Curr Sex Health Rep DOI 10.1007/s11930-016-0071-4
INTEGRATING THE PSYCHOSOCIAL (B MCCARTHY, RT SEGRAVES AND AH CLAYTON, SECTION EDITORS)
Toward a Trauma-Informed Approach to Adult Sexuality: A Largely Barren Field Awaits its Plow Ruth Cohn 1
# Springer Science+Business Media, LLC 2016
Abstract In the 35 years since the diagnosis of posttraumatic stress disorder was named, a body of knowledge has developed that defines psychological trauma and its effects. The growing subfield surrounding trauma was in the vanguard of bridging the gap between neuroscience and clinical psychology by developing perspectives that are inquisitive about brain function and by identifying signature disruptive dysregulations of the nervous system that traumatic experience may elicit. While we have anecdotal awareness of how these dysregulations affect adult sexual life, there is little formal research or scholarly literature in the mental health or medical fields about these effects. What little does exist tends to focus on the impact of sexual trauma, leaving out the vast array of other important categories of traumatic experience affecting sexual function. This article recommends increased research and education about all forms of trauma as well as the development of specific therapeutic methodologies to advance sexual healing in a sizeable client population suffering from sexual difficulties engendered or affected by such experiences.
Keywords Posttraumatic stress disorder (PTSD) . Developmental trauma . Dysregulations of arousal . Trauma-informed . Sexual trauma This article is part of the Topical Collection on Integrating the Psychosocial * Ruth Cohn
[email protected]
1
San Francisco, CA, USA
Introduction Ironically, the current field of trauma-informed adult sexuality replicates the population it represents. It is underdeveloped, poorly understood, minimized, and largely neglected. Making a significant appearance with the advent of the PTSD diagnosis in 1980, the subfield of psychological trauma is relatively young. Although it has grown significantly and has led the way in narrowing the gulf between neuroscience and psychology, this subfield has evolved largely in a vacuum. The larger psychology and medical fields have been slow to incorporate the theory and practice that it has produced. Only in the last few years have sexuality professionals become more interested in studying and teaching about trauma. This is a vital development. A current review of the literature shows that the field is wide open for research into the impact of all categories of traumatic (both psychological and physical) experiences on sexual function and relating, as well as the development of effective procedures and treatment strategies for addressing these difficulties. In my clinical work, many traumatized individuals and couples—including those in committed partnerships and marriages—exhibit massive avoidance of intimate or sexual interaction; longstanding, often conflict-laden sexual impasses; psychosomatic and somatic sexual ailments; sexual compulsivity; unusual or unwanted sexual practices or fantasies; loss of sexual desire or function and other difficulties. Their histories may include sexual trauma, other physical trauma or psychological trauma, and, most often, some horrific physical and psychological combination.
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Recent History: Understanding the Impact of Psychological Trauma Although lagging in its attention to sexuality, the trauma field has made steady and dogged progress over the last 35 years. The modern understanding of psychological trauma emerged from the experiences of veterans returning from the Vietnam War. Many suffered persistently from distortions and intrusions of remembered horrors, somatic complaints, sleep disturbances, haunting flashbacks and nightmares, and interpersonal difficulties. The symptom checklist for the newly created diagnosis of posttraumatic stress disorder emerged from these reported experiences of primarily young adults. Interestingly, the most likely cause of suicide among veterans, as well as the most common impetus for seeking psychological assistance, was the crippling loneliness engendered by trauma-torn relationships [1]. The shock of overwhelming destructive stimuli, the loss of close comrades and collaborators, and the largely scornful reception upon returning home severely disrupted the veterans’ capacity for interpersonal trust. In the 1970s and 1980s, domestic violence, rape, and abuse against women and children began to emerge from the shadows, appearing to cause similar kinds of disturbances to those suffered by veterans and spurring the development of numerous theories and treatments developed for these populations. When the 1990s ushered in the Decade of the Brain, the nascent trauma field was the first to Blook under the hood^ to try to understand the impact of overwhelming experience on both the brain and body. Among other findings, the amygdala was identified as a key player in the neurological and behavioral irregularities resulting from all manner of trauma [2]. In addition to the well-known chronic hypervigilance and exaggerated startle response associated with extreme fear, and the accompanying flood of stress hormones [3], trauma researchers discovered that the terrifying stimulus was greater than what the human organism was designed to process in its customary way. In effect, trauma hijacked the entire nervous system, forcing functions non-essential to survival to dim or go offline entirely. Extinguished brain areas often included the left prefrontal executive seat of the brain that controls logical cognition and language, resulting in speechless terror and fragmented memory processing. Researchers also observed the spontaneous intrusions of unintegrated traumatic memory and how the depressive hangovers that often followed the hormonal rush could give rise to severe vicissitudes of arousal and mood [4]. These torturous roller coaster-like cycles, referred to as the swing between Bintrusion^ and Bnumbing^ [5], became understood as the dysregulations of arousal emblematic of the traumatized.
Although the trauma field progressed largely apart from the psychological mainstream, the field of attachment and infant research developed on a somewhat parallel track. Its concurrent study of brain development [6, 7] correlated secure, caring and reliable early relationships with the later ability to regulate affect. Discovery of the failures of speech and memory processing during the actual traumatic event shed light on the frequent failure of traditional talk therapy to heal trauma symptoms. The Btalking cure,^ relying on narrative, cognition and language, often failed to access the deeper material that fueled the dysregulation. Treatment strategies began to evolve that might address and heal problems via other access routes, some body-based [8–10] and others more directly brain-centered [11], making therapy for the traumatized more specialized and effective. More and larger scale research is needed to bring these approaches into the evidence-based, insurancecovered mainstream, but data and anecdotal archives are accumulating. More recently, the subcategory of developmental trauma has emerged from the research. This type of trauma includes neglect, witnessing violence, a wide range of attachment disruptions, and other untoward life events that appear to similarly overwhelm the natural mechanisms for processing experience. The range of traumatized clients presenting for treatment is even greater than we knew. The trauma field is coming to understand that a longer and broader list of experiences can be understood as traumatic and pathogenic. Gradually, the concepts of relationship, affect regulation, and physiological arousal have become coupled, and treatment for adults with histories of developmental trauma is being elaborated and offered [12••, 13••]. Sexuality is an obvious companion on this journey.
Spotlight on Arousal Even a cursory perusal of the literatures of sexuality and trauma will locate in each the central role of arousal, highlighting the powerful dynamics of the body’s ways of holding, moving, charging, and discharging energy. Each field, respectively, is increasingly coming to understand the interplay between attachment, mind, and body [14, 15]; the rhythms of sympathetic and parasympathetic activation; and the exquisite delicacy of the entire dance. As we have come to understand the potential impact of psychosocial and qualityof-life factors on all manner of sexual complaints [16–18], it would seem to follow that a disruption of the baseline homeostatic balance of the body and nervous system such as trauma would powerfully contribute to sexual problems. Integrating an understanding of the interplay between trauma and relationship/sexual function into the healing of these individuals and couples makes every kind of sense.
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Let us look first at the impact of developmental trauma on sexuality. Using an example from my own practice, a couple in their late 60s came into my office complaining of a sexless marriage. For the duration of their partnership, Elise and Mark’s sexual relationship had been either formulaic and empty or nonexistent. It was a source of grief, anger, and despair for both of them. Over the past 30 years, they had shuttled in and out of couple’s therapy as well as traditional sex therapy, which emphasized sensate focus (alternating sensual and progressively erotic mutual touch). This approach invariably failed to diminish Elise’s reflexive response of frozen terror or nauseous disgust. She would begin with the intention, however resigned and dutiful, to please Mark. But as soon as she experienced his excitement, she was catapulted back into her trauma story and imagined herself literally Bflying away.^ Acutely sensitive Mark immediately felt when she had flown off. Her wordless abandonment ignited his silent, furious withdrawal. Her husband’s spontaneously erupting internal rage, in turn, evoked Elise’s father’s sudden, vicious verbal attacks that had invariably led to violence and havoc in her childhood. Awash in trauma, she flew away further, and more irretrievably, and Mark’s rage shifted into contempt, despair, and collapse. And because, as he described it, Bmy sex drive is relentless,^ he felt trapped in unremitting agony. The feedback system between Mark’s perception of persistent rejection and Elise’s terror of her husband’s blame-charged anger held the dynamics securely in place for many decades. The role played by Mark’s developmental trauma—cavernous parental neglect that convinced him his needs did not matter, that, in fact, he had no right to exist—was replicated in the couple’s sexual relationship, the one area of the marriage where he dared to reveal his personal needs. It was little wonder that his sexual hunger felt urgent and that his sexual function was anxious, insistent, and fragile. His erections and orgasms, always Biffy,^ grew even more so as he approached 70. Because Mark’s neglect had never been identified by any prior therapist or book he had read, he had little awareness of his own Bstory^ or why he felt so much pain. He truly believed that his unhappiness was entirely due to Elise’s behavior, and that his only option was to Bbe patient and wait.^ That was all he had ever gotten out of prior sex therapy experiences. While he had little hope that another new therapist could help, the prospect of another decade or two of sexless partnership seemed even bleaker. Neglect is a fairly new area of research. Under the rubric of developmental trauma research utilizing the Adverse Childhood Experience (ACE) scale [19], researchers are just beginning to understand neglect as a precipitant of great harm, sometimes causing deeper psychological damage than other forms of abuse. Mark was certainly unaware of these findings, nor what it might have to do with him.
In my therapy with Mark and Elise, I started by trying to level the playing field so that Mark’s history and developmental trauma occupied space. Until then, his belief that he was the patient, enduring sufferer, waiting for her to be Bfixed,^ echoed Elise’s own beliefs about herself. She considered herself irreparably Bbroken^ as well as the sole cause of their sexual problems, beliefs that stemmed from her father’s unrelenting tirades that his unhappiness—and his violent behavior toward her—was entirely her fault. This bifurcation of responsibility contributed to the couple’s deeply grooved impasse. My insistence that Mark inhabit the therapy with more than passive endurance was a great relief to both of them. When Mark declared one day that the one thing he had done for the relationship over the past week was Bcontinue to be patient,^ I stopped him. I asked Elise how she felt about her husband’s statement. After Elise’s acknowledged that Mark’s passive Bpatience^ was an unbearable burden, because she felt pressured to accept all of the blame for his unhappiness. She also explained to him how this onus of blame replicated her relationship with her father and heightened her fear and constriction with him. Then, I turned back to Mark, and we began to excavate his familiar feelings of gnawing, solitary waiting that duplicated his childhood. Sadly, he conceded, BIt’s the story of my life.^ Mark began to recount what it was like to feel lost and invisible in his blueblood family, with a famous father and a beleaguered, miserable mother who sent him away to boarding school at age nine. His mother never touched or desired closeness with him in any way. Long before puberty, he remembered feeling a phenomenal Bskin hunger^ and finding solace in frequent masturbation. Mark’s sexual history was a chronicle of repeated rejections and abandonments, leaving him alone with his ravenous libido and shame. His sexual performance with a partner had always been unreliable and was both a cause and effect of anxiety. When another person was involved, he could not trust even his own body. Yet masturbation continued to be lonely, shame-ridden, and only minimally satisfying. The continued experience of sexual rejection and neglect in the marriage had rekindled Mark’s childhood history and ignited anger, anxiety, and sexual symptoms. We worked at quieting the hyperarousal in his nervous system and processing his childhood experience of isolation and loneliness. Just as the trauma of neglect is effectively invisible because so much of the damage is due to unprocessed and therefore missing attachment experiences; so too is the hyperarousal and anxiety of neglect. Because their presentation is more static—passivity and silence—hyperarousal and anxiety tend to slip under the radar. Being spotlighted in therapy, having something to Bwork on^ was empowering and enlivening for Mark. Discovering the missing experience of having an impact in relationship as
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well as developing some understanding and compassion for himself were a kind of awakening for Mark. It was not always easy for Mark to get to the childhood antecedents evoked by his marital problems or to name a feeling. He had been so little mirrored in childhood that, as he put it, BI often only know what I’m feeling by observing what I do. I mean, I might notice myself staying out for hours on a walk with the dog, and only much later it dawns on me, ‘Oh, I am furious and avoiding Elise!’^ I taught both of them that bodily sensations might be an access route to emotion and memory, and we practiced noticing those sensations in our sessions. Mark began to discover how feeling his actual emotion in the moment was calming in itself. I taught them breathing practices that would help them intentionally quiet their activations. Mark continued discovering ways to be proactive in our work. I might add (and caution) that the resultant transferences can make the therapist a hero of sorts, in this case for the Bmiracle^ of bringing Mark out of the shadows while engaging him dynamically in the therapy. Freed from blame and her identified patient status, Elise became immediately calmer. The relief from focus and guilt made space for her to see Mark as distinct from her original perpetrators. Through growing sympathy for his pain, her easing fear was slowly making way for renewed love. Whereas before she would tighten and pull away both physically and emotionally when she felt responsible for Mark’s distress, now she could see how once again, he had disappeared under the radar and gotten nothing for himself. Our work on Mark’s childhood experience inspired Elise’s thoughtful consideration of him and deep compassion for the lonely little boy. It was moving to watch her as he told the stories, leaning toward him with soft, teary eyes and even sometimes reaching out a hand. She could viscerally feel how her violent revulsion and fear of him had been displaced projections of her abusive father. BIt’s not about you!^ she realized. She was then more open to hearing what her lack of sexual desire had evoked in Mark. When there was a clearly staked out and equal place in the room for Mark and his feelings, he could even become curious (as opposed to resentful or simply fatigued) about Elise’s trauma. She had been so very small—the abuse having begun when she was three or younger—and her father so very big Band fat and smelly!^ She graphically described certain kinds of seemingly innocuous touch, or being in a position where she felt small or unable to move, and how these experiences elicited bodily reactions. When emotion or overwhelming body sensation like nausea or pain spontaneously overtook Elise in sessions (which of course we tried to avoid) when she recounted experience, we worked with somatic interventions that allowed her to drop the thoughts and emotions and simply track sensation through her body. (We sometimes did this with Mark as well.) This moment-by-moment following of sensation, and awareness
of it, not only teaches presence and keeps a client firmly in the present but also provides the concrete experience of change and time passing, which is so frighteningly missing in trauma. Over the next several months, we used a variety of methodologies for calming them both, both in the room and in home practice. A simple practice of mindful gazing and very intentional touch, with synchronized breathing, was a powerful, connecting Bice-breaker^ for their slow return to sexual relating. I also offered them a series of specifically brain-focused sessions [19], which involved seeing them individually as well as in couple’s sessions, for a period of time. Each week, we carefully reviewed how they had felt emotionally and physically, apart and together, gradually arriving at the point where a loving sexual relationship became possible for the first time. Elise discovered that at age 68, free of perceived coercion, she felt sexual desire for the first time in her life. Meanwhile, Mark had his own first experience of not having to fight for his feelings to matter, let alone be gratified. Toward the end of our work together, Mark declared that the broader couple’s therapy and sex therapy fields Bhave got to be educated about trauma!^ Elise chimed in: BWe’ve lost so much time!^
Trauma and Sexuality: The Awareness Gap As a psychotherapist who has specialized in treating traumatized individuals, their partners, and families over the past 35 years, I have directly observed these complex and often agonizing somatic and relationship difficulties that all manner of trauma leaves in its wake. It was the frequency, magnitude, and persistence of intimacy and sexuality problems suffered by my traumatized clients that originally inspired me to pursue training and subsequent certification in sex therapy. I have seen an alarming number of traumatized clients like Elise and Mark who have suffered sexual despair and shame, alone or in partnership, over many years, in spite of working with psychotherapists and physicians to alleviate their distress. Many have long struggled in sexless marriages torn apart by ceaseless conflict. Even as the trauma field has advanced, evolving increasingly sophisticated science and developing a growing body of research and clinical knowledge about the nature of trauma and effective treatments for it, I have observed little cross-pollination between the fields of trauma and sex therapy. I was gratified when, in 2015, two major sexuality organizations showcased trauma in their educational offerings [20, 21] in recognition of the need for specialized information and methodologies to help traumatized people. Slowly, the sex therapy field is recognizing, and acting on, the need for a Btrauma-informed^ perspective and approach to adult
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sexuality. For its part, the trauma field appears slower to take up the task of studying trauma’s impact on sexuality, even with respect to the currently hot topic of Bsex addiction.^
refer them to my book [23, 24••] and articles on my website, www.cominghometopassion.com.
Beyond Childhood Sexual Abuse What Do We Mean By BTrauma-Informed?^ A Btrauma-informed^ system is one in which all components of a given service system—medical, psychotherapeutic, and/ or addiction treatment—have been re-evaluated in light of the role that violence plays in the lives of adults, children and adolescents, and families, as well as caregivers seeking these services. A trauma-informed system uses that understanding to design services that accommodate the vulnerabilities of trauma survivors and ensure that services are delivered in a way that avoids inadvertent retraumatization, as well as facilitating client participation in treatment. To the extent possible, a trauma-informed system also prioritizes closelyknit, collaborative relationships with other public sector service systems serving these clients. In addition, it seeks close working relationships with the local network of psychotherapists, physicians, and other professionals with particular clinical expertise in Btraumatology^ [22].
The Role of Psychoeducation Because all therapy, and certainly sex therapy, involves a measure of client education, trauma-informed clinicians also need sufficient knowledge about trauma’s disruptions of the customary workings of the nervous system and body, so that they can clearly inform clients and couples about these disruptions and their impact. This kind of information offers clients both an understanding of their difficulties and realistic hope. Clinicians would also help clients to recognize that while sexual trauma is a more obvious and expected source of sexual inhibitions, phobias, and dysfunction, it is by no means the only contributing factor. Burdened by shame and feeling pathological and alone, traumatized individuals and their partners may feel relieved and even Babsolved^ by learning about the impact of such factors as age and health on sexual life. As is typical, feeling more Bnormal^ eases our way. Another vital educational message, as emphasized above, is how the thinking part of the brain ceases to function effectively when trauma is reactivated and how the work of trauma processing enables individuals to increasingly stay in the present moment with their partners during sex and in general. Most importantly, understanding the natural history of trauma and neglect, including etiology and repair, gives clients a hopeful awareness that their experience has a known trajectory and that there are known positive outcomes. With my own clients, I often recount stories of such and also
Gaps in the clinical and scholarly literature reflect the elusive information clients sorely need. A review of recent research and clinical literature on the impact of trauma on sexuality turns up precious little. In the clinical literature, I found one slender volume, published in 2003 [25], which accurately identifies some of the difficulties but offers little in the way of treatment strategies. A notable exception to the silence on this topic is Zoldbrod [26] in this journal, who addresses the sexual sequelae of sexual trauma with somatic perspectives and interventions, and additionally acknowledges non-sexual developmental trauma. Apart from this notable contribution, the available scholarly literature linking trauma to adult sexual problems refers almost exclusively to sexual trauma and makes the correlation without studying or developing specific clinical approaches. Most of the available literature on sexual healing from childhood or adult sexual trauma can be found in the selfhelp or Bcrossover^ literature, with the latter attempting to bridge self-help and clinical material [27, 28]. These materials tend to be practical and instructive, although given the intensity of trauma activation, they can be challenging for sufferers to utilize successfully on their own. Additionally, these books typically cast the partner of the traumatized person in an Bendurer^ or helper role, which fails to acknowledge the dynamic nature of the sexual interaction and how the trauma survivor’s partner may unwittingly react from his or her own history. My own approach, as described in the above case of Elise and Mark, seeks very intentionally to level the playing field, not only to unburden any identified patient of the yoke of blame but also to engage the other partner, who may have been largely ignored in past therapy experiences. My experience has shown that most often this overlooked partner has developmental trauma, as well as sexual dysregulations and dysfunctions that are attachmentbased. In another case of mine [29], one partner, Martin had endured both childhood sexual abuse and developmental trauma. Molested by an elderly uncle, he was also raised in a fundamentalist religion. The fierce prohibition of masturbation led him to believe that his frequent Bself-abuse^ had done damage to his penis and caused it to no longer respond normally. At age 17, Martin left the religion. As a consequence, he was permanently shunned and disowned by his parents, family, and entire community. Martin’s experience taught
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him that taking care of his own needs, and in effect being authentically himself, resulted in damnation, ostracization, and injury; living a life congruent with his own beliefs meant losing everyone. Martin’s sexual function, always delicately sensitive, became exquisitely reactive to abandonment, real or imagined. His abandonment trauma was readily ignited by his partner’s anger or withdrawal, while any sexual approach reactivated his sexual abuse trauma. His exasperated and short-tempered partner, Ida, was fed up. We had much to address. For her part, Ida had sustained developmental trauma and was chronically fearful. She had grown up in a traditional culture that devalued women, and she had been the butt of endless criticism by both parents about being, Bfat, dumb, and a source of embarrassment to them.^ When she was afraid, particularly about being unwanted, she defaulted to vicious and humiliating criticism, much like what she herself had suffered. Martin’s awkward, self-conscious, and diminishing sexual initiative inspired Ida’s fear that she was of no use to him at all. She would then unleash the rageful criticism, which exacerbated his withdrawal, and the feedback system of reaction/counter-reaction continued with increasing fervor. It was exhausting, demoralizing, and damaging to their connection as well as their health. Often these couples arrive at our doors worn out and hopeless from the unrelenting re-enactments of their childhood experiences. Martin and Ida had no idea how to stop the cycle, let alone go near the sexual undertaking. I referred Martin to a sex-positive medical doctor, where he had his first examination of the status of his penis. The doctor, a colleague and friend of mine from the sex therapy field, was able to accurately diagnose that Martin did in fact have some penile irregularity, but it was congenital and treatable. And it Bworked^ just fine. Sex education, from both his new doctor and myself (both in Ida’s presence), was also a new experience for him, both normalizing his function while correlating some aspects of it to his sexual abuse and some to other factors. While processing his sexual and developmental trauma, we also invited Martin to be a compassionate audience for Ida’s bitter history of criticism and condemnation. Evoking compassion and empathy for that chronically devalued and hated little girl, and recognizing that the criticism was not really about him, again, calmed Martin’s hyperaroused, defensive nervous system. We similarly used brain-based and somatic interventions, which enhanced and expedited the calming of both of their nervous systems. To complement our work, Ida concurrently pursued sessions with a local EMDR practitioner. Slowly and cautiously, we approached carefully selected sexual practices.
The Nature of Trauma is to Re-enact It Because every episode of trauma activation unleashes a bath of stress hormones that is followed by a depressive backlash, both partners usually arrive at our doors plagued by ever-deepening depression and anxiety in addition to their other symptoms. Much of the early work of therapy involves reframing both the emotional/relational and the sexual difficulty as some sort of re-dramatization of their childhoods. Then, we set about interrupting the cycle of chronic mutual activation they are most often caught in. Our intent is to create a new feedback system of compassion. We seek to build a framework for understanding what is happening, so that clients can begin to empathize with each other, rather than feel endlessly, hopelessly caught in the powerful cyclone of their negative feedback loop. The heart of psychoeducation about trauma is that the nature of trauma is to re-enact it. Because the memory is often stored in a fragmented or wordless way, it searches for expression in a form that will ultimately translate into narrative. Generally, the more we search for trauma-related emotion and sensation underneath the relationship and sexual difficulty, the sooner we can both construct a coherent trauma story and achieve hope and ultimately sexual progress. Once the story is articulated in language in a coherent way, the need for symbolic representations of it disappears. The drama can end and the couple (or individual) can live and create an adult sex life in the present. Actual sex therapy, however, cannot advance until the system is stable and the trauma stories are slowly understood. It is painstaking work, and methodologies that calm the body and brain are required [30, 31]. Douglas Braun-Harvey’s approach [32] to working with men who suffer with sexual compulsivity, or what he calls Out of Control Sexual Behavior (OCSB), is an interesting and welcome complement to mine. Although he mentions childhood experience as a potential causal factor in some problem behaviors, generally it is not his emphasis. However, he does include such exploration in his work with his OCSB clients. A central aspect of his work is to place the concept of sexual health at the heart of treatment. By focusing less on specific behaviors that might be viewed as morally, culturally, or historically pathological or Bperverse,^ he resets the lens with a more subjective and relational elaboration of a sexual self-image and healthy sexual life. The individual and couple create a vision of what behaviors are unwanted and ego dystonic or Bout of control^ and what sexual practice is desired. He highlights consent, honesty, mutual pleasure, selfregulation, and safety from STDs, exploitation, and violence. His view is enlightening, refreshing, and compatible with my own. His paradigm and language are somewhat different. What I refer to as the activity of the prefrontal cortex appears as Bthe deliberative system^ in his lexicon. He teaches clients
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that it fails to regulate limbic activation, which in his model, the Bemotional system^ that engenders the unwanted impulses and behaviors. He does not emphasize the psychogenic material or view it as an obstacle if he does. He is an important teacher and his work regarding certain kinds of dysregulation has contributed to my approach.
Existing Literature on Trauma While little research has been conducted thus far on the impact of trauma on adult sexuality, a literature review does uncover research about the impact of all kinds of trauma on psychological and behavioral functioning: depression [33–36], anxiety [37], and dissociative disorders [38–40]; a wealth of literature linking trauma to a high incidence of alcohol and drug addiction [41–43], somatization and health problems [44–46], violence and domestic violence [47–49]; and relationship problems [50]. (Although my own work has shown a strong correlation between trauma and compulsive sexual behavior [51].) I have relied on case studies and have not as yet conducted formal research. Existing literature on sexual compulsivity (often referred to as Bsex addiction^) has introduced the possibility that prior sexual trauma could be a factor [52–54], but my search has not shown trauma-informed approaches to sexual compulsivity treatments. In sum, published research shows that the psychological and medical fields understand the connections between the general category of traumatic experiences and subsequent psychological, medical, and behavioral disorders. Effective psychotherapeutic methodologies of many kinds have been steadily developing over the past several decades [55]. Some researchers acknowledge that child and adult sexual traumas contribute to later relationship and sexual disruptions [56], although little literature offers trauma-informed sex therapy methodologies. Studies investigating a causal link between adult sexual problems and the more generalized category of traumatic experience, including developmental trauma, are largely lacking and so, of course, are treatment strategies for such. Assuming that these correlations exist, which my clinical experience consistently demonstrates, such populations may suffer persistent and painful sexual symptoms and impasses without receiving effective treatment. A notable exception can be found in the work of Rellini [54], whose research and clinical experience show a wide range of sequelae and a correspondingly wide range of sexual symptoms. She cautions against a narrow view that all cases of adults with sexual abuse histories manifest a single pattern of sexual dysfunction, and that sexual abuse is not even necessarily the primary causal factor in adults with sexual abuse histories. The predominant precipitant may be the result of other developmental experiences or deficits. I concur with
her caution against taking a single-lens approach to clients who have experienced sexual abuse.
Conclusions Since the diagnosis of posttraumatic stress disorder first appeared in the DSM-III in 1980, tremendous strides have been made in the study, understanding and treatment of trauma. Prior to that time, symptomatic war veterans were viewed as Bweak^ or Bcowardly.^ Prior to 1980, the standard text taught in US medical schools stated that the incidence of incest and other childhood sexual abuse was approximately one child per million [57]. More recent data show rates in North America ranging from 7 to 36 % for women and 3 to 29 % for men [58]. By the 1990s, the advent of neuroimaging technology had allowed researchers to begin building the physiological basis for understanding the powerful dysregulations of arousal and the major disruptions of the entire nervous system and body that underlie the psychological trauma symptoms long observed by physicians and mental health professionals. By definition, trauma is an overwhelming experience, meaning that the stimulus is greater than the organism’s capacity to process it in its usual ways. Aberrant processing may result in fragmentary and distorted memory and disruptions of a wide range of other bodily functions, including sleep, digestion, and even attention. As noted above, the growing subfield of psychological trauma has taken up the task of creating and evolving treatment strategies and protocols (beyond the familiar Btalking cure^) that address the disruptions and dysregulations of physiology. Also as noted above, I recommend adding nontraditional somatic methodologies when appropriate and safe and when clients are receptive, which they usually are. I continue to refer them back to their childhoods, using attachment principles to help them make sense of their confusing current relationship and sexual dynamics. It is validating to clients to put a name to their experience— trauma—and to understand that their sexual problems are not mysterious, unique, or evidence of personal failure. I teach and work with clients to develop coping skills, resilience, and the ability to incorporate and integrate new relational and sexual capacities into their self and relationship visions and their unique definitions of a healthy and loving sexual life. We strive to replace an identity centered on trauma with one that is confident and forward-looking. The subfields of sexology and sex therapy have similarly grown and developed somewhat apart from both the psychology and medical worlds. In different ways, both sexuality and trauma are shrouded in taboo. This is the case with trauma because danger, cruelty, and horror almost universally evoke distaste and denial, among not only the
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general public but also some professionals. In turn, many professionals and lay people avoid the subject or have a difficult time addressing sexuality because the millennia of moralizing, misplaced notions of Bmodesty^ and resulting shame have done their work. In any case, there has been far too little cross-pollination between the fields of sexuality and trauma. As a clinician who has straddled both fields, I daily observe the impact of trauma on sexual relating and function and the havoc this impact wreaks in the lives of individuals, couples, and, by extension, families [59]. The gap in the literature is glaring. This wide-open field of trauma-informed adult sexuality awaits researchers’ thoughtful examination and care. This approach is long overdue, as is the scholarly research to describe phenomenology and physiology that would provide a basis for effective treatment strategies and protocols. We need formal study correlating childhood adverse experiences with specific sexual health diagnoses, as well as systematic study of the treatment effectiveness of somatic, brainbased, and attachment-focused sex therapy approaches [59]. The addition of psychoeducation to standard sex therapy training programs about trauma and its impact on the brain, body, and relationship and sexuality is essential. The good news is that such education is beginning to take place. More widespread training on this element of treatment is vital. As Mark and Elise told me: BYou’ve got to get the word out about this. We can’t afford to lose so much time!^ [58]. Sexual health is now recognized, even by our government, as a vital component of human health [59]. It behooves us to provide the evidence basis that will allow the larger world: the medical, social services and mental health professions and the general public to understand this reality and take it seriously. Compliance with Ethical Standards Conflict of Interest RC declares that she has no conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects conducted by any of the authors.
References Papers of particular interest, published recently, have been highlighted as: •• Of major importance 1.
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