Assessing Intra psychic Blocks to Sexual
Pleasure Using the Milestones of Sexual Development Model
©Aline P. Zoldbrod, Ph.D. , 2003.
Originally published in Contemporary Sexuality,
American Association of Sex Educators, Counselors and Therapists,
Vol . 37, #11, pp. 7-13, 2003. Reprinted here by permission of AASECT.
The men and women who come to us for help are profoundly vulnerable.
They feel broken, unable to enjoy the basic human pleasure of being
sexual. Clinically, cases which first appear to be simple dysfunction
may later reveal extensive defects in sexual development. The focus
of this article is on deeply troubled men and women with intrapsychic
obstacles to intimacy stemming from family-of-origin issues.
Some of our most blocked patients experienced sexual abuse, and
appropriately staged treatment for them is well defined (Maltz,
2001). However, perhaps two thirds of them were not sexually abused,
yet standard behavioral exercises are too advanced and inappropriate
for them. How can we identify and help these clients, whose sexuality
never developed normally or whose sexual identity never evolved?
Sexual Difficulties are Normal Consequence of Non-Sexual Traumatic
Experiences in Childhood
What does it take for a child to grow into an adult who is able
to be psychologically and sexually intimate with the same person?
What creates the urge to merge emotionally, and also the permission
and ability to choose to lose control with our partner and experience
deep, sexual pleasure in our body? Clearly, sexual trauma in childhood
must not have occurred. But many kinds of families inflict "sexual
trauma" in a more diffuse way, affecting the platform upon
which the child’s healthy sexuality needs to be built.
Our sexuality is formed by subtle and not so subtle lessons we
learned in our family of origin. Consistent, good experiences with
loving touch, eye contact, trust, empathy, positively-constructed
body image, self esteem, and power are necessary building blocks.
These "Milestone" experiences link feelings of being loved
and feeling "good enough" with other developmentally crucial
abilities and associations, for instance, with:(1) embodied feelings
of pleasure, including (appropriate) familiarity with the sights,
touches, tastes, and smells of bodily intimacy;(2)the ability to
tolerate feelings, one’s own and others’ (3) emotional
closeness to another (4) relaxation, trust, safety, and energy flow;
(5) the expression of feelings, and (6) ultimately with the free
expression of sexuality. Without these good associations, letting
go and turning one’s body over to sexual experience with a
beloved other creates anxiety, not arousal. If these tasks were
not mastered, giving clients "permission" to be sexual
and assigning standard sexual homework is premature at best and
frustrating and doomed to failure at worst.
True, sex is bio-psychosocial, and multifactorial, and sexual
problems can be relationship based. But usually, our patients with
intractable primary problems were harmed by their upbringing. (Scharff,
1982). In some cases of lack of development or dis-integration,
undiagnosed hormonal problems may have been combined with family
patterns which were subtly or overtly inhospitable to sexual development.
Patients with deep-seated problems with sexuality and intimacy,
particularly those who did not experience overt sexual trauma, cannot
understand the root causes of their fear and conflict. They feel
impaired, abnormal, beyond help. Because they cannot conceptualize
what happened to them as being related to their sexuality, they
are hampered in changing their feelings and their sexual functioning.
Medical and mental health providers who are presented with patients
who have deep sexual blocks might presume a non-existent history
of sexual abuse as well ("You MUST have been sexually abused"),
further upsetting and demoralizing clients.
What follows is a review of several crucially important Milestones
in the development of healthy sexuality. Special attention is paid
to issues experienced by victims of non-sexual trauma and neglect.
A model (Zoldbrod,1998) of fourteen Milestones in Sexual Development
is useful to clients in explaining how certain non-sexual, negative
family experiences are related to sexual feelings. Understanding
the "why" of what went wrong, they feel less abnormal.
Clients can identify areas in which they are blocked and the negative
cognitions related to these blocks. This helps clients to be both
more realistic about a timetable for change and more optimistic
about the possibility of change. The therapist will find that the
process of looking closely at individual pathways to sexual development
aids in evaluating patients and in structuring and staging healing
interventions. The earlier the developmental breach occurred, the
less appropriate would be early use of standard behavioral sex therapy
Thinking About Three Groups of Families:
Nurturing, Affectionate, Stable and Appropriate Families, ■Operationally
Competent and Responsible, but Unaffectionate, Unempathic or Over
controlling Families ■Highly Unstable, Clearly Damaging Families
It is helpful to think of families as falling into three groups.
* Group One: Had warm, affectionate, empathic, trustworthy, well-balanced,
often harmoniously-intertwined parents. Clients’ human, inborn
potential to enjoy their sexuality and sensuality is intact. They
may have sexual problems, but are in basic ways, unscathed. They
have positive associations to touch, trust others, expect to be
loved , accepted, and treated empathically. They have the capacity
to be unambivalent about engaging in emotionally intimate relationships.
They can untangle troubled relationships and learn new sexual behaviors
with our help. Many times, they thrive in standard sex therapy.
* Group Two: Parents ( or single parent) "balanced "
and "responsible" but unaffectionate or not adequately
empathic. May be emotionally cold, critical, or emotionally over
controlling. Adults from Group Two suffer with sexual issues complicated
by lack of good experiences with touch, empathy, trust, gender or
power. However parents may be seen as responsible and family as
normal. Careful assessment of early issues with touch, trust, empathy,
self esteem, body image and power is important in planning appropriate
*Group Three: Unstable, damaging parents. Clients here grew
up in families where parent(s) were mentally ill, unstable, violent,
alcoholic, or abused drugs. In these families neglect, physical,
emotional, or sexual abuse occurred, either to our patient, or
to other members of the client’s family. This group suffered
trauma which created sexual sequellae. Experiencing, or even witnessing,
any of these "non-sexual" kinds of abuse and neglect
impacts adult assumptions about the safety of relationships, and
about life, itself. It negatively affects the wish and willingness
to be sexual (Levine, l988), or sexual with
another, real, person, and can eclipse sexual drive in patients
who are physically quite normal, and/or have coupled with a loving
However, at best, only those victimized
by actual sexual trauma believe that it is reasonable for them
to have sexual problems. Adults from Group Three need to have
in-depth assessment and the necessary rehabilitation in the areas
of touch, safety, empathy, trust, self esteem, body image, gender
and power before traditional sexual therapy is begun. Sexual problems
may include the full range of sexual dysfunctions, sexual avoidance,
sexual pain, sexual compulsions, and paraphilias.
Screening for Negative Family of Origin
Identifying oneself as a victim is painful.
Denial and minimization is so great that no matter how carefully
one screens clients for individual, family-of-origin issues affecting
sexuality unless you give a special instrument to screen for subtle
or detailed instances of chaotic unpredictability, neglect (physical,
medical or emotional ) or abuse, (see Ratner, excerpted in Zoldbrod,
l998), patients frequently maintain that their family experience
was "happy" or "normal".
Touch is a primary building block of sexual
desire and sexual motivation, the "ground zero" of sexuality.
Comfort with the touches, looks, sights, smells and sounds of
intimate contact is learned in the family of origin. I estimate
that possibly as many as half of our patients have some difficulty
experiencing touch as normal, relaxing, comfortable, and pleasurable
with a loved partner. When working with men, problem issues with
touch may be hidden until midlife, when testosterone levels are
lowered and raw, physical drive no longer powers sexual expression.
Only at that point, when arousal needs
to be fueled with touch and intimacy, do some men realize that
touch feels strange, tickles, or feels numb. ( While Viagra can
short-circuit this telling symptom, relearning touch would be
a more appropriate and long lasting solution.)
A detailed assessment of each client’s
experience with touch is important in the evaluation stage of
sex therapy. It is not safe to assume a positive association to
touch without gathering specific data. Two assessment/treatment
techniques (Zoldbrod, l998) are (1) drawing, annotating, and dating
a Body Map (2)giving the patient a list of word associations to
The dated Body Map is an outlined body
(front and back) which the client colors in, using a code to indicate
whether touch in that area is experienced as pleasurable, noxious,
or variable in the present. (I usually use green for "go",
red for "stop "or "no", and blue for "maybe".)
Partners should exchange body maps and take time in therapy to
explain the color code and the reasons for any "off-limits"
and "maybe" areas to each other and to the therapist.
Annotating the map is useful in helping partners remember what
kinds of touches are welcome and which are problematical and why.
In cases of illness or trauma, drawing " before and after"
body maps are extremely powerful. Many times, the body maps reveal
that clients are being touched in ways that are unwelcome or feel
Clients from Group Three typically have
body maps with a lot of red and blue and not much green. Progressive
touch exercises which focus on touching only the green and getting
permission to work on the blue areas are helpful (Zoldbrod, 1998).
It is not only clients from Group Three
who have problems with touch. Some patients who color their maps
with much green actually don’t enjoy touch very much. Patients
in Group Two often experience touch as "not normal"
and not associated with pleasure. A lack of good associations
to touch is not a neutral finding, it is a negative finding. Using
a word association test, other strange or negative associations
to touch are revealed and can be worked through.
Empathy and Trust
Trusting others to love us, to be reliable,
and to have empathy for our feelings is a primary intrasychic sexual
motivator and a major building block of sexual desire. (Levine,
Infants and children are helpless. Good
parenting involves the parent(s) accurately assessing the child’s
feelings and needs without assistance from the child.
Sexual feelings are intense body feelings.
Researchers at the Stone Center at Wellesley College (Jordan, 1991)
have defined empathy as a process whereby a person (ie, the parent
) allows themselves to feel in their body the feelings another person
(ie the child) is feeling, while at the same time, knowing that
it is the other person’s feelings they are feeling. A child
growing up receiving consistent parental empathy learns many positive,
complicated lessons which create the ability to enjoy sexual pleasure
within an intimate relationship. First, having receiving empathy,
the child will go on to expect to be cared for and understood by
others. Secondly, when a parent can tolerate the child’s difficult
or extreme feelings, the child then learns to tolerate the full
variety of his or her intense feelings. (Without the ability to
tolerate strong feelings in one’s body, the adult will not
be able to maintain erotic focus.) Thirdly, a child who receives
empathy for a wide range of emotions will then have the foundation
for interpersonal closeness. By definition, one can only have empathy
for those feelings in another that one can tolerate experiencing
in one’s own body. The child who received empathy will be
able to be empathic to others.
Feeling Good About Your Body (Body Image)
Body maps determine the ability to experience
pleasure. Body image mediates sexual behavior (Fisher, 1986). Adults
who grew up with parents who were affectionate and who praised them
for their physical exploits and competencies or attractive physical
aspects grow up to have relatively positive body images. (Women
from societies with oppressive, restrictive notions of female attractiveness
are affected by cultural standards, but those who had excellent
parenting may be less vulnerable to unreasonable pressures for physical
Clients from Group Two have body image problems
which come from a lack of parental praise, lack of positive construction
of a good body image through joint physical activities, or lack
of affection. The ""metamessage" that comes from
not being affectionately touched is that one’s body is not
adorable or treasured and that no normal person would want to touch
you. Feelings of body insecurity in turn create social anxiety about
one’s attractiveness and can contribute to difficulty in maintaining
one’s erotic focus in adulthood when a partner is found.
Clients from Group Three have profound disturbances
in body image. Parents who tease you about your looks, neglect your
physical or medical needs, don’t treat your body lovingly,
or hit you create a distorted body map, and feelings of body despair
or body worthlessness. Medical neglect ( for example, untreated
skin problems, wandering eye, endometriosis) creates physical problems
in adulthood which affect bodily health and functioning, the person’s
appearance, body image, and self esteem in general.(Zoldbrod, 1998).
Growing up as the witness to the physical abuse of a parent or another
sib demolishes body image almost as severely as being physically
abused oneself, by virtue of corrupting the safety of body boundaries
Unlike most of the primary milestones of
sexual development, unfortunately, a good body image can be fragile.
Illness, surgery, aging, or infertility can result in a body image
damaged in adulthood. Changes in body image during adulthood can
be assessed with the Double Onion technique (Zoldbrod, l993).
Power and Control
Parents have authority over children and
can wield it benignly or malevolently, or somewhere in-between.
Clients do not connect past experiences with power to their sexuality.
Commonly, clients assume that the power and control patterns which
were operant in their families are "normal" and will be
repeated in any intimate relationship. Group Two clients whose parents
were over controlling are ambivalent about getting into emotionally-dependent
relationships, an ambivalence which may over time appear symptomatically
as difficulty with desire, arousal, or orgasm. Clients from Group
Three who overcome their ambivalence and enter into intimate relationships
become obsessed with the power and control aspects of the relationship
and hyper-vigilant about losing control to another person, creating
the full spectrum of sexual problems, including pain disorders,
desire disorders. sexual aversion, sexual compulsions, and paraphilias,
or a dependence on scripted power and control relationships.
Permission to Explore Self and Sexuality
Research has shown that experiencing "negative
familial and cultural attitudes toward sex" does not create
adults who have problematical sexual functioning (Heiman et al,
1986). Ironically, if all of the preceding Milestones of Sexual
Development went well in the patients’ family of origin, patients
have learned enough good lessons about touch, love, empathy, trust,
power, relationship, and their own self worth to give themselves
permission. Patients from truly nurturing, competent, physically
warm families can make use of educational materials, books, friendships,
and psychotherapy and sex therapy. Simply giving permission before
the client has shown mastery of the earlier Milestones is not effective.
And a lack of permission in early life can be remediated a lot more
easily than problems with touch , trust, empathy, or power.
How Many Clients Have These Problems?
Data on Prevalence of Unstable, Damaging Families in the United
Families with many different problems harm
a chil's developing sexuality. Statistics are available for certain
groups of problem families, but totally unavailable for others.
(For example, total lack of physical affection between family members
is seen as quite normal in certain cultures and families, so no
statistics are collected on this phenomenon.) Here are some of the
groups for which we have statistics.
Spousal Abuse/ Violence
There are no research studies documenting
the high prevalence of sexual problems in adults witnessing wife-battering,
but this has been my clinical observation (Zoldbrod,1998). Each
year, about l0-15% of U.S. women, approximately two million women,
are physically abused by their intimate partners (Tjaden and Thoennes,
l998; Straus and Gelles, 1990. While separate statistics on emotional
abuse experienced by battered women are not available, the extent
of the problem has been noted (Sackett and Saunders, 1999.)
Zoldbrod (1998) offers a chart detailing
the many sexual sequellae for the child witness of family violence.
Most striking are disturbances in the body map, including numbing
and ticklish sensations, changed body boundaries, and inability
to experience relaxation, and a generalized inability to feel pleasure
when being touched sensually. Additional problems are "pseudo-sexuality"
with an emphasis on performance, anxiety, PTSD symptoms, poor socialization,
over concern with power and powerlessness, and gender conflict.
Distorted, highly negative cognitions about male-female relationships
are common as well.
Female children of battered mothers do
not want to identify with their victimized mothers. Male children
can suffer from erectile dysfunction, premature ejaculation, and
lack of desire stemming from conflicted feelings about being powerful
or assertive in a sexual relationship with a woman. Guilt over not
being able to protect one’s mother can affect willingness
to become intimate with a partner. Men and women have unresolved
feelings of anger at the mother for not being able to take care
of herself and them and disgust at her for continuing to be sexual
with a battering partner.
In the United States, alcoholism cuts across
all boundaries-race, economics, gender, and nationality . According
to the U.S. Department of Health and Human Services’ National
Institute on Alcoholism Abuse and Alcoholism’s statistics
(2002), nearly l4 million Americans, one in every thirteen adults,
abuse alcohol or are alcoholic. Sexias and Youcha (1985) estimated
that there are at least 22 million adults in America who lived with
an alcoholic parent (ACOA’s).
There is a literature which loosely ties
the dynamics of alcoholic homes to adult sexual and intimacy problems,
primarily citing trust issues. (Sexias and Youcha, l985). The typical
alcoholic home is marked by chaos, denial, emotional violation,
and vulnerability, and children typically experience feelings of
loss of control, worthlessness, and a dependency on secrecy for
A few other common ACOA problems deserve
note. (Zoldbrod, 1998). As with the children of battered women,
the children of alcoholics become "parentified children"
who have a great deal of difficulty letting themselves receive emotional
nurturance. Socialization skills are typically weak, since ACOAs
tried to maintain the family secret by not having peers visit them
at home or having close friendships where too much would be revealed.
orgasmic difficulties are caused by a negative
association to losing control.
Research has proven a clear association
between alcoholism, violence, aggression and impulsivity towards
others in the family (NIAAA, Alcohol Alert #38-1997). Children of
alcoholics typically deny or minimize the impact of their parent(s)
alcoholism on their sexual development, ignoring the negative effects
on their sense of trust, their expectation of empathy, self esteem,
and socialization skills. If the family dynamic included violence,
the sexual problems detailed above in this article will be relevant.
Child Abuse: A Broad Category of Neglect,
Physical, Emotional, Medical and Sexual Abuse
Child abuse has been described as a national
epidemic . In 1996, over 3 million children were reported to child
protective services as victims of child abuse and neglect, translating
to approximately 47 out of 1000 children, according to the National
Child Abuse and Neglect Data System (NCANDS, 1998 report). In a
breakdown of maltreatment cases, 52% involved neglect, 24% involved
physical abuse; 12% involved sexual abuse; 6% involved emotional
abuse; 3% involved medical neglect, and l4% involved "other
types of maltreatment."
These are statistics based on cases actually
reported to agencies. Much child abuse is not noticed by others.
Different kinds of child abuse create different sexual sequellae.
Children who grow up in homes where there is a lack of empathy and
a dramatic abuse of power or violence, particularly if male, are
prone to act out (Wolf, 1988) and according to research are more
likely than other children to become sexual criminals (Pierce and
Pierce, 1990.) Zoldbrod (1998) draws attention to the fact that
male and female victims of intense physical abuse also "act
in," experiencing sexual aversion, inhibited sexual desire,
sexual dysfunction, and pain disorders.
According to Tzeng et al, (1991) psychological
maltreatment is the most difficult type of child maltreatment to
measure, and "probably causes the most serious impact on children’s
psychological well-being." Emotional child abuse and neglect
create assumptions about human relationships which interfere with
a wish for vulnerability and closeness as an adult. Examples of
beliefs which must be changed in sex therapy are:
- If I get too close to someone I am not
one hundred percent sure of, they will hurt and eventually reject
- Most people are not what they seem, and
they usually have ulterior motives for things.
- It is better to do things on my own.
- Deep down, I am too needy and expect
too much out of most people, and once they find out, they will
- Other people don't want to hear my problems,
really, and can't change things for me anyway. (Zoldbrod, 1988)
Statistics collected by the National Mental
Health Association in Alexandria, Virginia highlight the fact that
many American families are made up of at least one parent with significant
mental illness. According to the Surgeon General’s Report
on Mental Health (1999) more than 54 Million Americans have a mental
disorder in any given year, although fewer than 8 million seek treatment.
Parents struggling with mental illness are hampered in their ability
to parent with energy, consistency, and empathy. Depression and
anxiety disorders are the most common, affecting 19 million American
adults annually, according to NIMH (1999). More than 2.5 Americans
have schizophrenia (according to Schizophrenia Bulletin, l998).
Bipolar disorders affect an additional 2 Million Americans, according
to NIMH (2000.) Severe child abuse and neglect is most common when
parents have more serious psychiatric diagnoses. However children
of depressed caretakers can experience chronic emotional neglect.
And children with extremely anxious caregivers absorb the anxiety
passed through their caretakers’ body, leading to distorted
associations to touch, difficulty with relaxation, and potential
ambivalence about close attachments.
Sexual problems caused by non-sexual trauma
are commonplace. Assessing the client’s mastery of the Milestones
of Sexual Development helps therapist and client to identify intrapsychic
blocks to letting go sexually with a loved partner and to target
Fisher, S. Development and structure of
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Jordan, J. (1991).Empathy and self boundaries.
In Jordan et.al. Women’s Growth in Connection (p67-80). New
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Retrieved September 6, 2003.
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incest perpertrators. In The incest
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women. Violence & Victims, 14, 105-117.
Scharff, D. (1982). The sexual relationship:
An object relations view of the family. Boston: Routledge and Kegan
Sexias, J & Youcha, G. (1986) Children
of Alcoholism: A Survivor’s Manual. New York: Crown.
Straus, M.A. & Gelles, R.J. (1990).
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to violence in 8,145 families. New Brunswick, MJ: Transaction.
Tjaden, P. & Thoennes, N. (2000). Extent,
nature and consequences of intimate partner violence. Findings from
the National Violence Against Women Survey (NCJ-18167) Washington,
DC: U.S. Government Printing Office.
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(1991) Theories of child abuse and neglect: Differential perspectives,
summaries and evaluations. New York: Praeger, p. 191.
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Services, National Institute on Alcohol and Alchoholism, (2002).Alcohol
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Available from NIAAA Publications Distribution
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Wolf, S. (1988). A model of sexual aggression/addiction.
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(ed),pp.131-137. New York: Haworth.
Zoldbrod, A. (1993) Men, women and infertility: Intervention and
treatment strategies. New York: MacMillan.
Zoldbrod, A.P. (1998) SexSmart: How your
childhood shaped your sexual life and what to do about it. Oakland,
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Resource for Patients
Patients can download the diagram and explanation
of the Milestones of Sexual Development on the internet at http://www.sexsmart.com