Sexual Addiction & Compulsivity, 10:275290, 2003 Copyright Taylor & Francis, Inc.

. ISSN: 1072-0162 print / 1532-5318 online DOI: 10.1080/10720160390268979

A Psychoanalytic Overview of Excessive Sexual Behavior and Addiction

JOHN R. GIUGLIANO
Private Practice, Philadelphia, Pennsylvania, USA, and Widener University, Chester, Pennsylvania, USA

Since sex as an addiction is a relatively new concept, there is a scarcity of theories, particularly psychoanalytic, regarding sexual addiction specically. This article briey describes how various psychoanalytic theories view the topic of excessive non-normative sexual behavior. Included are related topics such as impulsivity, compulsivity, substance dependence, deviance, promiscuity, and perversion, which are reviewed and integrated to facilitate a deeper theoretical understanding of the concept of sexual addiction.

The idea that sexual behavior can be manifested as an addiction is relatively recent. Sociocultural attitudes toward what constitutes normal sexuality have an extensive history, which is reected in social and psychological theory and in diagnosis over time (Coleman, 1986; Levine & Troiden, 1988; Schur, 1979; Szasz, 1980). However, the terms sex addicts and sexual compulsives rst began to appear in professional publications and in mass media in the 1980s (Carnes, 1983; Coleman, 1987; McConaghy, Armstrong, & Blaszczynski, 1985; Quadland, 1985; Quadland & Shattls, 1987; Schwartz & Brasted, 1985; Schwartz & Master, 1983). Carnes is probably the most prolic writer on this topic and has been credited with naming this disorder sexual addiction. However, how an addiction, including sexual addiction, can be understood psychodynamically has long been a matter of debate (Goodman, 1998). It is important to recognize that behaviors that appear similar may have very different meanings in different people, and therefore, may be prompted by different motives and etiologies, and represent varying psychological purposes. Sexuality also takes on differing meanings in different times and cultures. Although progress has been made in understanding what is now termed sexually addictive behaviors, the complexity and multidimensional
Special thanks is extended to Jeane Anastas, PhD, for her support in this effort. Address correspondence to John Giugliano, MSW, PhD, 17 Bryn Mawr Avenue, Bala Cynwyd, PA 19004. E-mail: imdrjohng@hotmail.com

275

276

J. R. Giugliano

quality of the problem requires continued investigation. Since sex as an addiction is a relatively new concept, there is a scarcity of theories, particularly psychoanalytic, regarding sexual addiction specically. Thus related topics of sexual behavior, impulsivity, compulsivity, addiction, deviance, promiscuity, and perversion have been reviewed. Although psychological organization may be assessed in a variety of ways, a developmental perspective may be particularly useful for understanding the intrapsychic organization of individuals who suffer from impulsive, compulsive, or addictive sexual behaviors (Settlage, 1990). The paradigm of developmental psychology views a series of stages that humans must undergo to achieve mastery of new capacities and abilities. Each stage brings the capacity for the management of more complex functions, creates new perceptions of self and the world, and is usually accompanied by new anxieties that require mastery at the subsequent level of development (G. Engel, 1962). Patterns of behavior that are self-destructive generally are prompted by complex motives. Usually such behaviors have pronounced defensive components. Descriptions of sexuality as defense against painful affect is provided by Bak (1953, 1956), Greenacre (1954, 1960, 1968, 1969), Khan (1962, 1964, 1965a, 1965b, 1969), and Kohut (1971). Accordingly, sexuality has nonsexual aspects. Thus, from the individuals perspective, sexuality can seem the best available way to protect oneself from real or perceived harm at any given time or in any given set of circumstances. Usually, the threat is not external but internal and relates to how a person experiences self and others, and how he or she perceived dangers or vulnerabilities in varied situations. Perceptions and experiences of vulnerability are not entirely objective; rather they are signicantly determined by the individuals psychological makeup. Such perceptions are strongly inuenced by past experiences and developmental history. However, this general dynamic is understood quite differently from different theoretical perspectives.

ATTACHMENT THEORY
Bowlby (1977) viewed attachment as a strong affectional bond between the primary caregiver and the child. This bond gives the child a sense of security and lays down a foundation for future attachment behavior. Silverman (1991, p. 183) stated that attachment accounts for an individuals need for proximity, care, and security with a separate other. Ainsworth (Ainsworth, Blehar, Waters, & Wall, 1978) clearly stated that parental sensitivity to the childs signals is paramount for the creation of a secure attachment relationship. Secure attachment is associated with more positive views of others (Collins & Read, 1990), reciprocity (Feeney & Noller, 1990), and trust (Hazan & Shaver, 1987). Individuals lacking a sense of parental attachment will tend to be

Excessive Sexual Behavior

277

anxious and insecure, making later peer attachments and committed monogamous romantic attachments problematic (Kernberg, 1974; Shaver, Hazan, & Bradshaw, 1988). Attachment theory is becoming increasingly popular among researchers and scholars; however it is rarely directly applied to the concept of sexual addiction thus far. Some attachment theorists view sexual promiscuity as offering a temporary relief for anxiety, insecurity, and depression comparable to chemical drug dependency (Hateld, 1988). Unrestricted sexual encounters may function as chemical balms for the insecurity wrought by poor attachment experiences (Walsh, 1995, p. 102). Similarly, studies of the antecedents of drug abuse often nd it connected to the lack of emotional attachment and commitment to others (Jessor & Jessor, 1977; Shedler & Block, 1990; Textor, 1987). Walshs (1995) study empirically supports the attachment hypothesis, nding that subjects who reported weak parental attachment were more involved in unrestricted sexuality and more drug usage than subjects who reported stronger parental attachment.

TRAUMA THEORY
As we learn more about the effects of trauma on our clients, clinicians are expanding their treatment to include a broader view of trauma theory. In the eld of sexual addiction, clinicians and researchers are examining how trauma, particularly sexual trauma, becomes manifested in trauma-related disorders and the addiction cycle (Schwartz, Galperin, & Masters, 1995). Schwartz, noting the high frequency of sexual victimization of children whom later became sexually compulsive, viewed sexual compulsivity as an aspect of posttraumatic stress disorder and dissociative disorders. In order to cope with the sexual trauma, individuals dissociate to avoid assimilating the full impact of the traumatic event (Elmone, Lingg, & Schwartz, 1996). Childhood sexual traumatization often involves partial or total amnesia regarding the details of the abuse and therefore is dissociated from sensations and affect (Braun, 1989). Schwartz et al. (1995) stated that addictive substances and behaviors later become a means to cope with feelings of depersonalization, numbness, emptiness, and physical and emotional analgesia. Ultimately, the trauma survivor can become analgesic due to the various changes in the central nervous system in conjunction with the trauma (van der Kolk, 1996). For the person who dissociates, destructive eating or forced sex can create a sense of safety in that it creates a sense of control when the person is feeling powerless. The need for sensation seeking or conict to provide relief from inner emptiness and boredom is another common feature of chronic dissociation (Schwartz et al., 1995). Repeated sexual experiences may serve the function of recapitulating the childs original lesson that the only way to experience

278

J. R. Giugliano

closeness or perceived love is through sex (Blum, 1973; Coen, 1996). Sexual exploits give a sense of revenge and the illusion of mastery over what was once beyond a persons control. Repetitive reenactments of the original trauma are relived in attempts to control the out-of-control; thus trauma coding begins the addictive cycle (Schwartz et al., 1995). Jacobs (1986) stated that a psychological precondition must exist in order for a person to acquire an addictive pattern of behavior. Jacobs characterized such preconditions as a childhood marked by deep feelings of inadequacy, inferiority, low self-esteem, and a pervasive sense of rejection by parents. Jacobs proposed that an altered state of identity develops, whereby a selfinduced dissociative condition is acquired. In a study on adolescents at risk for compulsive overeating, Jacobs found that addictive behaviors not only relieve anxiety but also bring on a dissociative-like state while overeating. Kuley and Jacobs (1988) found that problem gamblers reported a signicantly greater number of dissociative-like experiences than social gamblers. The self-induced dissociative state permits the person to detach from his early traumatic reality and become so engrossed in subjective fantasy that he or she is able to create and act out roles consistent with the modied/idealized self-image (Kuley & Jacobs, 1988). Specically, excessive sexual seductiveness in childhood, which would now be understood as a form of abuse or trauma, has long been thought to be related to the etiology of perversion (Chasseguet-Smirgel, 1974; Khan, 1965b, 1969; Litin, Gifn, & Johnson, 1956; McDougall, 1972; Sperling, 1959; Stoller, 1968, 1975). Coen (1981) speculated that a mothers seductive overstimulation combined with emotional neglect of the child may lead to the childs development of a defensive sexualized mode of relating in order to compensate for mothers unavailability and to stimulate mothers interest in him (Brody, 1960; Escalona, 1963; Greenacre, 1960). Coen (1981) termed this defense against early childhood trauma and neglect, sexualization.

DRIVE THEORY
The notion of sex as an addiction was possibly rst suggested by Freud in the late 1800s. In 1897, Freud described masturbation as the original addiction. He wrote that masturbation is the one great habit that is a primary addiction, and that the other addictions, for example, alcohol, morphine, tobacco, excessive gambling, etc., only enter into life as a substitute and replacement for it (as cited in Halliday & Fuller, 1974, p. 172). According to Freud, intrapsychic conicts arise unconsciously between the drives (libido and aggression) that strive to maintain their expression between the agencies (id, ego, and superego) of the mind. When conicts are handled through compromises that satisfy these agencies, the resulting behavior is adaptive and expresses aspects of the underlying conict but

Excessive Sexual Behavior

279

no symptoms arise. However, when the ego capacity is too weak relative to the intensity of the drive or affective state, compromise formation cannot be reached and symptomatic behaviors occur. For example, in the impulsive person, the egos inability to contain or modulate drives or anxieties resulting from internal conict leads to impulsive behavior in order to quickly escape or discharge the drive or affect. In the compulsive person, when conict cannot be resolved in the form of a compromise formation, the ego attempts to contain the drive or affect by mobilizing defenses. Compulsive symptoms arise as a result of defense mechanisms (isolation of affect, undoing, reaction formation) that the ego uses, unsuccessfully, in an attempt to escape the conict (Moore & Fine, 1990). According to traditional drive theorists, all adult disorders can be traced back to earlier stages (oral, anal, phallic, and oedipal) of psychosexual development to which the patient either regresses or is xated. For example, some psychoanalytic therapists, especially those operating from a classic Freudian perspective, might diagnose an exhibitionist man as xated at the phallic stage of psychosexual development. Castration anxiety is intense fear that the father will punish the oedipal boy for his masturbatory fantasies by cutting off the boys penis. The childs ego is too weak to manage progressively the castration anxiety evoked by oedipal situations (Freud, 1958a/1905). Thus, on a pre-oedipal dyadic level of development involving phallic issues, sexual addiction may be seen as repeated sexual conquests serving as a temporary reassurance against inadequacy and hopelessness of ever being able to obtain the love of the longed-for mother. It would account for what would be seen as a failure to develop an adult identity (Freud, 1938, 1958b/1919). On the triadic level, unresolved oedipal issues also may prompt sexually addictive behavior by maladaptively reenacting fantasized solutions to the oedipal conict (Baumbacher, 1992). Freud (1950) and Rado (1957) explained that the compulsive nature of alcohol addiction was associated with the concepts of libidinal and pleasure principles. Drive theory characterizes hypersexuality as libidinal energy that nds no outlet in genital activity and therefore produces neurotic symptoms, inner restlessness, and a disturbance in the capacity for work and love. Inadequate orgasm is followed by unpleasant tension. When sexual activity fails to relieve the damming of libidinal energy, more tension is generated, and so on. Compulsions can be seen as automatic but inappropriate attempts to nd an outlet for infantile instinctual tensions, of which the ego carries out the actions without conscious understanding of the meaning.

EGO PSYCHOLOGY
The development of ego psychology broadened the theoretical conceptualizations of addiction and perversion. In addition to stressing the adaptive

280

J. R. Giugliano

nature of drug use, attention has been paid to the interaction between the specic nature of the drug of choice and the character structure of the addicted individual. Therefore, the drug of choice simultaneously might represent the restoration of ego decits, regulation of affect, and an adaptive response to stressful life circumstances. Glover (1956) was the rst to suggest that drug use might serve a progressive rather than regressive function. That is, drug use is in service of the ego to defend against primitive and sadistic impulses (Okpaku, 1986). Perversion can represent an expression of the ego desire for control and mastery and a means of enhancing ego interests at the expense of instinctual wishes and object interests (Khan, 1962). Thus, perverse behavior also can function as a defense against, relief for, or means to master intolerable affects. Raynes, Auerbach, and Botyanski (1989) observed that ego decits in obese (food dependent) persons are similar to those in chemically dependent persons. These researchers cited two hypotheses, one of which is the external regulation hypothesis, which stated that individuals turn to an external source whose pharmacological properties serve to regulate the affect in a way their psychic structure cannot (Graham & Glickauf-Hughes, 1992). The external regulation hypothesis has been clinically documented for cocaine, heroine, and amphetamine users (Khantzian, 1997; Khantzian & Mack, 1994; Milkman & Frosch, 1973). This has become commonly known as the self-medication theory of addictions. The individual unconsciously selects an addictive substance or behavior as a means of coping to self-medicate or regulate decits and painful affective states. McDougall (1982) introduced an analytic interpretation of addictive sexuality. McDougall pointed out that as long as sexual functions are viewed as an anaclitic activity, they are irrevocably tied to an external object that is detached of essential introjects, perhaps because these are missing, dangerous, or damaged. This renders stable sexual relations linked to loving feelings impossible since narcissistic needs and fears predominate. Therefore sexual objects (erotic inanimate objects or people who are treated as inanimate/interchangeable objects) are relentlessly sought in the manner of a drug (McDougall, 1982). The sexual act becomes a drug intended to disperse feelings of violence and feelings of inner death. The sexual partner becomes the container for dangerous parts of the individual. Sexual exploits serve to release the frozen rage and feelings of powerlessness. Stoller (1975) called this triumph over tragedy and the person experiences revenge and the illusion of mastery. The illusion of mastery is achieved by gaining erotic control over what was once beyond his or her control. Stoller viewed sexual perversion as the erotic form of hatred, in which the person seeks release without genuinely caring about the other. This reverses the experiences of victimization as well as projects onto the other the overwhelming and painful affects.

Excessive Sexual Behavior

281

OBJECT RELATIONS THEORY

For object relations theorists the pre-oedipal period of separationindividuation is thought to be critical. Separation-individuation is a process where the individual develops the capacity to maintain a stable distinction between representations of self and representations of others (Cashdan, 1988). From an object relations perspective, sexual addiction can be understood as a failure to achieve self and other (object) differentiation. Without the capacity for stable memories and images that are necessary for internal regulation of self-esteem and tolerance of being alone, the individual is left vulnerable to unmanageable depression and intense anxiety when solitary. These individuals depend upon others to provide those functions which they lack, but which they need to defend against painful affects (Engel, 1984). One way the person with this type of ego decit may satisfy their merger needs is by sexual behavior. Sex becomes a vehicle for establishing at least transient contact with someone, anyone, who can meet narcissistic needs that help the addict stabilize their internal world and regulate intolerable anxiety or depression. So for the person with frail ego functions, others exist as transient part-objects, to externally regulate internal affective needs for comfort. For Winnicott (1971) the use of transitional objects plays an important role in the separation-individuation process. For example, the childs blanket becomes endowed with maternal regulating functions. The child transfers these functions from the mother to the blanket, and nally he or she internalizes the maternal representation into the self. The realization that he or she is indeed separate from the omnipotent caregiver can be a blow to the childs grandiosity, thus leaving the child with a frightening sense of smallness (Graham & Glickauf-Hughes, 1992). Reestablishing omnipotent control may be the central dynamic for the pathological gambler or the sexually addicted person who attempts to regain control of the lost object by endowing Lady Luck (Horner, 1984) or a sex goddess as a transitional object. Coen (1996) stated that sexual behavior represents oedipal sexual strivings which are diverted for narcissistic needs. The irresistible seducer becomes the central defensive role using sex to validate the grandiose illusion that the representational world can be omnipotently and pleasurably manipulated and controlled (Coen). Khan (1981) stated that perverts treat human objects as things, as transitional objects to be used, idolized, dirtied, then discarded. Khan described the seeking of an incomplete object/sex partner as similar to a drug x, used to escape pain, rage, depression, or paralyzing apathy. In the process of actualizing his needs the addicted individual fails to involve himself because his sex partner is not seen as a whole person with depth. Winnicott (1971) also spoke of a potential space or an intermediate area of experiencing within an individual, which lies between fantasy and

282

J. R. Giugliano

reality. It is within this potential space that the infant can use transitional objects without challenge, as if they are real. The ability to play and fantasize about life potentials and problems assists an individuals development as he or she progressively integrates, tests, and explores the boundaries of imagination and reality. Grolnick (19851986) stated, This interplay enhances reality testing, helps dene body boundaries, further differentiation of self and object representations, and builds a sense of self via increased internalization and assimilation (p. 404). The addicted person attempts to solve problems or control anxiety through illusory means and therefore is doomed to repeat the action endlessly because using the addictive behavior has no effect in reality on the problem the individual is trying to solve. The process of becoming addicted seems to be an increasing reliance on the sexual acting out for magical solutions, to the exclusion of progressive development and mastery of conicts (Graham & Glickauf-Hughes, 1992). For individuals who have established object constancy, a different set of behaviors may lead to sexual addictions. The realization of self as separate leads to anxiety regarding awareness of helplessness and loss of fantasies of omnipotence. Sex then becomes a way to regain a sense of control or mastery over the fear of intolerable helplessness. Addictions of all types, including sexual addiction, thus maintain a state of pseudo-independence (Weidman, 1983).

SELF PSYCHOLOGY
From a self-psychological perspective, one can view sexual addiction as repeated unsuccessful attempts at remedying central decits in an uncohesive psychic structure. Although sexual addicts do not necessarily have narcissistic personality disorder, sexual addicts may have some difculty with narcissistic issues. Kohut (1977a), a self-psychologist, sees narcissistic disturbance as central to the psychopathology of the addict. Kohuts (1971, 1977b) insights into the psychodynamics of alcohol addiction are directly relevant to understanding sexual addiction. The core difculty of these narcissistic persons is the absence of internal structure. Just as the alcoholic uses drinking to compensate for these missing structures, the sexual addict uses sex to reduce anxiety and increase self-esteem in the absence of adequate intrapsychic resources. Until these psychic structures can be built for the sexual addict, these decits will continue to be disabling. Kohut (1977b) wrote explicitly about addiction, which he saw as a regression or xation to the archaic nuclear self (a pathological stage when seen in adults) which can be the psychodynamic correlative of sexual addiction. When the characteristics of the archaic self are manifested after the development of the sexual addiction, then regression and pathological narcissism are seen as consequences of the addiction. The sexual addict uses

Excessive Sexual Behavior

283

sex in an attempt to compensate for the decits in the selfs capacities for tension regulation, self-soothing and self-esteem regulation, as well as fear of regressive fragmentation. Stolorow and Lachmann (1980) stated that for the perverse client to ward off disintegration anxiety, the motivationally most urgent function of the perverse activity is likely to pertain to an impelling need to restore or maintain the intactness of self (p. 150). Similar to the unhealthy narcissist, the sexual addicts sense of entitlement is due to the repression of archaic needs, which is demonstrated by displays of grandiosity to mask acute insecurity. Narcissistically disturbed individuals yearn for admiring and mirroring responses because they lack the inner resources to supply themselves with esteem and approval. Referring to chemical addictions, Kohut (1977b) stated:
By ingesting the drug he [the addict] symbolically compels the mirroring self-object to soothe him, to accept him. Or he symbolically compels the idealized self-object to submit to his merging into it and thus partaking in its magical power. In either case the ingestion of the drug provides him with self-esteem which he does not possess. Through the incorporation of the drug he supplies for himself the feeling of being accepted and thus of being self-condent; or he creates the experience of being merged with the source of power that gives him the feeling of being stronger and worthwhile. And all these effects of the drug tend to increase his feeling of being alive, tend to increase his certainty that he exists in the world (p. vii).

By substituting the words sexual activity for the ingestion of drugs and sex for drug in the above quotation, the passage effectively describes the function of compulsive sexuality for some sex addicts. Sexual activity gives the addict the feeling that he omnipotently can control the responses of another person concordant with his needs. The sexual addict seeks mirroring self-objects to achieve the feeling of being wanted, desirable, alive, or powerful. Like the mythological character, Narcissus, sexual addicts continually look for their own refection (in their sexual partners) to reassure themselves that they are attractive and that they do, in fact, have a self. The reection reafrms that they exist. The behavior becomes habitual because it can only relieve feelings of inadequacy temporarily because the decit in the self remains and so the addict returns to feelings of emptiness. Thus, what is behaviorally described as a cycle of addiction can be explained in self-psychological terms. The role of sexual behavior serves as a remedy for two different affective states, depletion and fragmentation. At one point Kohut (1977a) divided the pathology of the self into those disorders encompassing depletion and those involving fragmentation. Although this division was later dropped, it may be helpful to this discussion to clarify dichotomous motives and consequences

284

J. R. Giugliano

in the addictive cycle. Concerning depletion, habitual sex is an effort to ameliorate a hollowness, sadness, and boredom resulting from a shallow and empty existence. Sexual excitation is used as a vitalization and strengthening action, as a means to feel alive. Kohut referred to this form of depression as empty depression which is felt to be due to the general unresponsiveness of ones self-objects. The concept of the empty self is described metaphorically by Kohut (1977b).
[as if] a person with a wide open gastric stula were trying to still his hunger through eating. He may obtain pleasurable taste sensations from his frantic ingestion of food but, since the food does not enter that part of the digestive system where it is absorbed into the organism, he continues to starve (p. ix).

Such a use of sexualization is to be differentiated from an active effort to avert regression. Concerning fragmentation, habitual sex is used to ward off impending disintegration. With decits in self-consolidation, the person quickly fragments in the face of narcissistic assaults, causing fears of disintegration and annihilation. In this case sex is used in an effort to (a) give a sense of selfcontrol by controlling another, (b) merge with an idealized other to supply self-approval and strength, or (c) avoid the realization of feeling devoid of sustaining self-condence and sustaining ideals. Goldberg (1988) pointed out that this gives the appearance of an impulse disorder, which is basically to be seen as a secondary phenomenon. Understanding sexual behavior as two different forms of affective remedy is conceptually helpful but less distinguishable in actual clinical practice because they often overlap. As a result of the sexual encounter, the addict experiences narcissistic bliss consisting of intensly pleasurable feelings of grandiosity, invulnerability, tranquility, and numbness. The relief accompanying the orgasm or high has an antianxiety or antidepressant effect (similar to self-medicating theories), thus endowing the sexual addict with a temporary respite from fears of disintegration or empty depression. The relief is ephemeral because the sexual addict does not have the psychic structure or internal resources to sustain feelings of self-approval and self-esteem. As the compensatory structure proves inadequate, the sexually addicted person is left feeling vulnerable to painful shame reactions. The ongoing long-range consequences (legal, relational, nancial problems, and fears of public disclosure) are further experienced as narcissistic injuries. Consumed with insecurity and self-loathing, the sex addict becomes overwhelmed with depletion anxiety (Tolpin & Kohut, 1980) or self-destructive depression (Kohut, 1972), leaving the person with fears of self-collapse or feelings of deprivation, emptiness, and deadness. To avoid fragmentation, the person then returns to sexual activities to establish a sense of vitality and restore self-cohesion. The compulsive sexualization of others

Excessive Sexual Behavior

285

as mirroring self-objects restores narcissistic supplies. Compulsive sexual behavior is thus an attempt to obtain admiration, afrmation, and mirroring to stabilize a fragile sense of self. The habitual use of sex to restore a persons narcissistic vulnerabilities is central to the concept of sexual addiction from the self-psychological perspective.

SUMMARY
A review of the literature indicates that theorists and clinicians, depending on their professional orientation, have dened the subject of habitual out-of-control behavior very differently. How one denes the problem will inform the treatment goals and expectations. How one conceptualizes outof-control sexual behaviors, whether addictive, compulsive, impulsive, perverse, or even promiscuous, will determine the treatment. None of the psychoanalytic theories specically address the phenomenon of sexual addiction per se. The author conducted a literature search on perversion, addiction, promiscuity, sexuality, and deviance and then speculated on the theoretical formulations from the four major psychoanalytic psychologies. Trauma theory has been an exception to the dynamic theories regarding their direct formulation of how the trauma becomes coded into a sexual addiction. Schwartz et al. (1995) has been examining sexual addiction as an aspect of posttraumatic stress disorder and dissociative disorders, stating that addictive behaviors later become a means to cope with feelings of depersonalization, numbness, emptiness, and physical and emotional analgesia due to trauma. As we learn more about the effects of trauma on our patients, clinicians are expanding their conceptualizations of cases to include a broader view of trauma theory. There are diverse views of the etiology and meaning of non-normative sexual behaviors. Although theories may differ regarding the etiology of outof-control sexual behaviors, there are similar views regarding the functions of the sexual behavior. Most theories address themes of control, affect regulation, and inadequate psychic structures or internal resources.

REFERENCES
Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum. Bak, R. (1953). Fetishism. Journal of the American Psychoanalytic Association, 1, 285298. Bak, R. (1956). Aggression and perversion. In S. Lorand (Ed.), Perversions: Psychodynamics and therapy (pp. 231240). New York: Random House. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

286

J. R. Giugliano

Baumbacher, G. (1992). Assessment of promiscuous behavior. In M. Stern (Ed.), Psychotherapy and the promiscuous patient (pp. 318). New York: Haworth. Blum, H. (1973). The concept of erotized transference. Journal of the American Psychoanalytic Association, 21, 6176. Bowlby, J. (1977). The making and breaking of affectional bonds. London: Tavistock. Braun, B. G. (1989). Psychotherapy of the survivor of incest with a dissociative disorder. Psychiatric Clinics of North America, 12(2), 307324. Brody, S. (1960). Self-rocking in infancy. Journal of American Psychoanalytic Association, 8, 464491. Callner, D. (1975). Behavioral treatment approaches to drug abuse: A critical review of the research. Psychological Bulletin, 82(2), 143164. Carnes, P. (1983). The sexual addiction. Minneapolis, MN: CompCare. Carnes, P. (1991). Dont call it love: Recovery from sexual addiction. New York: Bantam Books. Cashdan, S. (1988). Object relations therapy: Using the relationship. New York: W.W. Norton. Chasseguet-Smirgel, J. (1974). Perversion, idealization, and sublimation. International Journal of Psychoanalysis, 55, 349353. Coen, S. J. (1981). Sexualization as a predominant mode of defense. Journal of the American Psychoanalytic Association, 29(4), 893920. Coen, S. J. (1996). Sexual disorders. In E. Nersessian & R. G. Kopff, Jr. (Eds.), Textbook of psychoanalysis (pp. 345390). Washington, DC: American Psychiatric Press. Coleman, E. (1986). Sexual compulsion vs. sexual addiction: The debate continues. SIECUS Report, 14(6), 711. Coleman, E. (1987). Sexual compulsivity: Denition, etiology, and treatment considerations. [Special Issue: Chemical dependency and intimacy dysfunction]. Journal of Chemical Dependency Treatment, 1(1), 189204. Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychopathology, 58, 644663. Elmone, P., Lingg, M., & Schwartz, M. F. (1996). Adult survivors of sexual trauma: A conceptualization for treatment. Journal of Mental Health Counseling, 18(2), 108122. Engel, G. (1962). Psychological development in health and disease. Philadelphia: Saunders. Engel, M. (1984). Recent developments in psychoanalysis. Boston: Harvard University Press. Escalona, S. (1963). Patterns of infantile experience and the developmental process. Psychoanalytic Study of the Child, 18, 197244. Feeney, J. A., & Noller, P. (1990). Attachment style as a predictor of adult romantic relationships. Journal of Personality and Social Psychopathology, 58, 281 291. Freud, S. (1938). Splitting of the ego in the defensive process, SE: 23: 271278. Collected papers, 5. London: Hogarth. Freud, S. (1950). Beyond the pleasure principle. New York: Liveright. Freud, S. (1958a). Three essays on the theory of sexuality: The sexual aberrations. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological

Excessive Sexual Behavior

287

works of Sigmund Freud (Vol. 7). London: Hogarth. (Original work published 1905). Freud, S. (1958b). A child is being beaten, a contribution to the study of the origin of sexual perversions, In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 17). London: Hogarth. (Original work published 1919). Gagnon, J. H., & Simon, W. (1973). Sexual conduct: The social sources of human sexuality. Chicago: Aldine. Gainnetti, V. (1993). Brief relapse prevention with substance abusers. In R. A. Wells & V. J. Giannetti (Eds.), Casebook of brief psychotherapies: Applied clinical psychiatry (pp. 159178). New York: Plenum. Glover, E. (1956). Psycho-analysis and criminology: A political survey. International Journal of Psychoanalysis, 37, 311317. Goldberg, A. (1988). A fresh look at psychoanalysis: The view from self-psychology. Hillsdale, NJ: The Analytic Press. Goodman, A. (1998). Sexual addiction. Madison, CT: International Universities Press. Graham A., & Glickauf-Hughes C. (1992). Object relations and addiction: The role of transmuting externalizations. Journal of Contemporary Psychotherapy, 22(1), 2133. Greenacre, P. (1954). Certain relationships between fetishism and the faulty development of the body image. Psychoanalytic Study of the Child, 8, 7998. Greenacre, P. (1960). Regression and xation: Considerations concerning the development of the ego. Journal of the American Psychoanalytic Association, 8, 703723. Greenacre, P. (1968). Perversions: General considerations regarding their genetic and dynamic background. Psychoanalytic Study of the Child, 23, 4762. Greenacre, P. (1969). The fetish and the transitional object. Psychoanalytic Study of the Child, 24, 144164. Grolnick, S. A. (19851986). Discussion: Dening and using a traditional therapeutic eld when treating psychiatric patients with medication. International Journal of Psychoanalytic Psychotherapy, 11, 403407. Halliday, J., & Fuller, P. (1974). The psychology of gambling. London: Harper & Row. Hateld, E. (1988). Passionate and compassionate love. In R. Sternberg, & M. Barns (Eds.), The psychology of love (pp. 191217). New Haven: Yale University Press. Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychopathology, 52, 511524. Horner, A. (1984). Object relations and the developing ego in therapy. Northvale, NJ: Jason Aronson. Jacobs, D. (1986). A general theory of addictions: A new theoretical model. Journal of Gambling Behavior, 2, 1531. Jessor, R., & Jessor, S. (1977). Problem behavior and psychosocial development: A longitudinal study of youth. New York: Academic. Kernberg, O. (1974). Barriers to falling and remaining in love. Journal of the American Psychoanalytic Association, 22, 486511. Khan, M. M. R. (1962). The role of polymorph-perverse body experiences and objectrelations in ego-integration. British Journal of Medical Psychology, 35, 245 261.

288

J. R. Giugliano

Khan, M. M. R. (1964). The role of infantile sexuality and early object relations in female homosexuality. In I. Rosen (Ed.), Pathology and treatment of sexual deviations (pp. 221292). London: Oxford. Khan, M. M. R. (1965a). The function of intimacy and acting out in perversions. In R. Slovenko (Ed.), Sexual Behavior and the Law (pp. 397412). Springeld, IL: Thomas. Khan, M. M. R. (1965b). Foreskin fetishism and its relation to ego pathology in a male homosexual. International Journal of Psychoanalysis, 46, 6480. Khan, M. M. R. (1969). Role of the collated internal object in perversion-formations. International Journal of Psychoanalysis, 50, 555565. Khan, M. M. R. (1981). The evil hand: From cumulative traumata to self-control. Nouvelle Revue de Psychanalyse, 24, 551. Khantzian, E. J. (1997). The self-medication hypothesis of substance disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231244. Khantzian, E. J., Mack, J. E. (1994). How AA works and why its important for clinicians to understand. Journal of Substance Abuse Treatment, 11(2), 77 92. Kohut, H. (1971). The analysis of the self. New York: International University Press. Kohut, H. (1972). Thoughts on narcissism and narcissistic rage. Psychoanalytic Study of the Child, 27, 360400. Kohut, H. (1977a). The restoration of the self. New York: International University Press. Kohut, H. (1977b). Psychodynamics of drug dependence. (Research Monograph 12, preface, viiix). National Institute on Drug Abuse. Washington, DC: U. S. Department of Health, Education, and Welfare Public Health Service. Kuley, N. B., & Jacobs, D. F. (1988). The relationship between dissociative-like experiences and sensation seeking among social and problem gamblers. Journal of Gambling Behavior, 4(3), 197207. Levine, M. P., & Troiden, R. R. (1988). The myth of sexual compulsivity. Journal of Sex Research, 25, 347363. Litin, E., Gifn, M., & Johnson, A. (1956). Parental inuence in unsafe sexual behavior in children. Psychoanalytic Quarterly, 25, 3755. McConaghy, N., Armstrong, M. S., & Blaszczynski, A. P. (1985, Aug.). Expectancy, covert sensitization and imaginal desensitization in compulsive sexuality. Acta Psychiatrica Scandinavica, 72(2), 176187. McDougall, J. (1972). Primal scene and sexual perversion. International Journal of Psychoanalysis, 53, 371384. McDougall, J. (1982). The narcissistic economy and its relation to primitive sexuality. Contemporary Psychoanalysis, 18(3), 373396. Milkman, H., & Frosch, W. (1973). On the preferential abuse of heroin and amphetamine. Journal of Nervous and Mental Disease, 156, 242248. Moore, B., & Fine, B. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press. Okpaku, S. O. (1986). Psychoanalytically oriented psychotherapy of substance abuse with observations on the Penn-VA study. Advances in Alcohol & Substance Abuse, 6(1), 1733.

Excessive Sexual Behavior

289

Quadland, M. C. (1985). Compulsive sexual behavior: Denition of a problem and an approach to treatment. Journal of Sex & Marital Therapy, Summer, 11(2), 121132. Quadland, M. C., & Shattls, W. D. (1987). AIDS, sexuality, and sexual control. Journal of Homosexuality, 14(12), 277298. Rado, S. (1957). Narcotic bondage: A general theory of the dependence on narcotic drugs. American Journal of Psychiatry, 114, 165170. Raynes, E., Auerbach, C., & Botyanski, N. C. (1989). Level of object representation and psychic structure decit in obese persons.Psychological Reports, 64(1), 291 294. Schur, E. M. (1979). Interpreting deviance: A sociological introduction. New York: Harper & Row. Schwartz, M. F., & Brasted, W. S. (1985). Sexual addiction: Self hatred, guilt, and passive rage contribute to this deviant behavior. Medical Aspects of Human Sexuality, 19(10), 103107. Schwartz, M. F., Galperin, L. D., & Masters, W. H. (1995). Dissociation and treatment of compulsive reenactment of trauma sexual compulsivity. In M. Hunter (Ed.), Adult survivors of sexual abuse: Treatment innovations (pp. 174186). Thousand Oaks, CA: Sage. Schwartz, M. F., & Master, W. H. (1983). Conceptual factors in the treatment of paraphilias: A preliminary report. Journal of Sex & Marital Therapy, 9(1), 3 18. Settlage, C. F. (1990). Childhood to adulthood: Structural change in development toward independence and autonomy. In R. A. Nemiroff & C. A. Colarusso (Eds.), New dimensions in adult development (pp. 2646). New York: BasicBooks. Shaver, P., Hazan, C., & Bradshaw, D. (1988). Love and attachment: The integration of three behavioral systems. In R. Sternberg & M. Barnes (Eds.), The psychology of love (pp. 3868). New Haven, CT: Yale University Press. Shedler, J., & Block, J. (1990). Adolescent drug use and psychological health: A longitudinal inquiry. American Psychologist, 45(5), 612630. Silverman, D. K. (1991). Attachment patterns and Freudian theory: An integrative proposal. Psychoanalytic Psychology, 8, 169193. Sperling, M. (1959). A study of deviant sexual behavior in children by the method of simultaneous analysis of mother and child. In. L. Jessner & E. Pavenstedt (Eds.), Dynamic psychopathology in childhood (pp. 221243). New York: Grune & Stratton. Stoller, R. (1968). Sex and gender. New York: Science House. Stoller, R. (1975). Perversion: The erotic form of hatred. New York: Pantheon. Stolorow, R. D., & Lachmann, F. (1980). Psychoanalysis of development arrests: Theory and treatment. New York: International University Press. Szasz, T. (1980). Sex by prescription. New York: Penguin. Textor, M. (1987). Family therapy with drug addicts: An integrated approach. American Journal of Orthopsychiatry, 57, 495507. Tolpin, M., & Kohut, H. (1980). The disorders of the self: The psychopathology of the rst years of life. In S. I. Greenspan & G. H. Pollack (Eds.), The course of life (pp. 425442). Washington, DC: U. S. Government Printing Ofce.

290

J. R. Giugliano

Van der Kolk, B. A. (1996). Trauma and memory. In B. A. Van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Trauma stress: The effects of overwhelming experience on mind, body, and society (pp. 279302). New York: Guilford. Walsh, A. (1995). Parental attachment, drug use, and facultative sexual strategies. Social Biology, 42(12), 95107. Weidman, A. (1983). Adolescent substance abuse: Family dynamics. Family Therapy, 10, 4755. Winnicott, D. W. (1971). Paying and reality. London: Travistock.