Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part XXXI

Betrayed As Boys: Psychodynamic Treatment of Sexually Abused Men
Richard B. Gartner
Chapter 4, Same-Sex Abuse

Same-sex abuse is often interpreted as a sign of the victim's or the abuser's homosexuality. Yet victims are frequently headed for predominantly straight sexual orientations at the time they are abused, and virtually all male abusers consider themselves heterosexual. Confusion of same-sex abuse with homosexuality gets further complicated when considered in the context of masculine gender ideals, as discussed in the previous chapter. In turn, they both interact with a man's understanding of his own sexual orientation and any ambivalence he feels about himself as an erotic, sexual being.
     These are all are complex, interrelated subjects for a male victim of childhood sexual abuse. As these themes emerge in treatment, both therapist and patient may be unclear about which is the crucial thread at any given moment. For example, a man may easily confuse shame about victimization with shame about same-sex behavior, or shame about homosexual wishes, or even shame about feeling sexual desire. It is important to track the patient's subtle shifts in focus as he moves from one of these feelings to another.
     Sexual victimization brings up concerns about sexual orientation when a boy equates victimization with passivity, and passivity in turn with homosexuality (Nasjleti, 1980). Ignorance, prejudice, and misinformation about homosexuality permeates our culture, influenced by socialized masculine gender ideals. Therefore, when a boy's abuser is a man, the betrayal is apt to be regarded by the boy or by anyone who hears about the molestation as something to hide, specifically, a worrisome indication that the boy is gay (see Johanek, 1988; Sepler, 1990; Struve, 1990).
     Thus, fears of homosexuality may especially interfere with the ability to process same-sex abuse. In this chapter, I will consider the history of homosexuality as a concept. I will then focus on homophobia and heterosexism, analyzing their effect on how sexually betrayed men come to terms with their abuse histories. In particular, I will address the common fear that childhood sexual abuse makes a boy gay. I will also focus further on boys' and men's shame about same-sex victimization, and how our culture reinforces their sense that silence and revenge are the only acceptable responses to such victimization.

UNDERSTANDING SEXUAL ORIENTATION
What is homosexuality and why is it worrisome? These appear to be obvious questions with obvious answers, but to properly understand the relationship between male sexual victimization and fears about homosexuality, we need to examine each of the relevant concepts in turn. In this and the following section, I will address sexual orientation, homophobia, and heterosexism, as well as the history of psychological theory in relation to them.
     Sexual orientation may be defined as the predominating erotic desire for a particular kind of sexual partner. Usually, this includes romantic and affectional attachment as well. In contemporary usage, the term is usually used to denote same-sex or opposite-sex attraction. Like gender identity, sexual orientation is a complex construct with multiple meanings. Further, it is shaped, created, and perceived through a cultural lens.' Individuals may be attracted to both sexes in different degrees at the same time, or they may be primarily attracted to one sex or another at different points in their lives. For this reason, common but erroneous binary concepts of heterosexuality and homosexuality (see Blechner, 1995a), by which men are thought to be entirely heterosexual or entirely homosexual, further confuse the integration of a sexual abuse history.
     Sexual orientation is often confused with sexual behavior. Kinsey and his associates, in their classic study Sexual Behavior in the Human Male (Kinsey, Pomeroy, and Martin, 1948), used largely behavioral measures to infer degrees of sexual orientation. In doing so, they attempted to move away from binary assessments of sexual orientation to take into account the diversity of men's actual sexual experiences. They assigned men numbers on a seven-step scale based on the frequency of homosexuality and heterosexuality in their behavioral histories, as well as in their dreams and waking fantasies. They then categorized gradations of sexual orientation from exclusive heterosexuality through varying proportions of heterosexuality and homosexuality to exclusive homosexuality. As they wrote:

The world is not to be divided into sheep and goats. Not all things are black nor are all things white. It is a fundamental taxonomy that nature rarely deals with discrete categories and tries to force facts into separate pigeon holes. The sooner we learn this concerning human sexual behavior, the sooner we shall reach a sound understanding of the realities of sex. (p. 65)

HOMOPHOBIA, HETEROSEXISM, AND SCIENTIFIC EXPLORATIONS OF THE ORIGINS OF SEXUAL ORIENTATION
In Chapter 3, I noted the need of boys endeavoring to establish traditional masculine identities to disidentify with women as they develop. Femininity and homosexuality are often equated in this process. The struggle to define oneself as "not female" frequently leads to a disparagement of qualities seen as feminine, and often to a (usually disguised) antagonism toward women. Hatred of homosexuals, who are often viewed as men who did not succeed in disidentifying with women, is usually more open. The widespread fear and prejudice against homosexuality in the United States has been well documented and discussed elsewhere (Isay, 1989; Sedgwick, 1990; Herek, 1991, 1998; Martin, 1991; Moss, 1992; D. Schwartz, 1993; Domenici and Lesser, 1995; Katz, 1995; Drescher, 1998). It is usually called homophobia, literally meaning "fear of homosexuality" but usually used to connote hatred of it. In most cases I prefer the term heterosexism, which implies an unconscious predisposition to view life from a heterosexual viewpoint, and therefore to be intolerant or prejudiced against alternate sexualities. D. Schwartz (1993) has proposed using the term heterophilia for these phenomena.
     Homophobia and heterosexism are ubiquitous throughout North American society. They were unfortunately prevalent in writings about psychiatric and psychological diagnosis and treatment for many years, although to some extent this has changed in recent years (but not entirely; see Blechner, 1993, 1995b; Drescher, 1996). In this section, I will briefly review the history of how homosexuality has been portrayed in the clinical literature. This will serve as a backdrop to understanding sexually abused men's fears that they may be gay.
     Homosexuality itself is a relatively modern idea, having first appeared in writing as a scientific term in 1869 (Wiedemann, 1962). Heterosexuality is likewise a relatively contemporary idea that was itself "invented" (Katz, 1995). Homosexuality was almost invariably thought to be pathological by psychological, psychiatric, and psychoanalytic writers from the late nineteenth century until at least the 1970s and, to a lesser extent, continuing to the present (see Bergler, 1956, 1959; Socarides, 1968, 1978, 1995; Nicolosi, 1991). The hypothesized pathological nature of homosexuality has at various times been viewed as stemming from moral, biological, and psychological sources. For decades, it adversely affected the psychotherapeutic treatments of many gay individuals. Martin Duberman, in his book Cures (1991), and Paul Monette, in Becoming a Man (1992), each chronicle harrowing histories in which he was thus affected in his own psychotherapy (see also the case of Owen later in this chapter).
     A rare exception to this trend to pathologize homosexuality is represented by the work of Evelyn Hooker (1957), a psychologist who devised a double-blind study of Rorschach responses of apparently welladjusted homosexual and heterosexual men in the general population. She found that there was no reliable way to discern any difference in their Rorschach responses, and therefore concluded that though homosexuality may be atypical it is psychologically within the normal range of sexuality.
     Initially far more influential than Hooker's work, Homosexuality: A Psychoanalytic Study of Male Homosexuals, the 1962 study by Irving Bieber and his associates, is perhaps the prime example of scientific work that pathologizes homosexuality. A ten-year study of homosexuals and heterosexuals undergoing psychoanalytic treatment, it was, in the years following its publication, nearly universally cited by writers who considered it to have confirmed traditional psychoanalytic ideas about the pathology of homosexuality (see Lewes, 1988, for an extended discussion of this issue). Bieber concluded that homosexuals were likely to have been involved in overly close, often seductive relationships with their mothers, and distant or hostile relationships with their fathers. The Bieber study claimed a 27 percent rate of conversion from homosexuality to heterosexuality through psychoanalysis, although details were not given about the treatments or the quality and duration of these conversions. This is close to the 35 percent conversion rate cited by Socarides (1968, 1995), a contemporary advocate of so-called reparative therapy to convert homosexuals to heterosexuality. Questions have been raised about whether these conversions reflect true changes in orientation. Even if we accept the figures Bieber and Socarides offer, however, their studies yield a failure rate of 65-73 percent, hardly convincing evidence for the validity of the treatment they advocate (Drescher, 1998).
     Subsequent empirical studies have consistently not differentiated homosexual and heterosexual adults on measures thought to indicate mental health (Lichtenberger and Buttenheim, 1998). In 1973, only eleven years after the publication of the Bieber study, the American Psychiatric Association voted to delete homosexuality from its list of psychiatric disorders. This was the result of a sea change in the psychiatric community, with mostly nonanalytic psychiatrists successfully challenging the dominance of the mostly psychoanalytic psychiatrists who had previously held sway. While the change itself did not stop the controversy (see Lewes, 1988), and still has not been accepted by some parts of the professional community, the depathologizing of homosexuality has gradually generalized to some degree in scientific writing. In recent years, a number of observers have documented and discussed the (often unconscious) homophobia and heterosexism prevalent in the clinical literature (Mitchell, 1978, 1981; Kwawer, 1980; R. C. Friedman, 1988; Lewes, 1988; Isay, 1989, 1991; Blechner, 1993, 1995a, 199b, 1996; Corbett, 1993; Lesser, 1993; Macintosh, 1994; Dimen, 1995b; May, 1995; Schafer, 1995; Drescher, 1998).
     In the 1990s, there has been increasing evidence offered by scientists for a biological model of homosexuality (Money, 1988; Hamer, Hu, Magnuson, Hu, and Pattatucci, 1993; LeVay, 1993; Byne, Hamer, Isay, and Stein, 1995; Zhang and Odenwald, 1995). This model has relieved many homosexuals from anguished feelings that they have somehow unknowingly "chosen" to be homosexual, and are therefore responsible for hurting their families or for what they may think of as their own "degeneracy." But the biological explanation of homosexuality can itself be used in the service of unconscious heterosexism. This is because the very question of why someone becomes homosexual, a question rarely asked about heterosexuality, can be an expression of nonaccepting and pathologizing hatred (Blechner, 1995b).
     In sum, homophobia, or heterosexism, has constituted a dominant societal attitude about sexual orientation. It is a bias that in itself has been called sexual abuse (Fitzgerald, in Morris et al., 1997). It has affected all homosexual individuals in our culture, as well as heterosexuals, and its effect on psychological theory and treatment has at times been devastating. Now let us look at its effects on boys who have been sexually abused.

THE INTERNALIZED MEANING OF HAVING A MALE ABUSER
Self-concepts in relation to both sexual orientation and gender identity have not yet coalesced for boys and adolescents, and therefore they tend to understand concerns about their own or others' orientation in a literal and concrete way (see Shapiro, 1994, and Chapter 10 of this book). Fears, prejudices, and misinformation about both sexual orientation and gender identity are particularly prominent in adolescence, when both are being consolidated. Such preconceptions about orientation create great confusion and internal turmoil for boys sexually abused by men. Sexual abuse may cause boys to remain caught up in the black-and-white views of homosexuality and heterosexuality that are characteristic of childhood and adolescence, when they were first abused. Thus, Bruno and Isaac both had simplistic, behaviorally oriented ideas about whether their same-sex sexual activity with abusers, and later with other men, meant that they were "actually" gay.
     Molestation by a man is likely to undermine a boy's sense of his gender identity and orientation, whether he is predominantly heterosexual or homosexual (Bruckner and Johnson, 1987; Dimock, 1988; Lew, 1988; Bolton et al., 1989; Gonsiorek, 1993, cited in Mendel, 1995; Mendel, 1995). This is particularly likely if he encodes his experience as a "feminizing" victimization (see Chapter 3), especially one that goes counter to his own object choice (see Chapter 2). The problem is made even more complicated when we take into account how far the boy's conscious understanding of his sexual orientation and identity has developed at the time of the abuse.
     We saw in Chapters 2 and 3 that a boy who has been headed for a predominantly heterosexual orientation is likely not to consider molestation by a woman to be abusive. If, however, he is abused by a woman and is not sexually aroused, he may take this as a sign that he is gay (Mendel, 1995). If he is abused by a man, he may perceive the very fact of his molestation as a shameful sign of "queerness" or femininity (Sepler, 1990; Struve, 1990). He may fear that he somehow invited the abuse and therefore is "really" interested in men. Or he may wonder why he was chosen by a man as a sexual target, and whether having been chosen means he is "truly" homosexual. Whether he is aroused or not, then, he may fearfully assume he is "really" gay.
     Meanwhile, a boy with even a partial awareness of being headed toward a predominantly homosexual orientation may be repulsed and frightened by sexual activity with a woman. When the abuser is a man, however, he may feel excited by what he considers a "sexual initiation." On the other hand, sexually abused boys who are predominantly homosexual may feel the experience prematurely hurried them into defining themselves as gay.
     As I outlined in Chapter 2, men are especially likely to think of their abuse as "sexual initiation" if the abuser is not a parent and is of the same sex as the boy's eventual primary object choice. But for nearly any boy molestation by a man brings up questions about his gender identity and sexual orientation, as well as worries about why he was chosen as a victim (Nasjleti, 1980; Finkelhor, 1984; Dimock, 1988; Lew, 1990; Struve, 1990; Mendel, 1995). Usually, sexually abusive behavior is fundamentally about power and aggression rather than about sexuality (see below). Even when homosexual desire is not the motivating force in a molestation, however, as Pescosolido (1989) notes, "The victim's perception is that of being involved in homosexual behavior. As a result, [he] is left with emotional confusion regarding his developing psychosexual identity. Essentially the victim may believe that something within himself almost magically communicated a homosexual invitation prompting the molestation" (p. 89; emphasis added).
     Pescosolido adds that there is even more uncertainty for the victim if he becomes erect or ejaculates during the abuse (see also Ehrenberg, 1992). While these are the normal physiological responses to stimulation, he may feel they provide proof of his participation in the act. Thus the boy, and later the man, may ask himself, "Was I chosen because I seemed interested? Was I interested? Did he know I was not man enough to resist? Did my `femininity' or 'sissiness' show enough to attract his attention?"

RAMON: SEXUAL ORIENTATION CONFUSION WHEN A MALE ABUSER IS ALSO NURTURING
When a male abuser is also a source of nurturance and pleasure, the boy's confusion about the implications of the abuse for his sexual orientation is especially painful and bewildering, as Ramon's case illustrates.
     Ramon returned again and again in therapy sessions to his feelings about the neighborhood puppeteer who first abused him. He was initially afraid to voice his internal experience, afraid I would censure his positive feelings about their relationship, afraid that he or I might decide he was gay or bisexual if he put his obsessive thoughts into spoken words. Finally, though, he sputtered that this man had been tender, that he had known how to make Ramon feel good, that the sex had been sensuous and arousing, and that he never felt pain, even when he had bled. He said, miserably, "It's never been so sweet, so nice with anyone again. What does that mean? Who am I?" I remarked that with this man he had felt safe and cared for, that he had felt this was the one person who focused on him and was attentive to him at a time when his world was coming apart.
     Later in treatment, Ramon revealed ashamedly that when he thought about his experiences with the puppeteer he felt an erotic "tingling" throughout his genital and rectal areas. He then talked about how during the period he had been abused by this man he woke up every morning waiting for the moment he could go visit the puppeteer and feel his tender lovemaking. He said, "I've been looking for that again ever since. I wish every day I could feel so good. But I don't think I'm gay--I never look that way at men on the street, and I like being with women. And if I tell anyone, my girlfriend, my friends, how I feel turned on when I think of being with him, they'll think I'm indecent--they won't take care of me any more."
     Ramon thus revealed that, for him, a prime motivation for being sexual at all was to feel cared about and to enjoy someone allowing him to be dependent. Ramon said he didn't really want to have sex with the puppeteer or someone like him again, although it was not clear to me whether he was saying this because he meant it or because he was trying to allay his own fears about being homosexual. Either way, he was obsessed with the sensations of safety, nurturance, and eroticism that had accompanied his abuse.
     We talked about this many times, and finally arrived at a model for thinking about it that seemed to pacify his intense anxiety. I likened the abuse experience to Ramon's thumb sucking as a very young child. In both instances, he felt comforted and calmed by the activity. He could remember those feelings with some longing in both cases, and yearn to have them again, but this did not automatically mean he as an adult actually wanted either to suck his thumb or to be penetrated again by a man like the puppeteer. That could be a separate decision for him. Ramon held on to this idea. At one point he actually resolved that to distract himself from his fears of homosexuality he would substitute sucking his thumb for the tingling in his rectal areas when he felt it again. Making this plan seemed to free him considerably, and he reported with relief some receding of his constantly recurring erotic sensations. While he remained confused about his sexual orientation, this confusion no longer interfered in the same way with his day-to-day life.

ARE MALE ABUSERS GAY?
Complicating the belief that abuse turns a boy gay is the related common folkloric myth that men who abuse boys are homosexual predators. This myth particularly extends to pedophiles who abuse large numbers of boys over time. While some pedophiles may consider themselves gay, it is far more often true that boys are abused by men who consider themselves heterosexual. Some of these men do not really differentiate between boys and girls, choosing whoever is most vulnerable and/or available (Dimock, 1989a).
     Groth and Oliveri (1989) studied sexual victimizers of children, focusing on pedophiles rather than incest offenders. They divide abusers into three categories: First, there are those with an exclusive fixation on children. Some of these are only interested in boys, some are only interested in girls, and some are interested in both or do not discriminate between boys and girls. Second are those with a nonexclusive fixation. While primarily drawn to children, they have a secondary interest in adults. A third category of abusers includes those whose pedophilia constitutes a regression. They are primarily oriented to adults, but during some periods of their lives they regress and are drawn to children.
     Groth and Oliveri report that if homosexuality is defined as being primarily oriented to adult men, then there are virtually no homosexual pedophiles. Among over 3,000 offenders they studied, they did not encounter a single man who had regressed from an orientation to adult men to an orientation to children. On the contrary, the men they studied who were nonexclusively fixated on children or who regressed from an adult orientation universally described themselves as heterosexual in their orientation toward adults, and indeed were usually homophobic (similar findings are reported by jenny, Roesler, and Poyer, 1994).4
     Pedophiles preying on boy victims often report that they are uninterested in or repulsed by adult homosexual relationships and are attracted to young boys' feminine characteristics and absence of such secondary sexual characteristics as body hair (Groth and Birnbaum, 1979). This supports the accepted clinical picture of sexual offenders and pedophiles as people who are psychosexually immature and who therefore in some way identify as psychological and psychosexual peers of the children they molest (Groth, 1982; Pescosolido, 1989).
     A related view of pedophilia, sexual abuse, and rape is that they are not primarily expressions of sexual desire but rather are abuses of power and expressions of aggression (Burgess and Holstrom, 1979; Groth, 1979; Pescosolido, 1989). This is congruent with the classical Greek concept of sexuality described in Chapter 3, in which sexual penetration was a means of further establishing the dominance of the penetrator over the person being penetrated (Halperin, 1989). Note, however, that in some cultures and subcultures, as described in Chapter 3, men who take a penetrating role in sexual activity may consider themselves heterosexual even if the person being penetrated is male.
     These are further arguments that in most cases when a man abuses a boy homosexuality is not fundamentally the issue. This is why I use the term "same-sex victimization" rather than "homosexual victimization" to refer to situations in which perpetrator and victim are of the same sex (see also Pescosolido, 1989). To talk about "homosexual molestation" or "homosexual incest" implies that homosexuality is what caused the offense, rather than the many complex possible dynamics that are actually associated with child sexual abuse.

THE FEAR THAT SEXUAL ABUSE TURNS A BOY GAY
A boy with a consciousness of being gay may welcome aspects of his sexual experience with male predators, especially if he has felt isolated and freakish in relation to his sexual desire. I discuss this attitude more fully below. On the other hand, as I said, such a boy may feel hurried into considering himself gay. For him, there are complicated questions beyond those of heterosexual boys might ask themselves, such as: "Did I ask for it? Was my interest in men so obvious? Did I really want it? If I found it exciting does that mean it was not a molestation?" and, finally, "Is this why I'm gay?"
     Any boy growing up gay in our society is likely to endure painful psychological and social struggles as he comes to understand his orientation and deal with people's reactions to it. In reacting to these struggles, he will probably go through a period of wondering about how he came to be homosexual. At such a time, he will look everywhere for an answer to the question "Why am I gay?" And, if he has been sexually abused by a man, it is easy for him to "blame" his sexual orientation on the abuse.
     Many boys or young men who have been sexually abused share the commonplace view that sexual abuse by a man makes a boy gay. Beau, for example, took it as a matter of course that any man sexually abused in childhood was molested by men, as he had been, and grew up to be gay, as he had. He was astonished to hear that some men in the group for sexually abused men he was joining considered themselves straight and that some (not always the same ones) had been abused by women.
     Paradoxically, however, a young gay man abused by a woman in childhood may use the reverse logic to account for his homosexuality. In that case, he may assume that fearful reactions to his female abuser generalized to all women, and made him later turn to men for sexual pleasure. Thus, whether the abuser is male or female, the betrayal complicates how the homosexual victim deals with being gay, and he may view abuse as the origin of his orientation.
     But if we were to assume sexual orientation is changed or directed by sexual abuse, similar logic could be applied to heterosexual men. Thus, straight men abused by women would think their early sexual experience with women turned them heterosexual. If abused by men, they might assume that fears of men made them turn to women. But heterosexual men do not seem to consider these possibilities, nor is there any reason for them to do so. By the same token, there is no reason for gay men to believe sexual abuse caused their orientation.
     Note that I am talking here about how the individual encodes experiences that coincide in his life. A boy or man knows he has been sexually abused and also knows he is attracted to men. As he puts together this knowledge, he is likely to add a causality between the two that is in fact logically specious. Interestingly, this conflict seems to get resolved for many sexually abused gay men by their mid- to late twenties. Most gay men I have seen at this age no longer link their orientation to sexual abuse, a finding also reported by Lew (1988, 1993) and Gonsiorek (1993, cited in Mendel, 1995).
Is there indeed a link between sexual molestation and subsequent predominant sexual orientation? As Mendel (1995) says, "The relationship between factors associated with childhood sexual abuse and sexual orientation is complex and controversial" (p. 169). In discussing the higher incidence of childhood sexual abuse among homosexual men, Finkelhor (1981, 1984) considers the possibility that boys growing up to be gay are more likely to be vulnerable to sexual victimization, but he favors the explanation that abuse fostered the homosexuality. This is contradicted, however, by the fact that most researchers believe predominant sexual orientation is established before latency, while most sexual abuse of boys occurs later (Gonsiorek, 1993, cited in Mendel, 1995; Mendel, 199S). Nor does it explain Simari and Baskin's (1982) finding that most of the abused gay men they studied had a clear sense of a homosexual orientation before their abuse or incest. I will return to the issue of gay boys being especially vulnerable to sexual abuse later in this chapter.
     The sexual confusion and homophobia seen in boys who were sexually abused by men is also discussed by Bolton et al. (1989). They conclude that there is no reason to believe that sexual abuse alone fundamentally changes or shapes sexual orientation, despite the conventional wisdom that premature sexual activity with a man can "turn" a boy homosexual. Whether a man's orientation is homosexual, heterosexual, or bisexual, however, sexual abuse often affects the quality of his sexual relatedness (Rosenberg, 1995; see also Chapter 8). I am referring here to such aspects of sexuality as sadomasochistic fantasies or activities, various erotic obsessions and compulsions, and the capacity for intimacy.
     Like Lew (1988, 1993), Bolton et al. (1989), Gonsiorek (1993, cited in Mendel, 1995), and Rosenberg (1995), my clinical impression is that sexual orientation is nearly always determined for reasons other than premature sexual activity. On the other hand, it is not at all uncommon for a straight man who suffered same-sex abuse to go through a period of sexual acting out with men, sometimes of a compulsive nature, while he struggles to answer for himself whether the abuse either means he was always gay or turned him gay. Andreas, for example, at one point in his thirties experimented sexually with men because of the numbness he felt during sex with his wife. Eventually, he decided he had even less interest in sex with men than in sex with women.
     I will now consider several other men described at greater length elsewhere in this book whose boyhood sexual abuse by men seemed not to affect their predominantly heterosexual orientation, although their capacity to relate intimately was often compromised: Ezra was a socially shy heterosexual man; as a child, he was lured to a wooded area by a neighborhood teenager who masturbated on his bare chest. Harris was repeatedly abused by his father; as an adult, he was sexually interested in women, often picking them up for one-night stands but unable for years to be available for a relationship. In his early teens, Julian had an ongoing relationship with a priest; as a man, he was troubled by his compulsive, time-wasting interest in heterosexual pornography. Quinn was abused by his grandfather starting as a preschooler; he grew up to be a heterosexual man who had severe problems with self-esteem and depression. Teo, a heterosexual man who as a boy was abused by his godfather for an extended period of time, had two troubled marriages before meeting the supportive woman who became his third wife. Willem was apparently abused by more than one of his mother's lovers and husbands; he grew up to be a heterosexual man with severe problems of emotional detachment. Zak also grew up heterosexual following horrendous and prolonged emotional, physical, and sexual abuse at the hands of his adoptive father.
     By way of contrast, I will now describe Bruno, a single man in his mid-sixties who suffered physical, verbal, and sexual abuse from several sources as a boy. Bruno is one of the very few men I have treated whose sexual orientation seemed fundamentally disordered by his reactions to same-sex abuse (a somewhat similar case is discussed by Gilgun and Reiser, 1990).
     Bruno came to treatment hoping to discover his sexual orientation so that he could pursue either men or women with a vigor that had eluded him all his life. In the eight months we worked together, it gradually became clear to me that his multiple abuse experiences with his father, brother, teachers, and doctor had left him afraid to expose himself to any possibility of further abuse or ridicule. This was true in all interpersonal situations, but especially true in the sexual arena. Bruno enjoyed socializing with women, flirting mildly with them, and escorting them to social events. In more intimate situations, however, he was terrified they would make sexual demands on him. He had some mild sexual interest in them but was sure he could not perform adequately and would be subject to ridicule from even the kindest women he knew.
     The youngest in a large immigrant working-class family, Bruno had been severely beaten as a boy by his father and one of his older brothers. His mother was overworked and passive, though apparently she herself was not abused. In describing his family, Bruno seemed to accept physical brutality as expected and acceptable, not unlike what happened in other families from his culture. The greater part of his conscious rage was reserved for the nuns in the parochial schools he attended. In memory, Bruno experienced these nuns uniformly as critical, derisive, terrifying, and cruel, particularly about what apparently was his undiagnosed dyslexia. He had numerous memories of humiliations he suffered from these women.
     When he was twelve, Bruno was taken to the family doctor for treatment of a mild illness. During the examination, the doctor engaged in mutual oral sex with Bruno, and told his parents to bring him back every week, which they did for three years. Bruno protested, but did not tell his parents about the abuse. They angrily told him he was ungrateful for the doctor's interest in him. Not coincidentally, the doctor did not charge any of the family for medical attention given in the years he was molesting Bruno. Finally, when Bruno was fifteen, the doctor lost interest in him, and, as Bruno later understood it, he became similarly attached to a younger boy.
     I have described Bruno's near-phobic reactions to the possibility of intimacy with women. He did have homosexual encounters, but we came to understand that his main interest seemed to be in attracting the other man rather than in having sex with him. While he often followed through and completed sexual acts with men, this appeared to be more out of a wish to placate them than from his own sexual desire. Indeed, as he got older, Bruno found that, more often than not, he would walk away from the other man once he knew the man desired him.
     Bruno went through his entire adult life in this manner, only coming into therapy in late middle age, never having had an intimate relationship, uncertain about his sexual orientation. He sometimes thought of himself as a homosexual who did not enjoy sex with men, and at other times considered himself a closet heterosexual who was afraid to have sex with women.
     My initial impression of Bruno was of a closeted gay man with low self-esteem whose cultural background made it impossible for him to accept his homosexuality. As we explored the nature of his sexual fantasies, I therefore felt it was crucial to distinguish his feelings about homosexuality from his own homosexual wishes. Bruno certainly shared some of the homophobic and heterosexist attitudes of the working-class Catholic family he grew up in during the 1920s and 1930s. On the other hand, he said he had reached a point in his life where he was more afraid of staying confused about his sexuality than of discovering that he was indeed gay.
     Having declared this, Bruno noted that, while he was enraged about the doctor's molestations, they had provided him with the heady experience of feeling attractive and desired. This was what he tried to repeat with men as an adult. These interludes with men were never really gratifying, he said, but they did sometimes result in completed sexual acts, which had not been the case with women except for a few prostitutes when he was a very young man. Bruno believed that his molestations by the doctor had turned him into an "unwilling homosexual."
     I was now confused about how to understand his sexuality and sexual orientation, and unfortunately had only meager fantasy material from him with which to support my various hypotheses. I felt his experiences with men supplied him with a way of functioning sexually, while his psychological paralysis with women prevented him from acting on the heterosexual impulses he also had. Yet his sexual desire never seemed to center clearly around men, and so, despite my initial impressions, I had trouble seeing him as fundamentally, or even predominantly, homosexual.
     We began to clarify Bruno's sense of inadequacy and his feelings about men and women, and to connect both with his abuse experiences in childhood. It became more and more evident that his ability to relate to anyone sexually was very limited. Indeed, the undeveloped quality of his interpersonal functioning indicated that in many ways he had never reached a level at which mature sexual relating was even possible. Instead, he was stuck at a preadolescent stage of psychosexual development. To the extent that he even wanted sexual relationships, the main desire seemed to be to find companionship and have his considerable dependency deprivations assuaged.
     As we delineated his need to be pleasing to women as well as to men, Bruno seemed to lose interest in both, at least for the time being. At this point, he told me a prevailing sexual fantasy had emerged of a partner who was a virginal hermaphrodite: young, feminine, and naive. He pictured this person as having breasts and female genitalia, but with small male genitals as well. The male genitals would calm his anxiety about being with a woman, while the virginal naivete would make it unlikely that Bruno's sexual performance would be criticized.
Bruno actually contacted a hermaphrodite who seemed to fulfill this fantasy. However, he broke off treatment before they met. The premature termination was not fully discussed. It could have been because of anxiety about the material he had uncovered; or because experiencing his sexuality felt dangerous; or because of a feeling I was leading him too quickly down a path of discovery about sexuality, whether gay, straight, or otherwise; or because of material he never hinted at, such as an erotic transference to me. I do not know whether any of my impressions about his orientation would have held up over time. Possibly his cultural background, combined with his abuse, did indeed make it impossible for him to acknowledge his homosexuality. Possibly he was right that his combination of abuse experiences had changed a fundamentally heterosexual orientation into a defensively homosexual one. Possibly he was neither gay nor straight nor even bisexual or transgendered, but rather of some unusual sexual orientation or gender identity as represented by his wish for a hermaphrodite partner (see D. Schwartz, 1995). Certainly his repeated traumas in early relationships left him functionally nearly asexual, disabled in all relationships because of his primeval terror of feeling closely connected to another person.
     Bruno suffered multiple abuses in the context of a brutal family system that demanded unquestioning compliance from him. Perhaps because of these complexities, Bruno, almost alone among the sexually abused men I have treated, was affected by his history so that on all these levels the directions of his sexual orientation became thoroughly confused.

GAY BOYS AS TARGETS OF MALE ABUSERS
Among men with histories of sexual abuse, homosexual men are more likely than heterosexual men to have had male abusers (Simari and Baskin,1982; Finkelhor, 1984; Johnson and Shrier, 1985, 1987; Mendel, 1995). On the surface, this finding supports the common belief that boys with male abusers grow up to be homosexuals. But the reasons gay boys are abused by male predators are tangled and complicated. Sensing themselves as different or "other" than their peers, they may project an air of vulnerability (Lew, 1993). Or they may have developed some awareness of their interest in boys and men, whether conscious or unconscious. And potential sexual predators, whether from inside or outside the family, are skilled at recognizing and taking advantage of such vulnerability or incipient sexual interest. Interestingly, the results of research investigating whether straight men are more likely than gay men to have had female abusers are not as clear-cut (see Johnson and Shrier, 1985; Mendel, 1995).
     Some boys whose gay orientation is at least partly conscious at the time of their abuse may welcome aspects of the molestation. Many boys in this situation feel very isolated in their developing gay identities. Indeed, they may have no idea that any other boys or men have similar sexual interests. In such a case, the boy may pay far more attention to the escape from this feeling of total isolation than to the abusive aspects of his experience (Myers, 1989). As Uri said about his concurrent abuse and personal devaluation at age thirteen by the twenty-two-year-old brother of his best friend: "I felt such joy discovering that I wasn't the only one who was aroused by men that I didn't care who showed me or how. As far as I was concerned, I had been liberated. I was no longer alone in the world. The sex itself felt good, and up till then having sexual thoughts had always been terrible for me. At the time, I hardly realized how horribly he was treating me--I didn't care about anything but my relief at not feeling like a total freak any more."
     Greg, on the other hand, used aspects of his early knowledge of his homosexuality to confirm for himself that he had indeed been abused. He was a boy growing up gay who had already in some ways integrated or accepted his sexual interest in men before he was abused by his father and grandfather.
     Greg remembered being interested in boys and men from early childhood. As an adult, he recalled his earliest pubescent fantasies and came to feel that they were confirming evidence of sexual abuse by his father. Although he had clear memories of his grandfather exposing himself to Greg when Greg was of latency age, his memories of abuse by his father were more shadowy. But he told me, with great embarrassment, that as a young adolescent he had had overwhelming, frank, consuming sexual fantasies about his father. Later, he began to think this was abnormal, and said, "I used to think it was because I was gay--yet another shameful thing about being gay--that I had sexual fantasies about my father. Then, as I grew up, I suddenly wondered--Do straight men have sexual fantasies about their mothers? I don't think so--not like I did, not all the time. Something was definitely going on between us if I was having fantasies like that. But I always thought it was just me and my dirty, evil mind."

GAY BASHING AS SEXUAL ABUSE
Sometimes when boys developing gay identities are sexually abused, the attack is a direct reaction to the abuser's recognition that the boy is homosexual. This abuse has a different character from incestuous abuse or molestations by pedophiles in that the victimization arises from hatred and prejudice about homosexuality itself. Violent antipathy to homosexuality is common among some heterosexuals. It appears to represent an attempt at mastery over fears about what is perceived as a threat to both masculinity and heterosexuality. This is especially likely among those who have never evolved beyond the concrete and simplistic views of homosexuality often held by adolescent boys whose sense of their masculine identity is not yet consolidated.
     Hatred for homosexuals in such cases may result in what has come to be known as "gay bashing." Its virulence can lead to particularly ugly outcomes. Witness the case of Beau, a gay man who suffered multiple abuses and a multiple rape as a teenager. Beau's effeminate mannerisms appear to have preceded in time any conscious consolidation of his homosexuality. His traumatic introduction to homosexual behavior through a severe gay bashing incident in early adolescence further eroded his already shaky sense of himself.
     An introverted boy, small for his age, Beau grew up in a conservative small town whose population included many rednecks and members of the religious far right. Both parents were well educated. He described his mother as vicious and verbally abusive and his father as fussy and fastidious, a man who spent time on intricate, isolating hobbies and was passive with his wife and nonresponsive to his son. Beau was often teased for his effeminacy. In addition, on a number of occasions in his preadolescence and teenage years he was groped or otherwise approached sexually by adult married men. On one occasion, he was fondled at his grandmother's wake by a professional man well known in the community. These incidents led him as an adult to be sneeringly infuriated at what he felt was the common hypocrisy of married men who were regarded as pillars of the community.
     As a ninth grader in high school, Beau was anally raped by three student athletes. They took him under the athletic field bleachers for the assault. An assistant coach passed by and saw what was happening. According to Beau, he said, "I want some of that too," and also raped him. At the time of this violation, Beau had already known he was emotionally drawn to men, but he had only the vaguest sense of what physical acts of sex involved. His rape trauma was therefore particularly profound, since it also served as his introduction to even imagining overt sexuality with men.
     School officials knew of the rapes, but never punished the assailants. Indeed, the assistant coach was eventually made head coach at the school. Beau said that when school officials called his father to tell him about the assault--it is not clear that they conveyed the news that his son had actually been raped--he told them to send Beau back to class. According to Beau, when he got home that day his mother called him a "little bitch" for having caused so much disruption.
     After the rape, Beau became an object of rampant abuse and derision on a daily basis at school. Boys would force him to choose either to fellate them or give them payoff money to leave him alone. Girls knew about this and openly called him a faggot and a sissy. He was miserable, frightened, and endangered till he graduated from high school and went away to college, never to return to his hometown again except for brief visits to his parents. I will come back to the sequelae of Beau's abuse in Chapter 8.

THE INTERSECTION OF ABUSE AND SELF-DISCORDANT HOMOSEXUALITY
I have discussed boys who were already moving in some way along a path toward confirming their homosexuality. What happens to a boy like this whose homosexuality is unacceptable to him?
     Many boys developing a homosexual orientation are bewildered by the meaning of their orientation. This confusion can last a lifetime if the boy never comes to terms with his sexuality. Homophobic and heterosexist biases are nearly omnipresent in our culture, although this is less true now than it was even a decade ago. These introjected societal convictions about homosexuality intersect with a man's developing attitudes about sexual abuse. Together, they may complicate a man's views of both his gayness and his abuse history. Sometimes a preoccupation with changing or hiding a gay sexual orientation distracts him from even thinking about the abuse.
     Let us return to Owen, the sixty-eight-year-old man whom I discussed in Chapter 2 with regard to his not encoding as abuse his "affair" starting at age twelve with a twenty-nine-year-old man, Calvin. Owen was a boy developing a homosexual orientation who before his "seduction" by Calvin had found at least one other boy with similar sexual interests. While apparently certain of his interest in men, he had extremely negative feelings about homosexuality, and was sure he would be ostracized by family and friends if he revealed his homosexual interests. Like many men, especially of his generation, he hid his homosexuality throughout most of his life. He sought treatment to "cure" his homosexuality, and apparently in his earlier therapies the focus on changing his orientation superseded any analysis of the meaning of his childhood "affair" with Calvin. Such a focus, as I have said, was common in the psychological treatment of homosexuals at that time. Yet we discovered that the subtle effects of his having been exploited by both Calvin and his family, and his willingness to be so exploited, were also central to his psychology. He never felt that his early sexuality with Calvin constituted molestation, but with time he agreed on the importance of analyzing his susceptibility to being manipulated.
     Owen called me for a consultation two months after walking out of his previous analyst's office in a rage. He had been in treatment with this analyst for most of the previous thirty years, at frequencies of one to three times a week. A major focus in that treatment, and in Owen's life up till then, was his conflicted feelings about his homosexuality.
     Even when involved with Calvin as a preadolescent and adolescent, and throughout college and a period in the armed services, Owen maintained and acted on the interest in boys and men he had evinced before meeting Calvin. He fell in love with other men several times. Some of these relationships were with heterosexual friends and were never completely enacted. Others were with more openly willing partners and included sexuality and, at times, living together, though never publicly as lovers. Most of these men eventually entered marriages with women, though Owen believed that many of these were basically marriages of convenience, as his own turned out to be. As was common in Owen's generation, these men, like Owen himself, seem to have been profoundly uncomfortable about homosexuality and appear not to have faced directly whether they were indeed gay. Indeed, for many years Calvin was the only person Owen knew who seemed content about being homosexual.
     Much of Owen's adult life struggle was about his sexual orientation. He lived a conservative life, sure that his interest in men was pathological and that revealing it, particularly the "wanton" relationship with Calvin, would mean rejection by his family. In his mid-twenties, he married, at her insistence, a woman who accepted his lack of enthusiasm for sex with her. He was recurrently depressed and started to see a psychiatrist a few years after the marriage. His depression continued and deepened. When he was about thirty, his wife called his psychiatrist, who met
with her alone and, with Owen's relieved permission, told her that Owen was homosexual. She immediately told Owen that everything was "all right" and she wanted to stay married. Feeling that he could not bear to disappoint her further, Owen agreed. The couple, who remained childless, divorced after twenty-five years when his wife fell in love with another man.
     Shortly after his wife learned of his homosexuality, Owen began to work with the classical psychoanalyst he saw for most of the next thirty years. According to Owen, this analyst confirmed his belief that homosexuality is a disease, and they set out to cure Owen of it. In general, Owen said, the analyst interpreted his homosexuality as an expression of anger toward women and maintained that he could get beyond this anger if he worked hard enough in treatment. Owen felt positively in many ways about his work with this analyst, and particularly felt helped during periods of major depression, when medication was effectively used in addition to an intensification of the psychotherapy. But it appears that the relationship with Calvin was never addressed except as a prime example of his early homosexual experience. Its exploitative aspects seem never to have been recognized.
     Nor did the efforts to "work through" Owen's "anger toward women" result in any shift in Owen's sexual orientation. He never understood or accepted the idea that he was basically hostile to women. After his divorce, Owen began to live a relatively open homosexual life, though he never came out to any of his family members. He remained convinced that they did not know about the sexual nature of his relationship with Calvin, and he felt certain they would be horrified by this knowledge. He had a few relatively brief but serious relationships with men who seem to have been needy and dependent. In each of these affairs, Owen ultimately felt used by the other man, and the relationships all ended badly. In his treatment, the thrust of the work until the 1990s continued to be an analysis of the lower level of psychic adjustment supposedly represented by his homosexuality.
     When Owen was in his early sixties, his analysis apparently shifted gears. He and his analyst began to focus on Owen's accepting his homosexuality and trying to develop a relationship with a man after all. But Owen and the analyst continued to have major ongoing arguments. The analyst said they disagreed "profoundly" about the origins of homosexuality, while Owen began to say more confrontationally that he never felt he had "chosen" one way or another to be gay. In addition, Owen felt he was being treated shabbily by his analyst, who sometimes called Owen several times over the course of a week, or even in a single day, to change appointment times for the convenience of the analyst's schedule. He also became aware of some ethically shady practices the analyst engaged in with regard to insurance billing. During one such argument, Owen left in the middle of a session and never returned." It is, of course, difficult to make judgments about a lengthy psychoanalysis on the basis of the reports of a disappointed patient. Nevertheless, Owen's treatment, as he described it, appears to be an example of an analyst using his authority to ally himself with a patient's compliance and convince the patient of the analyst's views about homosexuality. This may change a patient's behavior, but does not address the internal conflicts or confusions a patient may have about his sexual orientation (see Drescher, 1998).
     Two months later, Owen came to see me at the suggestion of a friend. He felt emotionally shaky, depressed, and bereft. Much of the beginning work with me focused on coming to terms with the way he terminated with his previous analyst. Despite my encouragement to do so, he did not feel he could go back and end the relationship more completely. Instead, he used those early sessions with me to articulate the ways he felt his analyst had failed him, his sense of loss over leaving that treatment, his positive connections to his analyst, and the ways he had allowed himself to feel used without confronting his analyst. Also, Owen's deep fears of interpersonal abandonment were delineated as we explored his relationship with his previous analyst. It was only much later that the earlier precursors of these patterns became clear to us both. He had been exploited by Calvin and his parents, and this pattern became the template in his adult life for his relationships with lovers and his analyst. I will further discuss this aspect of Owen's treatment in Chapter 8.
     We also began to approach Owen's internal conflicts about being gay. As he talked about his conviction that he had not chosen to be homosexual, he realized that I was not arguing with him, as he expected me to. He began to read, with my support, contemporary psychological and psychoanalytic texts in which homosexuality is depathologized. While he felt great relief at finding such validation for his own conscious beliefs, he continued to experience shame about being gay, and was unable to shake completely the internalized heterosexist and homophobic attitudes of a lifetime. In particular, he remained very fearful about revealing his homosexuality to his family or to his many old heterosexual friends. He was unwilling to risk being abandoned by them, even though his conscious belief was that most of them already knew he was gay. Thus, despite a partial amelioration of his shame about his homosexuality, he continued to suffer from internalized homophobic views. These were compounded by internalized shame about having been used sexually by a man as a boy, and having felt erotic pleasure in those early experiences.

CINEMATIC PORTRAYAL OF ABUSE OF BOYS BY MEN
Sexual situations between boys and men are cinematically portrayed in a very different light from sexual activity with women (see Chapter 2). In contrast to the sense that women are offering boys sexual education and pleasure, men are usually seen as humiliating and hurting boys through sexual activity (for example, The Prince of Tides, Sleepers, Porky's, Powder, The Boys of St. Vincents), sometimes for humorous effect (for example, My Life as a Dog, Porky's, Powder). Sexual scenes between boys and men are usually coercive and brutal, often involving outright rape if a sexual act is completed.
     In addition, these incidents are inevitably portrayed as shameful, and the boys in the movies are depicted as believing they must never discuss what happened to them. This silence usually has disastrous effects on them (The Prince of Tides, Sleepers, The Boys of St. Vincents, The Celebration).
     Boys abused by men are often portrayed as antisocial in later life. This is indeed often the case, but rarely do the movies show that, as is also frequently true, an abused boy may grow up sensitive and compassionate, although depressed, anxious, or agitated in one way or another. There is virtually no model for this relatively more positive outcome should he be able to talk about what happened to him, even though it has been demonstrated, as we will see in Chapter 5, that having a confidant ameliorates some of the worst effects of childhood sexual victimization.
     A boy abused by a man, therefore, can easily conclude from the movies he sees that he should be silent about a shameful experience, even though the effect of his silence spreads far beyond the specific betrayal situation and is likely to lead to devastating results. He views his experience as something that may cause ridicule or social ostracism if it is known. He learns he should keep quiet about same-sex sexual abuse in order to avoid derision and humiliation. Silence has terrible effects on the boys portrayed in movies, but the only action allowed them by filmmakers is hypermasculine revenge.
     I am, obviously, not advocating either censorship or limiting artistic freedom of expression in any way. I believe, however, that consciousness raising about male sexual victimization is as appropriate for creative artists as for all other members of society. In Mysterious Skin, a novel by Scott Heim (1995), when two boys sexually abused by their Little League coach reencounter one another in early adulthood, they are finally able to articulate the experience that led one to become delusional about being taken away by aliens and the other to become a sexually compulsive hustler. As one of them says afterward, "If we were stars in the latest Hollywood blockbuster, then I would have embraced him, my hands patting his shoulder blades, violins and cellos billowing on the soundtrack as tears streamed down our faces. But Hollywood would never make a movie about us" (p. 283).

Betrayed As Boys: Psychodynamic Treatment of Sexually Abused Men
Richard B. Gartner
Chapter 7- Dissociation and Multiple Self-States

Recent literature on sexual abuse has increasingly emphasized the role of dissociation, rather than repression, as a protective defense against the terrifying, inchoate, and disorganizing feelings that accompany childhood trauma. Repression, first hypothesized by Freud (1900), has historically been considered a primary defense mechanism by psychoanalysts. But the roots of dissociation as a construct go back earlier, to the nineteenth century (Charcot, 1887; Janet, 1887, 1889, 1898, 1907; Prince, 1890, 1907). In the history of psychoanalytic theory, Freud, Ferenczi, Balint, Sullivan, Fairbairn, Bion, and Kohut all wrote about dissociation as a response to early experience of psychological trauma (Bromberg, 1991). In recent years, dissociation has received more attention than repression in the literature, and, indeed, J. Singer (1990) has gone so far as to argue that repression has lost its usefulness as a concept.
     The history of the concepts of dissociation and repression have been well documented elsewhere (for example, Putnam, 1992; Davies and Frawley, 1994). Rather than fully recount that history again here, I will focus selectively in this chapter on the aspects of theories of dissociation and multiple self-states that have proved most helpful to me in my own work. I will describe dissociative models for personality organization as well as for dealing with trauma. I will also cite literature, most of it written about women, that conveys how dissociation works for sexually abused adults and suggests how to deal with it in treatment. In addition, using case material, I will demonstrate throughout the chapter how dissociative processes have affected the lives and psychotherapies of the sexually abused men I have treated.

DISSOCIATIVE PROCESSES

"Dissociation" refers to an unconscious severing of connections between one set of mental contents and another, often before they enter awareness. "Repression," by contrast, refers to the mastering of conflictual material by actively pushing it out of awareness.
     By "mental contents," we refer to several types of dissociated material. Most often, we are talking about dissociated affect, but we can also speak of dissociated behavior, dissociated knowledge of facts, and dissociated sensation, as well as dissociated interpersonal patterns (Pearlman and Saakvitne, 1995). Dissociation is accomplished through self-induced hypnoid states that protect the individual from psychic disorientation and pain. In dissociated mental states, the now-separated mental contents dwell side by side without reference to one another. In such states, good and bad feelings about the same object can thus coexist without conflict, for there are no connections between them that would alert the individual to the incongruities involved. This is how dissociation allows an individual to be conscious of the fact of a traumatic event in his history while dissociating and therefore not experiencing the overwhelming feelings about it that would otherwise disorient him.
     In their most extreme form, dissociative phenomena result in what in the past has been called "multiple personality disorder" (see Putnam, 1989, and Ross, 1989), but is referred to in current diagnostic manuals as "dissociative identity disorder." More frequently, dissociative disorders of a milder nature are seen in adults with histories of child sexual trauma.
     Dissociated experience has never been allowed into awareness, and therefore has never been encoded into language. Indeed, much of what we are exposed to in life is never verbally symbolized. Donnel Stern (1983, 1987, 1989, 1997) refers to this as "unformulated experience." Many such experiences remain unformulated for benign, nondefensive reasons. They may, for example, be unimportant or irrelevant at the time. Stern (1997) says that these experiences are dissociated in the
"weak sense" (p. 113). Drawing on the work of Harry Stack Sullivan (1956), he points out that the ability to dissociate is an important component in the development of personality. Every individual must dissociate "not me" experiences as he evolves psychologically in order to gain and maintain a reasonably consistent sense of self. Thus, experiences that, if integrated, would challenge that sense of self are dissociated, or, to use Sullivan's term, "selectively inattended." They are not verbally encoded and never enter awareness. These experiences, Stern (1997) says, are dissociated in the "strong sense" (p. 113).
     Briere (1995), whose work I discuss later in this chapter, sees dissociation intrinsically as an adaptational talent rather than as a pathological defense. Price (1994) speaks to this issue when she notes that in incestuous situations a child is totally dependent on those directly and indirectly involved and responsible for the child's abuse and exploitation. Dissociation, as she points out, is one of the defensive and adaptive strategies the child develops to deal with this untenable situation.
     The adaptive aspects of dissociation are highlighted in another way by Hegeman (1997). She emphasizes that in Western culture trauma is usually thought to cause dissociation, but that dissociation is a culturally patterned phenomenon. She notes that culturally patterned altered states of consciousness have been found in 90 percent of a sample of 488 societies. In these cultures, dissociated states may be both accepted and valued, as in trance states induced during shamanistic practices. By contrast, in our culture such states tend to be pathologized or marginalized, as in charismatic religions.
     Philip Bromberg (1991, 1993, 1994, 1995a, 1995b, 1995c, 1996a, 1996b, 1998), an interpersonal theorist like Sullivan and Stern, has written extensively about dissociation, both as a response to trauma and as a central organizing aspect of personality. Like Briere, he considers dissociation adaptational (Bromberg, 1994). He also posits it as a universal process that helps all human minds become systems of discontinuous and shifting states of consciousness. He believes dissociation is as basic to personality organization as repression (Bromberg, 1994, 1995a, 1995b; see also Goldberg, 1995), and that every well-functioning individual has been shaped as much by trauma and dissociation as by inner conflict and repression. We will return to Bromberg's conception of dissociation later in this chapter.

TRAUMATIC DISSOCIATION

Everyone has an ability to dissociate to greater or lesser degrees. Ordinary dissociation often results in daydreaming or other benign mental activities. By contrast, traumatic dissociation, a response to overwhelming life experience, has both numbing and intrusive features. It is a means for the self to maintain some fragile sense of functioning.
     Traumatic dissociation has usually been thought to be the far end of a dissociative continuum that starts with everyday dissociation, although some (for example, Stern, 1997) suggest these may actually be two different kinds of dissociation. Because it is easy to get the concepts of traumatic and everyday dissociation confused, Hirsch (1997) has suggested reserving the term "dissociation" for traumatic dissociation and calling everyday or developmentally normative dissociation by Stern's (1983, 1997) term, "unformulated experience."
     From where do pervasive dissociative states emanate? For Price (1997), dissociation results from cultural bans that determine and define acceptable speech, thereby preventing the symbolization and linguistic encoding of events that the culture will not allow into consciousness. For Bromberg (1991), dissociation arises when early object relationships have not allowed the normal development of tension-reducing mental structures. Because of this, presymbolized experience that is too intense to be cognitively processed is instead retained as raw data in unbearable mental states that are then dissociated in order to preserve other areas of functioning. Thus, dissociation is a protection against being incapacitated by the shock of "aspects of reality that cannot be processed ... without doing violence to one's experience of selfhood and sometimes to sanity itself" (Bromberg, 1993, p. 165).
     Davies and Frawley (1992, 1994) describe the dissociative process in more detail as a means to avoid ego dissolution when trauma presents the individual with too many disturbing stimuli. They describe how such material is split off from awareness before it has been symbolized, as well as how it emerges eventually in disguised forms. The ego is split, resulting in two or more self-states. These ego states, organized and functioning independently, enter consciousness separately, thinking, remembering, behaving, and feeling differently from one another. Not available to the rest of an individual's personality, "they are likely to make their presence felt via the emergence of recurrent intrusive images, violent or symbolic enactments, inexplicable somatic sensations, recurrent nightmares, anxiety reactions, and psychosomatic conditions" (Davies and Frawley, 1992, p. 31).
     Traumatic dissociation thus exists to protect the individual from the full shock of trauma. The ability to dissociate allows people to act as they must in order to save themselves from the overwhelming emotions that they would otherwise experience. Thus, a child who is raped nightly may learn to dissociate his unformulated terror and proceed in the daytime as though he lives an ordinary existence. This enables him to build up areas of competence while encapsulating his traumatized reactions to his abuse. If he has little capacity to dissociate, he might be so paralyzed by his feelings that he is totally unable to learn in school, relate to others, or develop other skills he needs in life. (I am talking here about relative competence. Many abused children do indeed have deficits in these areas despite their attempts to dissociate their trauma.)
     As a reaction to trauma, dissociation protects against personality fragmentation (Bromberg, 1994). It is a way of shutting down the information-processing mechanism so that pain is neither registered nor experienced (Madison, 1995). Its goal is "to maintain personal continuity, coherence, and integrity of the sense of self and to avoid the traumatic dissolution of selfhood" (Bromberg, 1993, p. 162). Thus, paradoxically, it is through fragmentation that dissociation restores a unified sense of self. This is accomplished by using hypnoid processes to separate out and unlink disorienting self-states of consciousness. These separate states of consciousness then become discontinuous, disparate, and unrelated experiences that coexist in multiple self-states. I will discuss the concepts of "unified sense of self" and "multiple self-states" later in this chapter.
     One of the protagonists in Scott Heim's novel Mysterious Skin (1995) illustrates this process. Molested twice by his baseball coach at age eight, he "loses time," and becomes amnesic for the periods when the abuse occurred. As he grows older, he comes to believe that during the lost time he was abducted by aliens. In a way, this is a creative reinterpretation of his alien experience as a molested child. He experiences himself as a relatively unified individual who must have had a unique experience that accounted for his loss of memory; he thus manages to maintain a cohesive sense of self through his dissociation. For years, he reads everything he can about UFOs and claims of alien sightings and abductions, until the dissociation finally begins to break down in his late adolescence.
     Brooke Hopkins (1993) is a layman who writes about his childhood maternal incest. Without using professional language or jargon, he finds poignant words to articulate his inner experience of traumatic dissociation:

There must be a form of trauma that produces what can only be described as an out-of-body experience, a trauma so total that one is forced, in order to preserve oneself, to view what is going on around one as if one were a detached spectator.... I seemed to experience all this as if I were somehow outside myself as well as in, as if I were viewing it all from some position two or three feet above my body as well as experiencing what was going on from within. (p. 45)

GENERALIZED DISSOCIATIVE PATTERNS

The chronicity of Patrick's abuse led him to resort to dissociation as a commonplace way of warding off anxiety in almost any uncomfortable situation. What had started out as a useful, perhaps even lifesaving, way of dealing with his trauma ended up as his principal mode of being-in-the-world. He developed compulsive behaviors like alcoholism, incessant masturbation, and anonymous, unpleasurable sexual activity as a means to hypnotize himself and return to a dissociated state. While behaving compulsively, Patrick entered trances, self-induced hypnotic states that replicated essential elements of his original dissociative reaction to trauma. These trance states provided Patrick with a speedy reentry to the protected dissociated state he had created while being abused.
     For example, rather than experience anxiety and unhappiness when he returned from holiday visits with his abusive family, he went directly to gay bars and fellated dozens of men in the back rooms (this happened in the years before the AIDS epidemic). Concentrating on the penis in his mouth was like concentrating on the yellow roses of the wallpaper in his living room as a child. It protected him from his emotional experience--in this case, the reemergence of his many conflicts about being with his family. After a night of compulsive and ultimately unsatisfying anonymous sex, Patrick was numb, exhausted, and could barely remember what had happened either at his family's home or in the back rooms of the bars to which he fled.
     Indeed, Patrick's dissociative tendencies were so well ingrained that they also took over in much less conflicted situations. He had not developed other ways to cope with anxiety, nor could he differentiate between states of minor versus overwhelming anxiety. Instead, he went through life on automatic pilot. When his unconscious radar signaled him that danger might be near, he began to dissociate. This happened once, for example, when he thought a waiter in a restaurant was being overfriendly. Momentarily anxious about the meaning of this approach, Patrick suddenly found himself out on the sidewalk, not remembering the act of leaving his meal on the table and walking out to escape the possible attentions of the waiter.
     But the dissociation did not always work completely, as witness his recurring night terrors of a stranger breaking into his room while he slept. In that case, danger was signaled by the "simple" act of going to bed at night. Going to bed, in his early experience, had meant that a "monster" might well come into his dark room and molest him. At times, he could fend off his anxiety about this. At other times, the anxiety broke through and he experienced a terror similar to what he must have felt as a small boy. In these states, he could not sleep, and constantly checked the locks on his doors and windows to assure himself that he was safe.
     As Patrick's patterns demonstrate, then, dissociation, though not in itself necessarily pathological, can become so. Individuals who have lived with chronic trauma like incest are likely to dissociate as their first reaction to all anxiety. But dissociation may or may not be an objectively appropriate reaction to every anxiety-arousing stimulus. Bromberg (1994) points out how the dissociative cure for anxiety can itself become the problem. By always mobilizing for disaster, the individual unwittingly contributes to its likelihood. In discussing Freud's case of Emmy von N, for example, Bromberg (1996a) writes that her "need to maintain the dissociative structure of her mind was her way of protecting herself against trauma that had already occurred--a protection against the future by plundering her life as if it were nothing but a replica of the past" (p. 70). Patients who have endured trauma can never be "cured" of what they have lived through-it will always be part of their history--but therapy can help them stop what they still do to themselves and others as a result of that traumatic past.
     People who dissociate chronically have large portions of their emotional life unavailable to them, and may have deficits of memory for many external events as well. Their ability to see the world realistically may thus be seriously compromised (Silber, 1979). Indeed, Rivera (1989) maintains that it is not multiplicity that gives problems to an individual with a multiple personality disorder (now called dissociative identity disorder), but rather the accompanying defensive dissociation and consequent inability to be fully cognizant of the world and even of the self. Through this distorted reality, caused by "dissociative virtuosity" (Herman, 1992, p. 102) in dealing with overwhelming and traumatic psychic hurt, traumatized individuals "learn to ignore severe pain, to hide their memories in complex amnesia, to alter their sense of time, place, or person" (Herman, 1992, p. 102).
     Most abusers were themselves abused (although, as I noted in Chapter 1, most abused children do not grow up to become abusive). They are likely to have learned to use trance and are often in dissociative states while committing sexual abuse. This helps explain why abusers often disown and disavow the enormity of their acts, or even have no memory of the events. They dissociate their guilt and thus feel a subjective sense of innocence (Grand, 1997). Victims may identify with the disavowed shame of their abusers, thus setting the stage for their own shame about the abuse (see the discussion of Lorenzo in Chapter 8). Acknowledging and remembering the abuser's dissociation can affect how both sexually abused adult and therapist think about the abuse situation, since it reminds them of the likely inner state and history of the perpetrator. This in no way excuses an abusive act, but it does sometimes make it more understandable.

ANDREAS

Consider Andreas, a man whose pervasive dissociation suffused every aspect of the life he constructed, distorting his perceptions, confusing his relatedness, and compromising his sexuality:
     Andreas's deeply dissociated states led him at times to lose coconsciousness among them, and the nature of these multiple self-states might qualify him as having a dissociative identity disorder. Even after years of intensive individual and group therapy, Andreas often maintained that he had no feelings at all other than anger, fear, and occasionally anxiety. When in his initial consultation with me Andreas said flatly that he had no feelings other than these, I answered that I did not believe him, although I understood he was not aware of them. He later told me he almost got up and left my office when I said that; he was angry because he felt that I was calling him a liar, but he was also afraid that I would make him feel emotions other than anger and fear.
     An example of Andreas's rigid dissociation was his claim that his physically and emotionally abusive father had no effect on his life, since the father had been missing through most of Andreas's childhood and had neglected Andreas or punished him when he was present. As Andreas described it to his group for sexually abused men, he had erased his father's presence from his mind and therefore was unaffected by him. When over many weeks group member after group member disputed this assertion, he finally said that he understood intellectually the arguments they made that the lack of a father must have affected him powerfully. "But," he contended, "if I truly acknowledge that my father affects my life, and of course he does, then my life is no longer in a neat little bottle that I can put on the shelf and just forget about. I'd get worried, I'd get anxious. I don't know if I can live like that."
     Andreas remembered his sexual abuse history over the course of a lengthy treatment with another male analyst before he was referred to my group. He recalled several men who, having initially snatched him off the street when he was eight, periodically abused him for about six years. The abusers seem to have been a ring of child molesters. Membership in the ring changed from time to time, and there were always several other boys being simultaneously victimized. Sometimes Andreas was forced to have sex with the other boys; this was particularly traumatic to him, and it left him with the irrational feeling that he was these boys' abuser.
     Andreas could not forgive himself for having obeyed these men when they ordered him to be in a certain place every week so they could come get him and continue their sessions of sexual abuse. He continued to ask himself, when he did not dissociate the entire experience, why he went to meet them weekly, never doubting their authority over him even though he did not know them and never even learned their names. He insisted, "By going back week after week, I became my own perpetrator." Only after several years of working with me did he tell me his abusers warned him that they would kill his mother if he did not come back to them as ordered. He believed them and returned because he was terrified that they could and would murder her. Despite this, he continued to blame himself for going back and for "not stopping the abuse."
     He never told anyone about his molestations. His parents finally found out about them when he was seriously injured one night by multiple anal rapes. He returned home bleeding profusely from the rectum. As he recounts it, his mother took him to the hospital but never asked for details about the abuse. His father sneered and said Andreas deserved whatever had happened to him. When memories of his sexual abuse returned shortly after his own son was born, Andreas was not sure whether to believe them. His recollections were finally confirmed, however, when he searched hospital records and discovered that his rectum had been surgically rebuilt during his childhood.
     Andreas also recalled repeated physical mistreatment and neglect by his father and an incestuous relationship with his mother that he could only allude to momentarily because it so sickened him. Both parents and all of his siblings were or had been substance abusers. In addition, his father was contemptuous and abusive toward his mother, who was of a different race than he. Isolated and depressed, living in an ethnically homogeneous community from her husband's background that refused to relate to her, the mother appears to have led a miserable existence throughout her marriage. Andreas thus had many repeated emotional traumata within his family to dissociate along with his sexual abuse by outsiders. This family context left him unprotected and vulnerable to abuse by strangers.
     Andreas's dissociative patterns helped him succeed in establishing an external life that was remarkable given how little support he had available to him during childhood. His story illustrates the positive, adaptational aspects of dissociative defenses. He graduated from college; married and raised a large family; was a pillar in his church; held a substantial and remunerative position with considerable authority over other workers; and maintained interesting side businesses as well. But his thoughts and feelings were rigidly and dissociatively separated. He constantly and consciously surveyed himself to make sure he did not allow himself to experience any emotions except anger. Not knowing how to feel anything in moderation, he made sure he felt nothing. He called this "living topside," meaning living solely in his head. On the rare occasions when emotion slipped through, he fell apart. If he allowed himself to feel, he always returned in fantasy to the occasion of his first molestation, and then could easily become flooded, crying incessantly. When this happened, he ruthlessly made himself furious at everything in his life: "After four or five days of being enraged, I'm back in control."
     Andreas maintained that he had no feelings about anyone except his children, and that he had only had intense feelings about them at the time of their birth. He forced himself to play with them "because it's good for them developmentally that I do so," but never felt playful or joyous around them. Sex with his wife had on the surface seemed successful in the first few years of his marriage, but he finally admitted to her that he felt nothing during sex. He could maintain an erection almost indefinitely, but he experienced no sensation and had no erotic fantasy life. He continued sexual relations with her because it was the "right thing to do morally," but he maintained that he had absolutely no other reason to want to have sex. He consciously dissociated so he could perform sexually: his wife would give him advance notice that she was interested in sex, and he would then get himself into a dissociated state, sometimes using marijuana and at other times creating a trance state. He was then able to perform sexually and satisfy her while "not present." Experiments with men had confirmed his belief that he was not gay, but rather that he had made himself virtually nonsexual. Later on in his treatment, as his dissociation began to break down, Andreas reported experiencing glimmers of sexual desire, but said he initially felt instantly nauseated whenever his sexual feelings were aroused.
     Andreas approached my group for sexually abused men with a curious mixture of indifference and terror. These existed in him side by side, with no reference to one another--exactly what happens during a dissociative episode. In group he initially disliked "checking in," the process in which every group member tells the group as it begins about his current emotional state (see Chapter 11). He hated how this made him immediately visible to the group, although he simultaneously knew instinctively that the group experience had great potential to help him. He felt exposed by the expectation that he would be self-revealing, and he also was reluctant to disclose the paucity of his emotional center. He often arrived late to avoid the check-in, even though this usually meant he stayed silent for the rest of the group. At first, he was unable to have a real verbal interchange with other group members; instead, he lengthily spoke at them. His competence in the work aspects of his life was very clear to all, but the near-void in his interpersonal relating was totally at odds with that competence.
     Over the first few months that he was in the group, Andreas gradually became slightly more comfortable, though he maintained his basic unrelated stance toward other group members. His first crisis came the first time a new man, Seth, entered the group. Already enormously apprehensive about a new man joining the group before ever meeting Seth, Andreas called me five days later and asked to see me individually. He was gray and glassy-eyed; his terror had broken through his dissociation. He told me that he had been unable to sleep since the night Seth entered the group, because he was sure Seth was an abuser. He asked me whether I knew if Seth had molested anyone, and I reiterated my policy of not allowing men in the group who had been abusers as adults. Since this was my general policy, I could say without compromising Seth's confidentiality that to the best of my knowledge Seth did not have such a history. I added that I could not guarantee this, of course, but that I thought it was important to explore why Andreas was so sure Seth was an abuser.
     It took a long time for Andreas finally to identify the specific reason for his terror, which was that Seth's hands seemed to him to be exactly like the hands of one of the men he remembered abusing him. Seeing Seth's hands had plunged Andreas back into the panic state he had endured as a boy. Never having allowed this dissociated panic into awareness before, he was now terrified in exactly the same ways he had been at age eight.
     Articulating this enabled Andreas to return to the group and tell them, and Seth, about his panic reaction. This was a breakthrough on several levels: Andreas had to relate to other group members more authentically in order to communicate his internal perceptions; he forced himself to relate his feelings and part of his history; and he began to identify some of the distorting mechanisms that suffused his experience.
     As his therapy continued, Andreas started a medication regime that helped him avoid the extreme bottoms of his occasional emotional breakthroughs. Only after many months of being on medication did he volunteer the information that the medication also helped him in his efforts to feel nothing at all. Fearfully, he acknowledged that he wanted to try having feelings and asked to take lower dosages of medication. Titrating his medication dosages allowed him to experiment with having feelings without the extremes he had always feared. He later said, "I've learned that when I feel nothing--that's when something's happening that's very important to me." These were, of course, only a few steps on his long and arduous path toward a less dissociated mode of being.

DISSOCIATED SEXUAL COMPULSIVITY

Compulsive sexual activity can be a compelling way to soothe the unregulated affect that emerges when dissociation breaks down. In common with other compulsive dissociative adaptations to trauma, such as gambling, overeating, and various addictions, sexually compulsive behavior is a dissociative solution to the problem of managing anxiety. Addictions can help a man experience highs that prove to him he is still alive when he begins to feel depersonalized, numb, and empty (Schwartz, Galperin, and Masters, 1995b). But they are also tools for numbing out when he is starting to feel and think in uncomfortable ways. Paradoxically, addictive behaviors, which themselves often seem to be examples of poor impulse control, are ways of controlling other impulses that are even more dangerous, like harming oneself or others.
     When the body is hyperaroused, it releases chemicals called opioids to tranquilize itself. The biological underpinning of how sexual compulsivity soothes anxiety involves the stress-induced analgesia that results when these chemical opioids are released to assuage pain during and after trauma (van der Kolk and Greenberg, 1987; van der Kolk, 1996). This analgesia is compellingly seductive. The bodily change is powerfully reinforcing, and the individual is moved to experience it again and again. A man is thus motivated to repeat the sexual behavior that first induced these self-soothing chemical opioids to be released. Since the secretion of the opioids was a reaction to traumatic sexual activity, the victim may become compulsively sexual as a means of recapturing those tranquilizing effects. Engaging in compulsive sex thus allows a man to reexperience directly the biochemical means his body used to calm his anxiety when the abuse first occurred. Also, in addition to offering some degree of physical discharge in itself, sexual compulsivity has the added force for a sexually abused individual of being very close to the original traumatizing behavior. The behavior itself becomes the central focus of his attention, allowing a self-hypnotic dissociative trance to take over his consciousness (see Spiegel, 1990).
     Both these self-soothing aspects of compulsive sexual behavior--the releasing of the opioids and the hypnotic focusing on the sexual behavior--serve to help the man regulate unmanageable affect that is triggered by seemingly innocuous reminders of his abuse (Briere, 1995; M. Schwartz, 1998, Cassese, in press). However, unpredictable situations may contain triggers that suddenly lead to unmanageably high levels of sexual arousal. In turn, this may lead both to greater dissociation and an inability to monitor the safety of his sexual activity (Cassese, in press). Dissociation thus puts him at risk for harm. For example, a dissociated individual has a reduced capacity to judge the danger of a sexual behavior like unprotected sex. Sexually abused individuals for this reason may be at greater risk of HIV infection (Cassese, in press).
     A man in this situation may also be less capable of saying no to a potential sex partner. This is certainly true when there appears to be no clear risk to the encounter, but may also be the case if danger is recognized. Lorenzo was a gay man who had been abused by a number of presumably heterosexual men in the small town in which he grew up. While he practiced safe sex when in dissociated states, he repeatedly put himself in potentially dangerous situations like picking up strangers in parks. As he began to recognize and intervene in this process, he described what he went through trying to say no when a man he disliked unceremoniously demanded to have sex with him: "I have this neighbor who claims to be straight but always comes to me for sex. I don't really like him, and I don't like sex with him. But yesterday he met me in the hall again and said, `Wait for me, I'll come by.' I got panicky. I didn't know if he would really come by--sometimes he doesn't when he says he will--but I knew that if he did come I couldn't say no. I go into some other state about it. I like it that someone wants me, and I feel so bad about myself that if he wants me--even if I don't want him--I have to say yes. So I left my own apartment, which is better than I've done in the past, when I've waited and had sex with him, or waited and he never arrived. Still, I had to leave my own home in order to not submit when a man told me it was time to be sexual with him."
     Earlier in this chapter, we saw how Patrick's dissociative sexual compulsivity soothed him when his anxiety was triggered. Such dissociative compulsions became Devin's principle approach to his life. Devin was originally referred to me for an evaluation related to serious legal charges resulting from compulsive sexual behavior. I cannot be specific here about the nature of those charges. Although I usually do not do evaluations for legal matters, I made an exception in Devin's case because I believed that he had committed a victimless crime, and that he had possibly been set up to be arrested for behavior in which he did not usually engage, although it seemed related to his history of sexual abuse. Sometime after that evaluation, while still waiting for a resolution of his court case, Devin sought treatment with me.
     In our first evaluative sessions, Devin revealed his involvement in an extraordinary number of compulsive behaviors, most of which were self-destructive either directly or indirectly. No longer actively drinking, chain-smoking, or doing drugs, his current compulsions included gambling, looking at pornography, overeating sweets, and maniacally collecting baseball cards. He followed sports scores doggedly, laboriously making endless lists that duplicated information he could otherwise have obtained easily and instantly in computerized form. He spent many hours in sex-oriented Internet chat rooms, and ran up immense phone bills on phone-sex lines. He shopped far beyond his means, incurring huge charge bills for items he never used. "When I have to buy something, I don't care about anything except the high I feel when I'm getting it. I have to have it! Then I get home, and I feel dirty and foolish. It's never stuff I really need, and I get embarrassed about buying it so I never use it. It just sits there in my house--I'd feel too embarrassed to take it back to the store." He went to peep shows and allowed men to fellate him there, sometimes vomiting afterward because of his conflicts about participating in homosexual acts. (He claimed that if he had the money he would compulsively go to female prostitutes instead.) Even when building a shelf in a closet, a positive activity in his own mind, he spent hours making exhaustive measurements and calculations, and could not rest till every closet in his house had shelves. "I didn't eat till it was done. I stayed home from work to do it. And I hate doing home repairs, I don't really know what I'm doing. But once I decided to make a shelf, it was like someone else was in my body, making shelf after shelf after shelf."
     Devin told me about his history of sexual abuse calmly, reciting the facts of his abuse history as though they had happened to someone he knew very distantly. In a way, they had, so detached was he from his own experience. His compulsions served to keep Devin out of touch with his inner life. Although occasionally emotion did break through his compulsive defenses, as when he noted that he was nauseated all the way to my office the first few times he saw me, usually he did not experience any disturbing feelings.
     For example, after being found guilty of the crime that had led to our initial consultation and failing to get a reversal after a lengthy appeal, Devin seemed indifferent to his fate. While awaiting sentencing, he said blandly that he knew he should be worried but wasn't. He added that anything could happen between now and the time he was sentenced, so he did not let himself think much about what he had done or what might happen in the future. Once sentence was passed and he was awaiting the start of a jail term, his mood remained similarly bland and even cheerful, though he did note the inappropriateness of his affect.
     Devin's father began to abuse him when he was about five years old. In the beginning, his father fondled him in the bath, but soon he was coming to Devin's room at night, groping and fellating Devin and asking him to touch the father's penis and squeeze it. Later, his father took Devin on business trips where the sex sessions were more extensive, and the father also took photographs of Devin in explicit pornographic poses. The abuse ended when Devin was about fourteen.
     Devin described his father as brilliant, a talented athlete whom Devin adored. "Everyone loved him--I always felt he was a good father--I never thought about all the other stuff. It was like some other person did those dirty things at night." The father was a dry alcoholic, nondrinking from the time Devin was three, and active in AA. He continued to smoke marijuana daily, however, and also sometimes did "other weird drugs." He bought a gun for no apparent reason, and would go off by himself for days on end without explanation-a habit Devin repeated in his own marriage. In addition, the father had a longterm girlfriend while still living with Devin's mother, and raised a child with her.
     Both paternal grandparents died from active alcoholism, and one paternal aunt died of a combined drug and alcohol overdose. None of Devin's siblings was alcoholic, but Devin had had severe alcohol and cocaine addictions. His driver's license had been revoked for repeated drunken driving offenses. At the time I first saw him, he had been alcohol- and drug-free for over two years following four attempts at rehab programs, and he attended AA meetings daily. But his life remained chaotic, pulled together loosely by his compulsions and his continuing capacity to function at his job. He was divorced, though he maintained a relatively positive relationship with his ex-wife, who knew about his history and his compulsions, and with his children.
     Devin never confronted his father about the abuse. He said he would have been far too embarrassed ever to raise the issue. "While it was happening, I'd get disgusted. Usually it felt bad--then I would pretend to be asleep. But I never told him to stop--it was not at all terrifying. And sometimes I wanted him to do it. It felt good and bad at the same time. When I heard him coming up the stairs, I'd get excited--it became pleasurable." Devin turned red as he said this, saying he was afraid I would think he was gay. Turning away from me, he added, "I knew there was something wrong with what we were doing, but it made me feel special. I loved my father so much, and I loved having this special secret with him. He never said to keep it a secret, but I knew I should. At the same time that I felt disgusted, I also felt special." Asked how he felt talking about the abuse, Devin said, "I know I should feel rage, but I don't. I don't actually miss him but I also don't hate him--I'm emotionless. I guess I make sure I have no feelings about him."
     When Devin was in his early twenties, his father was indicted for molesting a neighborhood boy. He asked Devin to testify on his behalf, and Devin did so, swearing in court that he could not imagine his father doing such a thing to anyone. The father was acquitted, but Devin was positive his father had committed the crime of which he was accused. He felt terribly guilty about the boy whose charges had been judged to be unsubstantiated. "I did a terrible thing to him. I'm not as bitter now, but I hated myself for what I did. Why did my father ask me to testify? I perjured myself when I was still young and idealistic about the law. Since then, I've been bitter and cynical about everything."
     His father died five years before my first meeting with Devin, and on his deathbed he apologized to Devin for what he had done. "Even then, I hated having to talk to him about it. It made me uncomfortable, very embarrassed. I told him it was okay, even though it wasn't." The father also told Devin's mother about the abuse before he died.
     Devin married in his early twenties, and could not say why he married his wife except that she wanted him. "I liked her but I never really thought I loved her, and within weeks I was fooling around with other women." His sexual problems with his wife included humiliating difficulties maintaining an erection and ejaculating. Although she seems to have been supportive about this, he avoided sex with her whenever he could. He had similar sexual difficulties with any woman with whom he had a relationship, but not with pickups or prostitutes. Apparently, with women he did not know there was less overwhelming emotion that had to be dissociated during sexual intimacy.
     His sexual problems with women made him wonder whether he was homosexual, as did the childhood abuse itself, especially in light of his sexual arousal during the molestations. He insisted, however, that he had no conscious erotic desire for men. Indeed, he got highly anxious in response to interpersonal approaches of any kind from a man, and was phobic about saying or doing something that might make him appear gay or, by extension, appear interested in men for anything at all. This seemed to be an aftermath of his conflicted pleasure when his father abused him. We also explored the alternate possibility of his having unconscious homosexual desires, whether related to the abuse or not, as represented by his allowing men to fellate him in the heterosexually oriented peep shows he frequented. These homosexual concerns affected his relationship with his son. While he had claimed to have no fantasies or impulses about molesting boys, he was worried that somehow he would abuse his son anyway. He had always refused to bathe the boy, and obsessively worried that he was spending too much time with him or looking at him too much.
     Devin's chronic homosexual panic was a constant in our work together. He sat miserably in his chair at the beginning of every session, afraid to make eye contact, warily surveying any slight behavior on my part that might possibly be construed as a sexual advance. He was unable to dissociate these feelings successfully. Yet he never missed a session and, indeed, the most hopeful aspect of our early work was his expressed wish to learn to sit with me without these interfering apprehensions. With time, he acknowledged shamefacedly that he looked forward to seeing me. Characteristically, this "confession" was accompanied by further alarm about its possible sexual implications. In this manner, in fits and starts our work proceeded slowly from, and returned frequently to, Devin's basic need to reestablish human relatedness through his slowly growing alliance with me (see Chapter 9 for a further discussion of this concept). Gradually, as our interpersonal connection grew, there was some diminishment of his dissociative compulsive behaviors.

DISSOCIATED REENACTMENTS OF ABUSE

Dissociated experience, unsymbolized in thought and language, exists as a separate entity outside self-expression, cut off from human relatedness, deadened to full participation in the psychic life of the rest of the personality. Price (1997) observes that trauma lies not just in traumatic events but in their unassimilated nature. Its effects cannot be healed until the wound from the trauma has been reopened in a new situation where it can be linguistically encoded. It has not been symbolized, and it is not amenable to verbal interpretation before encoding occurs. This is a crucial process in work with sexually abused patients because in most cases they cannot heal from dissociated trauma until they can think about it and experience it (Madison, 1995). For some severely dissociated individuals, however, traumatic experience may be linguistically encoded but the dissociation, while pervasive, is not powerful enough to protect them from feeling recurrently overwhelmed by their feelings.
     The effect of not symbolizing sexual abuse linguistically is far reaching. Recall the work of Conte (1985) and Gilgun (1990, 1991), who found that abused boys who had a confidant as they were growing up were less prone to develop symptoms. In particular, Gilgun found that boys with confidants were not as likely to become rapists, molesters of children, or violent criminals. These boys had verbally encoded their abuse experiences by talking about them to their confidants. Conte's and Gilgun's work demonstrates that dissociating traumatic experience rather than verbally symbolizing it makes the boy more likely to reenact his abuse unconsciously, often through acts of violence and criminality that occur in manhood when he is in a dissociated state. Those who have linguistically encoded their abuse experience are much less likely to need to reenact it in these ways.
     Of course, unconscious reenactments of abuse do not always take the form of criminal acts. They can occur in the course of everyday life, as when Abe gave gifts to emotionally abusive colleagues, repeating an unconscious pattern of placating his abusive mother. In addition, patients often reenact dissociated trauma in a therapeutic relationship. In such cases, the reenactments can create challenging and difficult therapeutic impasses, as we shall see in Chapters 9 and 10.

BREAKING THROUGH DISSOCIATION

As Sullivan (1956) notes, people are programmed to resist any breakthrough in their dissociative patterns: "The dissociated personality has to prepare for almost any conceivable emergency that would startle one into becoming aware of the dissociated system" (p. 203). Hegeman (1995a) discusses the consequent difficulties of using traditional treatment strategies in working with dissociated individuals, since the object of such work is to help patients confront material that dissociation has held at bay. Cognitive-behavioral approaches (see Ross, 1989; Putnam, 1992) suggest ways to restructure cognition about trauma as a means of resolving symptomatic responses to it later in life. While these approaches are certainly helpful, they do not address the damage that has been done to an individual's core ability to live in relationship with others.
     Transference cues play a crucial role in helping both patient and therapist gain access to dissociated material (Davies and Frawley, 1992, 1994; Hegeman, 1995a; see also Chapter 9 in this book). Treatment must change internal accommodations made to avoid awareness of the
original trauma because such accommodations also interfere with the self's development. Most important is the need to focus on a dissociated individual's relatedness: "The very fragmented, doubting self ... must be mobilized to engage with and negotiate the dissociated material. Therefore maximum attention must be paid early in treatment to restoring the patient's capacity for relationship" (Hegeman, 1995a, p. 187).
     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 (Sands, 1994). I will discuss the ramifications of this problem in Chapter 8.
     A sexually abused individual is likely to be very conflicted about allowing dissociated experience into awareness. Each step presents new strains and reasons to put brakes on the process. Saying he was afraid to open doors in his life and move beyond the plateau he had reached, Abe once recounted the story of Bluebeard, which had been a favorite of his in childhood. In that story, as he remembered it, Bluebeard told his wife she was free to go anywhere in the house that she wanted, but she was not to open a certain door or she would be punished. Eventually, curiosity got the better of her and she opened the door. Behind it she discovered the dead bodies of the previous wives that Bluebeard had killed. Abe said he was frightened about what dead bodies he would find if he opened more doors to his experience. I pointed out that opening up these doors had saved the woman's life, since she then knew what she was up against and could flee her husband. Abe had not thought about this aspect of the story before. Taking it as his cue, he went on with his difficult interior self-exposure.
     Numerous accounts have been written about how dissociated memories of traumatic sexual abuse can come rushing back in adulthood. Without entering here into the controversy about the validity of such recovered memories, a controversy I have written about elsewhere (Gartner, 1997b), I will cite one of these reports:
     Brooke Hopkins (1993) discusses how one night during his twenties he was suddenly inundated with memories of his sexual abuse by his mother:

I vividly recall how more or less involuntarily they came back ... how dumbstruck I was as I watched those memories come out, almost perfectly intact, after what seemed at the time like so many years, the almost physical excitement I felt as that whole portion of my childhood continued, with just a little renewed pressure, to unfold. (pp. 35-36)

Such closeness was utterly engulfing in its immediacy, engulfing and fantastically exciting. That's why, once the repression is lifted, it is not difficult to recall (if "recall" is even the right word); like Proust's involuntary memory, there are no intellectual structures to mediate the sensations. They are simply, overwhelmingly there, and they remain part of your body forever, a burden as well as a blessing. (p. 41; emphasis added)

MULTIPLE SELF-STATES

Classical psychoanalytic approaches have generally considered the goal of treatment to be the resolution of internal conflicts. Contemporary psychoanalytic literature written by those who consider themselves relational, interpersonal, and poststructural (for example, Rivera, 1989; Mitchell, 1992, 1993; Bromberg, 1993, 1994, 1995a, 1996b; Harris, 1994; Davies, 1996a, 1996b, 1997), rather than classical, has instead posited that understanding self organization, states of consciousness, and dissociation is central to psychoanalytic work. In particular, the ability to dissociate is thought to be key to the development of personality for all individuals. Most important, personality is thought never to be organized to produce a unified self, but instead is normally a set of multiple self-states, disunified and decentered, evolving out of the individual's normative dissociative tendencies (Pizer, 1996a). The concept of a single, unified self is considered a social construction, a "largely nonexistent unity of consciousness" (Bloom, 1997, p. 33).
     Davies (1996a, 1996b, 1997) likens personality organization to a kaleidoscope that makes "intricate patterns, varied but finite, conflating and refiguring themselves from moment to moment . . . whose patterns become recognizable over time, yet whose parts will come to light in different constellations of prominence and obfuscation" (1996b, p. 562). Each self-state embodies a particular position according to the role that self-state learned to play as part of the individual's overall survival strategy in childhood (Rivera, 1989). For these writers, we all exist in multiple self-states, states that are usually interconnected although separate. No one self-state represents the "real" self. Bromberg (1994) conveys this idea when he adapts Polonius's famous advice to Laertes in Hamlet: "To thine own selves be true" (p. 518; emphasis added). In this section, I will lay out the theoretical ideas behind the concept of multiple self-states, and in the next section I will illustrate the concept with two case examples.
     For traumatized individuals, the content of an idea may be dissociated from the affect surrounding it, as when an individual knows he was abused but experiences no feelings about it, or when an internalized concept of a parent as an abuser may be dissociated from the internalized
good and nurturing parent. But it is not only discontinuous and conflicting affective states that lead to the organization of multiple self-states. Rather, according to this line of thinking, all individuals are organized this way. Psyches are nonunitary, a series of separate self-states that with time "attain a feeling of coherence which overrides the awareness of discontinuity. This leads to the experience of a cohesive sense of personal identity and the necessary illusion of being `one self'" (Bromberg, 1994, p. 521; emphasis added).
     Different self-states are created in the different relational matrices through which we all move in our lives. Sullivan (1953) speaks of individuals having different personifications of personality in different interpersonal contexts, depending on the relationship with the significant
other person. Laing and Esterson (1964) capture the flavor of such relational matrices in their discussion of families of schizophrenics:

Each person does not occupy a single definable position in relation to other members of his or her own family.
     The one person may be a daughter and a sister, a wife and a mother. There is no means of knowing a priori the relationship between: the dyadic set of reciprocals she has with her father, the dyadic set with her mother, and the triadic set she has in the trio of them all together, and by the same token, she may be a sister to her brother, and to her sister, and, in addition she may be married with a son or daughter.
     Let us suppose that Jill has a father and mother and brother, who all live together. If one wishes to form a complete picture of her as a family person, let alone as a person outside the family, it will be necessary to see how she experiences and acts in all the following situations:
     Jill alone
     Jill with mother
     Jill with father
     Jill with brother
     Jill with mother and father
     Jill with mother and brother
     Jill with father and brother
     Jill with mother, father, and brother. (p. 6)

MULTIPLE SELF-STATES: TEO AND PATRICK

If dissociation is a normal and inevitable aspect of personality organization, dissociative identity disorder is the most severe of the many organizational possibilities that may ensue. Let us consider first Teo, a man who exhibited a relatively minor disorder of dissociation and multiplicity, and then Patrick, whose multiplicity was complex, rigid, pervasive, and appropriately termed a dissociative identity disorder.
     The lack of connectedness between his multiple self-states was all too apparent to Teo when he was first referred to my group for sexually abused men. Indeed, the main object of our work was to allow him to move easily among those states. This could only be accomplished after his mute child-self learned to speak to others about his sexual abuse.
     Teo had worked his way out of the gang-ridden streets he grew up in and became a globe-trotting businessman whose skills and abilities kept him in demand all over the world as a consultant. The father of six children from three marriages, he found in his third wife a woman who supported his need finally to face the demons from childhood sexual abuse by his godfather, Arnie. His abuse memories were vague, but he had no doubt that there had been a sequence of sexual activity, probably including mutual fellatio and masturbation, while Arnie baby-sat for him when he was seven and eight. In his late forties, Teo began an individual psychotherapy that forced him to confront the effects of this abuse. In doing so, he temporarily had to undo much of what he achieved as "Ted," the accomplished executive and entrepreneur, in order to find again the frightened child, "Teo," whom he had silenced four decades earlier.
     In our initial consultation for group therapy, Teo asked me to call him by that name, noting that to all his colleagues, friends, and relatives he was known as Ted. A veteran by that time of five years of individual therapy with a woman analyst, he had come to view Ted as the protector of Teo. He said he wanted at last to allow Teo, the child-self in whom all his dissociated fear and anger resided, to be known to his adult self and to others.
     Likeable and highly articulate when he chose to be, Teo took a mostly silent role in the group. Unusually, other group members allowed him this silence, accepting his statement that he had spent too much of his life being overly glib, and that for him talking was a way of hiding his pain and fear. His essential warmth and supportiveness to other group members came through in the brief remarks he did make and in the expressions on his face as others spoke.
     Teo was devoted to the group for the two years he attended it. He arranged his international business trips around the night the group met so that he rarely had to miss the group because of them. If he did miss a meeting, he often called from wherever he was to say hello at the hour we met. When he spoke in the group, it was often to offer support to other group members based on his own life experiences about whatever they were addressing at the moment. If he talked about himself, it was usually about how tired he was of being capable "Ted" in the business world; or about problems he might be having with one of his children; or, eventually, about his rage toward his godfather, Arnie, and toward the parents who did not protect him from molestation.
     A year after entering the group, Teo announced that he had sent a letter to all his clients worldwide, saying that for the present he would continue to work for them via fax and electronic mail, but would only rarely accept phone calls or be willing to travel for his work. He explained in the letter that this was due to personal stresses and needs. His clients were remarkably accepting of these terms, and he lost relatively little business, though he said he had been determined to go
through with his plan no matter what the consequences were. He had decided to give Ted a rest and allow Teo out into the world.
     If anything, Teo was now quieter than before. He was not able, and no longer tried, to voice what was happening inside. His Teo child-self was available to him, though he did not yet have the language to give it a voice. He bided his time, and neither the group nor I ever criticized him for this.
     After some months of near-muteness, Teo began to emerge as though from a cocoon. He began to tell some of his clients about his abuse history and his reasons for withdrawing into himself. He gave voice to his corrosive and alienated anger and cynicism, telling the group how he had bitterly divided the world into victims and victimizers: "The world is full of either victims or Arnies--or, at best, victims-in-training or Arnies-in-training."
     A few months later, Teo felt ready to leave the group. He was immensely grateful to it and his therapists. As he put it, "What made me better was that through individual therapy and my group I was able not to keep this abuse a secret any more--the more I could tell people, the better I got. It seems so simple, but I would never have believed it on my own." Here again is a demonstration of the need to symbolize trauma verbally in order to ameliorate its effects.
     Looking back at his dissociated mode of relating to the world, he was able to describe how he had coped with this world, and the price he had paid: "I learned a tape to say. I could handle any situation by turning it on and hiding while my mouth talked. It was only by learning that it was OK to be quiet--not to be on top of everything--that I found my voice. That was the paradox--I had to be quiet to find my voice." In the language of the theorists who posit multiple self-states, this voice was actually a group of several voices, those of Teo and Ted as well as other self-states that had never been as clearly delineated to me as these two. They constituted a chorus in which each voice was heard. Teo had learned to negotiate the gaps between these self-states.
     I return now to Patrick, the man whose child-self, "Paddy," was furious at the adult "Patrick" for allowing me into their private domain. Patrick was always clear that he and Paddy were different aspects of himself, and that there was always co-consciousness between the two. Yet Patrick and Paddy seemed like distinct entities, and I began to see them as separate personalities. Over the course of treatment, other personas emerged, unnamed but clearly different from these two. Patrick never completely gained an ability to move fluidly between his selfstates, but he did learn to bridge the spaces between them more of the time.
     I have described (see p. 143) how Patrick developed the alternative persona of Paddy, the furious and frightened child he had been while he was being abused. As Patrick, he ambivalently wanted me to enter his world. He invited me to share his childhood fantasy of living in a walledoff, protected tower. As Paddy, he was furious and frightened; he felt invaded by me and was in a rage at his own adult self for having allowed me to transgress into this protected, private space. Therefore, Paddy attacked Patrick after the session when Patrick allowed me, in fantasy, into their private tower.
     As we talked about Patrick and Paddy, it became clear that "Patrick" represented the part of him that had to interface with the world--charming and placating, though brittle--while "Paddy" represented the terrified, furious, and traumatized child who could not bear to be near another person. In a subsequent session, Patrick recalled that his abusive father had called him "Paddy" as a child.
     "Paddy" and "Patrick" exemplify Davies and Frawley's (1994) compelling description of the child and adult selves in the sexually abused women they write about: "The child self may be condemned to a world of unrelenting paranoia, but the adult persona, having ejected these toxic experiences, attempts a rudimentary integration" (p. 72). Davies and Frawley describe at length the vicissitudes of treating an adult like Patrick who has such bifurcated self-states, noting that such an individual often develops in treatment to a point where it is possible to articulate "the ongoing struggle between that aspect of personality that wants to function independently and successfully, and those more childlike aspects that feel such an adaptation to represent a `sellout' and betrayal of the child who suffered so unmercifully" (p. 73). They then emphasize the critical importance of reaching some integration of the experience of the adult and child personas.
     Patrick displayed other prominent self-states besides Patrick and Paddy, such as the toddler I described earlier in this chapter who was afraid of the monster who came into his bed at night. I often felt I was dealing with a different person in one session from the man I had treated the session before. Indeed, he sometimes seemed to switch suddenly before my eyes. For example, in one session he described with pain how in all seasons and all weather his father, while supposedly doing childcare for him and his siblings, took them to the edge of what Patrick now knew to be a gay beach, then disappeared for hours. He got very quiet, clearly close to tears. Then he startled me as he suddenly laughed harshly and mockingly: "This is silly! I don't know why I'm talking like this. What I really want to tell you is how much I want to suck you off and have you as my lover!" In a flash, he had again become the seductive, bold, and brittle man who in our first session had told me with a smile how he had had sex with his brother for several years and tried to seduce his father at age seventeen. Because of the emergence of such separate personas, the rapid oscillation among them, and Patrick's seeming inability to bridge the spaces between them, I came to see Patrick as suffering from a moderate dissociative identity disorder.
     By the fourth year of treatment, we had finally progressed sufficiently to talk about Patrick's sexual relationship with his three-yearyounger brother during adolescence and even once in adulthood. Doing so forced him to reconsider the implications of that relationship and his need to dissociate many aspects of it. He remembered that he and his brother were always so furious at each other during the day in the years they were sexually involved at night that they seemed truly to hate each other. They never spoke to one other during sex or about the sexuality in their relationship. With time, Patrick acknowledged that his brother, the "bottom" in their sex acts, never seemed to enjoy the sex, and never achieved orgasm with Patrick. On the other hand, Patrick, the "top" and the consistent initiator of the sexual activity, was nearly always orgasmic. Another self-state, that of a predatory teenager, thus gained prominence, and one day Patrick said, with horror, "I guess I was his abuser. I never realized that, I never thought of it that way." He began to wonder about his brother's life trajectory: Had he also been abused by their father? Had he led a promiscuous life in part because of his abuse experiences, whether with Patrick or with their father? Had that led him to contract HIV and die? When he verbalized these unanswerable, previously dissociated questions, we sat together in silence, allowing their implications to sink in. These implications were as unbearable to us both as the memories of his own abuse.