Relational Aftereffects in Manhood of Boyhood Sexual Abuse
By Richard B. Gartner, Ph.D.

Abstract: Despite its high prevalence rate, the sexual abuse of boys is undeerrecognized and undertreated.  This paper will examine the relational aftereffects of boyhood sexual abuse that emerge in adulthood.  The vicissitudes of relational restructuring through the transference and countertransference are explored, with examples discussed of the various transference/countertransference paradigms often encountered.

Since 1980, there has been an outpouring of books and papers on childhood sexual abuse.  The emphasis in them has nearly always been on sexually abused girls and their reactions to the abuse as women.  This focus on women misleadingly implies that the occurrence of sexual abuse among boys is rare.  But, as Holmes and Slap (1998) conclude, "the sexual abuse of boys is common, underreported, underrecognized, and undertreated" (p. 1860).  Approximately one in six boys experiences direct sexual contact with an adult or older child by age sixteen (Urquiza and Keating, 1990; Lisak, Hopper, and Song, 1996).
Men with sexual abuse histories are similar in many ways to women abused in childhood, yet there are differences as well.  I have elsewhere (Gartner, 1999a; see also Gartner, 1994, 1996a, 1996b, 1997a, 1997b, 1999b, 1999c, 1999d) addressed a number of issues related to the sexual abuse of boys and its aftermath as boys become men.  These include the definition of sexually abusive situations for boys; the social isolation and shame sexually abused men often experience; the effects of masculine gender socialization on processing boyhood sexual abuse; the likelihood that boys will encode their sexual activity (especially with women) as a benign introduction to adult sexuality; the meaning and aftereffects of same-sex molestation for boys; and the ways in which encoding of abuse experiences are affected by portrayals of sexual situations between boys and adults in movies.
Sexually abused adults often relate to other people in flawed or distorted ways.  Chronic disturbances in relationships have been detailed throughout the clinical literature on incest (for example, Gelinas, 1983; Courtois, 1988; Ehrenberg, 1992; Davies and Frawley, 1994).  In this article, using numerous clinical vignettes to illustrate my points, I will focus on the impact of boyhood sexual abuse on adult sexual and other intimate relationships.  I will also demonstrate how these relational sequelae affect the therapeutic relationship, often causing an intense transference/countertransference interplay in the treatment.

Trust, Honesty, and Intimacy

When a child lives with chronic abuse and/or incest, he grows up in an environment marked by a traumatic relationship or set of relationships.  He learns to survey the world suspiciously and sees victimizers everywhere.  This is actually a functional reaction when abuse is ongoing, a time when he may need to protect himself from further hurt and exploitation.  However, this way of looking at the world often creates severe difficulties when he leaves the immediate world of his molesting environment.  Having lived with pervasive pathogenic family dynamics and dysfunctional systems of relating, a boy in this situation is likely to develop profound difficulties in interpersonal relating.  Through incest and abuse, he has developed severe relational disturbances (Sands, 1994);  relating itself has become traumatic.  Relationships are experienced as fundamentally dishonest, dangerous, and mystifying.  Dishonesty in primary relationships leads a child to grow up distrusting all relationships.  One man communicated his anguish about this dishonesty by saying, "Our family motto was always, ‘If you can't say anything nice, don't say anything at all.'  But for me the best family motto would be ‘If you can't say anything honest, say nothing.'"
Sexually abused men may not understand what involvement with others entails and what they risk or, alternatively, do not have to risk when they are intimate with others.  Distortions about intimacy are a logical extension of having had faulty, corrupt early relationships with abusers and, often, other adults.  Their understanding of interpersonal relating was often valid in those early destructive relationships, but such perceptions interfere with their ability to create nonabusing intimate relationships in adulthood.
Situations involving trust, sexuality, intimacy, power, and authority may pose particular problems to an abused man.  Abuse is likely to have occurred when he was especially receptive to interpersonal approaches as a boy (Briere, 1995).  If he was undermined at this vulnerable developmental stage, when he was especially needy of contact with others, he may be starved for intimacy while simultaneously remaining phobic about it.  He will have potent fears for his safety in human relationships, and these will affect the extent to which he can accept the interpersonal closeness he often desires.
Many men ignore such intimacy disorders in young adulthood, only coming to acknowledge any deficits in their relationships later in life.  In early middle age, when many abused men seek therapy, they may feel more secure psychologically.  By that time in their lives they also may be forced to relate to others more intimately.  If they encounter problems relating to partners, making career changes, or having children, they may finally be moved to face developmental impasses about trust and intimate relating that were impossible to address in childhood or early adulthood (Horsley, 1997).

Power and Authority

A child who has been fundamentally betrayed in a relationship with a parent, caretaker, or other parent substitute often expects similar betrayal in future relationships, especially from those he perceives as authorities.  His ability to form attachments is seriously compromised by his internalization of authority figures as treacherous and undependable.  He consequently develops the sense that he will be betrayed by those he cares about and trusts.  Wariness and anxiety about interpersonal encounters influence all relationships for such a man.
For Lorenzo   , distrust stemming from molestations by men in his small town was compounded by the reactions of a trusted priest to whom he confided information about the abuse and his own growing sense that he was gay.    By the time he was fifteen, Lorenzo had had numerous exploitative sexual encounters in which he sexually serviced older boys and men, all of whom were publicly identified as heterosexual, and many of whom were married.  Confused about the meaning of his own behavior, and only vaguely knowledgeable about sexual orientation, he did nevertheless begin to wonder if he were gay.  He had no idea who to talk to about this in the working-class mill town in which he grew up.  Then he remembered a priest who had once served in the town for two years before being transferred to a large city three hundred miles away.  He'd always thought this priest was "cool," and so he called him and said he needed to talk to him.  The priest came to Lorenzo's town for a visit, and Lorenzo first told him about his abuse experiences and then said he thought he was gay.  "He looked at me and said, ‘I knew you were gay the minute I laid eyes on you!'  So, I said, ‘Why didn't you tell me?' and he said, ‘Some things are better to discover on your own.'  So, at first he was good about it -- he invited me to visit him, and when I did he took me around the city and showed me gay neighborhoods, gay bars, gay shops.  That part was good, but then we went back to the house he lived in with other priests, and I wanted to get high -- I was a crazy kid in those days, and I asked him where to get grass.  He said, ‘No problem, just go upstairs and ask Father Donald.'  So I went upstairs, and there was nice Father Donald, and we got high together, and then he made a pass at me."  Lorenzo laughed.  "It was the first time anyone serviced me, and I really liked it.  When I went downstairs and told the first priest about it, he said, ‘Oh, sure, Father Donald does that with everyone.'  Can you believe this?  He knew what was going to happen when he sent me up there!  Later, I found out he was gay too, and had sex with other boys, though never with me."  Lorenzo was talking faster and faster, and I asked him to slow down and tell me what he felt about all this.  "I thought it was funny.  And exciting."  Then he paused.  "But, you know, I'm thirty-five now, about the age Father Donald was then.  I have no interest in fifteen-year-olds!  My nephews are that age!  I'd never go near them for sex."  I asked again how he felt about what happened with the two priests.  For the first time, he seemed reflective.  "It was a terrible thing to do.  They knew how fucked up I was about sex with all those men, and how unsure I was about being gay.  I went to them for sanctuary!  And they just helpe__d me party with them."  Lorenzo began to look sad.  "In those days I really believed in the Catholic Church.  No more."  His disillusionment with authority had been revealed.
The power differential between child and abuser can dramatically affect the boy in later life (Dimock, 1988).  The anticipation of betrayal by an authority may take the form of fears, fantasies, or even outright expectations of inappropriate sexual advances.  Thus, in our initial meetings Seth focused on the facts that my office is situated in a hotel and that I have a couch in it that he felt could serve as a bed.  Reminded of the circumstances of his molestation in a hotel room by a family friend, his anxiety nearly overwhelmed him and interfered with his ability to form a relationship with me.
Power has been eroticized during sexual abuse.  It was through power and control that a boy was introduced to sexuality, so his adult sexual relationships are often driven by attempts to regain and maintain control and power over an intimate other.  Thus, love relationships cannot be shared partnerships.  Instead, they become arenas for power plays about who is in charge and in control.   Lewis, for example, had such a need for control in intimate relationships that he had thrown partners across the room if he even momentarily felt they were physically taking charge during lovemaking.
To an abused boy, vulnerability often becomes associated with powerlessness.  In adult relationships, he either needs complete control, as Lewis did, or when feeling vulnerable he anxiously reacts as if he were still powerless and needed to appease authorities.  For example, when he was a young child, Abe's father explicitly gave him the impossible job of keeping his capricious, imperious, and narcissistic mother pacified.  Predictably, he failed and consequently became the focus of both parents' rage.  As an adult, he anxiously gave presents to people he felt he had displeased, as well as to those who were abusive to him.  He felt powerless and vulnerable in relation to them, and hoped that these presents could somehow placate them and keep them from attacking him.  It simply never occurred to him that he could be directly confrontative or survive their disapproval.

Maintaining Emotional and Sexual Distance

A common way to fend off the anxiety that accompanies a sexually abused man's interpersonal relationships is to keep them as distant, formal, and emotionless as possible.  When relating is traumatic and he is phobic about emotional attachment, he can only allow himself to be emotionally removed.  Consider how this dynamic worked for Willem, and how it affected the vicissitudes of his therapeutic relationship:
Openly distant in his interpersonal relationships, Willem maintained such a coolness in relation to others that he believed he had no relationships whatsoever, nor did he acknowledge or remember a history of relating closely to others earlier in his life.  Deserted by his biological father, Willem was the son of an alcoholic mother who had a series of husbands, boyfriends, and one-night sex partners.  Feeling rootless because of his mother's unstable relationships, Willem had no doubt about the veracity of his vague and disturbing memories of direct sexual abuse, apparently by one or more of these men.  He also believed he witnessed his mother's sexual relations with them at times.  Shortly after she and her third husband divorced when Willem was twelve, the mother died suddenly.  He was never told the cause of her death.
As an adult, Willem had great success in a career that required keen intellectual prowess and analytic ability.  He maintained that he had no feelings, and indeed his emotional life was sparse, barren, and brittle.  He had acquaintances, but no friends, and on the surface he had no capacity to bond to others.  He married in his mid-twenties, and when his wife divorced him five years later he precipitously tried to commit suicide in a particularly lethal way.  His life was saved, and he entered an inpatient psychiatric facility from which he emerged more openly vulnerable, needy, and dependent.  He quit his career, and was convinced to start outpatient psychotherapy.
In sessions with me, Willem was wary, seemingly waiting for me to make a false move.  Over the course of our work together, he repeatedly demanded more connection to me than he felt he had.  Each time we addressed this issue, however, he seemed to disappear.  He either canceled appointments because of other commitments or came to sessions and just sat there, impassive and impermeable.  Nevertheless, we made progress.  In our early contacts, we went over Willem's history and saw how little he knew about his early life or family origins.  He then decided to try to find out about his mother's death.  Obtaining a copy of his mother's death certificate, he was shocked, and yet not totally surprised, to discover that she had committed suicide.  As he considered his mother's depression, alcoholism, and death, his own suicide attempt became more understandable as an unconscious repetition of hers.  His need not to rely on other people or to create bonds with them also seemed reasonable in this context.  As he confronted these themes, he gained a clearer sense of wanting to live and accomplish something important in his own life.
Willem's commitment problem remained a constant in his treatment.  Despite this, he made remarkable strides in the rest of his life.  Having originally stated that he had "no history," meaning virtually no early memories and no relationships with anyone from his childhood, he eventually contacted the sister and former friends whom he had not seen in ten years.  He began to observe with some emotion that his pattern in adult life of moving from city to city, job to job, and girlfriend to girlfriend, reflected an understandable but devastating incapacity to connect to others.  Progress in these areas was slow, but when he left treatment after two years, he had partially healed and was no longer a man without a history.

Rage: One Emotion Allowed to Men

Masculine gender norms endorse anger as one of the few emotions open to men (Bruckner and Johnson, 1987; Lew, 1988; Sepler, 1990; Struve, 1990; Isely, 1992), and rage is the only affect many sexually traumatized men can express (Dimock, 1988; Sepler, 1990).  As Crowder (1995) puts it, "Anger is powerful and energy-filled and it is an affective state that is egosyntonic with masculine cultural roles.  Anger and rage can become a ‘catchall' emotion for male victims.  Because it is a powerful and active emotion, expressing anger is more acceptable than displaying more vulnerable emotions" (p. 24).  In many cases, underlying sadness, loss, and desolation are hidden beneath this rage.  But Crowder (1995) notes that "male survivors tend to be able to contact their anger and rage at having been abused long before they can feel their grief.  They often display active and violent revenge fantasies.  Women survivors, on the other hand, are initially more in touch with their sadness and depression" (p. 38).
The consequences of a furious mode of living in the world are obvious in men who become sexually or emotionally predatory or abusive as adults.  Many nonabusive men, however, also live with an unbridled rage that affects their capacity for intimacy and the quality of their relationships.  In Quinn's case, discussed below, his anger stayed front and center for years as he confronted his abuse by his grandfather.  While he never acted out his rage antisocially, it frequently broke through, affecting his ability to work with supervisors and clients, and influencing his more personal relationships as well.
Quinn's considerable rage was easy to recognize, but consider the monumental fury underneath Beau's seemingly quiet, passive, and polite exterior.  This fury flowed unchecked and periodically overwhelmed him, nearly drowning him in its intensity.  Beau, having had emotionally unsupportive and victimizing parents, was raped by three student athletes and a coach in high school, and then was further victimized by many other students.  During his college years, he continued to be sneered at and derided by classmates.  He was hospitalized for psychiatric reasons three times between the ages of eighteen and twenty-six.  Each hospitalization was precipitated by an explosion of temper following a dissociative episode in which he felt the ground or furniture moving.  During the hospitalizations, his feelings emerged about the rape and its aftermath, about being gay, and about his extreme sense of being ostracized and not belonging anywhere.  He was emotionally isolated, telling himself there were good reasons to distrust every group he encountered: gays and straights, men and women, every racial and ethnic group.  He had superficial friendships with one or two gay men and had had two brief love affairs.  Neither relationship lasted long, and together they further embittered him.
Because of problems relating to teenage boys at his job, Beau, then in his late twenties, sought individual psychotherapy.  A few months later, he was referred to my group for sexually abused men.  Seemingly gentle and soft-spoken, for the first few weeks after entering the group he was quiet, hardly appearing to attend to what others said.  Eventually, he started to talk about his trouble relating to the teenagers at work.  In particular, he focused on his susceptibility to being sexually aroused by them and on his fury at them because they resembled the high school students who had abused him sexually and physically when he himself was a teenager.  At this point, group members asked more about his internal experience.  As he described his feelings, he suddenly erupted in a frenzy I have seldom seen outside an inpatient unit.  With his face distorted by rage and his body moving half out of his chair, he railed inchoately about his rapes and his fury at abusive men and cruel women.  After ten minutes of near-psychotic fury, he collapsed, weeping and gasping for air.  The group was hushed as he exploded, but afterward most of the men talked about identifying with his rage, some in fear they might similarly erupt, others in envy that they were unable to do so.  Each understood Beau's rage from firsthand experience, and seemed not to be afraid during his outburst.

Responsibility for Others' Feelings

Boys often feel responsible for their sexual abuse, a feeling that has several sources.  Being responsible for one's fate is part of the socialized masculine gender ideals every boy internalizes to some extent (Pleck, 1981, 1995; Pollack, 1995, 1998; Levant and Kopecky, 1995; Levant and Pollack, 1995; Levant and Brooks, 1997; Lisak, 1993, 1995;  Brod and Kaufman, 1994).  In addition, boys often attribute their abuse to having given off a message saying they were interested in sex with their abuser or were vulnerable to predators in general.  This may be compounded by an abuser telling the boy that this is happening because the boy is so handsome and desirable, or because the victimizer loves him so much, or because the abuser knows this is what the boy "really" wants.  The abuser thus confirms that it is the boy's fault that he is being molested.  In addition, incestuously abused boys may have been told implicitly or explicitly that they are responsible for their family's well-being, or for the mental health of one of their parents.
The boy's sense of responsibility for his abuse may build to a generalized sense of responsibility for everything that happens to him and for the emotional health of those around him.  Its pervasiveness for Victor, a man sexually abused by his father three nights a week for several years in early adolescence, came to light in the following incident:  One day Victor arrived back at his office from our session and found that his supervisor had forgotten to cover for him, although this was a standing arrangement they had about his therapy appointment.  He called me anxiously and explained that we had to change our appointment time so that this would not happen again.  The next day he called again and said he would be able to keep the usual time.  When he came to his session, he began to talk about his reactions to tension in the air at work.  He said he had assumed that the anxiety in the office when he returned was about his absence, that he had gotten panicky about his job, and so he had called to change our appointment.  Upon reflection, however, he realized that his bosses were stressed about something unrelated to anything that had happened when he was gone.  "When I feel tension in the air, I assume it's about me, and I have to give in or submit to whatever is demanded, whether it's at work or with my family or with my lover."  By the time he got to my office, he seemed both resentful of his supervisors and of me because he assumed I was put out by his call and I had not wanted to accommodate his wish to change the appointment time.  I pointed this out and he agreed, "Yes, after I give in or submit, I get very angry at whoever it is I give in to, and I create scenarios about their being disagreeable or uncaring about my needs."
While molesting Victor, his father would tell him the abuse was happening because he loved him and because Victor was so handsome.  Victor's resulting sense of being responsible for the abuse was compounded by the sexual pleasure he felt simultaneously with his disgust and shame.  In addition, he felt that the nightly molestations calmed his father down and kept the family somewhat more peaceful than it otherwise would have been.  He remembered how he felt when his father got tense or angry.  The father would cry out, "If it weren't for all of you I wouldn't have to be here -- I'd be free!"  Victor said he accepted the blame for his father's moods.  He added, however, that his current reactions of feeling responsible for others were also colored by his history with his mother.  She would tell Victor he was perfect and worth all the sacrifices she made:  the job she hated, the marriage she was stuck in.  Feeling responsible for his mother's disappointments, Victor again reacted with anxiety.  He felt as trapped as each of his parents felt in their marriage.  The reactions to the incident at work were influenced, then, by the guilt and fear he felt in relation to both parents, the responsibility he felt for their unhappiness and for easing their pain, and the resentment he ultimately felt about this dynamic.

Differentiating Abuse from Other Interpersonal Dynamics

Men with sexual abuse histories may have little real sense of the differences among sex, love, nurturance, affection, and abuse.  For them, these concepts are roughly equivalent.  As Price (1994) notes, "Intimacy becomes identified with abuse, exploitation, sexuality, engulfment, and enmeshment" (p. 213).  Misidentifying relational experiences is an adult sequel to the sexually abused child's "confusion of tongues" between the languages of tenderness and passion described by Ferenczi in 1933 (see also Gelinas, 1983; Johanek, 1988; and Ganzarain and Buchele, 1990).  Explaining his near-phobia about emotion-laden experiences, Keith said, "For me, violation means intimacy, and intimacy means violation.  Someone has an emotional flareup and I want to dive into it.  I fuck it, I become one with it, I feel those raw emotions again, like I did with my mother.  Then I wind up being the caretaker of the person with all the emotions."
For me, the best illustration of how sexuality, love, nurturance, affection, and abuse get confused for sexually abused men lies in Abe's words.  A man who suffered from exceptionally inappropriate seductive overstimulation as well as verbal abuse, Abe said one day in despair: "No one will ever love me unless I'm completely their servant.  So I bring gifts to people who have abused me, I allow sadistic sex.  I don't yet know to what lengths I'll go to feel loved.  I keep returning to that wonderful cozy nest of abuse and incest.  It's a sewer and yet it's my spiritual home.  Why do I continue to allow abuse as an adult?  Because when I'm being abused, someone's attention is completely focused on me.  I know that's not love, but it really feels like love."  Abe summed up his family's confusion of love and abuse in a motto often repeated to him by both parents: "It's better that we shit on you than that someone else kisses you."  In other words, their abuse was the best love he could hope for in life.
In a psychology where emotions are blurred this way, affection is highly suspect and is experienced as both sexual and abusive, erotic and violating.  Abe, for example, at one point acknowledged that any interpersonal movement toward him, even a dinner invitation, could be experienced as hurtful and abusive.  This distorted view of positive relatedness was poignantly highlighted by a verbal slip made by a man who once said, "I was depraved [sic] of love by my family."
Long-term, arduous work is required in psychotherapy before a man can begin to allow himself to embrace more freely his own loving feelings.  Cory inadvertently discovered he had begun to make this shift after his wife suffered a miscarriage.  In wonderment, he said, "I had let myself love it.  I didn't even worry about the pain I feel now.  And even though I cried all this week, I know now that I've opened up a big wonderful space in my heart where there had been a void -- and I can love my child --  I can love my child when I have me."

Ambivalence about Being Sexual

The difficulty differentiating sexuality, love, nurturance, affection, and abuse has many consequences for relationships involving intimacy, sexuality, and/or love.  It also affects a sexually abused man's relationship to himself as a sexual being.  Having experienced his first sexual arousal in an abusive context, he links sexuality to "coercion, nonmutual exchange, and sometimes violence. . . . The pairing of secrecy and sexual arousal often leaves a victim feeling very ashamed of his sexuality, especially if he senses that his sexual expression is deviant.  Some survivors are unaware that their sexual behavior has been shaped by abuse processes and they believe that they are misfits or weird or crazy because of the nature of their sexual desires and expression" (Crowder, 1995, p. 32).
"Although incest is an abuse of power, it is also an abuse of sexuality" (Price, 1994, p. 224); this abuse causes distortions about all sexual situations.  Experiencing erotic excitement becomes negatively charged.  As Victor succinctly put it, "All pleasure is bad.  Do you know why?  It's bad that my father is touching my penis.  His touching my penis gives me pleasure.  Therefore, it's bad to have pleasure."  Victor elaborated on the ambivalence he developed about sexual arousal with his father: "I hated when my father talked to me while he touched me.  He'd say, ‘You're so big, you're so hard, you know Daddy loves you and that's why he does this.'  But I don't think I ever believed him.  I felt like a hooker when he said that.  I'd rather he would have just touched me, and kept quiet.  At least it felt good and I didn't have to think about it being my father who was doing it.  When he touched me, he'd open my pajamas and by the time I woke up he'd have fished my dick out and it would be hard.  I'd let him touch it for a while -- then I'd get upset and I'd turn over.  He'd beg me to turn back.  Sometimes he'd sigh and say ‘OK, if that's how you want it,' and I'd feel guilty.  I felt I wasn't doing what a good son would do.  So I'd turn around again and let him continue, and he'd be so grateful."  Noting one Pyrrhic victory in his struggle about sexuality and abuse, Victor forlornly concluded, "At least I never came with him -- I always made him stop before I came."
An additional problem about being sexual involves the shame a sexually abused man attaches to having been abused.  This shame often becomes associated with all sexual arousal (Rusinoff and Gerber, 1990; also see Hastings, 1998), so that arousal itself becomes shameful.  Also, if a man restimulates memories and fantasies about his abuse experience, he may confuse these with sexual desire (Briere, 1995), which may add to his shamed and phobic response to sexuality.  One goal of treatment in such cases is to separate out and attempt to repair these feelings.
Lorenzo described the process by which shame about abuse can get translated into shame about sexuality:  "I realized one day that I was in the gym, looking around, admiring men's bodies, not coming on to them, but feeling attracted and yet terribly ashamed of my desires.  It was crazy -- I felt like a pedophile, even though these men were my own age and I have no interest in children.  I couldn't understand it, but then all of a sudden it hit me.  The men who abused me had no shame about what they did.  They invited me to come give them blow jobs when I was as young as eight and nine, and then I'd see them in church with their wives or on the street, and they were totally casual, pillars of the community.  Sometimes it was as though they hardly knew who I was.  So I took on their shame!  I took it in.  They couldn't own it, so I did -- and I still do!  I walk around feeling my desire, and feeling I'm terrible for having desire, that desire itself is abusive.  I feel the shame they should have felt but never did!"
Not surprisingly, many sexually abused men feel ambivalent about being sexual at all.  They have learned to be extremely wary both about their own sexual feelings and about sexual approaches from others.  (In this, they resemble sexually abused women.)  Sexual situations, or situations interpreted by the man as including sexual elements, tend to bring up the dissociative defenses he learned as a boy while being abused.  Sexual dysfunctions are common among these men, including lowered or excessive sexual desire, sexual aversion, erectile disorder, inhibited orgasm, and premature ejaculation (Glaser, 1998).  For example, Hugo, a gay man in his forties, was seventeen when he went through the last of a series of molestations by older male cousins.  "I was trying to express my anger at the way I was being treated, so I willed myself not to have an erection, and I succeeded.  I only meant for that night!  But the result was I could never again have a spontaneous erection with anyone I cared about."  As a result, he spent years trying to negotiate satisfying relationships, knowing all the time how "defective" he was in comparison with the men to whom he was attracted and whom he tried to engage intimately.  Not until the drug Viagra came on the market was he able to achieve erections regularly when he felt aroused.  Only at that point did Hugo realize the extent to which his sense of masculinity and power had been compromised by his impotence.  He had to mourn the losses to his self-concept from twenty years of battling paralyzing shame, self doubt, and feelings of inadequacy whenever he tried to be sexual in a related, intimate way.
Similarly, during the course of their psychotherapies, both Andreas and Cory became aware of severe dissociation during the sex act.  Andreas "functioned" sexually with his wife but felt physically and psychically numb.  Cory had felt physically paralyzed as a nineteen-year-old when a male college dorm counselor tried to seduce him.  In adulthood, he continued to dissociate during sex with his wife: "Once I get things going in sex, I can just turn the machine on automatic and leave."
Some sexually abused men avoid interpersonal sexuality altogether.  Others may attempt to manage sexual relationships while suffering from the ambiguous intensity they experience during intimacy.  The pain of this situation was summed up by Cory when on various occasions he said, laughing but only half-humorous, "The trouble with sex is there's always someone in your face," and "I don't want any spontaneity in sex unless I know what's going to happen," and "If you really think about sex and all that happens in it, who would ever want it?"

Sexuality as Interpersonal Currency

On the other hand, a child whose sexuality has been compromised by early abuse and eroticized relationships learns that sexuality and seduction constitute his interpersonal currency.  Having learned that his sexuality is valuable to others, he may make it the basis for his self esteem.  If that happens, sexuality permeates all his interpersonal encounters.  In addition, interpersonal closeness often becomes eroticized because sex is the only way for the man to feel intimate (or seemingly intimate).
Hungry for interpersonal contact but phobic about it, believing that sexual closeness is his chief opportunity to feel loved but experiencing love as abuse, a sexually abused man who allows himself to be sexual at all often solves his dilemma by engaging in frequent, indiscriminate, and dissociated sexual encounters.  These are not free or joyous expressions of hedonistic, lusty sensuality.  Rather, they represent a man's imprisonment in an empty behavioral circuit from which he feels there is no exit.  Incessantly pursuing sex, he nevertheless achieves very little intimacy.  Nonmonogamous sex is not necessarily bad, but it is often not fully intimate (Glaser, 1998), especially when it involves compulsive seeking after partners.  In these situations, a man usually looks for sexual release to allay his anxiety rather than because he feels sexually interested in or aroused by another person.   He is momentarily soothed by impersonal expressions of sexuality, much as he might be by other compulsive or addictive behaviors like drinking, taking drugs, or overeating.  Yet he does not feel loved once the sex act is concluded.  These incidents leave him feeling empty and lonely, while the idea of fully pursuing interpersonal relatedness fills him with a dread of repeating his abuse history.
While it is not uncommon for men who have been sexually abused to become sexually abusive as adults (see below), these men, like their female counterparts, often enough find adult relationships in which they themselves are sexually abused or otherwise exploited.  Such relationships often include boundary-less merging with the loved one, so that the man is eternally anxious about being left, never feels capable of having independent thoughts or feelings, and increasingly wants to devour and be devoured by his mate.  Sometimes a man alternates impersonal compulsive sexuality with a drivenness to merge with a partner, with each tendency balancing and saving him from the excesses of the other.  Either way, he ends up continuing to feel unloved while striving to regain a momentary sense of being loveable.  Examples of how sexually abused men express these conflicts include Chet and Patrick.  Chet, a straight man who became an icon of the underground counterculture, went to bed with countless groupies while simultaneously drowning in intense, boundaryless love affairs.  Patrick was a gay man who would return to the city from holiday visits to his abusive family and go directly to the back rooms of gay bars, where he would fellate dozens of men.
Some men use their sexuality to get what they need, to bond to authorities, and to manipulate others if necessary.  What may have started as a desperate means of keeping some sense of power in a relationship where he is outmatched becomes a man's characteristic way of relating.  This can create considerable grandiosity about his sexual prowess and unrealistic expectations about his influence over others (Shapiro, 1999).  This grandiosity is an attempt to transform trauma and helplessness into omnipotence and control.  In adulthood, it can turn into a general sense of unrealistic entitlement that is in line with a child's developmental level, both cognitively and psychologically (Price, 1994).
On the other hand, a man may feel that he has nothing to offer but his sexuality.  Ramon, for example, had a sense of himself as someone whose worth and power were defined by his sexual capacities and attractiveness.  While his psychological dysfunction arose from a number of sources, his childhood sexual abuse was a central part of his personality organization:
A forty-year-old man who had successfully finished drug rehabilitation two years earlier, Ramon started therapy because he was deeply disturbed about memories of child sexual abuse that had been breaking through his thoughts since he had attained sobriety.  A likeable man with remnants of the Latin good looks that had made him the object of many adults' desire as a child and teenager, Ramon stuttered, cried, and seemed to be falling apart before my eyes as he tried to tell me about his first molestation.  Left to shift for himself when his mother went to work after his father deserted the family, Ramon at age eight was clearly vulnerable to exploitation and abuse.  Sam, a well-known neighborhood "character" who delighted children with his impromptu sidewalk puppet shows, invited him home, amused him with puppetry, then began to caress him and penetrated him anally.  This was the first of many visits to Sam, who always treated Ramon in a loving manner while molesting him.  With time, Ramon yearned to spend more and more time with Sam, the only seemingly caring and kindhearted adult in his life.  Ramon described his relationship with Sam in conflicted terms:  Continuing yearning, desire, and regret alternated with shame, anger, and depression.  After Sam moved away, Ramon was picked up regularly by both men and women who would engage in sex with him.  Money or expensive gifts were often exchanged for the sex.  At fifteen, Ramon met an older, wealthy gay man who invited Ramon to live with him, which he did for a few years until the man lost interest in him.  Ramon assumed he was no longer enticing to this man because he was getting too old to be physically attractive and was too stupid to be appealing on any other level.
Although concerned that being in therapy would make him discover he was gay or bisexual, Ramon said he sometimes did not care whether he was with a man or a woman, that his strongest motivation was to make sure his partner did not leave him.  "They always left, even though they seemed to care so much about being with me.  Every time I was with someone, I figured, I've got this one, they're really attracted, they'll stay.  But they always left."  Interpersonally, his need was for nurture and kindness rather than for mature genital relating.  While he worried about the stigma of being seen by others as bisexual or gay, and indeed as an adult had always chosen female partners, he sometimes acknowledged that the sex of his partner was not as important to him as a sense of being cared about and supported.   His desperation about being abandoned, as he had been by his father physically and by his mother in many other ways, was the motor that ran his psychological machine.  As he left the session during which he laid this out, he poignantly whispered as he passed me at the door, "I hope you don't get tired of me."
Ramon's early experiences left him confused about his value.  "There was something wonderful about knowing I was blessed with good looks and my body produced this liquid that felt so good and could make other people so happy too."  He then confessed, however, that he had never felt he was good for anything else, that he did not feel he had anything else to offer the world besides his body.  "I know how to make men or women happy in bed, but that's all I know."

Ambivalence about the Abuser

The ambiguity and complexity of feelings concerning their abusers tend to influence sexually abused men as adults so that all close relationships become suffused with suspicion and irresolvable ambivalence.  This is especially likely if the abuse occurred in the context of a seemingly loving relationship, particularly a familial one.  Intense intermingling of love and hate for an abuser leads to highly charged, fluctuating feelings about loved ones in adult life.  This ambiguity may itself be paralyzing and may lead to the linking of seemingly contradictory impulses.  For example, we will see below cases where cruelty was eroticized as sadism and being violated was sexualized as masochism.
Consider the ambivalence Julian felt about his victimizer:  Coming from a psychologically and physically invasive family in which emotions and boundaries were ignored, Julian was deeply ambivalent about the parish priest who simultaneously mentored, loved, and molested him.  This priest made Julian his special altar boy, invited him to visit him in his rooms, and undertook to educate him in classical literature, languages, and music.  He particularly taught Julian to idealize the male relationships described in Greek texts.  These included intellectual mentoring, deep interpersonal commitment and intimacy, and physical sexuality, which started between them a few months after the mentoring began.  This sexual activity eventually included kissing, oral and anal sex, and group sex with another boy.  The priest maintained that their relationship existed on the highest plane possible for two human beings, that they had attained the ideal glorified by the greatest poets and philosophers of the ancient world.  He reiterated that they experienced all forms of love together: love of beauty, love of thought, love of logic, love of art, and love of one another that was intellectual, sensual, and emotional.  Julian did love this priest, and he craved the companionship and deep interest offered to him.   Nevertheless, he was confused and conflicted about the sex that accompanied the priest's mentoring.  "He did so much for me!  Anyone would think he was the best mentor a boy could ever have, and, except for the sex, he was."  With the priest's encouragement, Julian learned to turn to him for sexual soothing whenever he was in trouble.  This resorting to sexual pleasure whenever he felt stressed became the forerunner of Julian's later sexual addiction.  As an adult, he was a compulsive masturbator driven to furtively view peep shows; he seemed consumed by female pornography when he was anxious.  He felt out of control, in the grip of the sexual impulses that flooded him at such times.
Nevertheless, because of his relationship with the priest Julian's intellectual world opened up as it might never otherwise have done.  As an adolescent, he was grateful for the intellectual and emotional expansion the relationship afforded him.  Simultaneous with this, however, he was covertly enraged about the exploitation and mystification involved in their sexual activity.  His grades improved dramatically and he eventually went on to attain an advanced degree.  Yet as an adult he remained ashamed, conflicted, and secretive about his relationship with the priest.
Ambivalence toward the abuser may be resolved through denial of one or the other side of it.  A boy may then either experience only the abusive or only the loving aspects of his molestation.  Such a denial keeps a man stuck in an untenable psychological position, and he may swing abruptly from one side of his ambivalence to the other, unable to tolerate the paradoxical ambiguity (Pizer, 1998) of his relationship with a beloved but abusive adult.
For example, Quinn's ambivalence about such a grandfather made him able to experience only one extreme feeling at a time.  He did not permit his fury at his maternal grandfather to enter consciousness until after he remembered his sexual abuse from ages four till eight.  Weekly molestations consisted of the  grandfather fondling Quinn, performing mutual fellatio on him, and penetrating him anally with fingers and, at times, his penis.  The interpersonal context of the abuse was one in which the grandfather was very affectionate to Quinn, telling him this was something they did because the grandfather loved Quinn so much.
Once Quinn recalled the abuse in his early twenties, he could no longer allow himself also to remember the loving, affectionate aspects of his relationship with his abusing grandfather.  At that point, he got depressed and sought treatment.  He was in a constant rage, barely able to talk about anything except his outrage at his grandfather and the parents who had not protected Quinn from him.  While he proclaimed that he had worked through his victimization, and that he now considered himself a "survivor" rather than a "victim," these claims were hollow indeed.  He could not talk about anything but his victimization, and was angry if anyone suggested he "let go of it."
Quinn's healing did not truly begin until he gained the capacity to simultaneously feel both sides of his ambivalence.  For the first few years in the group, his stance was nearly static, although he simultaneously began to develop a moderately successful business for the first time in his life.  He had periods of massive depression, and when he talked it was about how angry he was at his grandfather, how images of his molestations kept haunting him while he was asleep and awake, how infuriated he was when anyone said he should be forgiving and/or "move on."  It was difficult to work with him on these issues except to listen and be supportive.  Pointing out how he was stuck in his anger was perceived as undermining his victimhood, even though he counterphobically maintained that he no longer considered himself a victim.
A crucial turning point in Quinn's treatment occurred three years after we first met.  He had heretofore always talked about "my grandfather and what he did to me."  One day, however, he referred to "Grandpa" in this context.  I asked him about this term of affection, noting that he had never used it for his grandfather before.  He began to reminisce about how Grandpa had adored him.  In a very different tone than usual, he talked about how he had felt comforted and loved in Grandpa's embrace.  As he spoke, he sounded shy and said he was scared that others would deride him for loving Grandpa, his abuser.  He then said that, while he had never liked the sexuality with Grandpa, it had seemed a small price to pay to obtain the tenderness he craved.  Recognizing his affectional needs had a dramatic effect on Quinn.  For the first time, he was willing to consider antidepressant medication, which was effective in lifting his mood and stabilizing his oscillating self-esteem.  His continuing rage subsided somewhat, and he was able to promote his business more productively.  Acknowledging his needs for tenderness and love, particularly from a father figure, helped free Quinn from his furious and constant demands that his molestation be the center of everyone's relationship with him. Instead, he finally reached inside for the hurt that had been covered by his fury.  To his surprise, he was then finally able to start putting together a life in which his history of sexual abuse remained an important influence but was no longer the primary focus of his daily experience.

Abusive Relationships

Abusive relationships, whether overtly sexual or not, are another possible legacy of childhood sexual abuse.  Research suggests that, contrary to conventional wisdom, about 75% of sexually abused boys do not grow up to be sexually abusing men, though about 75% of abusing men were themselves abused as boys (Lisak, Hopper, and Song, 1996).  Nevertheless, Dimock (n. d.) has commented that in his experience, which is different from mine, most sexually victimized men have also been physically or sexually abusive to someone else.  When this is the case, even if there was only a single episode in childhood and adolescence, it often creates a barrier to recovery because of the man's subsequent guilt and shame.
The men I have worked with have not included adult abusers.  An extensive literature exists about working with this population (see, for example, Maletzky, 1991).  I have, however, worked with a number of men who as children or adolescents enacted sexual abuse with other children.  Other men I have treated were covertly abusive or exploitative in their adult relationships._
Abusiveness is a product of identification with an internalized image of the victimizer, a clear example of identification with the aggressor.  Consider, for example, Isaac, who was raped twice at age six in boarding school and had twelve separate encounters with sexual predators by age seventeen.  At that point, he  found  a young man who seemed to like and nurture him.  Ned, a man in his early thirties who worked in the family business, was a distant relative by marriage.  Isaac idealized Ned as a mentor and older brother figure.  Ned took an interest in Isaac's sports activities and talked to him in a manner Isaac considered flatteringly adult.  He felt like he had finally found the older brother or father he had been seeking.  But when Ned attempted to seduce Isaac in the guise of giving him a haircut and rubdown, Isaac froze.  When he then started to shake uncontrollably, Ned stopped the sexual approach.  Soon after this incident, Isaac visited his father in another state where he lived with his second wife and Isaac's half-sister and two half-brothers.  Uncertain about what might happen with Ned if he returned home, Isaac precipitously decided to live with his father for his senior year of high school.
During the year Isaac lived with his father's new family, he initiated sexual activity with his ten-year younger half-sister.  Its aftermath left him guilt-ridden for decades, ashamed of himself and terrified of ever acting spontaneously on impulse.  One day, his sister came into his bedroom while he was lying on his bed masturbating.  He quickly covered himself but then asked her to come into the bathroom, where he locked the door.  Lying on the floor, he told her to straddle his face, and he licked her vagina while he masturbated behind her.  This sequence was repeated a second time a few weeks later.  At the end of high school, Isaac went away to college in a distant state.  There, he got heavily involved in pot smoking and flunked out.  He moved to New York City, where he remained underemployed for many years in a low-level service industry job.  Attending college sporadically over many years, he finally graduated at the age of forty-one, six years after first beginning psychotherapy.
Abusiveness can also be reenacted subtly in everyday relationships.  Keith was involved in a covertly sexual relationship with a mother that led them both to descend into alcoholism until he went into rehab and cut himself off from her in his early twenties.  Seemingly well-related, Keith nevertheless managed to maintain a personal remoteness from others.  He was subtly exploitative as an adult while rationalizing to himself that as a victim he was blameless and had the right to do whatever he felt he needed to do.   For example, he worked freelance in an industry in which people tend to be partially involved in a number of projects simultaneously, knowing that only some of them will materialize into paying work.  Therefore, a certain amount of juggling of business ventures is necessary, and occasionally people have to back out after they have done a great deal of work on a project.  After two situations occurred in which he withdrew from ventures because of more definite and substantial offers elsewhere, he talked with some surprise about the bitterness he encountered from the people who had expected to work with him.  These people felt he had made a personal commitment to them and had then gone on to deceive and betray them.  The sense of treachery went far beyond what might be expected in a business situation, and initially Keith was perplexed by it.  As we explored how he cultivated business relationships, Keith conceded that he "seduced" potential work partners into wanting to work with him.  "I feel they won't want me on the basis of my skills, so I pull out all stops.  I show them how incredibly I understand their needs.  I make sure they bond to me.  Then if I pull out of a commitment or a semicommitment for reasons that are totally understandable from a career point of view, they feel personally betrayed.  I never understand why, and I never get it that I'm hurting them.  And if I do get it, I don't care.  I'm always the victim -- I can't imagine anyone else being victimized, and certainly not that I'm doing the victimizing."  Keith said this matter-of-factly, communicating little sense even then that he really cared about whether he hurt people.

Sadistic and Masochistic Themes

A natural next step from repeatedly entering abusive relationships is actively to seek sadomasochistic sexual contacts (Wright, 1997; see also Ehrenberg, 1992).  My experience with this subculture is small, but two different gay men have told me that every man they knew who (like themselves) was deeply involved in bondage and other sadomasochistic practices had been sexually or otherwise abused in childhood.  While their claims may well have been exaggerations, they do suggest that clinicians should explore for a history of sexual abuse with patients involved in sadomasochistic behaviors.
Sadistic fantasies not acted upon are also common.  Victor reluctantly told me after several years of treatment that he had recurring sadistic fantasies of tying men up and either tickling them till they screamed or bringing them nearly to orgasm but not allowing the orgasm to take place.  He had never considered the possible connection between these fantasies and the fact that, in his own abuse, his grandparents had tickled him mercilessly as part of a sexual game, and that later, when his father abused him, Victor kept himself from reaching orgasm, in part to frustrate his father.
Many men who have been abused develop lifetime patterns of allowing themselves to be exploited in ways that are not explicitly eroticized.  Abe and Owen demonstrate both erotic and nonerotic masochistic relatedness:
Abe at forty-five led a life in which he felt exploited or abused by acquaintances and colleagues.  This continued a pattern set with his verbally abusive father and his vicious, narcissistic, fascinating, and seductive mother.  By age twelve, Abe had regularly looked to be picked up by older men.  Many of these men were interpersonally cold and hurtful to Abe during sexual encounters.  They thus were abusive emotionally in addition to being pedophiles.  At the time, however, Abe felt good about being chosen by them.  It did not occur to him until decades later that he had perpetuated with them a pattern of being exploited and abused, and that they had been criminal offenders who took advantage of his neediness.  Indeed, they were the first in a long line of inaccessible people with whom he reenacted the dynamic he had lived with both parents, especially his mother.  He craved the love of these parent substitutes even as he chose them because they were incapable of giving it.
As an adult, Abe felt profound shame about his body and his sexuality.  A semicloseted gay man, he was involved in a difficult but devoted relationship with another man that had lasted for over ten years but had not included any sex after the first year.  Sexuality was reserved mostly for anonymous, compulsive, unpleasurable encounters or short, intense affairs with extraordinarily inappropriate and uncaring men.  In the past, Abe had engaged in sadomasochistic and dangerous sexual behaviors, including being tied up and anally fisted during anonymous encounters.  He recounted these incidents with great shame, never having told anyone about them before.  He described a brief affair he had once had with a man who broke it off by saying he was disturbed by how much Abe wanted to be hurt and how much he had grown to want to hurt Abe.  Though startled by the man's words, Abe did not take in their meaning until an incident some years later, when he found himself in a sadomasochistic sexual encounter with a man whose hands were at Abe's throat.  Abe suddenly understood that he liked being choked this way.  The implications of this discovery had a powerful effect on him and were influential in getting him to stop his alcohol and drug abuse, as he realized these substances promoted his pursuing to their furthest extremes the dangerous sexual behaviors he craved.
Several years after beginning treatment with me, Abe had stopped acting on his impulses to have compulsive, often masochistic sex, and began to bring up how he continued to re-create his abusive family in interpersonal situations.  One day he said with great emotion that he realized he could not walk away from a particular professional group of people who over the years had ignored or derided his achievements.  He was poised to enter a new contractual arrangement with them.  He discerned how little he could ever get from these people, yet he was astounded and horrified to note that he was unable to give up hoping for validation from them.  He cried out with passion, "I have to get them to recognize my worth!  They become my mother and father, people who have no capacity to see beyond themselves, who care nothing for me, who don't even think about me when I'm not there.  But I keep trying to change them, I keep hoping they'll turn around and say, ‘Abe really has something there -- we were wrong about him -- look, he's terrific!'  And, even as I see that there is zero chance that they will do that, I also can't give up on the possibility!  I see it all, but it does no good -- I can't stop myself from repeating it yet again!"  He wept as he clenched and unclenched his fists, repeating over and over that he knew he could expect nothing from these people but was just not capable of leaving them.  Yet, in all this we also saw that he had managed to encapsulate the abusive repetition to an important but isolated area of his life, and was simultaneously behaving very differently in other areas of his personal and professional worlds.  And, indeed, he resigned from his work with this abusive group a few months later.
After six years of therapy, Abe finally began to address his sexual masochism directly.  Following a successful professional endeavor, he was overcome with sadomasochistic fantasies, and clipped an advertisement for a leather-oriented dominator from the back pages of a gay newspaper.  He did not act on his wish, but brought it up in therapy instead.  We explored the multiple meanings of the fantasy:  He wanted to be in pain, first, because he felt he should feel pain rather than good feelings about his success, since that was his familiar role.  Indeed, he said he felt it was a betrayal of his mother to feel positively about himself.  Second, he wanted to feel a more defined pain than the foggy suffering he experienced after good feedback about his work.  Third, he said that perhaps if it got bad enough, he would be moved to say "Enough!" and stop it.  And, fourth, by choosing to be in pain and by making it explicit and defined, he felt in control of it, rather than lost in its maelstrom.
Owen, another gay man, had what he called a long-term "affair" beginning at age twelve with Calvin, a man seventeen years his senior.  Owen's parents received various favors from Calvin, and closed their eyes to the sexual possibilities in the relationship between him and their son, even when Calvin treated the family to vacations they could not otherwise have afforded and shared a room (and bed) with Owen while Owen's parents and several siblings shared a second room.  Owen never felt that his early sexuality with Calvin constituted molestation, yet over time in treatment we discovered that the subtle effects of his having been exploited by both Calvin and his own family, and his willingness to be so exploited, were  central to his psychology.
Shortly after starting treatment with me at the age of sixty-eight, Owen began a relationship with Jimi, a young man from a third world culture just barely over the age of consent.  Owen was astounded, frightened, and intrigued when Jimi pursued him.  He wondered why Jimi would be as interested as he claimed to be in a man fifty-one years his senior, and considered whether he was being suckered by a young hustler.  The parallel to the "affair" between Owen and Calvin was of course unmistakeable.  We talked about the similarities as well as the differences in the two relationships as he began a liaison with Jimi.  Jimi came from a culture that venerated older people, a fact that Owen could not comprehend.  In addition, Jimi seemed instinctively to see Owen as a mentor who would introduce him to an Americanized culture that was totally foreign to Jimi's parents, who spoke no English and worked long hours at menial jobs.  Owen, who considered himself ugly and undesirable, was both flattered and suspicious of Jimi's attentions, and constantly worried that he was being exploited for his money.  Indeed, Owen did spend a great deal of money on Jimi, who had virtually none, and he alternated between feeling generous and foolish for doing so.
It appeared that Jimi did genuinely care for Owen, and, while he profited from the relationship, he also gave a great deal to it.  As Owen developed and deepened their relationship, we had the opportunity to examine and analyze Owen's proneness to and suspiciousness about exploitation.  This eventually led us back to the history of Owen's relationships with Calvin and with his parents.  Owen continued to view Calvin as not having abused him, since he enjoyed the sex, but he did finally recognize the exploitative aspects of the relationship.  He acknowledged that he would never have been interested in Calvin had Calvin not pursued him.  In addition he realized that his youth and vulnerability had attracted Calvin, who took advantage of them.  Owen also looked differently at his parents' acquiescence in his relationship with Calvin.  He began to feel that his parents had taken advantage of him by asking him to act as a surrogate parent to his younger siblings while they put their energy into caring for his seriously ill sister.  A subtle lifelong pattern had thus begun in which Owen learned to expect exploitation and to defer to others' needs.  We looked at how this had been true with his parents, his ex-wife, a previous analyst, friends, various former lovers, and me.  In each case, and again with Jimi, Owen's fear was that love would be withdrawn if the other's needs were not satisfied.  Since this was intolerable, he had allowed many exploitative relationships to develop throughout his life.  Intimacy with Jimi became a testing ground for Owen's abilities to change these patterns.  He had to limit Jimi's insatiable desire to take up his free time, to say no to requests for overly expensive gifts, to go alone to cultural events he enjoyed if Jimi refused to accompany him.  Tempestuous at times, the relationship proved to be a catalyst for Owen's growing ability to stand up for his own needs, even when being pressured to do otherwise by someone he loved and was afraid to lose.

Relational Reconstruction in the Therapeutic Dyad

The vicissitudes of intimate relatedness described thus far affect the therapeutic relationship as well.  The primary need of a patient who has experienced incest or other childhood sexual trauma is to gain the capacity to relate to others in more functional ways.  Relational restructuring occurs above all through the interactive and current relationship between patient and therapist.  Attention must be paid early in treatment to enhancing the patient's ability to relate (Davies and Frawley, 1994; Hegeman, 1995), a critical factor because it is in the present, emotionally alive therapeutic relationship that the scenario for abuse gets rewritten.  And this can occur only if patient and therapist are able to co-construct a meaningful intimate relationship (Ferenczi, 1930; see Balint, 1968; Bromberg, 1991; and Hegeman, 1995).
A sexually abused man is less in need of "insight" about his history and its aftereffects than of a relationship that permits him to let himself be known intimately without fear of interpersonal merging or exploitation.  This is one reason that the relationship between therapist and patient must be active and genuine.  The therapeutic relationship simultaneously gives the man a laboratory in which to reenact his old abusive relational scripts with new outcomes.  If, for example, he relates through distrust because of his abuse experiences, he has conceptualized relationships as invariably headed toward some kind of betrayal.  If he cannot trust, it makes sense that he will feel that the therapist is malevolent.  He has an internal narrative in which life leads inevitably to traumatic conclusions.  Encountering the therapist within an intimate relationship where distrust is not warranted, at least not in the way it was when he was a child, he experiences a new perceptual truth that propels him to resymbolize his conception of relatedness.  He is changed because of a relational encounter that is experientially, not only conceptually, different from what he knew before (Bromberg, 1993)._  As he retells his history, he is also able to reconstruct and reconcile formerly bewildering and contradictory events in a new relational context.  Traditional efforts at "reconstruction" without this new relational reality fail because the patient's internal core personality remains untouched (Bromberg, 1995).
Davies and Frawley (1994) identify four paradigms recurringly found in therapeutic relationships with sexually abused women.  They also apply to work with sexually abused men, though the clinical picture may look different.  The four paradigms Davies and Frawley describe are:

1. The sadistic victimizer relating to a furious but helpless victim,
2. The collaborator in a seductive relationship where one participant is the seducer and the other is seduced,
3. The powerful but idealized rescuer of an entitled child who demands rescue, and
4. The nonabusing but uninvolved parent relating to an unseen and neglected child.

 

These four paradigms all involve two complementary relational models, each of which may be alternately enacted by both patient and therapist as they relate to one another.  Thus, over the course of time the patient may enact the victimizer while the therapist enacts the victim; then the patient may enact the victim while the therapist enacts the victimizer; then the patient is the seducer while the therapist is seduced; then the therapist is the seducer while the patient is seduced; and so on.  Through these models, patient and therapist fluctuate between the two roles in each paradigm, and in a single treatment every one of the models may occur at some point.
Such transference/countertransference reenactments are vehicles for communication to the therapist about the internal relational experience of the child as he was being abused.  They are powerful tools, but they are also forceful and often coercive catalysts in the therapeutic relationship.  It is important to remember that neither reenactments nor countertransference reactions to them are necessarily "mistakes."  Rather, they are unavoidable phases in the treatment of traumatized, dissociated patients.  Reenactment compels the therapist to experience the patient's original reactions to abuse, reactions that are his dissociated aftermath to a deeply traumatic childhood experience.  To heal the patient of the trauma, the therapist must experience that trauma is some way.  The reenactment may be symbolic of the abuse, but the feelings engendered in the therapist are very real.  These may include helplessness, impotence, rage, inadequacy, shame, guilt, idealization, omnipotence, overstimulation, humiliation, torture, and fear (Price, 1994), all internal states with which the patient is very familiar.
I will now briefly discuss and illustrate with male patients each of Davies and Frawley's four transference/countertransference paradigms, focusing on the inner experience of both participants:

The Abuser and the Abused Victim
It has commonly been noted that abused patients tend to identify with their abusers and then to be transferentially abusive to their therapists.  In doing this, they are repeating with the therapist what happened to them as children.  The abuser/victim relational configuration is particularly upsetting to work with for both patient and therapist because of its ubiquitous intense transference and countertransference enactments.
When the patient takes the position of the abuser, he retains a bond to the victimizer through unconscious identification.  This stance also allows the patient to keep at bay his feelings of helplessness.  He projects this helplessness onto the therapist, whom he may then devalue.  In this context, the patient may demand special treatment from the clinician.  Boundary violations of the therapist, such as making contact with people or institutions in the therapist's personal life, are also likely at such times.  When this happens, the clinician feels intruded upon and penetrated, often coming to dread therapy sessions.  Yet it is crucial for this enactment to occur.  In dealing with it, the therapist must walk a tightrope between ignoring the man's abusive behavior, and thus becoming the unseeing parent, and expressing a feeling of victimization that may evoke excessive guilt in the patient.
Alternating and concurrent with abusive behavior toward the therapist is a dynamic in which the patient repeats a victimized relationship with the therapist, and the therapist reenacts the abuser's role, usually (but not always) in some symbolic way.  When the therapist enacts the abuser and the patient becomes a victim, the patient may react to the inequality of their relationship, feel victimized by the fee, or otherwise feel exploited by the therapist.  In turn, the therapist may become intrusive or controlling.  Often, a therapist who has usually been the victim in the transference/countertransference enactment may explode after months of abuse, instantly reversing the abuser/abused dynamic in the relationship.
The transferential reenactment of abuse may be subtle and symbolic.  It may come through as a tendency to manipulate and exploit the therapist in covert ways.  But the abuser/victim dynamic can be direct and overt as well.  Witness my relationship with Abe, whose relationships with both parents had led him to deal with other people in ways that resulted in his feeling perpetually victimized.  In the fifth year of his treatment, he was at a midpoint in his shift away from being a perennial victim.  A man who had perceived, found, or created abuse in nearly every interpersonal situation, Abe had evolved to a point where he was no longer blaming all his troubles on others.  Instead, he had just begun to see how he participated in setting up abusive relationships.  During this period, we repeatedly delved into his expectations of abuse from me.  Each of us experienced the other as abusive on occasion, and it was the live interactions between us about these feelings that got through to him.
For example, one day Abe exploded in rage when he felt I had not comprehended the extent of his vulnerability when I commented on his abrasiveness.  I assume he was correct that there was at least a partial failure of empathy in my remark, though his reaction to it seemed nearly out of control.  Abe snarled about my inability to empathize, and then castigated me about my defensiveness in the face of his attack.  I felt assaulted, and no doubt I was defensive and counterattacking at least to some degree in my reaction.  Yet, in general I remained attuned to him, continuing to talk to him, giving my point of view without invalidating his perceptions of me.  Our interchange got very heated on both sides.  I pointed out in several ways how he had escalated and compounded any abuse that might have existed in my original comment.
At the end of what had nearly become a screaming match, we both felt spent, but we had also somehow arrived at a point of mutual respect.  I had been at least symbolically abusive in my original remark,as is nearly inevitable in working with an abused patient (Davies and Frawley, 1994).  I had nevertheless reacted to his subsequent transferential victimization of me in a way that served as a model for how one can remain in a significant relationship but not permit mistreatment.  On his side, he felt that I heard him.  When we talked about our clash during the next session, I said at one point that I hated our arguments, that I found them difficult and draining, but that I simultaneously welcomed them, because they gave us an opportunity for a live encounter in which we affected one another, with each of us surviving and growing from it.
Abe brought up this comment a number of times in subsequent years as a revelation to him, a sign that I cared about him enough to endure a taxing and painful emotional state.  He recalled the screaming marathons in his house as he grew up, which typically ended in violence, brutal punishment, or threatened suicide.  He found it impossible to believe I cared enough about him to endure what had passed for human interaction in his family.
This led him to think differently about our relationship, and about relating in general.  He saw that his negativity about interpersonal situations developed even when things were going relatively well.  He became able to assert himself at times, to move away from rather than toward abusive situations, and to avoid most exploitative relationships.  Yet he still feared being around people, and was often sure he had been or would be manipulated and misused.  In the midst of his continuing despair, he said he was glad it was so clear that real abuse was no longer occurring.  It made him realize that he carried around his abuse history and assumed it was recurring even when he "knew" it was not.  As he said, this was an important differentiation.
What in our relationship helped him get to this point?  It is true that I sat and listened to him for years, pointing out over and over how he was "arranging" continuing abuse, and noting things he might have done or said in a given situation to stop what he considered to be exploitation.  At times, I rehearsed with him how to deal with tense interpersonal situations.  I believe, however, that Abe's most important shifts came from his overarching direct experience of our relationship as basically nonabusive.  Especially compelling for him was my willingness, when things heated up between us, to stay related to him and even to acknowledge some personal shortcomings and errors.  With time, Abe developed an enhanced capacity for tolerating the ambiguity of a relationship in which both highly positive and highly negative qualities coexisted.  In addition, our relationship offered him the opportunity to encode linguistically his interpersonal experiences with me and with others.

The Seduced and the Seducer
Particularly noteworthy in any discussion of transference and countertransference in work with sexually abused men is the sexualized transference and its sequelae.  Like many sexually abused women, men with a history of sexual abuse tend to expect every relationship to involve seduction by one party or the other (see Siegel, 1996).  A child with such a history often grows up to be a seductive and seduceable adult.  I noted above that sexually abused children learn that sexuality is their interpersonal currency, a means of bonding to authority figures whose love they long for, need, and fear.  As adults in psychodynamic treatment they reenact this dynamic again and again, and the concentration of seductive energy in the therapy can overwhelm both patient and therapist.  A sexually abused adult brings an intensely seductive manner of relating into treatment, sometimes to the point of outright attempts at seduction of the therapist.  It is therefore not surprising that adults sexually abused in childhood have been found to be more often subject to sexual abuse by their therapists than other patients (Smith, 1984; Gabbard, 1989; Kluft, 1990; Lymberis, 1994).  These, obviously, are "real" abusive countertransferential reenactments.
As Price (1994) puts it, "The sessions and the office may be cloaked in an erotic atmosphere and tension that may be difficult for the analyst to contain and tolerate" (p. 225).  Thus, the ambiance of the treatment is filled with a sense of seduction, and therapist and patient each recurrently feels seduced by the other.  The patient may be afraid of being flirtatious or seductive, fearing that this will bring on abuse.  Concurrently, however, he may feel that this is the only way to get what he needs, having been trained to seduce in order to maintain a primary relationship.  The therapist may feel both attacked and aroused by this behavior.  Should the clinician feel sexual arousal from the eroticism of the material being presented, he or she may feel guilty and exploitative, and may want to withdraw emotionally from the overstimulating emotional field of the therapeutic relationship.  Nonetheless, it is imperative that the therapist remain emotionally available.  This must happen concurrent with the therapist conveying the idea to the patient that sexual feelings are acceptable and not instilling guilt and shame about the erotic energy in the relationship.  It must simultaneously be communicated that one can set boundaries, not act on sexual feelings, but also not deny them.
In such instances the therapist must be careful to monitor countertransferential feelings about sexuality, love, nurturance, affection, and abuse, the same feelings the patient has trouble differentiating.  It is important to articulate the differences among these feelings over and over, and to demonstrate, for example, that it is possible to be nurturant without having sexual designs.  To do this with a sexually abused man, though, the therapist may have to sort through the same kinds of intense, inchoate feelings about the patient that the patient experiences in virtually every relationship of his life.  For example, my treatment of Patrick required me to find new capacities to work with his enactments in many interpersonal spheres, but particularly in our sexualized transference/countertransference relationship.  Patrick was the victim of profound sexual abuse by his father for several years starting at age two or three.  Though severely depressed at his core, on a more superficial level he was openly seductive with me, frequently referring to me as his lover and jauntily offering to have sex with me.  At such times, his manner was brittle and mocking, as though he were daring me to take his offers seriously.  He laughingly recounted how he told his friends details of his sexual fantasies about me.  On the occasions we were able to  explore these fantasies in a more sober vein, what emerged was an image of me as an eroticized but loving father figure.  He imagined he would feel safe in my arms, and was eager to perform all kinds of sexual acts on me to secure my permission for him to stay close to me.  He imagined I would protect and support him, both emotionally and financially.  At this point, at least, there was no hint of the other side of this transference, namely, that I would be the abusing and hurtful father as well.
In our work together, Patrick brought in all the eroticized themes of his life, often reenacting them with me so that I felt traumatized, disturbed, and exhausted.  A subtle example occurred one day when he heard me cough and offered with a faraway smile to listen to my chest with a stethoscope for signs of bronchitis.  On the face of it, this was a caring, if inappropriate, offer.  But his dissociated smile, followed by a wolfish grin, made it clear that he was seductively interested in molesting me by invading my boundaries in the guise of taking care of me.
A far more glaring example occurred one day when he suddenly removed his trousers in a session, supposedly to show me exactly what had once happened when he overtly tried to seduce his father.  When I told him to put his pants back on, he became angry, ridiculed me for being sexually constricted, and finally accused me of shaming him about his abuse experience.  Outwardly, I worked with him in a reasonable manner about this, asking what he was trying to accomplish by taking his pants off, what he imagined my response would be, and what the meaning could be of his engaging in what he knew was unacceptable behavior with me.
But my interior life was chaotic as we struggled about the meaning of what he had done.  I felt tantalized and seduced, stimulated to have exciting but bewildering feelings while feeling dimly that I might be humiliated because of the inappropriateness of those feelings to the situation.  I felt Patrick had suddenly reversed the power relationships in the room by standing up while I remained seated and by being sexually aggressive, even though he remained affectively disconnected from his predatory sexuality.  At the same time, however, he experienced me as abusing him by shaming him about early sexual experiences.  I wondered how true it was that I was too constricted to deal with the complexities of sexual experience Patrick described and enacted.  I wondered what would happen if my colleagues found out that my patient had partially disrobed during a session.  I wondered whether in some way I had been unconsciously seductive with Patrick, and whether his getting undressed was a response to inappropriate behavior on my part.  I wondered who Patrick would tell about what he had done, and what they would think.  I imagined him ridiculing me to them, blandly and amusedly telling them how nonplused I had been when he had acted so flamboyantly and seductively with me.  In short, I countertransferentially felt the anger, ridicule, abuse, excitement, coercion, arousal, and shame that Patrick had felt first as a child, and then again with me.  This is what Herman (1992) would call my "traumatic countertransference" to Patrick.
What was the transferential meaning of Patrick's behavior?  As I see it, his disrobing was an attempt to seduce me as a reenactment of his relationship with his father.  I believe Patrick was deeply ambivalent about the response he wanted from me.  He was testing me to see if I would molest him, but he did not know what kind of outcome he hoped for.  Patrick as a young man had actually tried to seduce his father, who apparently was no longer interested in him as a sexual partner, possibly because of Patrick's age or the greater likelihood that the relationship would be publicly revealed.  Patrick's attempt to reestablish a sexual bond with his father seems to have come from a longing for the closeness that had accompanied the abuse, at least on a symbolic level.
Through his seductive behavior with me, therefore, Patrick wanted me to enact a seduction, on the one hand, in order to reexperience the painful intimacy he had once had with his father.  Yet he was also hoping I would stop the reenactment.  This would help him create a new narrative about the abuse.  It would help him experience the possibility of a different outcome, an outcome in which his father substitute set limits on the sexuality in their relationship but not on the intimacy.

The Rescuer and the Needy Child
It is easy for therapists to be drawn into the role of omnipotent savior, as Davies and Frawley note, since "we have chosen, after all, to live our lives as professional helpers" (1994, p. 178).  The therapist's wish to heal deprivation and emotional starvation is magnified many times over when a man's circumstances include a history of having been abused, neglected, violated, or otherwise victimized as a child.  After all, in boyhood the man did need rescue but did not get it.  The urge to make psychological reparations can be strong, and is further intensified by the man's corresponding wish to find a caretaker who will, finally, protect and deliver him from his trauma.
Thus, the therapist becomes the rescuer in a therapeutic relationship when the horrors of the abuse elicit internal caretaking responses.  Rescue fantasies recur throughout treatment, but they are especially likely when the patient is beginning to integrate experiences and mourn.  At such a time, the therapist may get caught up in the poignancy of the patient's situation.  The patient may become like a wounded child who demands that he get recompense for his suffering.  He may want to replace his childhood with a wonderful new one given to him by the therapist.  If this happens, clinicians must try to balance their reactions, allowing the man's long-buried yearnings for relatedness to emerge while also permitting him to rail against his original losses.
The flip side of this equation occurs when the therapist is needy in some way, and the patient tries to make things better.  The therapist may feel, for example, that he or she has given and given to the patient, but is unappreciated.  At such a moment, the clinician may have the impulse to retaliate through emotional withdrawal.  On the other hand, when the patient becomes the rescuer, he is often acutely attuned to the moods and needs of the therapist.  He may act to help the therapist partly out of a fear that if he does not do so the therapist will be unable to give to him.  But he may also be acting out of loving wishes to nourish the therapist.  Accomplishing this may have the added benefit of making him feel capable of being a nurturer.
To illustrate some of the ramifications of the patient's wish for an idealized rescuer, consider Harris.  A highly intelligent, self-contained professional man in his forties, Harris had been sexually abused by an alcoholic father for a period of years during latency.  Otherwise, the father spent much of his time drinking, was verbally abusive to his children and wife, and never held a steady job.  Harris grew up in a psychological fog, overresponsible for his mother and brothers but with no real goals in his own life.  In early adulthood, especially after his father's death, he led a life grimly similar to his father's.  He never worked steadily, took occasional courses at schools, and led what he called an "indolent" life, spending his evenings in bars picking up women for one-night stands.
By the time he was thirty, Harris was profoundly frightened.  He started treatment with a woman analyst and began to work for a living, initially at a humiliatingly low-level job as a stockboy in a store.  He put himself through college and professional school, marrying when he was about forty.  Despite these obviously positive changes in his life, Harris maintained much of his psychological fog, with occasional flashes of inchoate rage, usually suppressed quickly or directed inward in some self-destructive manner.
He was referred to my group for sexually abused men by his female analyst.  Having had a history of difficult relationships with male authorities, he was initially wary of me.  But he quickly saw me as an expert who would save him from the aftermath of sexual abuse he was just beginning to face.  In his first months in the group, he looked to me to be his nurturer, and protected me from attacks by other group members.  He swiftly developed an idealized view of me as a fathering figure who was giving him what he had sorely lacked all his life from his own father.  He defended me from criticism by other group members, often using methods so subtle I only detected them in retrospect.
This became apparent when another group member attacked me in the last moments of a group session because he did not like my practice of making summarizing comments at the end of a group.  Because time did not permit us to deal with the issue, I elected not to make any such remarks that night.  Harris came to the next group session in a fury, declaring that the other man had deprived him of what he needed from me.  At first, Harris raged chiefly at this other man  But it was clear that Harris's anger was as much with me, his transferential father, as with the other group member, his transferential sibling.  He felt I had capitulated to unreasonable demands and was willing to cut Harris off from a primary source of nurturing from me.  His struggle with these feelings helped us both to recognize the enormity of Harris's neediness, but it also signaled the end of his view of me as his rescuer.
With time, Harris dropped his idealization of me and instead voiced directly the transferential rage that had always lurked beneath it.  He became painfully sensitized to any change in my tone, particularly one that conveyed to him a wavering of empathy, a condescension, or a patronizing attitude.  Sometimes he startled me with the immediate fury of his response.  At other times he kept his anger hidden, then spit it out at me later when I least expected it.  He often told me about my many shortcomings as a therapist.  He particularly focused on what he called my callousness and inability to see how hurtful I was, as demonstrated by my ignoring his directives about how to listen to him and my repeated failures to meet his needs.  Eventually, he left the group for over a year, and on his return we were able to work through these issues more effectively.

The Ineffective Parent and the Neglected Child
If a boy grows up with a parent unable, unwilling, or not caring enough to see what is happening and save him from harm, he has to find a way to resolve this relational injury.  A relationship between a nonabusing but nonseeing, ineffective, and uninvolved parent and a neglected, unseen, and unprotected child may result in profound attachment trauma that precedes any sexual abuse.  Because the parent is loved and needed by the child, this relational constellation is split off from consciousness, with the child preserving the image of a loving, available parent.  But, while he preserves the parent consciously as devoted and capable, unconsciously he may set up relationships in which people who seem accessible and loving are actually uncaring, unavailable, or unfeeling.  If this kind of dynamic is replicated in the therapeutic dyad, the man creates a situation in which he seems to be establishing a positive relationship, but actually experiences the therapist as cold, callous, or rejecting.  Out of this hurt, the man may become alienated, hurt, and despondent.  Eventually, these feelings may turn to anger, and he may retaliate.
When a patient enacts the neglected child, he denies his own wishes and protects and caters to the therapist, feeling this is the only way to get his needs met.  Therapists may not easily see the falseness of this presentation because it is initially experienced as positive relatedness from the patient.  Over time, however, the patient becomes deeply disappointed in the therapist, and this disappointment can turn to covert rage.  Eventually, he may develop an openly hostile transference, experiencing the therapist as not seeing him, not remembering important things about him, and not caring sufficiently about him.
All the aspects of this pattern came into play in my work with Abe, whose narcissistic parents were unable to see or care about his needs.  He had always seen them as malevolent and hateful, but with time he acknowledged that perhaps they hardly knew he existed in the world.  In a way, this was a graver injury to his self-esteem than thinking they wished him harm.  In our work, Abe often seemed able to relate warmly to me, but he was quick to notice any failings on my part, and was then alternately hurt, depressed, and attacking.  At such times, he saw me as he saw his parents, and he fluctuated between thinking I did not want him to succeed in life and believing I was not capable of feeling empathy for him.  On my side, I frequently found myself burdened by the complicated interpersonal field we lived in, and periodically pulled back emotionally for relief from it.
On the other hand, a man may identify with the unavailable parent and turn on others who had expected emotional resonance from him.  In the therapeutic relationship, he may seem indifferent, compassionless, or cruel.  The clinician then becomes the neglected child countertransferentially, experiencing him- or herself as unwanted, unimportant, and unconnected to the patient.  It is crucial that the therapist not abandon the patient emotionally during these periods.  However, feeling wounded, unappreciated, or depressed, he or she may eventually be pulled to behave callously toward the patient, becoming, for example, sleepy or forgetful during sessions.
Both sides of the ineffective parent/neglected child paradigm were played out in my work with Patrick, whose overburdened mother managed to provide physical caretaking for her nine children but otherwise lived in a depressed, alcoholic haze.  She continued to deny that the family had severe problems into her old age.  Witness the oscillations in my relationship with Patrick as we approached the premature termination of his psychoanalysis:
After four and a half years, Patrick's therapy benefits were cut off by his insurance company.  While he had made some remarkable changes in therapy, he was still often moody, depressed, and isolated.  He was highly changeable in his feelings about me and the treatment, and continued at times to question the veracity of his memories.  He had developed a highly structured work and school life in part so he did not have to deal with emotional relationships.
As it became clear that the treatment would end, Patrick's initially strong dissociative defenses reemerged and predominated in our work.  In retrospect, I see that he was preparing himself for what a major trauma.  The difference between this time and his childhood trauma, however, was that now I was able to break through his dissociation at times, and he sometimes expressed relief when I did.
Patrick had always voiced some ambivalence about the therapeutic process.  It was demanding and painful, often leaving him depressed, frightened, and wondering if his memories were themselves simply a reflection of his craziness.  He passively allowed the insurance company to resolve his ambivalence about treatment by dictating that he would stop.  He seemed to feel it was natural that he not be cared for, and this combined with his usual resistance to treatment, making him proceed implacably toward the conclusion of our work.
As we approached our final session, I tried to talk to Patrick about his feelings about the termination.  He responded formally in general terms.  When I pressed him toward the end of a session about how he felt about our relationship ending, he said coolly, "Ours has been a professional relationship.  You have always behaved as I would expect a competent professional to act."  I felt stung, and, internally, I recoiled.  I recognized that on one level he was telling me that he was grateful I had acted appropriately and kept our boundaries clear by maintaining the professional frame of our work despite his efforts to break it.  Yet I also felt his interpersonal distance repudiated the intensity of our therapeutic relationship.  As I thought through my reactions, however, it occurred to me that Patrick was resorting to his usual dissociated way of reacting to anxiety and pain.  In addition, he was reestablishing the rigid boundaries between us (indeed, between himself and everyone) that he felt were necessary in order for him to function in the world.  I realized I had to ask more about his reactions.  We had been alternating in the roles of unavailable, ineffective, and cold caregiver and needy, depressed, and wounded child.  When he was feeling needy, as when he wanted my help in order for his medical benefits to continue, I was ineffective, and probably at that time he experienced me as unavailable and cold.  When he was cold, I felt abused, wounded, and enraged.  Each of us activated such responses in the other.
In the next session, I asked Patrick further about his feelings, reminding him of the many emotional ups and downs we had experienced, and doubting that his statement reflected everything that was going on inside him.  He closed his eyes and was silent for a moment, then said quietly, but passionately, "I have been abused by my father and my brother.  My other brother died of AIDS in my arms, and I had to go choose clothes for him to wear for his cremation, then scatter his ashes alone.  My mother continues to act as though everything has always been fine in the family.  If I can get through all that, I can certainly handle not seeing you!"  Then he burst into tears and sobbed about all his losses as I sat with him, my own eyes filled with tears.
This declaration had many meanings.  It was a needed rebuilding of boundaries between us.  It was an affirmation for Patrick that he could indeed survive.  But it was also a demonstration of a new ability to verbalize his trauma rather than to dissociatively sleepwalk through it.  He broke out of his seemingly cold stance and grieved in this session and those that remained to us.  His capacity to do this personified all the work we had done to allow him to mourn openly the childhood innocence he lost through abuse.

Conclusions

Trauma becomes especially pernicious when terrifying early dissociated experiences are linked to the very fact that one is in a relationship.  This is a particularly apt way of considering what occurs when a traumatic relationship must be dissociated, as in chronic incest.   In such cases, there may be a severe disturbance about having relationships at all because relating to others is itself linked to terrifying dissociated experiences.  I have discussed how sexually abused men's adult intimate relationships are affected by their histories.  Themes that have recurred in my patients' lives and treatments relate particularly to the areas of abuse, trust, and sexuality.  I have therefore focused on interpersonal problems stemming from distrust, anxiety, and rage; from men's difficulty differentiating abuse from other interpersonal dynamics; from their frequent ambivalence about themselves as sexual beings; from the emotional and sexual distance characteristic of their relationships; from the ways they relate to others through their sexuality; from the ambivalence some of them feel about their abusers; and from the propensity many of them have to develop relationships that are predatory and abusive, on the one hand, or masochistic and victimized, on the other.  In addition, I have focused on how these dynamics emerge in the transference and countertransference of an evolving therapeutic relationship.

 

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