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WOMEN’S COLUMN MASTHEAD HERE (SUBTITLE IN PMS COLOR) Treatment of Sexual Problems Among Women with Histories of Childhood Sexual Abuse One of the most common problems women with histories of childhood sexual abuse (CSA) experience are difficulties with sexual functioning. Sexual problems are multiple and various, but interestingly, are not among the most pressing problems women wish to address in the initial phase of treatment. Generally, clients want to focus more on global problems in interpersonal functioning such as issues of power, control, trust and intimacy that affect almost all of their relationships. Sexual issues emerge in the middle stages of healing when the woman feels comfortable enough to have an intimate relationship and impaired sexual functioning is creating a stumbling block to greater closeness and warmth. It also emerges when the woman feels free enough of the abuse that she can begin to imagine herself as a healthy sexual person. Therapists can help clients understand the connections between abuse events and sexual functioning difficulties and normalize what clients may experience as bizarre sexual reactions. For example, many of the women I have worked with who report flashbacks, experience them during sexual activity. Explaining this reaction as a common characteristic of a post-traumatic syndrome, often provides clients with a sense of relief. Teaching clients and their partners specific coping strategies to deal with these intrusions may further help to mitigate these distressful reactions. Of note, therapists who specialize in "sexual healing" of abuse survivors, such as Wendy Maltz, report that traditional sex therapy techniques do not often work well, either because survivors will not do traditional exercises or do them indifferently. Maltz attributes this to abuse survivors having to grapple with two taboo topics: sexuality and sexual abuse. Having to describe to the therapist the nature of specific physical dysfunctions and having to disclose that the prescribed sexual exercises activate dissociative experiences or degrading images of oneself as "damaged goods" is, understandably, very difficult for clients. The types of sexual problems treatment-seeking CSA survivors present may include: avoidance, fear or lack of interest in sex; negative feelings such as anger, disgust, or guilt with touch; vaginal pain or orgasmic difficulty; intrusive or disturbing sexual thoughts; not becoming aroused or feeling sensations, or feeling emotionally distant; compulsive or inappropriate sexual behaviors. Before a client actually engages in sexual techniques to enhance functioning, it is important to step back and identify the triggers that generate negative perceptions and sensations. The therapist can address the negative beliefs the client has about her sexuality and sex in general with the goal of creating a positive meaning for sex and developing a positive self-image. Typical beliefs identified by Maltz include "I am the names the offender called me" and "I am what was done to me." Traditional cognitive restructuring, done in an empathic way, can help resolve these beliefs. A second critical goal of the first phase of treatment involves identifying and diffusing triggers which create overwhelming feelings of disgust, anger, or produce flashbacks or dissociation. Triggers can be certain words, sensations, or smells. Once a trigger is identified, the client may, in the early stages of work, wish to avoid them and focus on positive experiences. Granted that sexual activity necessarily includes potential triggers (e.g., hearing heavy breathing, seeing/touching genitals) eventually the client will need to learn how to tolerate the perceived "noxious stimuli," and begin a process of stimulus response reconditioning with the intent of neutralizing or demystifying the "noxious stimuli." Exposure techniques such as systematic desensitization may help the client achieve these goals. Client and therapist can assess that the stimulus in and of itself is not frightening only the memory associated with it. In addition, exposure to the stimulus in a frame which re-organizes it meaning (i.e., being with a trusted lover) can help create a new response to it. Lastly, clients may find it useful to ride through bad moments such as dissociation or flashbacks with a lover's help and return to love-making. This can reinforce the attitude that the past cannot dominate the woman and her lover. After the first phase of treatment has been completed, the couple may not find it necessary to go on to the second phase, which is the technical aspects of sexual pleasure and pleasuring. However, it is more likely to be successfully utilized if the client and her partner have developed a positive frame for their sexual experiences and techniques for coping with abuse-specific problems (e.g., flashbacks). It was through one of my clients that my attention was brought to Wendy Maltz’s work on sexual healing. Although my client was in couple therapy where the problems of sexual functioning were being directly addressed, reading this book helped me understand the phases of recovery that were needed and helped clarify how I, as her individual therapist, could be of further help. This included ways to identify physical triggers for dissociative and/or flooding experiences during sexual contact and identifying beliefs about herself as being bad, worthless, degraded and a commodity during sex. We also worked on relieving her of sense of inadequacy as a sexual partner and sense of guilt and shamefulness about having these beliefs about herself. We focused partly on understanding why she had these experiences but mostly on what she could do to change. She had some wonderful personal resources such as a fun-loving nature and a rich imagination which allowed her and her partner to try new things. A component to the treatment which required some work was the development of patience about the pace of progress. We adjusted to the reality that change was to come slowly in bits over time. This work stays with me since it became very clear that when the client was ready to address her sexual problems, effective work on them enhanced her general self-esteem and self-confidence. Improved sexual functioning translated into improved sense of self. Lastly, to borrow a quote from Maltz's book "No one should have to suffer through life sexually damaged because of something that happened in the past. Healthy sex is something everyone deserves and can be achieved." (p. xviii). Reference Maltz, W. (1992). The sexual healing journey: A guide for survivors of sexual abuse. New York: HarperCollins Publishers, Inc.
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