Neglect Informed Sex Therapy: Evil? “Solutions”, Health

In the early years of the Millennium, it seemed as if the world was suddenly haunted by a dreaded and insidious enemy. It kind of reminded me of the opening lines of Marx’s Communist Manifesto, which I read with great ardor in my first months of college in 1973: “A spectre is haunting Europe…” It resounded rather like the trailer of a terrifying horror movie. This spreading “evil” was so-called “Sex Addiction”, which was rapidly becoming the diagnosis du jour. My phone was ringing off the hook with panicked spouses breathlessly complaining about their partners’ rabid behavior; or the accused partner lamenting that they had been kicked out of their homes. It was a newly named “diagnosis” which had no nosology, no research, no scientific basis at all. And yet as is so often the case with a new sensation, the world was suddenly full of “experts.” Suddenly a new, high-priced treatment industry began mushrooming around it, and the nightmarish stories abounded.

Because my practice was primarily adults with sexual trauma histories, and I worked a lot with couples, I guess people thought I was a logical person to call. I didn’t think so… I tried urgently to inform myself and searched in the sex therapy conferences, information, diagnostic, scientific and clinical. I kept coming up pretty dry. For a long time, I could only find one article, which I quickly clung to like a lifeline “Compulsive sexual behavior: what to call it, how to treat it?” by Eli Coleman (2003). I knew and admired Eli from hearing him at conferences, and I remember calling him more than once. Flying by the seat of my pants, I really disliked that work, and did my best to send those couples elsewhere. The question was where? There was the panoply of pricy “specialists” and treatment programs. that I was soon hearing distressed and distressing stories about. We were barely emerging from the AIDS crisis so those were some challenging times in the sex therapy world, and in the world really. 

Thankfully we have come a long way since then, and after a few years of flailing, I subsequently met my colleague and friend Doug Braun-Harvey who wrote the truly ground-breaking book, Treating Out of Control Sexual Behavior: Rethinking Sex Addictionwhich was helpful and continues to be a resource about sexual health.

So, what does all this have to do with neglect? Now that I am long out of the weeds, or those anyway, I can think more objectively about that question. The sex addiction model, although I would hardly say there was one distinct “model,” generally tended to moralize and pathologize, as one of my sex therapist colleagues said only semi-tongue in cheek, “A sex addict is anyone who has more sex than me…” The fact is that my experience has shown that sex that is random, impersonal, and somewhat disconnected, may indeed be relevant to our topic.

Last week I wrote about the heart of neglect trauma, the “dilemma without solution.” After the blog went out I realized to my sheepish dismay and embarrassment, that I never articulated the precise words Dr. Main used to define it. Mea Culpa!! Thankfully, as ever the opportunity for apology and repair is available! The only thing that thankfully makes it survivable and even safe to make a dumb mistake! So, I can tell you here, because as ever it is infinitely relevant. The dilemma is defined as follows: The source of longing and the source of terror are the same person.” The child is therefore faced with this terrible non-choice of reaching toward and pulling away, reaching toward and pulling away, and on and on until they collapse in despair. Ultimately in many cases, the adaptive default is self -reliance which is an effective if lonely strategy in many cases. We went over this last week.

In sexuality, however, self-reliance presents additional challenges. Clearly, we can do it all ourselves, but most of us would agree that it is not the same. So, we must elaborate some other creative way, to be sexual and be safe. This is what I tend to find among the vast world of neglect survivors. For me, when I was young and un-recovered, sexual compulsivity was a ready solution. Numbers, frequency, superficial distance, and a lot of alcohol, kept it impersonal and disconnected enough to be less “dangerous,” at least in the emotional sense. I could even feel proud or powerful about how many guys I could “get”. Oy vey. 

As I got older and became a bit more civilized and more discriminating, alcohol became the main “safeguard” against getting too close, although I still managed to have plenty of dramatic heartbreak stories. I kept voluminous journals about it all, and I still have the shelf of them, although I can honestly say that for some reason, I don’t throw them out, I have never cracked the covers and they all remain unread! Needless to say, everything changed and became much more difficult when I got sober. By then I was 28 and in therapy. I had to begin to face the “dilemma,” which I slowly did. But admittedly it took me some time! 

Among my neglect survivor clients, I have observed many creative “solutions” to the sexualdilemma. Now the internet has provided a vast world of cyber partners, where one can have erotic experiences without risking the vulnerability of authentic flesh and blood relationships. This becomes quite an issue among many couples, and even within guilt-ridden individuals, however as evidenced by a more than thriving mega-industry, it continues to be an option.

Less now, post-AIDS (well almost) than before, anonymous sex has been an option. At the corner of our block in San Francisco is a park once a famous destination for anonymous sex liaisons. I can remember when I first moved in in 1991, seeing rather guilty-looking individuals slinking out of the park, after assumably having their trysts in the bushes. That seems to have stopped, at least to my observation. There used to be bathhouses and hot tub places that were similar, and I sometimes heard about them from shame-ridden clients trying to stop frequenting them. I have not heard those stories in quite a while.

More typically, and a “solution” that I still encounter in my work, and is truly painful for both parties to work with, is what turns out to be serial infidelities, which most effectively drive a wedge between partners, which is often painfully difficult if not impossible to repair. I don’t want to say impossible, but it requires two truly committed partners willing to stay the course, to get there. And all too often another generation of neglected kids is the tragic result. 

Similar and perhaps in many cases slightly less difficult to repair, is employing sex workers. And I have had a few clients who were sex workers, a rewarding way to have plenty of sex, in many cases stay “in control,” and not get attached. And many more, and this is what I see most often, neglect survivors may partner “unwittingly” with someone who is unable or unwilling to have sex, or have sex with them. They may have a miserable and cycling conflict/fight about it. Or may sink into a long and sexless partnership. It is surprising how many couples have ended up like this. 

“Spectatoring” is a term used in sex therapy. It maps remarkably neatly onto the “one-person psychology.” The person is focused on their own performance and observing themselves in action almost as if watching a show, while also imagining and being perhaps fixated on their impact on the partner. Again, unrelated, detached, and ultimately solitary.  All this is to say, the dilemma without a solution leaves a cavernous void or scar, that the survivor is hard-pressed to heal if truly satisfying sex is to be possible.



Sex therapy with neglect is largely relationship work. It is some of the hardest work we do. One reason why I am so crazed about talking about sex, (even to the point of sometimes shocking people with my candor, I’m afraid. Hope I have not offended you!) is because so few will talk about it, or so it seems to me. Doctors don’t warn their patients about the sexual side effects of medications, procedures and illnesses; psychiatrists don’t warn patients about the sexual side effects of some of the most popular psych meds; many therapists, sadly are tongue-tied on the subject, even many couple’s therapists don’t inquire. 

Many of you have heard my rant before. My apologies. If we can’t get good quality sex education in the schools, we might start by becoming able to talk to our kids at home; and learning ourselves what is “normal”. We can do our part in raising regulated and sexually healthy children. And Doug Braun-Harvey’s book provides what I think is a wonderful model (Not necessarily for children!) for his “Six Principles of Sexual Health”, which you can also find by Googling. So much more to say on this, to be continued!  

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