Schwartz M (2020) Developmental Psychopathological Perspectives on Sexually Compulsive Behavior. JSM Sexual Med 4(8): 1059.

The developmental factors contributing to sexually compulsive behavior, paraphilias, and sex offender behavior have been poorly delineated [1]. Worse still, what little has been written on the subject is stuck in a conceptual quagmire.

“It is important to note that our theory suggests that a failure to attain intimacy in relationships is but one aspect of the development and maintenance of sexual deviance. We have, at other times, pointed to sociocultural factors [2], the role of pornography [3], biological processes and interaction as well as conditioning [4] and developmental experiences [2,5].”

In other words, many different factors may contribute depending on the clients. How best to embrace and incorporate these factors into a successful treatment approach? The robust conceptual frame of developmental psychopathology may provide the answer

This approach departs from traditional models that identify unidimensional static “causes” of a disorder [6] and instead charts a developmental trajectory for a symptom within the evolution of the individual attempting to adapt [7]. Critical life events precipitate positive or negative life experiences, or circumstances then mitigate them, thereby increasing or decreasing the degree of disability and the likelihood of symptom emergence. Adaptation continually unfolds within an ever-changing context, allowing for developmental deviation or amelioration of an ontogenetic process [8]. Maladaptation can result from different developmental pathways, probabilistically related to disturbance. Individuals beginning on similar paths may diverge, manifesting different symptoms of psychopathology. Thus, despite marked initial deviation, the capacity to rebound is mediated by prior adaptation and evolves over time within the total framework of developmental influence. To treat the client according to this model, the clinician must endeavor to construct or reconstruct all contributing biological, psychological, and social trends from an individual’s past and present to understand how they coalesce into the individual’s current functioning.

The mother’s attunement to the child facilitates the experience-dependent maturation of the neurological hard wiring of the child’s brain during this critical early period. Maturation proceeds hierarchically from the lower limbic emotional structures, through the midbrain and up to the structures of higher cortical function [9]. Therapists are now discovering [10] that strong affect is the window into “deep structure” in which core beliefs (schema) and unconscious internal working models shape the “love maps” [11] during the first ten years of life. More attention is currently being paid to the attachment between infant and caretakers in the first years of life, laying down a permanent structure for later pair bonds, outlined in large part by the original writings of John Bowlby.

The importance of viewing development through the lens of attachment theory is that sexual disorders can be better understood as a manifestation of courtship, attraction, love, affection, and intimacy. Without adequate parenting, a child may grapple with an “increased” appetite for nurturing and caretaking, while simultaneously adapting to expectations of being hurt, disappointed and abandoned by dismissing such needs. In this way, needs themselves become “dangerous” and associated with fear. One solution to both needing and fearing is paraphilia. The person becomes aroused by pictures or objects, rather than people; the fetish distances and provides a ritualistic illusion of control, in what would otherwise be a terrifying situation. The object will not abandon or hurt, and yet it provides comfort. Preoccupied individuals will turn to more and more sex to fill their needs for caretaking; avoidant individuals will use sexual activity to be alone and disconnect while still feeing alive and experiencing affective respite from emptiness through intense release. Disorganized individuals typically flip-flop between the two extremes [12].

Sexually compulsive individuals actively maintain the “rules of attachment” laid down in infancy. Some deny their unmet emotional needs by distracting themselves with sexual obsession. Others are consumed with doubt of the partner’s love and require sex as constant reassurance they are loved. Sexual behavior ultimately functions to preserve unaltered internal working models of attachment.

To change these cemented patterns, the primary focus of treatment needs to be on facilitating the development of secure attachment with self and others. This begins with an attuned relationship with the therapist so that a therapeutic focus on changing internal working models can be maximally effective.

Disorganized attachment results in individuals turning to sexual objectification of self and others as an active survival strategy to cope with the inability to articulate internal states and use other people for comfort. Clients unconsciously turn to sex in to shore up and justify preexisting expectations of unresponsive and unpredictable caring. They actively use paraphilia to avoid anticipated rejection in intimate relations. Disorganized attachment leads to the development of segregated dissociated internal working models of self and the attachment figure. The individual states, “I don’t know who I am,” “I feel like an imposter,” or “I’m really bad, but pretend to be good.” This is starkly exemplified by the priest who has been a “devoted servant of God,” but who molests children or has chronic affairs with church wives, or the family man who has routine homosexual liaisons or engages repetitively in other “sexual addictive” forms of acting-out. Similar to the childhood experience of the mother who was both kind and mean, the person with disorganized attachment may perceive closeness with all potential partners as necessary and distressing, leading to deep-seated ambivalence to courtship and numbing of feelings of affection.

Within the developmental model of affectional systems, critical capacities must be assimilated, or compensating symptoms may emerge. These capacities include affect regulation, social skills (and perceived efficacy in attempting to negotiate social relationships), and empathy and compassion for others (and capacity for accurate attunement regarding cues from others). In other words, the client must begin to know the mind of self, the mind of others and to make meaning of the world around them. These structural capacities make up the stage on which psychological dramas unfold [13]. They are the targets of development-based psychotherapies. It is critical to dissect the structural deficits that occur with abuse and neglect and repair them with cognitive-affective-behavioral therapies.

At the core of a person’s capacity to bond is self-empathy and self-care. Without validating caretakers, the individual does not internalize a caring relationship with self. As a result, modes of processing and organizing information (including affects) unfold to make these beliefs self-perpetuating. These modes ultimately organize an individual’s range and type of interactions, constraining possibilities for new learning about intimacy. Such difficulties sometimes cause sex offenders to be described as “fixated:” structurally stuck at child and adolescent stages of development and fearful of adult relationships and responsibilities. This description can accurately be applied to all manifestations of disorganized attachment.

The self comes to exist in the context of others, within an aggregation of experiences of the self in relationship. Invariant aspects of the self and others in relationship are abstracted into what Bowlby called “internal representational models.” New experiences are then absorbed into earlier representations, creating and maintaining an individual who is distinct from others. The internal working models of sexual compulsives are filled with self-hatred and the need to compensate by pretending to be powerful, effective or competent. This imposter imbalance creates anxiety. Eventually the uncontrolled sexual behavior allows him or her the relief of being caught and punished.

Attachment deficits in the first year of life typically lead to self-cohesion difficulties, leaving the individual vulnerable to fragmentation. Epstein [14] has suggested that the result of internal self-fragmentation is the creation, metaphorically speaking, of “black holes that absorb fear and create the defensive posture of the isolated self-unable to make satisfying contact with oneself or others.” Without integration, the individual experiences his or her identity as many “selves,” or feels like an imposter due to the inherent contradictions. Each “self” can produce behavior and initiate action. One system can even be cut off from another, leading to unconscious motives for behavior. This fragmentation may explain why some individuals can find young children sexually arousing, (i.e. a part of self with a developmental age of 6-10 takes executive control but has the sexual arousal of an adult). Where there is extreme internal encapsulation, a person can act with seeming integrity ( such as being a member of clergy or the principal of a school), have multiple sexual partners, molest a child, lie, and seem quite sincere, while experiencing no conflict or contradiction. Dissociation allows for the apparent anomaly in which “good people do bad things.”

A person’s love map [15] is drawn by age 5 or 6. The map organizes the self, and sets the parameters of future relational choices. Opinions about what is attractive in oneself and in one’s potential partners are organized in the context of the love map. Persons with vandalized love maps maintain a “confirming bias” by selective interaction with others in the environment. They choose relations that fit the existing core schemata and avoid or devalue relations that might refute central beliefs and effects of schemata. In this manner, the individual with intimacy disorder is held lost and captive by the damaged love map until they can learn the new lesson: “Not all partners will hurt me. Only the partners I choose to actively re-create the chaos.”

Abused children encounter substantial difficulty in accomplishing the developmental task of regulating their emotions within the caretaker relationship [16], which contributes to further social rejection. Learning to turn to people as a source of comfort is essential for metabolizing toxic negative emotions. Fearing and avoiding close relationships leaves individuals vulnerable to alternative solutions such as compulsive pornography or addiction. Some individuals, however, seem to be “saved” by novel experiences with a loving caretaker, teacher, friend, girlfriend, or therapist. Research is currently underway to better understand and promote this type of resilience.

During early adolescence, there are rehearsals of courtship preceptive behavior [17] such as touching, kissing, holding hands, and so on. Boys who fall behind in courtship rehearsals develop social anxieties and fears that cause them to fall further behind. They often turn to pornography, which can quickly become predictable and soon require greater deviation to be stimulating. Pornography provides infinite amounts of deviant arousal conditioning at a critical period when boys are flooded with testicular androgens. Girls may also feel compelled to visit sexual websites or chat rooms, with their endless opportunities for the vulnerable and naïve to experiment with deviant experiences. Compared to 25 years ago, female sexual compulsions are at new highs.

Gender differences in the behavior of adolescents who are avoidantly attached to their caregivers are likely biologically based. Sroufe found that avoidantly attached boys were more likely to bully, lie, cheat, destroy things, brag, act cruelly, disrupt the class, swear, tease, threaten, argue, and throw temper tantrums. Girls were more likely to become depressed and blame themselves. The same early deprivation leads to acting out and aggression in boys, which is quite likely why boys are more inclined to meld aggression with sexual behavior as a solution to affect dysregulation.

Judith Herman [18], observed that abused children develop maladaptive self-regulatory mechanisms. Their capacity to reflect on their own feelings and those of others is impaired [19]. They often seek chaotic relationships, re-creating and re-enacting the familiar early rejections and frustrations in new formats with peers in school [20], which likely is a way of dealing with autonomic dysregulation [21]. Purging, vomiting, compulsive sexual behavior, compulsive risk-taking, gambling and exposure to alcohol and drugs become vehicles with which abused children regulate their internal state. The abused and neglected child comes to anticipate abandonment, rejection, unfairness and conflict with caretakers and teachers, which leads to powerful feelings of rage, anxiety, and helplessness. Unable to establish safety in or out of the home, the child survives by suppressing affect and then is compulsively driven to activity for release. Acting-out is often punished, ostensibly for the “child’s own good” [22], further suppressing rage and activating the search for additional tension-reducing activity. Tension reduction affords self-soothing, anesthesia from pain and restoration of affective control, increasing the likelihood of repeating the behavior.

Suppression of affect seems to leak into somatic function [23], causing increased medical symptoms, and also into somatic symptoms related to sexuality (mostly males) and to eating (mostly females). When it impacts sexuality, the abused individual seems to equate strong emotions with compulsive acting-out, i.e., I’m lonely=I need sex; I’m frustrated=I need sex; I’m sad=I need sex. These releases are exacerbated by increased autonomic arousal [24]. The individual may feel sad, angry, or lonely, but within the context of alexithymia will experience the affect as hypersexuality. He or she may browse internet porn for hours, cementing the connection and habit. In this manner, the individual discovers that this behavior can be self-soothing; it becomes a habit and eventually part of their identity as they view themselves as an “exhibitionist,” a “pervert,” etc. The relationship with objectified sex on the screen makes them feel more like an object as it further insulates them from anticipated or actual rejection from other people.

In the dissociative daze of childhood sexual abuse, children seek to repeat elements of a traumatic event or unresolved ambivalent attachment. They do to others what was done to them [25]. Often they identify with the aggressor and display assaultive behavior or turn the anger inward and self-destruct.

Horowitz, studied adaptations to severe stressors in childhood and suggested that the common “natural” result of severe trauma is repetition, which consists of flashbacks, intrusions, and reenactment until completion. Dissociative defenses resulting from both trauma and disorganized attachment interfere with completion, mastery and “working through” the trauma. If the stress response cycle is not successfully completed, erroneous schema become engraved into the internal working model of self. Relationships created by unresolved individuals are likely to reenact throughout their lives by means of disguised repetitions, with accompanying numbing and intrusions [8]. The result is that many victims of childhood abuse experience memory disturbances [12] and are left to repeat the trauma in disguised form unaware of its origin. Compulsive reenactment often includes “acting-in” compulsions such as self-cutting or eating disorder, or “actingout” compulsions such as hypersexuality or destructive partners like alcoholics physical abusers. These re-enactments can become addictive-like, serving as distractions from the internal emptiness and constriction and giving the individual the illusion of control. This reliance is further potentiated by endorphin release [8,9], extreme alterations in cortisol regulation and dopamine release from the median eminence.

Serendipitously, the study of sexual abuse victims has resulted in a new understanding of paraphilia and sexual compulsive behavior. Men and women who are sexually abused will frequently present clinically with violent paraphiliac sexual arousal and imagery, the result of “trauma-bonding” [25]. In trauma-bonding, sexual arousal is paired with terror and violence at a critical stage in the child’s development. Fantasies, for example, might include being aggressively assaulted by faceless individuals. Trauma-bonded individuals can easily find others with similar proclivities on the internet, further entrenching deviant arousal such as apotemnophilia or enema fetishes. Thereafter, there is a tendency to revisit the terror and high arousal, as if to master, complete or comprehend it. Traumatized children in therapy tend to repeat violence in their play rehearsals, and molested children often act out the molestation in their doll play. This is an example from one sexually abused client who was sexually acting out indiscriminately with alcohol.

As a child I would lock myself in the bathroom and play with dolls the way I had been touched. One would be in bed, the other would fondle him or here. I could not understand why I did that or where it came from. I was ashamed of this awareness but couldn’t help acting it out. I thought the same belonged inside me, that the awareness was created solely from me.

During my teenage years, I turned to boys to duplicate some of these feelings – of being cared for or loved. I knew I was fooling myself. I felt the emptiness I was left with after my liaisons with boys, but it was all I had. I was desperate to feel loved. My need for affections was so great, I couldn’t say no to many people and I rarely did.

Do you want to know why I had my tubes tied at 18? Because whenever I thought of myself around my child, a mental image would appear. The image was clear, and I believed in its certainty. 

Adults traumatized as children appear frozen at the point of trauma, acting-out the violence over and over in their selfdestructive decisions. Sexually abused women will often selfmutilate, a compulsive-ritualized self-destructive act, and describe their response as “an intensely pleasurable release” that helps them feel alive. Psychologically, there is an analgesic effect associated with the cutting and quite likely an opioid endorphin release centrally, which the individual experiences as pleasurable [18]. Cognitively, there is dissociation and depersonalization.

Dissociation implies numbing-out, a disconnection of thoughts and feelings. Importantly, dissociation may serve as an automatic defense. During the trauma, an individual may feel as if he or she is leaving the body and becoming part of the ceiling, which is a functional defense against the intolerable feelings of being inside a body that is under assault. Dissociation in males seems somewhat different than in females. Research on the effects of experiment-induced post-traumatic stress on monkeys suggests gender-specific effects, with males more dramatically manifesting the impact. Male monkeys tend to act-out, while females act-in. The adult male deprived of parenting in childhood will often viciously attack other monkeys out of fear, hyperresponsivity, and consequent anger [18]. The female, also hyperreactive, bites herself and develops catatonic symptoms.

Human females who have been victims of neglect and sexual and/or physical abuse often report that they do not feel entitled to express their pain and fear retribution if they show strong emotion. When in close proximity to a male, particularly in a potentially intimate interchange, they dissociate. During any kind of sexual contact, they “numb-out,” not thinking or feeling but instead locked in terror, feeling unentitled to say no. On the biofeedback machine, discussion of a sexual encounter is often associated with levels of anxiety sufficient to precipitate a panic attack. A common sexually compulsive posture on the part of some women in response to this terror is to allow a “seductive” part of their personality to “take control” of the situation. They then maintain the illusion that they are in control of their sexual victimization “this time.”

Human males, on the other hand, are often unaware of their affective states, being so dissociated that they never register fear, anger, anxiety, or any emotion other than irritability. When they approach a fearful situation, they bypass all affect. Their ritualized behavior patterns become the sole automatic response to fearrelated situations. This numbing requires more intense erotic stimulation to produce orgasm. Men typically oscillate between over-controlled working, drinking, eating or sex, to being outof-control in order to avoid encountering or remembering situations that are terrifying. The masculine counterpart in acting-in behavior consists of rigid rules and rituals to bind the anxiety and quell the unconscious fear.

Depersonalization reflects that the individual has been treated like an object and thereafter feels like an object and objectifies others. Because of the trauma bond, abuse survivors repetitively re-victimize themselves and can seem to invite chaos and crisis, in some cases not just out of familiarity and expectation but also, paradoxically, as a means of mastering the trauma. Masochistically, the emotional and physical pain may “feel good” and provide an escape from the numbness and emptiness resulting from the dissociation and depersonalization.

Two changes are occurring in how contemporary families are raising children. First is the increasing overindulgence of children by buying them products to compensate for parental neglect and absence. The second is the premature sexualization of children. These changes can lead to internal trauma and early sexual experimentation without the safeguard of emotional maturity and grounding.

The over-indulgences are often accompanied by over-control in which the parent is enmeshed with the child and has highly perfectionistic performance expectations of achievement. It is as if the child is “fed but not nourished.” Such families are often chaotic, and the attachments are disorganized. Rarely does this self-sufficient parenting allow for natural maturation. The cost of surviving in such families is to abandon the development of an autonomous self. The child becomes needy and develops strong dependency in relationships, wanting to merge while simultaneously wanting to run away out of fear of rejection and loss of control. Such individuals have a poor sense of self identity. They continually seek attachment to finish the self -- two halves making a whole -- but the relationships are conflicted. Sexuality seems premature in such relationships and can be experienced as traumatic since the individual is immature for her or his age. It is not uncommon in the treatment of male exhibitionists or voyeurs and in female anorexics to find their primary relationship is with their mother and they still live at home, a relationship they feel is necessary but distressing,

The second change is the premature sexualization of children by early exposure to eroticism through the family, media, and role expectations. Children are also reaching puberty earlier, and John Fowles writes that this is as if “a ship is sent to sea without a rudder.” Kids are genitally and socially eroticized without sufficient guidance and launching for healthy attachments. They have not yet received the appropriate “love education.” The result is that children can be exposed to sexuality and look okay on the outside but be traumatized internally by premature sexual and love experiences. In such cases, the vulnerable child may be genitally aroused but make poor decisions that will change their lives. Internet chat rooms and pornography easily introduce these lonely, isolated children to destructive liaisons.

Such individuals often confuse the need for affection with sexual arousal. This tendency is exacerbated by the media’s frequent and sensationalized use of sexuality to get the attention of children and adolescents without the ameliorating influence of parental guidance. Sibling or peer group pressure further encourages a “sexualized child” who experiments with sexual behaviors before he or she is emotionally ready.

Early attachment disorganization can be experienced by adults as numbness, constriction, emptiness, and feeling mechanical and like an object -- all of which propel the individual to seek relief, escape and connection. Such individuals were labeled “bypassers” by Masters and Johnson [26] because they became sexually aroused reflexively without much attraction or affection for their partners. Typically, such individuals feel internal polarities of dependency: needs that feel insatiable because of childhood neglect and are also experienced as terrifying. The individual exerts “control” over these feelings by engaging in periods of hyposexuality to avoid intimacy. Eventually the natural desire to escape loneliness and bond with another takes over, and they enter a release phase of being out-of-control and hypersexual. It is quite common to see overcontrol to out-of-control cycles, much like the anorexic-binge eating type. Individuals move from sexual abstinence (anorexia) to sexual excess (bingeing). In some ways sex is objectifying and depersonalizing and therefore non-intimate. Often after the release of orgasm, emptiness quickly follows; much like smoking crack cocaine quickly requires another hit. This can appear addictive, in that the individual quickly cycles from the high of an illusion of connection or escape from emptiness to the deep loss of profound aloneness.

This pattern used to be common within the gay community at anonymous sex parties or in bath houses where the individual “fucks” multiple times in an evening. Now it is increasingly common in cybersex addictions in which individuals compulsively masturbate to their computer screens. In 1999, there were about 20 million unique visitors each month to the top five pay pornography sites. Today approximately 40 million Americans admit to regularly visiting pornography websites.

Sexually compulsive behavior is the result of a set of sequential developmental “dominos,” starting with the temperament of the child, parent-child attunement and attachment patterns, social interactions, and adolescent pair-bonding. Repair requires intrapsychic facilitation of self-cohesiveness, agency and metacognition, and interpsychic rehearsal of healthy relationships. Deviant sexual arousal patterns typically unfold in the context of trauma bonds, disorganized or avoidant attachment, and fear. As bonding becomes more closely associated with intimacy, safety and connection, sexual arousal patterns often change spontaneously to reflect the desire for a healthy, authentic relationship with self and others.

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