Men with sexual compulsivity: Relationship between adult romantic attachment styles and sexual behavior types
Table of Contents CHAPTER 1: INTRODUCTION 1 Problem Statement 3 Purpose of the Study 5 Significance of the Study 5 Research Question 6 Variables and Definition of Terms 7 Explanatory Variable: Attachment Style 7 Outcome Variable: Sexual Behavior Type 9 Summary 12 CHAPTER 2: REVIEW OF THE LITERATURE 13 Attachment Theory 13 Adult Romantic Attachment Theory 16 Hazan and Shaver's Theory 16 Bartholomew's Model of Attachment Styles 21 Effects of Adult Attachment on Relationships and Sexual Behavior 24 Anxious Attachment 25 Avoidant Attachment 26 Brief Historical Overview of Compulsive Sexual Behaviors 28 Sexual Scripts and Excessive Sexual Behaviors 28 Diagnostic Categories of Excessive Sexual Behaviors 30 Critique of Sex Addiction/Compulsivity 34 viii
Theories on Excessive Sexual Behaviors 35 Psychodynamic Drive Theorists 35 Ego Theorists 36 Object Relations Theorists 37 Self-Psychology Theorists 38 Neurobiology 38 Trauma Theory 40 Attachment Styles and Compulsive Sexual Behaviors 41 Vandalized Lovemaps and Compulsive Sexual Behavior 45 Arousal Template and Sexual Behavior Types 47 Sexual Behavior Types 48 Treatment Implications 56 Critique of Existing Research 56 CHAPTER 3: METHODS 59 Measurement 61 Experiences in Close Relationships Revised (ECR-R) Questionnaire 61 Sexual Dependency Inventory Revised (SDI-R) Questionnaire 62 Sampling 65 Data Collection 67 Ethical Considerations 68 Procedure 69 Data Analysis 69 ix
Hypotheses Tested 70 Limitations of the Research 71 Summary 72 CHAPTER 4: FINDINGS 73 Demographic Profile of Sample 73 Location 73 Race/Ethnicity 74 Age 74 Relationship/Family Status 74 Sexual Orientation 76 Education Level 76 Employment Status 77 Income 79 Spirituality 80 Sexuality Continuum 82 Sexual Dependency Inventory Revised Section II 82 Attachment Style 83 Scores on Sexual Dependency Inventory Revised (SDI-R) 84 Reliability of Sexual Dependency Inventory Revised 88 Testing of Hypotheses 90 Demographic Factors 101 Summary of Findings 102 x
CHAPTER 5: DISCUSSION 107 Review of Assumptions and Findings 109 Fearful-Avoidant Attachment 110 Preoccupied Attachment 112 Dismissing-Avoidant Attachment 113 Theoretical Implications: Trauma Theory 116 Implications of the Research Findings for Clinicians 117 Limitations of the Research 120 Recommendations for Future Research 121 Conclusion 123 REFERENCES 124 APPENDIX A 135 APPENDIX B 149 APPENDIX C 151 XI
List of Tables Table 1. Sexual Dependency Inventory Items 65 Table 2. Relationship Status 74 Table 3. Times Divorced 75 Table 4. Number of Children and Stepchildren 75 Table 5. Sexual Orientation 76 Table 6. Education 77 Table 7. Employment Status 78 Table 8. Income 80 Table 9. Spirituality 81 Table 10. Sexuality Continuum 82 Table 11. Sexual Addiction Self Assessment 83 Table 12. Attachment Style 83 Table 13. Summary scores on Sexual Dependency Inventory Revised Items 86 Table 14. Transformed Scores on Selected Typologies 88 Table 15. Reliability of Sexual Behavior Typologies 89 Table 16. Variable Recoding Key for Attachment Styles 91 Table 17. Regression Coefficients for Hib 92 xn
Table 18. Regression Coefficients for H]C 93 Table 19. Regression Coefficients for Hid 94 Table 20. Regression Coefficients for Hie 95 Table 21. Regression Coefficients for Hif 96 Table 22. Regression Coefficients for Hig 97 Table 23. Regression Coefficients for Hih 98 Table 24. Regression Coefficients for Hn 99 Table 25. Regression Coefficients for Hij 100 Table 26. Regression Coefficients for Hik 101 Table 27. Variables Excluded from Model 102 Table 28. Summary of All Hypotheses Tested 104 Table 29. Attachment and Sexual Behavior Types 110 xm
List of Figures Figure 1. Relationship Between Frequency and Power/Intensity of Sexual Behaviors ... 90 xi v
List of Appendices APPENDIX A 135 APPENDIX B 149 APPENDIX C 151 xv
1 CHAPTER 1: INTRODUCTION Compulsive sexual behavior has become recognized as a social phenomenon because of the devastating effect that it has on individuals, interpersonal relationships, and occupational stability (Carnes, 1991). Pop culture has glamorized compulsive sexual behaviors with reality TV shows like such as Celebrity Sex Rehab. Recently, several celebrities and government officials have been exposed and a few sanctioned with loss of their position for sexual indiscretions. After being exposed, some admitted to having a problem with sex and identified as having a sex addiction. Over the last 20 years research on individuals with compulsive sexual behavior has gained increasing attention. Historically words such as Don Juanism, nymphomania, erotomania, satyriasis, and hypersexuality were terminologies describing out-of-control or excessive sexual behavior (Coleman, 1991; Bancroft & Vakadinovic, 2004; Money, 1999; Giugliano, 2004). The various terminologies used by researchers and mental health professional to describe excessive sexual behavior indicates the theoretical paradigm regarding the behavior and its treatment intervention (Coleman, 1991; Bancroft & Vakadinovic, 2004). The current terms used to describe this behavior are sexual compulsivity or sexual addiction (Bancroft & Vakadinovic, 2004). Those who exhibit excessive sexual behaviors are not always classified as having a sexual compulsivity, however there is a segment of the population who report struggling with obsessions and compulsions around sex (Coleman, 1991). Many such individuals face a variety of legal, financial, physical, and emotional consequences due to their behavior (Carnes, 2001). The term sexual compulsivity will be used to describe the excessive, out of control or unmanageable
2 sexual behaviors discussed in this study. In Chapter Two, I will present a more detailed account regarding debates about terminologies. The purpose of this study was to better understand the relationship between adult romantic attachment styles and sexual compulsive behavior types. Adult romantic attachment is described as a bond marked by the individual remaining in close contact with the attachment figure. The partner is used as safe haven of protection and support in times of danger, illness and stress. The partner is also used as a secure base to explore the environment that gives a feeling of safety, security, and confidence that brings about undistracted and uninhibited exploration (Fraley & Shaver, 2000). The definition of sexual compulsivity/ sexual addiction according to Carnes & Wilson (2002) includes two elements: (a) escalating patterns of sexual behavior that the individual is unable to control, despite a desire to stop the behavior and (b) harmful consequences including social, emotional, physical, legal, and financial losses or harm to self or others (p. 5). Compulsive sexual behaviors can occur at three levels according to Carnes (2001b): • Level 1 consists of behaviors that are not socially acceptable but are considered minor offensive behaviors, including compulsive masturbation, compulsive relationships, anonymous sex, excessive use of pornography, and prostitution. • Level 2 consists of behaviors that warrant legal sanctions because they are sufficiently intrusive, including obscene phone calls, exhibitionism, voyeurism, and frotteurism.
3 • Level 3 behaviors are highly illegal, including rape, molestation, incest, and child predators/child pornography (p.66). Problem Statement Based on studies of over 1500 sexual addicts, Carnes (1989) suggested that sexual compulsivity is present in as much as 8% of the adult male population and around 3% of the adult female population. Weiss (2004) estimates the incidence of uncontrollable sexual behavior in the general population is between 5% and 18%. Compulsive sexual behavior is a concern not only because of the effects on self and others. The concern is that the sexual behavior has the potential to reduce a person's ability to form intimate romantic relationships (Carnes, 1991; Cassidy, 2001; Katehakis, 2009; Leedes, 1999; Popovic, 2005; Zapf, 2007). A person's ability to form close relationships is impacted by feelings of isolation and loneliness (Popovic, 2005). Individuals with maladaptive parental attachments and dysfunctional beliefs about closeness or fear of rejection may avoid intimacy. The Diagnostic and Statistical Manual-IV (DSM-IV) has linked loneliness to psychosexual disorders that may include sexual dysfunction, paraphilias, gender identity disorders, and sexual behaviors not otherwise specified (Popovic, 2005; Torres & Gore-Felton, 2007). Some intimacy-disordered behaviors such as antisocial and sexual offences have been associated with feelings of loneliness as a destructive way to find closeness (Popovic, 2005). According to Hanson & Morton-Bourgon (2004), "The forms of sexuality that develop in the context of pervasive intimacy deficits are likely to be impersonal and selfish, and may even be adversarial" (p. 2). Some individuals who experience blocks in
4 attachment exhibit problematic attachment styles by engaging in excessive sexual behavior (Schwartz & Masters, 1994). Sexual compulsivity according to the sexual addiction paradigm is not about the sexual behavior itself but rather the sexual behaviors are mechanisms clients use to cope with anxiety and depression by masking or numbing out emotions (Goodman, 1998). Using an addiction model, the secret life of the individual with compulsive sexual behaviors is similar to the alcoholic or drug addict. Engaging in the sexual behavior becomes more important than family, friends, and work. The addiction system includes beliefs, impaired thinking, compulsive behaviors, and unmanageability that allow the person to further isolate (Carnes, 2001b). This study identified attachment styles of men with sexual compulsivity, using adult romantic attachment theory to understand the relationship between attachment and ten sexual behavior types exhibited by this population. Only a few researchers have studied attachment as related to sexual behaviors (Zapf, 2007). Similarly, research on attachment and compulsive sexual behavior is also limited. Understanding the relationship between dysfunctional attachment patterns and sexual behavior types in men with sexual compulsive behaviors helps clinicians and researchers understand the impact of early childhood experiences. The sexual behaviors exhibited by this population limit the ability to form intimate emotional relationships with the self and others and use sex as a tool to mask emotions.
5 Purpose of the Study The purpose of this study was to better understand the relationship between adult romantic attachment styles and the sexual behavior types exhibited by men with compulsive sexual behaviors. Although there is a body of literature on the relationship between substance abuse addiction and attachment theory, there is a gap in the literature about the relationship between sexual addiction/compulsivity and adult romantic attachment styles. The findings also inform understanding of the relationship between attachment styles and the typologies of sexual behavior exhibited by individuals with sexual compulsivity. Significance of the Study Cassidy (2001) proposed that individuals who did not have secure attachment experiences in childhood could possibly improve their ability to achieve and maintain intimacy by reworking his or her internal working models in adult romantic relationships. By helping men with compulsive sexual behaviors understand their attachment style and how it is linked with their sexual behavior type will help increase self-awareness, decrease cognitive distortions about relationships and sex, reduce the spiral of shame and guilt, and help them work towards building closeness in adult romantic relationships (Corley & Alvarez, 1996; Zapf, 2007). Families affected by sexual compulsivity will be able to repair disconnection in family relationships and begin the healing process of learning to relate in a more intimate manner. This study will also benefit mental health professionals in assessing and treating individuals and families affected by sexual compulsivity. As mental health professionals
6 better understand the relationship between attachment styles and compulsive sexual behaviors types, therapeutic interventions may be improved. For example, a therapist might work with a client who has compulsive sexual behaviors to explore problems related to attachment. The therapist could develop therapeutic interventions that focus on reworking the client's negative internal working models of attachment and teach relationship skills that enhance the individual's ability to achieve and sustain closeness with others. Research Question The two research questions addressed by this study are: 1. In what ways is there a relationship between adult romantic attachment styles and sexual behavior patterns in men with compulsive sexual behaviors? 2. Do demographic factors differentiate the relationship between adult romantic attachment styles and sexual behavior patterns in men with compulsive sexual behaviors? Two primary hypotheses with 11 sub-hypotheses were investigated in this study. Those eleven were based on sub-hypotheses as related to secure attachment, and three types of insecure attachment: dismissing-avoidant, preoccupied, and fearful avoidant, and ten categories of sexual behaviors. A detailed discussion of each of these attachment styles is provided in Chapter Two. 1. Insecure attachment styles will be found in men with sexual compulsivity. 2. A preoccupied attachment style will be found in men with sexual compulsivity who engage in intrusive sex.
7 3. A fearful-avoidant attachment style will found in men with sexual compulsivity who engage in exhibitionistic sex. 4. A dismissing-avoidant attachment style will be related to men with sexual compulsivity who pays for sex. 5. A dismissing-avoidant attachment style will be related to men with sexual compulsivity who engage in exploitive sex. 6. A dismissing-avoidant attachment style will be related to men with sexual compulsivity who engage in trading sex. 7. A dismissing-avoidant attachment style will be found in participants with sexual compulsivity who engage in seductive role sex. 8. A fearful-avoidant attachment style will be associated with men with sexual compulsivity who engage in fantasy sex. 9. A preoccupied attachment style will be found in men with sexual compulsivity who engage in voyeuristic sex. 10. A fearful-avoidant attachment style will be related to men with sexual compulsivity who engage in anonymous sex. 11. A fearful-avoidant attachment style will be found in men with sexual compulsivity who engage in pain exchange. Variables and Definition of Terms Explanatory Variable: Attachment Style Attachment style is the explanatory variable for this study. Attachment includes secure attachment and three insecure subsets that include dismissing-avoidant,
8 preoccupied, and fearful-avoidant. The instrument that I used to assess attachment was the Experiences in Close Relationships Revised Questionnaire (ECR-R) developed by Fraley, Waller, and Brennan (2000). It is a self-report measure of adult romantic attachment that assesses avoidance and anxiety. This instrument draws from the theoretical framework on adult romantic attachment by Bartholomew (1990) and Hazan & Shaver (1987). The definitions of attachment styles used in this dissertation are based on those of Zapf (2007), as follows: 1. Attachment - The strong affectional bonds between human beings. 2. Secure attachment style - An individual with this style is comfortable with intimacy and autonomy in romantic relationships. He or she is able to maintain a sense of self worth and lovability and expects others to be accepting and responsive. 3. Preoccupied attachment style - The individual with this style has a negative view of the self. He or She is not able to maintain a sense of self-worth and feels unlovable. He or she sees positive value and worth in others. The individual is preoccupied with romantic relationships and strives for acceptance from others as a way to achieve self-acceptance and self-worth. 4. Dismissing-avoidant attachment style - The individual avoids or dismisses intimacy and close relationships. He or she is able to maintain a sense of self- worth and lovability and seeks to maintain independence. He or she evaluates others negatively and exhibits invulnerability to protect his or her self from hurt and disappointment.
9 5. Fearful-avoidant attachment style - The individual is fearful of intimacy and is socially avoidant. He or she is not able to maintain a sense of self-worth and feels unlovable. He or she evaluates others negatively and expects negativity, untrustworthiness and rejection from others. This individual avoids others as a way of self-protection from anticipated rejection. Outcome Variable: Sexual Behavior Type The outcome variable for this study is the sexual behavior typology that was divided into ten categories. The sexual behaviors discussed in this study are behaviors that may be practiced by individuals who do not have sexual compulsions as part of healthy sexual expression. This study focused on the sexual behaviors that are problematic for individuals who struggle with compulsive sexual behaviors. The Sexual Dependency Inventory-Revised (SDI-R) was the instrument used to categorize the ten types of sexual behaviors exhibited by men with sexual compulsivity (Carnes, 2005a; Delominico, Bubenzer, & West, 1998). Compulsive sexual behavior patterns can manifest in a variety of ways. The compulsive sexual behaviors used in this study were limited to those posed by the International Institute for Trauma and Addiction Professionals (IITAP), 2008. The operational definitions in the SDI-R defined the ten categories of sexual behaviors as follows (International Institute for Trauma and Addiction Professionals (IITAP), 2008): 1. Fantasy Sex- The person is obsessed with a sexual fantasy life. Their arousal is dependent on sexual possibility with obsession and preoccupation prolonging the arousal. The obsession can be heightened by masturbation, fantasies,
10 relationships, and situations that are sexually charged. Orgasm or direct sexual contact with others is avoided but masturbation or sex with self will be compulsive. Individuals engaging in fantasy sex believe that escaping into fantasy is the only way to cope with reality. 2. Seductive Role Sex- The arousal is based on conquest and diminishes immediately after initial contact. The seduction of the other person is the primary goal. This individual may have multiple sexual or romantic relationships, affairs and unsuccessful serial relationship. Seductive sexuality is used to gain control of others and having power over others heightens by increasing risks and increasing the number of partners. 3. Voyeuristic Sex- The arousal is based on visual stimulation and is used to escape into an obsessive trance. This can be achieved by pornographic images in books and film, visual sex, magazines, peep shows, window peeping and secret observation of others. The individual can also sexualize materials that are not meant to be sexual. The individual has a distorted belief that because he or she only observes and does not engage in sexual contact they are not harming anyone. 4. Exhibitionistic Sex- Sexual arousal comes from reactions of shock or interest from the viewer. The exhibitionist is aroused by attracting attention to their body and sexual body parts. Some of the behaviors that he or she might engage in include: exposes themselves in public places, in cars, wearing clothing that is meant to expose, and masturbating with the hope of being caught by someone
11 else. The behavior is justified by pretending that it was accidental and the victim wanted to see them. 5. Paying for Sex- The individual purchases sexual services. The arousal is connected to payment for sex and the money itself. The individual might engage in paying for: prostitutes, sexually explicit phone calls, pornographic lines or sexual favors. The payment creates entitlement and a sense of power over meeting one's needs and the arousal starts with having money and searching for a person to pay. 6. Trading Sex- The individual sells or barters sex for power. The individual receives money, services, goods or drugs for sex or uses sex as a business. The arousal is based on gaining control of the other person by using sex as leverage. 7. Intrusive Sex- The sexual arousal occurs by violating others' boundaries without repercussions or discovery. The high is about the boundary violation and orgasm is the secondary goal. The individual might participate in the following behaviors: touching others intrusively, using power or position, sexual harassment, inappropriate sexual humor and sexual advances or gestures. 8. Anonymous Sex- The individual engages in high-risk sexual behaviors with unknown persons and the arousal does not involve seduction or cost. 9. Pain Exchange- The individual engages in behaviors that hurt the self and/or sadistic hurting or degrading of another. The arousal can be achieved by watching others hurt or being hurt by others and can be triggered by fear or
12 reenactment of a fearful event that are built off of humiliation and shame. Pleasure and orgasm is elusive or may not be achievable without pain or violence. 10. Exploitive Sex- The arousal patterns are based on targeting and exploiting vulnerable people. The person who engages in this behavior prey upon vulnerable populations such as the elderly, children, distressed persons, or professional misconduct with clients. The arousal might happen during the grooming process by building trust with the potential victim. The boundary violations are typically explicit and often illegal. The person might cross the line by forcing sex, administering drugs or alcohol, or using their position of power. Summary This chapter has addressed the problem leading to the need for this study and its potential significance, as well as the study's purpose, research questions, hypotheses, and key terms. Chapter Two presents a review of relevant literature on attachment theory, adult romantic attachment theory, and effects of attachment on sexuality as well as a review of literature on compulsive sexual behaviors, theories on excessive sexual behaviors, and the 10 types of sexual behaviors exhibited by individuals with compulsive behaviors. Chapter Three provides a detailed description of the research methods used to examine these issues, including data, sampling, instrumentation and data analyses. Chapter Four presents the results of the data analysis addressing the research questions posed in the study. Chapter Five provides an overview of the research findings, implications, limitations of the study, and recommendations for future research.
13 CHAPTER 2: REVIEW OF THE LITERATURE The chapter begins with an overview of early attachment theory developed by Bowlby (1980, 1988, 2005) and Ainsworth (1978). The overview is followed by the theoretical framework of adult romantic attachment theory that incorporates the work of Hazan & Shaver (1987), and a fourth attachment style, identified by Bartholomew (1990). I next review and discuss the literature on attachment and sexual behaviors. A section on compulsive sexual behaviors begins with a discussion of the debate surrounding the terminology for sexual compulsion. The chapter concludes with a description and review of the literature on the ten compulsive sexual behaviors exhibited by individuals with sexual compulsivity. Attachment Theory In the 1960s, British psychiatrist Bowlby was one of the pioneers of the attachment theory. Bowlby proposed that humans have an innate biological attachment system that creates an intense bond between an infant and its mother (Fisher, 2004). He observed how infants reacted to being separated from and reunited with their mother. The need for closeness and proximity is important to this attachment system (Bowlby, 1988). His work suggests that early attachment experiences with the caregiver have a profound impact on child development. Attachment relationships have three components as identified by Bowlby (1988), which act as the why and how behind the function of the attachment system: (1) proximity maintenance with the caregiver (2) the caregiver being a safe haven for the infant, (3) a secure base. This third component helps the infant explore its environment and engage in activities that are unrelated to the
14 attachment figure (Bowlby, 1988). According to this theory, when the child feels secure and feels that the attachment figure is responsive and available to meet his or her needs, the child will be more likely to explore the environment away from the attachment figure (McMillen, 1992). As the secure child develops he or she will become confident with spending more time and distance apart from the caregiver (McMillen, 1992). Bowlby (1988) also theorized that children develop internal working models of themselves that reflect the image their parents have of them, based on the child's experience of the parent's ability to meet his or her needs. The internal working model includes the cognitive and affective systems that unconsciously guide how children interact in relationships with their primary caregivers and outside interpersonal relationships (McMillen, 1992). These internal working models are generally stable and continuously updated throughout the developmental life span. If a child experiences early disturbances in the satisfaction of attachment, this could lead to the development of dysfunctional internal working models that affect the child's ability to be vulnerable (Andersson & Perris, 2000). The inability of the individual to experience vulnerability leads to dysfunctional assumptions and beliefs that the individual carries regarding his or self and relationships with others (Andersson & Perris, 2000). In the 1970s, research on attachment by Ainsworth, an American psychologist, expanded upon the work of Bowlby. Ainsworth, Blehar, Waters and Wall (1978) observed mothers, fathers, and children in their natural environment and in a highly structured laboratory environment they called "the strange situation" (cited in Bowlby, 1988, p. 8). Ainsworth and her colleagues added to Bowlby's attachment theory by
15 proposing three patterns of attachment styles based on types of caregiving the child received. They assessed children as fitting into one of three categories of attachment styles: secure, anxious resistant, and anxious avoidant. 1. Secure attachment style - Seen in children who are confident that their attachment figures will be responsive, available, and supportive if they experience stressful or frightening situations (Ainsworth, et al., 1978). Such children will also believe that other people will be responsive to their needs and that they are worthy of the response. 2. Anxious resistant attachment style - Exhibited by children who experienced their attachment figures as unreliable to meet their needs. This pattern develops when a caregiver is only available and responsive to the child's needs sometimes, and uses threats of abandonment to control the child. This child tends to develop an internal working model of the self that questions his or her worthiness of being responded to appropriately. Based on uncertainty, these individuals are prone to separation anxiety, and have a tendency to be clingy and anxious about exploring the world. 3. Anxious avoidant attachment style - Can develop as early as age one and is associated with a maternal aversion to physical contact and nonresponsiveness to behaviors and needs such as crying. The person with this attachment pattern appears to not have confidence that others will be responsive to their needs. This person may live life without love and support from others.
16 Bowlby (1988) theorized that attachment patterns have a tendency to be consistent across time because the attachment process is inherently self-perpetuating. Adult Romantic Attachment Theory The theoretical framework used for this study is adult romantic attachment theory as articulated by Hazan & Shaver (1987) and Bartholomew (1990). Hazan and Shaver's Theory Hazan and Shaver (1987) developed an adult romantic attachment theory based on Bowlby (1988)'s framework and Ainsworth, et al. (1978)'s three-part model of infant attachment. Their original model was designed to categorize adult experiences into what they saw as three attachment styles: secure, anxious/ambivalent, and avoidant. These were later reconceptualized into four styles of Bartholomew (1990), as will be discussed in the next section. Hazan and Shaver (1987) believed that adult romantic love involves the same attachment behavioral systems as in childhood, which includes attachment, sex and caregiving. In adult romantic attachment emotional bonds develop between romantic partners in a similar manner as infant-caregiver attachments (Fraley, 2004). As Fraley, Brumbaugh, & Marks, 2005 discusses, Hazan and Shaver (1987) found several similarities between infant-caregiver attachment and adult romantic attachment: (1) adults and infants participate in close, intimate bodily contact with the attachment figure; (2) both adults and infants feel safe when the partner or caregiver is in close proximity and responsive; (3) both groups engage in "baby talk" with the attachment figure (4) adults and infants feel insecure when the attachment figure is inaccessible and nonresponsive (5) adults and infants share discoveries with the caregiver or partner; (6)