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Monica Meyer

on 3 May 2018

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Transcript of Asphyxiation

What About S&M in Sex Addicts?
Sadomasochistic Behaviors
in Sexual Addiction

Monica Meyer, PhD, CSAT-S
Clinical Director of Gentle Path at The Meadows

Varying Definitions of Sadomasochism
Sexual Masochism
APA, 2013
Sexual Sadism
APA, 2013
A preference for sexual activity that involves bondage or the infliction of pain or humiliation. If the individual prefers to be the recipient of such stimulation this is called masochism; if the provider, sadism.

Often an individual obtains sexual excitement from both sadistic and masochistic activities.
Mild degrees of sadomasochistic stimulation are commonly used
to enhance otherwise normal sexual activity.

This category should be used only if sadomasochistic activity is the most important source of stimulation or necessary for sexual gratification.

Criteria for Sadomasochism
“The use of psychological dominance and submission, and/or physical bondage, and/or pain, and/or related practices in a safe, legal, consensual manner in order for the participants to experience erotic arousal and/or personal growth”
(p. 40).
Williams, 2006
Healthy Sexuality

“I’m pansexual and kinky. I’m open to all things and whatever sexual preference and gender there is. I don’t pick my partners based on those things. It’s all about the energy I feel and if we click or not. I give safety classes and demos on blood-born pathogens. I’m a house leader for a BDSM club in LA and I ride with a BDSM leather motorcycling club. I’m a heavy edge player. Top and bottom. I’m into edge play like hooks, suspensions, blood, artistic cutting, piercing, etc. I play rough. .."
Katie's Experience
"...In the BDSM community I’ve been so much more accepted and it makes me happy. I was not acceptable [in other settings]. I hid who I was and it was sad for me. I’ve managed to become pretty well known in the Fet [Fetish] community and it’s way more fun for me. I don’t have to hide anything anymore. And I’m enjoying the fetish modeling so much.
I’m having a blast.”
Katie (Continued)
In two studies, 58 sadomasochistic (SM) practitioners provided physiological and psychological measures of relationship closeness before and after participating in SM activities.

Increased Intimacy
The increases in relationship closeness combined with the displays of caring and affection observed as part of the SM activities offer support for the modern view that:

SM, when performed consensually, has the potential to increase intimacy between participants.
Sagarin et al., 2009
Sexual health professionals must use caution when applying diagnoses to sexual behaviors.

In order to avoid over-pathologizing sexual behavior simply because it is "outside of the norm," we must approach our clients with an openness and flexibility that
not only recognizes, but
celebrates all of the diverse manifestations of healthy
human sexuality
A sex positive perspective in the treatment of sex addiction
Is BDSM Associated with Any Mental Health Problems?
Numerous authors report minimal or no evidence of psychological dysfunction among S&M practitioners.
Krueger, 2009, 2010; reviews:
Sandnabba et al., 2002;
Weinberg, 2006
Normative levels of:
obsessive-compulsive symptoms
posttraumatic stress

Above average levels of:
dissociative symptoms
Psychopathology in
Community Sample of S&M
Connolly, 2006
Some Evidence of
Higher Rates of Trauma & Abuse
Women who experienced childhood sexual abuse were more likely to be sexually abused as adults.

S&M practitioners reported higher rates of childhood sexual abuse than was found in the general Finnish population,

Sexually abused women were more likely to engage in masochism than non-abused women.

Those reporting childhood sexual abuse were more likely to also report a history of suicide attempts, psychological treatment, and medical treatment for S&M-related injuries than their non-abused counterparts.
Sandnabba et al., 2002;
Nordling, Sandnabba, and Santtila, 2000
Many Theories But
Limited Research
Beyond Safe, Sane & Consensual
According to Freud sadomasochism originates in childhood from the combination of children being sexual, and the repeated act of spanking or beating.
“Sadomasochistic games (master-slave, parent-child fantasies) do not typically involve real acts of punishment but rather offer an arena in which past suffering, pain and humiliation can be enacted (this time with happier endings), and thus underlines the theatrical and mastery
elements in erotic life.”
Davidson & Layder, 1994
Repetition Compulsion
Sexual Dominance as
Sexual dominance is compensatory for lacking power and control or feeling sexually inadequate.

A study evaluating this theory found no differences in self-esteem between Doms and subs, though authors note that these findings may reflect that the compensatory strategy worked.
Damon, 2002
: attempt to
deal with unconscious
guilt, worry or responsibility over internal feelings of superiority, strength or powerful urges.

: guilt over urges to inflict pain is counteracted by the sub's sexual excitement so there is
no real victim.
Bader, 2002
Counteracting Guilt & Worry
Traditional psychiatric and psychodynamic theories rely on pathology, maladjustment and history of childhood abuse to explain S&M interest.

While these theories may apply to a small, specific subset of SM practitioners, they are not supported in the majority of SM practitioners.
One Theory Does Not Fit All
Powls & Davies, 2010
When Are S&M
Behaviors Problematic?
Consider the following:

Impairment or Distress
Relationship Problems
MMPI-2 Correlates
of S&M in Sex Addicts
A series of multiple regressions established associations between both low (and high risk S&M behaviors (HD and PE on the SDI-4.0) and MMPI-2 scales.

The trauma-related symptoms (PK) scale predicted both high and low risk S&M behaviors, across sexes.

Among men, low and high risk S&M behaviors were predicted by several other psychopathology scales. Only high risk behaviors were predicted by additional scales in women.

Hopkins et al., 2016
Wiseman, 1996
Traditional explanations for the development of an SM arousal template inaccurately assume:

the sexual behavior is problematic
represents psychopathology
may have originated in trauma
Why Might S&M Behaviors
Be Associated with More Trauma or Pathology
in a Sex Addict?
Diagnostic Criteria
for Sex Addiction
1) Failure to resist urges to act out
2) Engaging to a greater extent than intended
3) Unsuccessful efforts to stop or control
4) Inordinate amount of time spent
5) Preoccupation or obsession
6) Failure to fulfill other obligations
7) Continue despite negative consequences
8) Need to increase intensity or risk
9) Losses due to behavior
10) Withdrawal when behavior is stopped
Caring / Trust
Respects Rules
Out of Control
Requires Escalation
Violates Trust
Breaks Rules
Trauma & Addiction
Addiction to Trauma
Repetition Compulsion Revisited
Van Der Kolk, 1989
No evidence for mastery and resolution theory.

Pain or fear produces a natural opioid response that serves a soothing function.

Victims of abuse may require much higher stimulation of this system for soothing.

Abuse victims neutralize their hyperarousal with addictive behaviors including compulsive re-exposure to the trauma.
This could explain, in part, why childhood trauma is associated with subsequent self-destructive behavior, including:

chronic involvement with abusive partners,
sexual masochism,
violence against self or others.
Van Der Kolk, 1989
Addiction to Trauma
Self-Destructive Patterns
"With the initial infliction of pain, there comes the rush of adrenaline. Then come the aftereffects of the endorphins being released. Sessions can become so intense that my mind can enter an alternate reality (sub-space). I basically check out."
Sophia's Experience
The Secretary
Trauma Repetition
One Theoretical Explanation of S&M Behaviors in Sex Addicts
PTSD/Overt Traumatic Experiences
Relational/Covert Trauma & Neglect
Attachment Disorders
This theory doesn't apply to most BDSM practitioners because they are not sex addicts or childhood trauma survivors.
Even Some S&M Sex Addicts
Don't Fit Into This Theory
BDSM Culture or Lifestyle as protective

S&M represents an escalation of the addiction (cybersex)

Sex-Offender: may be more closely related to rage or compensatory mechanisms
Sadistic Fantasies:

kidnapping women, sexual torture, break them into attentive sex slaves using machines and cult psychology tactics.
Sadistic Behaviors:

Seek female partners to degrade, humiliate, ignore and abandon via webcam
S&M pornography with violent themes
Focus on forced orgasms, mind games & eventual sexual interest from woman
Compensatory Themes:

Psychological distance reduces fear of inadequacy related to body image issues and early rejection experiences.

Mom's emotional neglect relates to
obsession with attention & eroticized rage.
Machine Porn
Sex Addicts with a History of Trauma
Clinical Case Studies
“Estimates of the mortality rate of autoerotic asphyxia range from 250 to 1000 deaths per year in the United States.”
Uva, 1995
2 Types of Trauma
Overt Trauma:

physical, sexual, verbal abuse, rape
traditional PTSD
Covert Trauma:

emotional incest, addicted family system
relational trauma
neglect / abandonment
May observe a more direct trauma repetition.

Focus on the sensory components.
May observe a more compensatory trauma reaction.

Focus on attachment, cognition, core beliefs and
the story.
Married business owner in his late 40's. Acting out behaviors included:

Escorts & Prostitutes
1 significant 10-year affair
Asphyxiation w/orgasm
Rape wife while sleeping
Painful sex, size difference
Swallowing ejaculate
Playful masochism
Nathan's Trauma
Groomed by a male music teacher and ritualistically molested from
age 12-16.

Drugged and incapacitated
Orgasm & ejaculate
Painful anal penetration
Alcoholic health professional in his early 40's. Sexual behaviors included:

Escorts & dominatrices
Extreme pornography for hours
Giant women degrading men
Crushing, smothering, asphyxiating
Urination, body odor, disgust
Peter's Trauma
Physical & sexual abuse by older, overweight sister. Molestation by father. "Pimped out" to father's cruel & sadistic male friend at age 9.

Smothering & asphyxiating
Sadistic mind games
Deep sense of worthlessness & shame
for S&M Trauma
Repetition in the Sex Addict
Trauma & sexual behaviors often share sensory qualities.

1) Bottom up modalities:
Somatic Experiencing, TRE, yoga, mindfulness, experiential, art

2) Top down modalities:
CBT, family of origin, insight development, narrative, interpersonal process
Covert, Relational Trauma, Eroticized Rage & Attachment Issues
Cybersex addict in his early 20's
Isaac Cruickshank (c 1800)
Cuckold Departs for the Hunt
Male sex addict in his late 20's with significant depression, suicidality and Borderline Personality Disorder. Behaviors included:

Masochistic porn with themes of male humiliation and domination
Cuckold porn (large penis, Black men)
Pressuring girlfriend into fantasy and role play around cuckold theme
Brian's Trauma
Leonard's Trauma
Early rejection experiences with deep fears of sexual inadequacy and
general worthlessness.

Attention-seeking games have a Borderline quality - ensure the rejection he fears most.

Investment in victim role &
covert racism.
Sexual behaviors rooted in trauma-based core beliefs, attachment disorder, & emotional dysregulation.

1) Top down modalities:
Therapeutic relationship, CBT, family of origin, insight development, narrative, interpersonal process, anger work.

2) Bottom up modalities:
Somatic Experiencing, TRE, yoga, mindfulness, experiential, art
Treatment of Attachment &
Compensatory Themes in the SM Sex Addict
Pulling It All Together
BDSM healthy lifestyle or identity and is not based in trauma or psychopathology.

Appears to be some evidence of trauma and psychopathology in sex addicts who practice SM.

Trauma may inform specific behaviors among these sex addicts.

Overt & covert trauma may contribute to
different manifestations & treatment implications - many have both!

Body, Mind & Relationships
Can a recovering sex addicts
safely reintegrate SM practices into their healthy sexuality?
Monica Meyer, PhD, CSAT-S
Gentle Path at The Meadows
Development of the S&M Arousal Template
Bondage &

Trauma Bonding &
Abusive Relationships
Someone dealing with sex/love addiction and trauma also may be more likely to get into abusive relationships or not set appropriate boundaries.
Be Clear About
Treatment Goals
Goal of treatment is not to extinguish sexual interest in SM behaviors (in fact, this is likely not possible & rings of reparative therapy).

Patient may or may not have an interest in reintegrating SM into their healthy sexuality in recovery.

Reintegration is possible and encouraged in the context of attachment, safety and health.
May be safest in the context of a healthy relationship but this is individualized to the patient.
Focus on honesty, authenticity and integration of parts of self.
May included values clarification and kink-affirming therapy.
Defining Healthy BDSM
Safe, Sane & Consensual (SSC)

Risk-Aware Consensual Kink (RACK)
Safe to Risk Aware
Omit Sane

Caring, Communication, Consent & Caution (4C)
Retain Caution & Consent
Add Caring & Communication
BSDM vs. Sexual Sadism
Mahmoud, 2015
Although BDSM has elements of sadism, consent and willing partners are paramount.

BDSM is a form of sexual expression, not an indication of psychological issues.

Sexual sadism is a form of violence or sexual assault and frequently comorbid with narcissism and psychopathy.
Wismeijer & van Assen, 2013
Personality Dimensions
BDSM participants were:

less neurotic
more extraverted
more open to new experiences
more conscientious
less agreeable
less sensitive to rejection
higher ratings of well-being
lower need for approval (female)
less anxiously attached (female)
Well-Adjusted Majority
Stigma can produce self-fulfilling prophesy of mental illness and help-seeking.

Only 6% of individuals an an early sample expressed any distress about their SM desires.

Mental health's troubled history with understanding minority sexual practices (homosexuality as mental illness).

Majority of SM practitioners represent a non-deviant, well-adjusted and well-functioning majority.
Powls & Davies, 2010
Sound familiar?
Treatment of Nathan
Fearful of killing partner.
Arousal template work drawing parallels.
Significant trauma work (somatic-focus)
Long-term supported transitional living with intensive therapy and restricted access to the community.
Not interested in healthy BDSM and likely his behaviors are too risky.
Treatment of Peter
Intense shame and pain after sexual behaviors.
Arousal template work to draw parallels.
Intensive trauma work (somatic focus).
Long-term transitional living with restricted access to internet and community.
Couples therapy with girlfriend including trauma & sexual behaviors disclosure.
He didn't want to resume BDSM in his relationship at this time due to trauma repetition reminders.
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