz, Harmony Place Monterey, USA, Fax: 831-373-3821; Email: [email protected] Sexual Behavior and Therapy after Submitted: 23 July 2020 Accepted: 15 September 2020 Published: 17 September 2020 Childhood Sexual Trauma ISSN: 2578-3718 Copyright Mark Schwartz* © 2020 Schwartz M Harmony Place Monterey, USA OPEN ACCESS Abstract Keywords Treatment of sexual desire and arousal difficulties after a childhood history of sexual trauma is • Sexual behaviour complex. Adding to this complexity is the lack of a comprehensive description of proven treatment • Sexual trauma components. This article summarizes components of successful treatment based on concepts and • Childhood protocols formed across 40 years of clinical experience, as well as a review of existing clinical research. INTRODUCTION rape are more likely to be raped again. Victims of child sexual abuse are at greater risk of becoming prostitutes [8], or posing The landscape for therapists treating sexual disorders is quite for pornography. different now than just a few decades ago and remains poorly mapped. Oversights occurred on both ends of the sexual desire In our clinical experience, victimized children often re-enact spectrum resulted in little being known about both hyposexuality behaviors and will sometimes touch other children sexually and and hypersexuality post-trauma. From the sex therapist’s have recurring body memories on a somatic level. Adult clients perspective, Masters and Johnson [1], failed to recognize the vast use pornography or create imagery during sex of violent acts to numbers of clients with inhibited sexual desire [2]. At the other become aroused or orgasmic, which often feels confusing and end, Kaplan [3], said, “In my experience, excessive sexual desire revictimizing. They create traumatic bonds and recreate violent is so rare as to constitute a clinical curiosity when it’s a primary interchanges in and out of the bedroom, replaying the trauma in symptom.” A majority of texts on trauma and PTSD have shown a disguised form. In an unconscious masochistic way, fear and pain near total absence of chapters on treating sexual disorders (with seem to be intertwined with pleasure. notable exceptions [Courtois, 2005]) [4], despite the fact that the sexuality of most people is almost certainly affected by incest, THE TRAUMA - SEXUALITY CONNECTION rape, or stigmatized sexual encounters. Two comprehensive The roots of such sadomasochistic images and behavior lie in reviews on the sexual sequelae of child sexual abuse on desire internal working models of disorganized attachment (discussed and arousal in women document a risk for adult sexual desire in text), where affection and terror become wired together. As are unaware of the clinical wisdom related to dissociative features This wiring may also be biochemical; the dysregulation of the difficulties [5]. Even within the subspecialty of sex therapy, many of sexual behavior. Chefetz [6], most articulately supports the cortisolDan Siegel system states is [9],the hallmark“Neurons of that PTSD fire [10], together and sexual wire together!” arousal is relevance of dissociative theory: “The absence of a clear and coherent sense of being present accompanied by significant cortisol changes. Women who show in a body and experiencing the sensations associated with decrease, report lower sexual satisfaction [11]. The result might sexual activity, including the sensual ones, is an indication of the bean increasethat passionate in cortisol arousal to an in erotic sex depends film, rather on violencethan the evenexpected at a dissociative isolation of somatic experience from awareness. The biochemical level. human need to hold and be held is missing in action when there is isolation of somatic experience from awareness. Or, as one of the dissociative barriers related to isolation, disconnection and his patients is quoted, ‘I am a million miles away, but he never The first stage in recovering sexual function requires breaking notices.’” to gain safety can be reclaimed and embodied. Chefetz again affect suppression so that the part of self that was sacrificed adequately document the most common manifestations of rape traumaEven during the best sexual somatic-based interactions. texts The related other to trauma under-discussed [7], do not elegantly reflects this, isolation of elements of experience often riddled with shame, phenomenon is the ubiquitous concept of revictimization: when “We repeat because the dissociative process maintains the a person reenacts the event and puts him or herself in situations terror, hatred, helplessness, and all the other miseries of human where aspects of the event are likely to happen again. Victims of tragedy.” Cite this article: Schwartz M (2020) Sexual Behavior and Therapy after Childhood Sexual Trauma. JSM Sexual Med 4(7): 1054. Schwartz M (2020) Central In other words, sexual enactments can hold dissociated parts classically and operantly conditioned, paired now and ever after of the patient’s self and relational history. The symptoms have with images of violence and feelings of violation, humiliation, lost connection to the events that catalyzed their onset and take unbounded terror and fear of death. In the future, when the child feels scared, he or she will feel aroused. Many scary things are parts of the individual self that have long been disconnected [12]. likely in the environment of a child being chronically, sexually on a life of their own. Therapy consists of finding and connecting abused. In response, he may begin to touch himself or move Sexual re-scripting is a required component of recovery, in ways that temporarily resolve the genital sensory overload allowing for the creation of a new template in the brain for that seems to occur out of nowhere. The child does not know affectional interchange. The hardwiring of fear and pain with she is a compulsive masturbator -- she simply seeks relief from pleasure requires changing habits strongly cemented by operant overwhelming sensations. If in response, the child is punished and classical conditioning, often relating to masturbation and or humiliated, or the perpetrator uses these actions to convince pornography. the child that he or she “wants” more abuse, the damage is DISSOCIATION, DISORGANIZED ATTACHMENT compounded exponentially. AND SEXUALITY A 30-year longitudinal study by Sroufe and colleagues [13], the dissociative child may split, and a part of self encapsulates One “solution” to this irreconcilable conflict and shame is that demonstrated that individuals with a history of disorganized the belief system or cognitive distortions propagated by the attachment in infancy are more likely to have dissociative perpetrator. This part of self may claim to “like” the abuse, welcome it, view his or her own existence as centered around performing sexually and claim to view the perpetrator as an ally ofdisorder life is alsoin adulthood. the source With of danger, disorganized causing attachment, fragmentation the parent of the or “my only friend.” This adaptation is not uncommon when the child’swho is self-system,depended on i.e. as “I a am source bad, ofthey safety are good.”in the firstThe resultfew years can sexual abuse is escalating at the hands of a particularly brutal be a hatred of self (shame) and anger at both self and others, amplifying self-injury and fear. The sexual arousal patterns are by other caregivers. It permits the child to not have to relinquish father or father figure in the context of little available nurturing thereby wired with contradictions; the schema of safety, trust and a beloved and needed love object: the father. The cost, however, is intimacy are wired to fear and betrayal, and pain with pleasure. a part of self that continues to enact its role over and over (often Parts of self become polarized and the individual receives internal into adulthood), even after the abuse that originated it has ceased. messages that are contradictions. The following clinical vignette In so doing, the self-attributions of badness become increasingly illustrates this internal confusion. entrenched, and the individual is drawn to circumstances likely to culminate in revictimization after revictimization. TRAUMA BONDING AND SEXUALITY DISORDERS OF INTIMACY The basic philosophy of treatment is that sexual problems are intertwinedWhen sexual that unfolding under occurshealthy, prematurely developmentally and in a contextnatural a subset of intimacy disorders and require the “integration” of circumstances,of force, coercion, would brutality not. The and most objectification, damaging fusion elements of elements become disorganized, contradictory and dissociated systems; what Mary may be the pairing of terror with sexual arousal. One dissociative Main at Berkeley has described as “earned-secure” attachment client described how she experiences this phenomenon relative to her sexual response. Fear had become hardwired to sexual look at one’s past and a metacognitive shift to make meaning of [14]. “Earned-secure” attachment refers to a creating a “fresh” sensations because of repeated incest. recollections (Table 1). “I don’t know that we’ve ever experienced true sexual arousal Also critical to recovery is formally breaking the trauma bond. -- only fear arousal driven by terror, anxiety or excitement that is destructive choices of reenactment and enables the client to attach The therapist identifies the dissociative parts of self involved in a physical response

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