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(www.plasticsurgery.org). In 2011, more than 300,000 such surgeries were performed, a 4% increase from 2010 and a 45% increase from the year 2000. More than 90,000 breast lift operations were performed in the United States in 2011, a 72% increase from the year 2000. Research on the effects of cosmetic breast surgery on women's sexuality is sparse, although one survey of 26 women who had undergone breast augmentation surgery revealed that 46% reported having sex more frequently after the surgery, 39%

reported being more willing to experiment sexually, and 31% reported an increased ability to experience orgasm (Stofman, Neavin, Ramineni, & Alford, 2006).

Data on the extent to which dissatisfaction with women's genitals results in surgery or other procedures are severely lacking. However, it appears that at least awareness of such surgery has grown, as in 2010 an entire special issue of the professional journal Reproductive Health Matters (Vol. 18, No. 35) was devoted to the topic of genital cosmetic surgery and the related controversies, and in 2011 Goodman performed a review of the available research reports. For women, these surgeries most commonly include reducing the size of the labia minora (labiaplasty) and/or the clitoral hood or

"tightening" of the vagina so that it "feels" or functions like a much younger, prematernity version.

Beyond concerns about the appearance of one's labia, another motivation for labiaplasty may be to correct excessively long or thick labia that cause pain during vaginal penetration. How often is the motivation for surgery functional versus cosmetic?

In one study from a private gynecology practice in a large U.S. city, of the 131 women who underwent the surgery during a period of 27 months, 32% did so strictly to correct functional impairment, 31% because of both functional impairment and aesthetic concerns, and the remaining 37% indicated strictly appearance-related concerns (Miklos

& Moore, 2008). Perhaps more surprising were the results from a similar study conducted in the United Kingdom involving 33 women who had been referred to gynecologists by their general physicians because of a stated desire for labiaplasty (Crouch, Deans, Michala, Liao, & Creighton, 2011). Surprisingly, the women averaged only 23 years of age, and all had labia minora of normal size (although three were offered surgery to correct significant asymmetry). Follow-up data on the effects of labiaplasty on women's sexuality are sparse (Berer, 2010), but rates of satisfaction appear high and incidence of complications low (Goodman, 2011). See Veale et al. (2013) for discussion of how to screen for body dysmorphic disorder among women seeking labiaplasty.

**Potential Influences on Sexual Body Image**

Although the combination of influences on body image is unique to each client, research points to a few general risk factors for body image concerns during sexual activity. One such variable is gender, or at least gender roles. Traditionally, concerns about appearance have been considered feminine. Traditional masculine ideologies prescribe a cool indifference to one's physical features as a source of sex appeal; instead, masculine sexual appeal rests on confidence, achievement, status, and experience. Although there 331

are indications that males are increasingly concerned about physical appearance as a source of their sexual appeal, there still appears to be a marked male-female discrepancy in this regard (e.g., Owens, Allen, & Spangler, 2010; Pascoal et al., 2012). Also, when body image concerns are present, males may be more concerned about their degree of muscularity (e.g., Filiault, 2007), whereas females may be more concerned about their degree of fat (e.g., Pujols, Meston, & Seal, 2010). However, this apparent gender difference may be exaggerated due to the research being focused typically on young adults (college students).

A gender difference in the nature of concerns during sexual activity also has been demonstrated by multiple researchers, at least based on college-student samples. For example, Meana and Nunnink (2006) found that college males reported more frequently being concerned about their sexual performance than their bodily appearance during sexual activity with a partner. Compared with their male peers, female college students reported more frequently being concerned about bodily appearance during sexual activity. However, among the women, concerns about appearance versus performance were equal in frequency.

Some factors influencing body image concerns during sexual activity are more developmental or experiential in nature. Perhaps the most obvious factor is actual physical appearance. However, appearance changes over the lifespan, and indeed sexual body image may as well (Montemurro & Gillen, 2013). Even an individual who approximates the cultural ideal of sexual attractiveness currently may continue to be influenced by a history of having been overweight or deemed less attractive in some way (Annis, Cash, & Hrabosky, 2004). Also, physical disability or changes in bodily appearance or function due to illness, accident, or surgery may profoundly influence an individual's body image during physical intimacy with a partner (e.g., Moin, Duvdevaney, & Mazor, 2009).

Other important factors in the development of body image concerns during sex include specific comments, criticism, or teasing regarding one's sexual appeal, appearance, or bodily functioning (Annis et al., 2004). Such messages could be general or highly specific. For example, an individual may have been raised in a sociocultural environment in which genitals and their sexual functions were deemed dirty, shameful, and a source of anxiety. Conversely, a person may have had an unremarkable upbringing, yet have been traumatized by the negative reactions, verbal or otherwise, of one or more specific sexual partners

An individual's body image also may be influenced by current life circumstances aside from his or her sexual partners. For example, particular occupations such as modeling, dancing (erotic or otherwise), athletics, and sex work may facilitate either body confidence or anxious self-consciousness, depending on numerous factors. For example, physical exercise and body competence inherent in an occupation may facilitate comfort and confidence with one's body that then extends into the bedroom.

Receiving continual positive feedback regarding one's attractiveness and sexual appeal at work may facilitate a positive body image during sexual activity. Conversely, work-related criticism, interpersonal comparison, or competitiveness based on appearance or body competence may undermine body image during sexual activity.

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Other risk factors for body image concerns include exposure to unrealistic standards or images of what is implied to be normal. Research on what psychologists refer to as

"contrast effects" has shown that exposure to images of very attractive people tends to leave the viewer less satisfied with his or her own appearance, especially when the viewer already has low self-esteem (Jones & Buckingham, 2005). So repeated exposure to professional models in various media may foster a negative body image for some.

Similarly, repeated exposure to professionally produced erotica, with its digitally altered images, scripted sexual poses, and highly edited finished product, may lead the viewer to judge his or her sexual appeal and functioning as inadequate. These contrast effects may be insidious, affecting self-perceptions even when viewers are aware that the models and actors are professionals and the media based on fantasy.

**ASSESSMENT**

Researchers use numerous scales and inventories to measure various aspects of body image, so it may be tempting to ask which ones would be useful in a clinical context.

However, most such measures are not specific to body image in a sexual setting. Even those that are may generate a score designed for use by researchers interested in correlating the score with other variables. Clinically, however, the scores lack interpretative meaning for the individual testtaker. Without an established cutoff score indicating substantial problems, what does a particular client's score indicate? For the individual, phenomenology is more important than a numerical score.

Clinicians who ask new clients to complete a packet of self-report materials may choose to include some specific questions pertaining to body image concerns. Rather than using a formal scale per se, directly asking about body image concerns that interfere with sexual functioning is much less ambiguous. Consider this sample set of questions a clinician might pose to a client either in an intake packet or during an interview: Does how you think or feel about your body ever interfere with your sex life?

If yes, in what ways? For example, does it affect your frequency of sexual activity, your ability to ask for what you want and set limits with your partners, or distract you from focusing on your pleasure during sex? What have you tried before to work around the problem? What happened?

The initial query casts a broad net, with the follow-up questions aimed at better understanding the phenomenology of the body image concerns as experienced by the client. What are the specific characteristics of the body image concerns? In what ways do they affect the client's sexuality? What has the client attempted as a means of coping or remediation?

It also may be productive to investigate ways in which the client uses body image concerns to make sense out of negative sexual outcomes. In other words, does the client attribute his or her sexual problems to those aspects of body image over which he or she is dissatisfied, regardless of whether those attributions are accurate? As long as sexual problems are attributed to deficits in appearance or bodily functioning, the client is 333

unlikely to have considered solutions other than alteration of the body, which may not be realistic or helpful.

It may be good practice to routinely include for all clients a broad screening question pertaining to body image during sexual activity. Otherwise the clinician might fall into using implicit stereotypes or assumptions about the types of clients most likely to experience such problems. For example, if a client appears sexually attractive, it might be easy to assume that the client does not experience body image concerns (and vice versa). In reality, research has revealed that body image is only weakly correlated with attractiveness as judged by others (e.g., Weeden & Sabini, 2007).

Assessment may be more complex when working with couples. In addition to the sheer number of issues to assess, some pertain to the individual members of the couple, whereas others to their joint interactions. In that regard, consider the case of Stefan and Maria:

Stefan and Maria were in their mid-40s and had been married 15 years, during most of which they had been raising their two children. Although they sought treatment for Maria's low sexual desire and lifelong anorgasmia, both admitted that their sexual relationship had been lacking almost since its onset. Maria typically avoided sex, engaging in it once every few weeks, "just to please her husband." Maria was able to become lubricated and experience some arousal during sex, but reported that her arousal quickly plateaued and then tapered off. Maria and Stefan agreed that this had been the case throughout their relationship and that, despite some experimentation, nothing seemed to help.

The assessment revealed that both Maria and Stefan held conservative sexual attitudes deriving from their Italian Catholic backgrounds and lacked knowledge of female sexual functioning. Indeed, Maria had never even looked at her genitals, had a strong aversion to them, and consequently had never allowed her husband to perform oral sex on her. Stefan noted that each also had gained weight over the years and that neither felt attractive or comfortable in their bodies, although both denied decreased attraction to the other. Whereas Stefan's negative body image had not affected his interest in sexual activity, Maria dreaded having sex. Typically she would

"lie there and hope he would quickly get it over with," all the while distracted by her hatred of her body. Not only did Maria never ask for things that might give her more pleasure, but she was also mostly unaware of what might do so and reported feeling few sensations she would call "enjoyable." Sensing her detachment during sex, Stefan felt insecure and would try to rush sex for her sake. With the focus on their negative body images and sex as a chore to get through, neither Stefan nor Maria attended to what they could do to make it more satisfying.

**APPROACHES TO TREATMENT**

Currently there are no published reports on the assessment of interventions to improve 334

body image concerns during sexual activity. Accordingly, clinicians addressing body image concerns in the bedroom are left to "bootstrap" techniques shown to be effective at improving body image generally, which tend to fall along cognitive-behavioral lines.

Therapists must also factor in comorbid psychopathology and whether the client has a steady sexual partner who may be affected by, and willing to work on, the problematic body image.

Because body image interference with sexual functioning frequently has its roots in anxious self-consciousness and resulting distraction from sexual stimuli, addressing thoughts experienced by the client during sexual activity is a prime place to start.

Making such thoughts explicit may be enough to reveal their inherent irrationality, and client anxiety decreases. In other cases, however, the client may readily recognize the irrationality of the problematic thoughts, yet still react to such thoughts as though they were valid. Depending on the nature of these irrational or inaccurate thoughts, the clinician and client may collaborate on developing "experiments" so that the client can empirically test the validity of his or her assumptions. One such experiment may involve seeking explicit feedback from the client's sexual partner.

Clients with body image concerns frequently engage in "mind reading" about what partners believe, think, and feel. Clinicians working with the couple have the opportunity to facilitate detailed discussion of each partner's perceptions of, and reactions to, the body-image-related concerns. This seemingly obvious step toward possible resolution of the concerns may not have occurred to the client due to assumptions that the partner's beliefs, thoughts, and feelings are "obvious" or simply the same as the cultural norm or stereotype. One risk, however, is that the partner will agree with the client or exacerbate the client's negative body image through criticism. In such cases, couple counseling is warranted. The body image concerns involve both members and may be a symptom of larger relationship problems.

Even when a client's partner is very supportive, positive feedback may be discounted by the client, thereby maintaining the negative self-schema, through rationalizing that the partner is being polite or conflict avoidant. It may be necessary to engage the client in an ongoing process of cognitive restructuring, emphasizing that undoing these ingrained thoughts and assumptions will not occur suddenly or completely but takes practice, with resulting incremental improvement. Such a process entails repeated awareness of problematic cognitions and explicit self-refutation of those thoughts and beliefs.

When discussion of client versus partner perceptions does not appear to be effective at decreasing client anxious self-consciousness, homework might entail massage or sexual activity during which the client's partner verbalizes his or her thoughts and feelings about the client's body and sexual appeal. By tying expression of partner perceptions to actual experiences of physical intimacy, such expressions become more valid and can be based on specifics (e.g., "I love how your ____________.") versus generalities that may or may not be true (e.g., "I think you're as sexy as when we first met").

Being massaged or pleasured by one's partner is an aspect of sensate focus, and the same approach may be helpful for learning to focus on the immediate sensual 335

experience rather than cognitive distraction over body image concerns. Similarly, mindfulness training and practice may help clients learn to be aware and focused on the present moment—their immediate sexual experience—and thus be inoculated against disruptive body image distractions (de Jong, 2009).

Any strategies that facilitate decreased anxiety while engaging in sexual activity with a partner will likely have the positive effect of reducing future anxiety through the well-established process of systematic desensitization. Consideration of antianxiety medication may be warranted in some cases to facilitate that process. Intentional use of systematic desensitization also may be a primary intervention to disrupt body image anxiety during sexual activity. For example, explicit relaxation training and practice may be paired with viewing, or allowing the client's partner to view or touch, those body parts that prompt body image anxiety. Past avoidance of viewing or revealing problematic body parts simply reinforced body image anxiety and must be reversed.

Consider the previously introduced case of Stefan and Maria:

Early treatment with Maria and Stefan concentrated on education about the female and male sexual response cycles, with an emphasis on the importance of "sexy"

thoughts and adequate sexual stimulation. Connections among thoughts (e.g., interpretations, expectations, attitudes, and beliefs), feelings, behaviors, and physiological response were explained, particularly with respect to Maria's negative body image and her ensuing sexual difficulties. Relaxation exercises were introduced, and the couple was instructed to practice these before engaging in self-examination exercises. In a relaxed setting, Maria used a mirror to examine her genitals for the first time and to sketch what she saw. She was asked to then describe what she saw, using neutral or positive terms, and if comfortable, to discuss her drawing with Stefan. Both were encouraged to practice the same exercise on their own, noticing and describing their entire bodies. Maria admitted surprise at enjoying the experience of genital examination, although she felt shy and uncomfortable sharing the experience with Stefan. Stefan, too, was surprised to discover that he could think of his body in new, positive ways.

Next, an alternative model of sexuality was presented, one based on valuing intimacy and pleasure rather than goal-directed sex (i.e., reaching orgasm). A temporary ban was placed on sexual intercourse, and for the next month, Stefan and Maria were encouraged to engage in sensate focus exercises while telling each other authentically what they enjoyed about specific aspects of the other's body. They were encouraged to explore and discuss what turned them on, both during masturbation and together (e.g., types of touch, activities, scenarios), and to reinforce each other for touch they found arousing. Maria was instructed to practice asking for what she wanted. It was agreed that the ban on intercourse would end on Maria's initiative.

Maria and Stefan initially found this assignment quite challenging. Stefan worried that they would never have sex again. Maria, while reassured by the intercourse restriction, still felt indirect pressure to initiate and anxiety about the vulnerability that came from a more intimacy-based model of sexuality. However, after weeks of exploring resistances and ongoing practice of direct communication between them 336

about their fears and expectations, their sexual relationship opened up. Maria began to take the lead and found it arousing to do so; in fact, she found that once things got started, it was not always easy to stop, and the ban on intercourse soon became a seductive boundary they had fun taunting each other to cross. With this increased intimacy, both began to take better care of their bodies: They went for walks together, exercised more, ate less out of boredom, and soon felt more comfortable with themselves and each other. In subsequent months they experienced more sexual intimacy and pleasure. Maria had not yet attained orgasm but was experiencing more desire and arousal than ever before.

As with Stefan and Maria, particular forms of body work may facilitate increased comfort with the client's own body. Regular physical exercise may improve body image, even in the absence of weight loss. Rather than simply enhancing physical attractiveness, exercise may affect body image through an increased sense of body competence and connection to one's body. Exercise may facilitate a sense of personal ownership of one's body and increased awareness of bodily sensations. Although research on the topic is needed, particular forms of exercise may be most beneficial for addressing body image concerns pertaining to sexuality. For example, yoga combines physical exercise with relaxation (breath work) and mindful awareness, thereby addressing both physical and cognitive aspects of body image concerns.

In some cases clients have developed unrealistic standards for the appearance or functioning of bodies generally or the genitals specifically. Particularly in cultures with a high degree of personal privacy, seeing naked bodies and genitals representative of one's age, gender, and ethnicity may be very rare. Instead, images of professional models and actors may have filled that void, leaving the client feeling inadequate by comparison.

Intervention in such cases may involve homework entailing online searches for images demonstrating the range of bodies and genitals that characterize the population (e.g., amateur erotica, medical photos).

Human nature is such that we more readily compare our circumstances with those who are better off than us (upward comparison) rather than those who are worse off (downward comparison). Part of the value in exposing particular clients to a wide range of images of bodies and genitals is to make explicit that not everyone is thinner, more muscular, or more attractive. Rather than focusing on what could always be better, the therapist may help the client consider what could be worse.

**CASE DISCUSSION**

Claire, a slim and attractive 28-year-old white woman, was initially referred for complaints of vaginal numbness and soreness during intercourse, infrequent orgasms, poor lubrication and mental arousal, and clitoral hypersensitivity. Claire was single but engaged somewhat regularly in casual, often unprotected, sex—generally under the influence of alcohol so as to "get out of her head." Claire was consumed by negative 337

thoughts about how her partners might evaluate her body and "sex appeal" and navigated each sexual encounter in ways to appear as attractive as possible. Rather than avoid sex entirely, Claire frequently had unwanted sex because it was easier than saying

"no."

Claire had struggled with poor body image since her early teens. With numerous younger siblings she had to take care of, Claire reported feeling that it was not okay for her to take up any space, physically or mentally. Not surprisingly, Claire's discomfort with "taking up space" had migrated to the realm of her sexuality. As a result, Claire had learned to disconnect from her own body, both its needs and its pleasurable sensations.

Claire's first experience of sexual intercourse had occurred against her will; he had penetrated without her consent, and she felt she couldn't stop him. This initial experience set the stage for her subsequent pattern of "passive consent" with men. Claire seduced men as a means to feel attractive, then went through the motions of having sex to avoid saying "no," all the while feeling little connection to her own bodily experience.

Early in treatment Claire was surprised to learn how her problematic issues with body, self, and sex were connected. She learned about the detrimental effects of focusing on "unsexy" thoughts and feelings, such as her hatred of parts of her body or fears of her partner's reactions, and that she missed many informative signals (e.g., bodily cues of pleasure and arousal, or signs of anxiety suggesting that she should not engage in the activity at all). Although Claire was aware of intense bodily sensations, she was devoid of accompanying feelings of pleasure—instead she felt numbness or overwhelming hypersensitivity. Lacking the assertiveness skills to improve her situation (e.g., by using lubricants, directing the sexual activity, or stopping altogether), Claire typically experienced vaginal pain and soreness and a lack of interest in sexual activity.

Consequently, Claire used alcohol or drugs to get over the "hump" of anxiety-related reluctance in the face of an impending sexual encounter and to dull her self-conscious thoughts and fears while engaging in sex.

In addition to helping her build a more defined sense of herself, as well as skills in asserting that self, relaxation and mindfulness exercises were taught and practiced as a way of easing her into becoming reacquainted with her own body. Claire was asked to start attending to her bodily sensations (e.g., hunger, anxiety, arousal) as informational signals and not problems to be avoided or smothered. She was encouraged to trust her body, her needs, and her instincts and ultimately to pursue behaviors that represented self-care. Claire found this very difficult and showed much resistance, reporting that she would prefer to be taken care of by others.

Through exploration of her resistance, Claire eventually became more aware of the connections among how she felt about herself, how she treated her body (with regard to drugs and alcohol, food, sex, and sleep), and the kinds of men she attracted. Gradually, Claire began to see that the more she engaged in self-care, the better she felt about herself, and the easier it became to act in her own self-interest in the future. She started to "say no" to sexual activity with men who saw her as little more than their "catch for the night" and began to build meaningful relationships with men who valued her thoughts and feelings. Claire began to see that her body image had very little to do with how she looked.

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As Claire became more self-accepting and assertive, her thoughts about her body became less punitive and all-consuming. She began to experience more pleasure during sex. She asked for more of what she wanted, and she focused more on how it felt to receive it. Her pain disappeared entirely, her arousal levels increased, and she found that she was more orgasmic than ever before. By the end of treatment, Claire had begun to crave real intimacy in the context of a committed relationship, although she still struggled with the inherent vulnerability. Although not there yet, Claire was on the road toward autonomy and loving self-care.

Claire's case illustrates the problems when clients are more focused on analyzing their bodies than actually being in them. Although aspects of Claire's treatment were focused on sexual activity, treatment more generally included bolstering her general self-worth and restructuring her beliefs about herself and her body so that her body was not viewed as her enemy to be avoided or subdued. Direct attempts at behavioral change were met with resistance initially, but creating the safe and supportive space needed to take new steps resulted in slow yet steady progress.

**CONCLUSIONS**

Although body image concerns do not constitute a specific clinical diagnosis, the role of such problems in understanding and improving sexual functioning can be of utmost importance. Research has demonstrated some general factors and issues related to body image concerns during sexual activity, but numerous questions remain. For example, the prevalence of such concerns, in both clinical and community samples, is unclear.

Also, research is needed on the mechanisms and dynamics through which body image concerns affect sexual functioning, including the effects of bodily alteration. More important for clinicians, empirical evaluation of therapeutic strategies and techniques to address body image concerns in the bedroom is lacking entirely. The ultimate goal, of course, is to better serve those clients who seek to improve their sexual lives and require more positive body images to do so.

**REFERENCES**

Annis, N. M., Cash, T. F., & Hrabosky, J. I. (2004). Body image and psychosocial differences among stable average weight, currently overweight, and formerly overweight women: The role of stigmatizing experiences. Body Image, 1, 155–167.

Berer, M. (2010). Cosmetic surgery, body image and sexuality. Reproductive Health Matters, 18(35), 4–10.

Cash, T. F., Maikkula, C. L., & Yamamiya, Y. (2004). "Baring the body in the bedroom": Body image, sexual self-schemas, and sexual functioning among college women and men. Electronic Journal of Human Sexuality, 7.

Crouch, N., Deans, R., Michala, L., Liao, L., & Creighton, S. (2011). Clinical characteristics of well women seeking labial reduction surgery: A prospective study. British Journal of Obstetrics and Gynecology, 118, 1507–1510.

de Jong, D. C. (2009). The role of attention in sexual arousal: Implications for treatment of sexual dysfunction.

Journal of Sex Research, 46, 237–248.

Filiault, S. M. (2007). Measuring up in the bedroom: Muscle, thinness, and men's sex lives. International Journal of 339

Men's Health, 6, 127–142.

Frederick, D. A., Peplau, A., & Lever, J. (2008). The Barbie mystique: Satisfaction with breast size and shape across the lifespan. International Journal of Sexual Health, 20, 200–211.

Goodman, M. P. (2011). Female genital cosmetic and plastic surgery: A review. Journal of Sexual Medicine, 8, 1813–

1825\.

Jones, A. M., & Buckingham, J. T. (2005). Self-esteem as a moderator of the effect of social comparison on women's body image. Journal of Social and Clinical Psychology, 24, 1164–1187.

La Rocque, C. L., & Cioe, J. (2011). An evaluation of the relationship between body image and sexual avoidance.

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Lever, J., Frederick, D. A., & Peplau, L. A. (2006). Does size matter?: Men's and women's views on penis size across the lifespan. Psychology of Men and Masculinity, 7, 129–143.

Littleton, H., Breitkopf, C. R., & Berenson, A. (2005). Body image and risky sexual behaviors: An investigation in a tri-ethnic sample. Body Image, 2, 193–198.

Meana, M., & Nunnink, S. E. (2006). Gender differences in the content of cognitive distractions during sex. Journal of Sex Research, 43, 59–67.

Miklos, J. R., & Moore, R. D. (2008). Labiaplasty of the labia minora: Patients' indications for pursuing surgery.

Journal of Sexual Medicine, 5, 1492–1495.

Moin, V., Duvdevany, H., & Mazor, D. (2009). Sexual identity, body image and life satisfaction among women with and without physical disability. Sexuality and Disability, 27, 83–95.

Montemurro, B., & Gillen, M. M. (2013). Wrinkles and sagging flesh: Exploring transformation in women's sexual body image. Journal of Women and Aging, 25, 3–23.

Morrison, T. G., Bearden, A., Ellis, S. R., & Harriman, R. (2005). Correlates of genital perceptions among Canadian post-secondary students. Electronic Journal of Human Sexuality, 8.

Owens, T. E., Allen, M. D., & Spangler, D. L. (2010). An fMRI study of self-reflection about body image: Sex differences. Personality and Individual Differences, 48, 849–854.

Pascoal, P., Narciso, I., & Pereira, N. M. (2012). Predictors of body appearance cognitive distraction during sexual activity in men and women. Journal of Sexual Medicine, 9, 2849–2860.

Pujols, Y., Meston, C. M., & Seal, B. N. (2010). The association between sexual satisfaction and body image in women. Journal of Sexual Medicine, 7, 905–916.

Sanchez, D. T., & Kiefer, A. K. (2007). Body concerns in and out of the bedroom: Implications for sexual pleasure and problems. Archives of Sexual Behavior, 36, 808–820.

Schick, V. R., Calabrese, S. K., Rima, B. N., & Zucker, A. N. (2010). Genital appearance dissatisfaction: Implications for women's genital image self-consciousness, sexual esteem, sexual satisfaction, and sexual risk. Psychology of Women Quarterly, 34, 394–404.

Stofman, G. M., Neavin, T. S., Ramineni, P. M., & Alford, A. (2006). Better sex from the knife?: An intimate look at the effects of cosmetic surgery on sexual practices. Aesthetic Surgery Journal, 26, 12–17.

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Veale, D., Eshkevari, E., Ellison, N., Cardoza, L., Robinson, D., & Kavouni, A. (2013). Validation of Genital Appearance Satisfaction scale and the Cosmetic Procedure Screening scale for women seeking labiaplasty.

Journal of Psychosomatic Obstetrics and Gynaecology, 34, 46–52.

Weeden, J., & Sabini, J. (2007). Subjective and objective measures of attractiveness and their relation to sexual behavior and sexual attitudes in university students. Archives of Sexual Behavior, 36, 79–88.

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**CHAPTER 17**

The Treatment of Sexual Dysfunctions in

Survivors of Sexual Abuse

Alessandra H. Rellini

**S** exual abuse is not uncommon in the history of sex therapy clients. However, "a therapist should not assume that the sexual dysfunction of an individual with a history of sexual abuse is the result of abuse." With this caveat in mind, Rellini suggests that the possibility of sexual abuse should be treated as a "working hypothesis," and she counsels clinicians to collect sufficient information to determine whether the pattern of sexual difficulties presented by a patient matches the commonly discussed clinical profiles of sexual difficulties in sexual abuse survivors. Rellini critically reviews the literature and notes that the heterogeneity in sexual outcomes as a result of sexual abuse makes generalizations difficult. She also notes that the experience of other forms of abuse (physical and emotional maltreatment and neglect) are perhaps just as important to consider when formulating a treatment plan. While noting that there is little empirical support for the efficacy of the existing various treatment approaches, her review provides important guidelines for conducting sex therapy with men and women who have experienced sexual abuse in childhood.

**Alessandra H. Rellini, PhD,** is Associate Professor in Psychology at the University of Vermont. Dr. Rellini is a Fulbright Scholar, and her research on the psychophysiological responses of women and their treatment implications has been funded by competitive private and government grants. She has over 40 publications, and her work has received numerous awards from the International Society of Women's Sexual Health, the International Society of Sexual Medicine, the Scientific Society for the Study of Sexuality, the Society for Sex Therapy and Research, and the International Society for the Study of Traumatic Stress. Currently, Dr. Rellini serves on the editorial board of the Archives of Sexual Behavior and the Journal of Sexual Medicine, and she is part of the Standardization Committee for the International Society of Sexual Medicine.

Sexual abuse is a common experience among individuals seeking treatment (Sickel, Noll, Moore, Putnam, & Trickett, 2002), and, therefore, it is an experience that we are likely to find in the histories of our sex therapy clients. For example, among 412 married women seeking psychological counseling at a sexual dysfunction clinic, 20% reported a history of childhood sexual abuse (Sarwer & Durlak, 1996). In the larger population, nonpenetrative sexual abuse (i.e., fondling) was reported by 12% of men and 23% of women, and penetrative sexual abuse (i.e., vaginal penetration, anal penetration, and oral sex) was reported by 4% of men and 13% of women (Najman et al., 2005). The experience of abuse among clients varies in terms of age at which the abuse occurred, the relationship with the perpetrator, the types of behaviors that occurred, the frequency of these behaviors, and the clarity of the patients' memories (Rellini & Meston, 2007).

The symptoms that emerge after sexual abuse are heterogeneous, varying greatly between clients and showing a constellation of possible outcomes rather than a specific 341

syndrome (Schloredt & Heiman, 2003). Research has found a significant association between sexual abuse and sexual dysfunctions in both women and men, with sexual dysfunctions being reported by double the number of men who had been abused as compared with nonabused men (Najman et al., 2005). Other disorders are common among these clients, including depression, borderline personality disorder, eating disorders, posttraumatic stress disorder, and other anxiety disorders (Polusny & Follette, 1995). The great variety in types of abuse and in their long-term sequelae creates a challenge in identifying a specific approach that can address the complexity of sexual dysfunctions following sexual abuse. Despite the heterogeneity of symptoms and experiences, accumulating evidence points to overarching themes, risk factors, and mechanisms that are common in the sexual lives of many sexual abuse survivors and that can be used as guiding points when conducting sex therapy with this population.

To facilitate the treatment of sexual dysfunction among individuals with a history of sexual abuse, this chapter reviews the empirical evidence on the types of sexual dysfunction most commonly experienced, the most appropriate assessment methods, and the potential mechanisms of action that link the abuse to sexual functioning. There is only scarce information on the treatment of sexual dysfunction in sexual abuse survivors, but a comprehensive review of the extant literature on clinical studies and on potential malleable targets for treatment will provide guidance to the clinician treating this population. Finally, two case studies that illustrate the complexity of sexual dysfunction in sexual abuse survivors will showcase the limitations of our current understanding of sex therapy with sexual abuse survivors.

**DEFINITION OF SEXUAL ABUSE**

Researchers have adopted a number of different operationalizations of sexual abuse, mostly based on activity-specific criteria (Peters, Wyatt, & Finkelhor, 1986), that is, definitions that rely on an objective description of the abuse, such as behavior(s) that occurred during the abuse, the age of the abuse onset, and the relationship with the perpetrator. Comparing results from studies using different definitions is complicated because it is currently unclear whether sexual abuse can be considered on a continuum, with some types of abuse representing more severe forms, or if some types of abuse are qualitatively different from others. Independently from the categorical–continuum argument, the variance in definitions adopted by researchers makes it hard for clinicians to know when the results can be applied to their clients.

Defining sexual abuse in the therapy room follows different parameters. For the therapist, the patient's perception that he or she was sexually abused is the cornerstone of the definition. This requires the individual to recognize the event as abusive and to label it. This is a relationship-specific definition (Peters et al., 1986). The difference between activity- and relationship-specific definitions is noteworthy because not all individuals who experienced sexual abuse based on behavioral definitions will self-identify as sexual abuse survivors (Rellini & Meston, 2007). Women endorsing the 342


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sexual abuse label are more likely to have experienced more chronic and invasive sexual behaviors (i.e., vaginal penetration from a parent or a parental figure) and tend to have lower sexual functioning than individuals who respond positively to more commonly used activity-specific definitions (Rellini & Meston, 2007). For men, research has shown the tendency to redefine, retrospectively, the abusive experience as normative (Holmes

& Slap, 1998). Both men and women who have been exposed to childhood sexual abuse are stigmatized in our society; they are perceived as victims, weak, and damaged. It is likely that the burden of this stigma may explain the reticence of individuals to identify as sexual abuse survivors. To overcome these limitations, the therapist needs to pay particular attention to using both definitions of abuse when collecting the sexual history of patients: Relationship-specific definitions allow for a more client-centered assessment, whereas the activity-specific definition enables a more detailed review of the important sexual experiences that may have affected the patient's sexuality.

**EPIDEMIOLOGY OF SEXUAL ABUSE AND SEXUAL**

**DYSFUNCTIONS**

Because of the tendency for people not to report sexual abuse, prevalence estimates are conservative (Green, 1996). Rates reported by community studies tend to indicate that approximately 28% of women and 10% of men have a history of sexual abuse prior to age 14 (Loeb et al., 2002; Leonard & Follette, 2002). These rates are slightly lower than they were prior to 1998 but remain alarmingly high (U.S. Department of Health and Human Services, 2003).

The estimate of sexual dysfunction among sexual abuse survivors is complicated to interpret. It is not possible to directly test whether sexual abuse caused the development of sexual problems. Clients who identify as sexual abuse survivors are likely to believe that the abuse has indeed caused sexual dysfunction. However, the fact that child sexual abuse preceded the development of sexual dysfunction and the ethical limitations precluding an experimental study using randomization make inferences based on semiexperimental data the only tool available to understand this relationship.

Correlational studies consistently point to a significant relationship between sexual abuse and adult sexual functioning (Loeb et al., 2002). For example, a review of 38

studies reported that across methodologies, samples, and measures, childhood sexual abuse is a risk factor for adult sexual dysfunction (Neumann, Houskamp, Pollock, & Briere, 1996). Variance in effect sizes is noteworthy, with studies conducted with college students showing smaller effects than studies conducted on the community samples (for a review, see Rellini, 2005). A recent summary of epidemiological studies reported that among a population-based sample across different countries, sexual abuse is positively associated with greater sexual difficulties (Lewis et al., 2010). In a random community sample, 40% of women with a history of childhood sexual abuse had experienced lack of sexual desire in the previous year (Laumann, Gagnon, Michael, & Michaels, 1994).

American women who felt forced to have sex by a man reported lower desire and 343

greater sexual arousal disorder than women with no history of forced sex. For Swedish women, a history of sexual abuse predicted higher numbers of sexual dysfunctions, and the strongest effects were observed for orgasmic dysfunction. For these women, sexual abuse that occurred more than once (chronic) was specifically associated with greater sexual dissatisfaction. In Moroccan women, sexual abuse negatively predicted sexual interest. The data on men recruited from the community showed small effects of sexual abuse on sexual function (Elliott, Mok, & Briere, 2004; Laumann et al., 1994). A study on college students confirmed the small effects and also reported that more severe forms of abuse (i.e., rape) were more strongly associated with sexual dysfunction (Turchik, 2012).

It is important to note that a statistical significance does not mean that all individuals with a history of sexual abuse will develop sexual dysfunctions. Indeed, the effect sizes of these studies are modest, suggesting that many women who experienced abuse are able to develop satisfying sexual relationships and do not experience sexual dysfunctions (Watson & Halford, 2010). In a study conducted on women seeking sex therapy, 37% of women with a history of sexual abuse did not have sexual dysfunctions, and 48% of women with no history of sexual abuse had sexual dysfunctions, highlighting the fact that sexual abuse is neither sufficient nor necessary for the development of sexual dysfunction (Sarwer & Durlak, 1996). Thus a therapist should not assume that the sexual dysfunction of an individual with a history of sexual abuse is the result of the abuse. Moreover, accumulating evidence is pointing to the negative effects of other forms of childhood maltreatment on adult sexual functioning, such as physical abuse and emotional neglect (Schloredt & Heiman, 2003; Rellini, 2005). Sexual abuse is an important aspect of the patient's history that needs to be assessed, and, for individuals who have experienced sexual abuse, the case conceptualization should include sexual abuse. However, the therapist should consider the abuse as part of a working hypothesis while continuing to collect data to assess whether the pattern of sexual difficulties observed in the patient matches the most commonly discussed profiles of sexual abuse survivors. Embracing in haste the assumption that sexual abuse is the problem underlying the sexual dysfunction may cause a negative reaction from the patient, who may not feel understood. Also, this hasty decision may obfuscate other important factors of the sexual dysfunction. For example, a recent study on sexual abuse survivors reported that everyday hassles predicted lower sexual functioning better than the severity of the abuse and the development of posttraumatic stress disorder symptoms, suggesting that daily problems can have more serious effects on sexual function than moderate symptoms of posttraumatic stress disorder caused by the abuse (Zollman, Rellini, & Desrocher, 2013).

Some sexual dysfunctions and sexual problems are associated with sexual abuse more strongly than others. Low sexual desire is one of the most commonly reported sexual dysfunctions in women with a history of childhood sexual abuse. Among women seeking therapy, hypoactive sexual desire disorder was experienced more frequently by those women who had experienced more invasive forms of childhood sexual abuse, such as forced vaginal penetration and the presence of physical force during the abuse (Sarwer & Durlak, 1996). Difficulties in becoming sexually aroused occur frequently in 344

survivors of childhood sexual abuse recruited from the community (Becker, Skinner, Abel, & Treacy, 1982; Fergusson & Mullen, 1999) and from clinical populations (Westerlund, 1992; Becker, Skinner, Abel, & Cichon, 1986). In particular, sexual arousal problems secondary to childhood sexual abuse have been positively correlated with fear of being out of control, with guilt or shame regarding the abuse (Westerlund), with guilt during sexual arousal (Heiman, Gladue, Roberts, & LoPiccolo, 1982), with younger age at the time of the abuse, with repeated incidents of abuse, and with knowing the assailant (Becker et al.). Epidemiological studies indicate that difficulty reaching an orgasm is often reported by women who have experienced sexual abuse (Lewis et al., 2010). A rigorous epidemiological study that utilized a representative random sample of the population reported that both physical and sexual abuse prior to age 12 were associated with sexual pain and that the association was particularly strong when the perpetrator was a parent or parental figure or a sibling (Harlow & Stewart, 2005).

The association between a history of sexual abuse and sexual satisfaction tends to be stronger than the association with sexual function (Leonard, Iversone, & Follette, 2008; Rellini & Meston, 2007), suggesting that clinicians should inquire about sexual satisfaction even if patients report no sexual problems. The fact that sexual satisfaction has stronger effects than sexual dysfunction also has been suggested as evidence that the sexual difficulties of sexual abuse survivors may not be completely captured by the currently available definitions of sexual abuse (Rellini & Metson, 2007). Indeed, sexual abuse survivors report concerns related to their sexuality for which there is no clear DSM diagnosis. Examples of such concerns include promiscuous risky sexual activities that are perceived as out of the patient's control, unwanted sexual abuse fantasies (Maltz, 1992; Wilson & Wilson, 2008), and difficulty trusting one's partner (DiLillo et al., 2009).

The sexual dysfunctions for men who experienced sexual abuse have received limited attention in the literature, partially because only recently have studies have focused on men. Among 302 male college students, 21.7% reported unwanted sexual contact, 12.4%

experienced sexual coercion, and 17.1% reported rape1 (Turchik, 2012). Men who reported rape experienced more sexual dysfunctions than men who did not experience any type of unwanted sex; however, the measurement of sexual dysfunction was quite primitive (one item not previously validated), which prevents any inference of the type of sexual dysfunction experienced by these men.

**ASSESSMENT**

Because of the negative connotations associated with the "sexual abuse" label, assessment may be more effective if the therapist is careful about the words utilized. In our research and clinical work we use one of the following opening sentences to begin the discourse: "Have you ever been in situations in which you were forced or coerced to engage in sexual activities?" or "Have you ever engaged in sexual activities against your will?" No matter how careful the wording selected to begin this conversation, some 345

clients will adamantly deny any unwanted sexual experiences in the beginning of the interviews but will end up disclosing sexual abuse by the end of the interview. To provide an illustration, a woman was almost done with her assessment interview when she revealed that her first orgasm occurred when she was 10 years old through manual stimulation initiated by her uncle, who was 30 years old at the time. When asked whether she felt forced or coerced at the time, she paused and then answered positively (despite having previously denied experiencing abuse).

There are several reasons why clients may not reveal sexual abuse in the beginning interview. First, they may not see the experience as abusive, and this may be particularly true for men, who are socialized to interpret any sexual offer as a confirmation of their masculinity. Also, men are likely to report that the abuse led to pleasant physical sensations, and this may add to the confusion (Najman et al., 2005). For the woman in the preceding example, the fact that she reached orgasm during the event precluded her from labeling the event as abuse, because she experienced pleasure. Second, the perpetrator may have seduced the child and convinced him or her that the sexual behavior was a form of love. Usually, this dynamic is most common in intrafamilial abuses. Third, the patient may not feel comfortable talking about these events with the interviewer, who is still a stranger. For this reason, we ask about sexual abuse toward the end of the assessment interview, after the client has had the opportunity to see us respond in a supportive and nonjudgmental way.

Asking questions about past abuse is an important step in the history taking for all clients, independently from the response, because it sends the message that the therapist is open to listen and that it is okay to bring this information into the therapy room. A thorough assessment should also include questions about forms of abuse other than sexual (i.e., physical abuse, physical neglect, emotional abuse, and emotional neglect).

Given that childhood sexual abuse is often accompanied by other forms of abuse and that these types of abuse can affect sexuality, a comprehensive assessment should include, at minimum, questions about the family environment in which the patient grew up. Interview questions can be supplemented with the Childhood Trauma Questionnaire (CTQ; Bernstein, Fink, Handelsman, & Foote, 1994), a widely utilized scale that offers clinical cutoffs to identify the severity of abuse that is considered clinically meaningful. The CTQ is composed of six subscales, five of which are reliable and valid for clinicians and researchers: Physical Abuse, Sexual Abuse, Emotional Abuse, Physical Neglect, and Emotional Neglect.

Important details of the abuse that could explain underlying patterns of the sexual dysfunction include the following: age of abuse onset, type of behaviors during the abuse (e.g., penetration behaviors), age of and relationship with the perpetrator (e.g., family member or parental figure, acquaintance, boyfriend, or stranger), frequency of the abuse (e.g., isolated incident or chronic). Other details that may have an impact on the experience of the patient include the following: Was the patient the only one who was victimized? Did the patient reveal the abuse to someone he or she trusted? What was the response of the person who was told about the abuse?

Although less discussed in the literature, sexual abuse during adulthood perpetrated by a partner can also have negative effects on sexual function. Thus questions about 346

unwanted or forced sexual experiences within a dating or committed relationship are important. In cases when the patient reveals forced sexual activities by a partner, the therapist should inquire about experiences of physical abuse, because sexual abuse often occurs along with physical abuse within a relationship, and studies have shown that the negative effects of combined physical and sexual abuse are more severe than the effects of physical or sexual abuse alone (Katz, Moor, & May, 2008).

Assessment of sexual function in sexual abuse survivors should follow the normal protocol that is utilized for all clients. In my clinic, we assess severity of the main sexual dysfunction symptoms and sexual satisfaction using questionnaires such as the Female Sexual Functioning index (FSFI; Rosen et al., 2000), and the Sexual Satisfaction Scale (SSS; Meston & Trapnell, 2003). In addition, we measure the mechanisms targeted in therapy, such as the Cues of Sexual Desire (McCall & Meston, 2006) and the Sexual Excitation and Sexual Inhibition Index—Women (SESI-W; Graham, Sanders, & Milhausen, 2006). The Dyadic Adjustment Scale (DAS; Spanier, 1976) is also an important scale that we monitor throughout treatment to ensure that improvements in sexual function are corresponding to improvements in dyadic adjustment. A complete review of questionnaires for the assessment of sexual dysfunction is available (Giraldi et al., 2011). In compliance with our goal to provide evidence-based practice, the assessment does not end after the first two sessions. We ask clients to complete the scales assessing targeted mechanisms on a monthly basis, and every 4 months we administer the scales assessing symptoms and sexual satisfaction. We utilize these tools to redirect the treatment goals in case we fail to see the expected changes in symptoms or in case the client is showing a significant drop in other areas we are monitoring. In particular, for sexual abuse survivors, it is important to continue monitoring psychiatric symptoms that are comorbid with sexual dysfunction.

**COMORBIDITY**

The high comorbidity of sexual abuse with psychiatric conditions requires a comprehensive understanding of the overall picture of the disorders and dysfunctions affecting the individual. A complete description of trauma-related problems goes beyond our scope; however, it is important to acknowledge the value of a comprehensive assessment of all psychiatric disorders. At this time, it remains unclear whether psychiatric disorders, such as depression, posttraumatic stress, and eating disorders, should be addressed before sexual dysfunctions. To date, only one study reported data relevant to this question (Schnurr et al., 2009). In this randomized clinical outcome study, 246 women received either prolonged exposure or supportive therapy (present-centered therapy) to treat posttraumatic stress disorder. Unfortunately the sexual measure was not specific to sexual dysfunction (i.e., the scale included items on negative thoughts during sex, feelings of shame and guilt during sex, and no items addressing sexual desire or difficulties becoming sexually aroused or reaching orgasm); thus interpretations of the findings need to be cautious. Prolonged exposure 347

significantly reduced posttraumatic stress disorder symptoms and sexual problems at posttreatment, but only when all participants were included in the analyses. When only those individuals who reported significant sexual problems at pretreatment were included in the analyses, the treatments showed no improvements in the sexuality of these women. Thus, for individuals with posttraumatic stress disorder and with mild sexual problems, alleviating posttraumatic stress symptoms may be enough to alleviate their sexual symptoms. However, for individuals with more severe sexual problems, simply reducing nonsexual symptoms may not be enough. More studies are needed on individuals with other types of psychiatric conditions and different levels of severity of symptoms, as well as on individuals both in relationships and single, to provide a more comprehensive picture of the best way to approach the treatment of sexual dysfunctions comorbid to other psychiatric diagnoses in women with a history of child sexual abuse (CSA).

**THEORETICAL MODELS**

Although a number of articles and books have been written on how to treat sexual dysfunctions in sexual abuse survivors, very little empirical evidence is available on the efficacy of such approaches. In response to the scarce information available on this topic, researchers have gone back to the drawing board and focused on proposing and testing theoretical models to identify treatment-malleable factors that influence sexual function in survivors of sexual abuse. Among the theoretical models proposed to explain the sexuality of sexual abuse survivors, Finkelhor and Browne's (1985) four traumagenic dynamics model has accumulated the most evidence. The four dynamics proposed are traumatic sexualization, betrayal, stigmatization, and powerlessness. Although this model has been mostly proposed to explain the hypersexuality of women exposed to childhood sexual abuse, it is feasible that each of these dynamics alters a child's cognitive-emotional orientation to the world, which may affect the view of the sexual self (i.e., sexual self-schema). The first dynamic, traumatic sexualization, refers to conditions of the abuse under which a child's sexuality is shaped in developmentally inappropriate and interpersonally dysfunctional ways. For example, sexually abused children are often rewarded by their offenders for engaging in sexual behavior. Through this, the child may have learned to use sexual behavior as a means for manipulating others to get their own needs met. The second dynamic, betrayal, affects developing sexual schemas by teaching children that they cannot trust people, even those on whom they depend. Stigmatization, the third dynamic, can affect sexual schemas via the negative messages that lead to a sense of the self as evil, worthless, and shameful. The fourth dynamic, powerlessness, occurs when the child experiences having her or his body space repeatedly invaded against her or his wishes. This intrusion affects the ability to be assertive, which can lead to an imbalance in power in future romantic relationships and may translate into dysfunctional relationship dynamics. The traumatic sexualization model by Finkelhor and Browne (1985) has been shown to be associated 348

with promiscuous sexual behaviors and the high HIV/STI infection rates among individuals with a history of childhood sexual abuse. However, to date, the ability of this model to explain problems with low desire, difficulties becoming sexually aroused, and reaching orgasm remain speculative.

Trauma-focused models have also been utilized as a conceptualization frame for several approaches to the treatment of sexual dysfunction in survivors of sexual abuse.

These models are based on the assumption that sexual abuse at an early age teaches individuals to respond to sex with fear. The fear response, conceptualized as the reexperiencing of emotional, physiological, and cognitive responses that occurred during the trauma (including dissociation), may be specific to aspects of the situation or the perpetrator—for example, a woman who experiences fear during sex with partners who have beards but who is comfortable with men who are well shaved. The reexperiencing of the fear, typical of posttraumatic stress disorder, may also be associated with internal sensations so that the trigger for the fear response may be feeling sexually aroused. The underlying assumption is that a fear response is expected to inhibit normal sexual function.

Despite the potential usefulness of a trauma model, some major limitations need to be acknowledged. First, the underlying assumption that, for all individuals, the sexual abuse was traumatic does not apply to all survivors of CSA. Trauma is defined as an experience that caused sudden feelings of horror, fear for one's life or integrity, and hopelessness. Although many CSA survivors often report such feelings, many do not (Rellini & Meston, 2007). Especially for individuals with whom coercion was used, the conceptualization of the abuse as traumatic may not apply. Second, this model assumes that anxiety and fear may inhibit sexual responses. Research has shown mixed results on the effects of negative affect on sexual responses, with some studies showing that anxiety actually facilitates sexual arousal (Peterson & Janssen, 2007). A study found that negative affect prior to exposure to sexual stimuli was indeed higher in women with a history of CSA as compared with women with no history of abuse. Also, women with a history of CSA have lower physiological sexual arousal responses to sexual stimuli shown in the laboratory. However, negative affect did not predict sexual responses in women with a history of CSA (Rellini, Elinson, Janssen, & Meston, 2008). Despite these limitations, it is feasible that some adult women with a history of CSA may experience a stress response during sex. Indeed, female CSA survivors showed an increase in cortisol responses (a hormone released during stress) during exposure to sexual stimuli (Rellini, Hamilton, DelVille, & Meston, 2008), suggesting that, for these women, sexual stimuli acted as stressors. It is important to note, however, that the increase in cortisol was not found in all women with a history of CSA and that it remains unclear why some did and others did not show the cortisol response.

An important factor that emerged from this study is that the increase in cortisol was independent from self-reports of anxiety or fear experienced during exposure to the sexual stimuli. Thus women showing a physiological response that suggests an anxiety response did not necessarily report subjective feelings of anxiety or fear. This may indicate that not all dysfunctional sexual processes may operate at the conscious level. A woman may report feeling comfortable and open about sexuality, but her body may 349

carry the scars of her past experiences, and this may cause her physiology to reject sexual activities. Other evidence that the impairment experienced by women with a history of CSA may occur underneath the consciousness level comes from a study on implicit associations (Rellini, Ing, & Meston, 2011). Women with a history of CSA showed a weaker association between sex and pleasure as compared with women with no history of abuse. Interestingly, both women with and without a history of sexual abuse visualized romance (e.g., a candlelight dinner) as pleasant. Also, both groups reported having positive feelings toward sex. The discrepancy between implicit (i.e., automatic) and explicit (i.e., conscious) attitudes toward sex is an obviously important point to take into consideration during therapy, as approaches designed to modify cognitive distortions or dysfunctional beliefs may not be useful when the impairment occurs at the implicit level. On the other hand, behavioral approaches designed to expose the woman to sexual stimuli and experience positive and pleasant sexual responses may be more effective at teaching more functional sexual responses.

**APPROACHES TO TREATMENT**

As previously indicated, despite the existence of many psychological interventions to treat sexual dysfunction in sexual abuse survivors, very few have empirical support for their efficacy. Most of these interventions focus on helping the client becoming more assertive, on relaxation training, on stopping the "reenactment" of the abuse during sex with the partner, and on challenging beliefs about the abuse (Bolen, 1993). Recently, mindfulness-based programs have shown promising results for the treatment of sexual arousal dysfunction in women, and effects are particularly strong for individuals with a history of sexual abuse (Brotto, Basson, & Luria, 2008). Mindfulness is an approach rooted in the Eastern tradition of meditation. The main goal of mindfulness is to teach the individual to be present in the moment, fully and nonjudgmentally. Brotto and colleagues were the first to test the efficacy of this treatment for sexual dysfunction in women, and they specifically selected exercises that helped patients to practice focusing on sensations in the present moment (Brotto et al., 2008). For example, one of the exercises asked women to hold a raisin in their mouths for 5 minutes while focusing on the sensations associated with the raisin. Another exercise instructed women to perform a body scan, carefully focusing on the sensations first in their toes and then slowly up their bodies to their heads. During these exercises, distracting thoughts are likely to intrude and affect the ability to be in the present moment. The main directions provided by the therapist are to notice the distracting thoughts and to redirect one's attention to the task, without judgment. It is indeed this constant redirection of the mind to the present moment that helps individuals become more aware of the here and now and more in tune with their sensations in the moment (for more information on this approach, see Brotto & Luria, Chapter 1). In a recent study, mindfulness was compared with cognitive-behavioral therapy (CBT) for the treatment of sexual dysfunction in women with a history of CSA (Brotto, Seal, & Rellini, 2012). Mindfulness increased 350

subjective sexual responses during a laboratory sexual psychophysiological assessment and also modified the relationship between physiological and subjective sexual responses to the erotic videos used in the assessment. Specifically, after treatment, a lower physiological arousal was needed to achieve a higher subjective state of sexual arousal. To the extent that physiological sexual responses can facilitate sexual arousal by providing feedback to the individual, the fact that less physiological sexual arousal was needed to reach higher levels of subjective sexual arousal indicates that mindfulness increased the sensitivity of the sexual response.

Theoretically, mindfulness in the bedroom could positively affect sexual arousal through two paths. First, it could reduce distracting thoughts, which can have an inhibitory effect on sexual arousal. Second, it could increase focus on physical sensations, thereby increasing arousability. These hypothesized paths are in line with the dual-control model of sexual arousal proposed by Bancroft and Janssen (2000), purporting that sexual arousal is the product of the balance between inhibitory and excitatory forces.

Larger studies with control groups are needed to test whether this promising treatment is more effective in survivors of sexual abuse. It is feasible that one of the inhibiting factors affecting sexuality in women with a history of sexual abuse is distraction caused by intrusive thoughts about the abuse. Clinicians have indeed reported that many survivors of sexual abuse report dissociation symptoms during sex.

To provide an example, a patient explained that she felt like she was floating above the bed during sexual activities with her partner. Another, revealed she would "get out" of her body and hide in the corner of the room, leaving her body behind. For other women, the dissociating aspect may not be as extreme. For example, many women with a history of sexual abuse mention that they cannot focus on the present moment and become distracted, but cannot pinpoint the thoughts that distract them. To date, it is unknown whether these distractions and tendencies to dissociate during sex are more pronounced in survivors of sexual abuse as compared with women with no history of abuse and whether dissociation is directly affecting sexual responses in these women. In my laboratory, a recent study showed that, although dissociative symptoms were more prevalent in survivors of sexual abuse, these symptoms were not associated with greater sexual arousal problems in individuals with a history of sexual abuse (Bird, Seehuus, Clifton, & Rellini, 2012). More studies are needed to investigate the complex relationship between dissociation, distractions, and sexuality before we can have a good understanding of the impact of sexual abuse on these cognitive processes.

No study, apart from Brotto, Seal, and Rellini's (2005) recent investigation, has compared the efficacy of different treatments for sexual dysfunction in sexual abuse survivors. However, a number of studies have pointed to treatment-malleable factors specific to sexual dysfunction in sexual abuse survivors. In particular, studies have focused on sexual self-schemas, and more recent studies have addressed emotion dysregulation and experiential avoidance.

Scholars have purported that trauma affects one's sense of self (Dutton, Burghardt, Perrin, Chrestman, & Halle, 1994), a construct commonly referred to as self-schema.

Self-schemas are conceptualized as blueprints utilized by the individual to filter, 351

organize, and understand self-relevant information. Schemas also play a key role in the regulation of cognitions, affect, and behaviors (e.g., Kihlstrom & Cantor, 1983; Markus

& Zajonc, 1985). The role of sexual self-schemas in sexual problems can be understood within the theoretical model proposed by Barlow (1986) and previously introduced to explain mindfulness and sexual arousal functioning. In this model, the distraction from sexually arousing stimuli is caused by anticipatory anxiety, which is the product of negative expectations (e.g., "My partner will think there is something wrong with me because I cannot become aroused"). The anxiety causes the attention to shift away from sexually relevant cues (the distraction addressed during mindfulness treatment).

Eventually, a belief that the experience is doomed to fail may be transformed into a belief about the self, which becomes a part of the sexual self-schema (e.g., "I am sexually inadequate"). Empirical studies identified three main categories of schemas: romantic/passionate, open/direct, and embarrassed/conservative.

Studies have shown that women with a history of childhood sexual abuse hold significantly different schemas than do women with no history of abuse. Specifically, sexual abuse survivors perceive themselves as less romantic/passionate and more embarrassed/conservative (Meston, Rellini, & Heiman, 2006; Rellini & Meston, 2011).

Studies on the implicit (nonconscious) association between schemas and sex have corroborated that women with a history of sexual abuse perceive sex as less pleasant than women with no history of abuse (Rellini, Ing, & Meston, 2011), providing further support for the idea that expectations and attitudes toward sex are different for survivors of sexual abuse.

The effects of schemas on sexual function may be mediated by the impact of schemas on mood. For example, initial evidence indicates that feeling less romantic and passionate is associated with greater depressive symptoms and that these symptoms mediate the lower sexual satisfaction observed in sexual abuse survivors compared with women with no history of abuse (Meston et al., 2006). Moreover, it was a combination of less romantic/passionate and more embarrassed/conservative sexual self-schemas that mediated the relationship between a history of sexual abuse and greater negative affect in anticipation to sexual stimuli (Rellini & Meston, 2011). From these findings, we can deduce that therapy might be more effective with sexual abuse survivors if it addressed sexual self-schemas. Especially an approach aimed at increasing the perception of the self as passionate and romantic and reducing a sense of embarrassment and conservative attitudes toward sex may be most effective for these women.

Unfortunately, to date, no information is available on the benefits of a treatment targeting sexual self-schemas in sexual abuse survivors; although a number of validated manuals are available for the modifications of schemas, such as schema-focused therapy.

Briefly, this approach is a modification of cognitive-behavioral therapy and was developed to treat individuals with symptoms that are characterological and therefore more stable and harder to modify (for a comprehensive description see Young, Klosko,

& Weishaar, 2003). The treatment is divided into two stages: assessment (further divided into identification, activation, and conceptualization) and change. Cognitive techniques within this approach are utilized to allow the patient to explore new ways to respond to targeted situations. The underlying assumption of this therapeutic approach 352

is that acting against a set schema allows the individual to accumulate information about herself that contradicts the original schema, thereby promoting a change in her self-view.

In addition to self-schemas, emotion dysregulation is becoming the center of attention of many scholars studying and testing treatments for a variety of psychiatric conditions. Emotion dysregulation is commonly referred to as difficulties in recognizing and tolerating negative emotions and in self-regulating affective states and lacking of self-control over affect-driven behaviors (Carver, Lawrence, & Scheier, 1996; Gross, 1998). The ability to recognize, tolerate, and modulate negative affect has been the core of exposure treatments and, more recently, the focus of acceptance-based treatments, including dialectical behavior therapy (Linehan, 1993), mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2001), acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), and integrative couple therapy (Jacobson & Christensen, 1996). The underlying assumption is that difficulty regulating emotions leads to experiential avoidance, or the willingness to engage in potentially harmful or dysfunctional behavior to avoid experiencing internal states, including emotions, physical sensations, thoughts, memories, and so forth. Specific to sexuality, initial studies have shown evidence for a significant relationship between low sexual satisfaction and high emotional dysregulation, including the tendency to avoid experiences, in trauma survivors (Rellini, Vujanovic, Gilbert, & Zvolensky, 2011; Rellini, Vujanovic, & Zvolensky, 2010; Staples, Rellini, & Roberts, 2012). Specifically for women with a history of childhood sexual abuse but not for women with no history of abuse, the tendency to avoid interpersonal closeness and avoid emotional involvement predicted orgasm functioning (Staples et al., 2012). The lack of longitudinal data on the development of sexual problems in relation to the tendency to avoid experiences prevents specific directional interpretation of these findings. However, one plausible interpretation is that trauma survivors who allow themselves to have corrective sexual experiences and do not shield themselves from the emotional experiences that occur during sexual activities are able to develop satisfying sexual experiences. To this end, it may be a helpful treatment goal to teach clients with a history of sexual abuse to be more in touch with their emotions, reduce avoidance of internal sensations, and increase satisfying sexual activities with partners.

It is also interesting to note that studies on the ability to understand and modulate emotions showed that lower sexual satisfaction but not lower sexual function was correlated with higher emotion dysregulation (Rellini et al., 2010; Rellini, Vujanovic, Gilbert, & Zvolensky, 2011). It is feasible that trauma survivors with emotion dysregulation may negatively interpret sexual experiences, even if their ability to become sexually aroused, have an orgasm, and experience sexual desire is normal. Alternatively, it is also feasible that the low sexual satisfaction experienced by trauma survivors may not be captured by the currently available diagnoses for desire, arousal, orgasm, and pain disorders (Rellini & Meston, 2007). Clinical experience and the literature suggest that individuals with a history of sexual abuse frequently report hypersexuality (i.e., numerous sexual partners, one-night stands, and unprotected sexual relations; Loeb et al., 2002). Indeed, hypersexuality is more strongly associated with a history of sexual 353

abuse than any other sexual dysfunction (Rind, Tromovich, & Bauserman, 1998). It is possible that a feeling of being sexually out of control may cause distress to individuals with a history of sexual abuse. This may explain why it is not just the difficulties in experiencing desire, becoming sexually aroused, or reaching orgasm that preoccupies these patients but mostly the feeling that sex is out of their control. Although there is no empirical evidence in support of this hypothesis, the case study of Louise and Frank, described later, provides an illustration of how avoidance of sexual activities and hypersexuality coexist in patients with a history of sexual abuse seeking sex therapy. The first case (Myla) shows how sexual abuse can affect all relationships of the client, including the trusting relationship with the therapist.

**CASE DISCUSSIONS**

**Case 1: Myla**

Myla's case is a good illustration of the importance of considering how the abuse may affect the patient's ability to develop not only romantic relationships but also therapeutic ones. Myla was referred to individual therapy from our clinical outcome study because she did not meet inclusion criteria but was distressed by what she defined as low sexual desire. Myla was a slim, attractive woman in her 30s. She was a stay-at-home mom, although her children (5 and 8 years old) were now old enough so that she was considering starting a career again. She had been married for 12 years to a successful businessman. Myla had experienced a drop in sexual desire ever since her first child was born, but she had decided to remain with her husband for the sake of her children. However, now that her children were older, she was considering alternatives, and this was her "last attempt to make things work." Myla felt that the core of her marital problems was a feeling of distance from her husband and believed that reintroducing sexual activities with him would fix the problem. Myla had had sex with her husband only once in the previous 12 months. She scored below the clinical cutoff on the Female Sexual Functioning Index (FSFI-Total = 20), and on the Cues of Sexual Desire scale (McCall & Meston, 2006), she scored very high in the romantic/implicit (R/I), love/emotional bonding (L/E) and visual/proximity (V/P) factors (R/I = 3.4; L/E =

3.5; V/P = 3.6) as compared with the norm of individuals with and without hypoactive sexual desire disorder. However, her score on Erotic/Explicit (E/E = 3.4) was in the range of the hypoactive sexual desire disorder population. These scores suggest that Myla identified a number of things that activated her sexual desire, with cues in the relational realm captured by R/I and L/E (e.g., Feeling a sense of security in your relationship, Having a romantic dinner with a partner) being particularly important for her. The first working hypothesis was that the lack of romantic and love-related cues in her daily life could be a factor in her low desire. Myla did not find explicit sexual cues (e.g., Sensing your own or your partner's wetness, lubrication, or erection; You experience genital sensations—e.g., increased blood flow to genitals) to be arousing. Her scores on 354

the SESI-W (Graham, Sanders, & Milhausen, 2006) were all within one standard deviation from the norms provided by the authors, except for the factor Relationship Importance (e.g., If I think that a partner might hurt me emotionally, I put the brakes on sexually).

During a semistructured clinical interview, Myla reported that she found her husband attractive and felt love toward him, although she was unhappy with her relationship and did not feel she could trust him. On the DAS (Spanier, 1976), her scores showed that she felt that she and her husband agreed on many areas of their lives, including finances, parenting, and how to handle the in-laws (DAS consensus = 49).

However, the scores for cohesion and satisfaction were very low, 10 and 25, respectively.

Moreover, the total score on the DAS was 90. Considering that the cutoff for couples experiencing distress is 101 (Spanier, 1976), Myla showed a relatively low score. The average DAS among divorced couples is 70.7, and for married couples it is 114.8; thus Myla fell right in the middle, indicating that, although her marital difficulties caused much distress, they were not quite at the level of individuals who have sought a divorce.

An encouraging sign was Myla's response to the last item of the DAS: Which of the following statements best describes how you feel about the future of your relationship? To which she answered, "I want very much for my relationship to succeed, and will do my fair share to see that it does."

Myla's problem was not just low sexual desire; Myla engaged in masturbation once a week and also experienced feelings of sexual desire when in the presence of other attractive men or when watching sensual movies. During masturbation, she felt sexually aroused, noticed an increase in lubrication, and 7 out of 10 times she masturbated to orgasm.

Myla denied any history of sexual abuse during the semistructured interview and on questionnaires specifically geared toward the assessment of abuse. As therapy progressed, it became evident that Myla's decision to withhold information about her past abuse had common roots with her current sexual problems.

Based on these data, I proposed to Myla to start couple therapy to address the underlying relationship blocks that affected her desire, but she was adamantly against this option because she had already completed 6 months of couple therapy and felt it did not help. Myla believed that increasing her ability to experience sexual desire would lead to more sexual activities, and this would solve their inability to feel connected.

Psychoeducation was introduced to help Myla understand that, in the presence of relationship problems, increasing sexual functioning in one of the partners does not necessarily lead to greater sexual satisfaction (Stephenson, Rellini, & Meston, 2013).

However, Myla insisted that she wanted to have individual sex therapy to fix her level of sexual desire.

The therapy selected for this case was a combination of mindfulness and schema work. Treatment goals included a greater sense of desire for sexual activities with her husband, greater awareness of and ability to express sexual likes and dislikes during sex with him, and greater frequency of partnered sexual activities initiated by the client.

After two sessions dedicated to psychoeducation on the sexual dual-control model (Janssen & Bancroft, 2007) and the female sexual response, the therapy moved toward 355

exploration of sexual self-schemas.

One of the assignments designed to increase Myla's awareness of her schemas consisted of writing her sexual and relationship history. One year after giving birth to her second child, she started masturbating more, but, right when she was considering initiating sex again with her husband, she discovered that he had lied to her about his use of alcohol. Myla and her husband had decided to give up alcohol to raise their children in an alcohol-free environment. This decision was important for Myla and her husband because of the history of alcoholism in both families. Myla felt betrayed and insulted when she found that her husband had been drinking behind her back. She felt angry at him for thinking she was so "stupid" to not notice. They had an explosive argument (7 years before therapy), and Myla never forgave her husband.

Her narrative of her sexual development was otherwise unremarkable, which made her report of sexual abuse a few sessions later even more shocking. Although the treatment plan called for work on problematic schemas, Myla's schemas did not need this intervention; thus we went back to assessment mode to determine whether the problem was in the lack of sexual pleasure experienced during sex or due to difficulty communicating sexual likes and dislikes (after all, Myla had not had sex with her husband in a long time). At the session following the assignment, Myla reported that she had not completed the sensate focus exercises. Through a behavioral analysis of the obstacles encountered in completing the exercise, it emerged that she never fully committed to engage in the sexual activities. Indeed, she knew she was not going to complete the exercise the minute she left the therapy room. After much exploration, Myla realized that she really did not want to engage in sexual activities with her husband because having sex with him and experiencing pleasure during sex with him would have meant that she forgave him and that it was OK for him to think she was "so stupid" as not to find out he was drinking. This is the point in therapy where her history of abuse emerged: She had been sexually abused by an uncle when she was 12 years old. When asked to explain the reasons for not coming forward with this information earlier on, she said that she may have forgotten or did not recall any direct question about this.