Sex Therapy
With Survivors of Sexual Abuse

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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.

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.

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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.

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