Sexuality and Its Disorders: Development, Cases, and Treatment


Mike Abrams

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    My gratitude to my wife, Dr. Lidia D. Abrams, who was both supportive and helpful in the research and preparation of this text. A dedication to my daughters, Dax Lily Abrams and Kira Lidia Abrams, who always provide me pride and delight. To the great institutions of higher learning: The Graduate Center of the City University of New York, New York University Brooklyn College, and Queens College, for providing a working-class New Yorker a first-rate and free education. I extend my perennial thanks to the late Dr. Albert Ellis, who laid the groundwork for modern psychotherapy and was the primary founder of sex therapy. He mentored me in clinical psychology and sex and couples therapy, and gave me the privilege of coauthoring with him three books and other publications.


    I would like to thank people who provided the insightful interviews that have contributed greatly to this book. Some of them are key figures in the development of evolutionary psychology.

    Special thanks goes to Marija Milisavljevic, MA, who provided tremendous help in all phases in the research and organization of this book.

    My appreciation to Jane Anne Blakney-Bailey, PhD, whose review, edits, and comments contributed a great deal to the quality of the work.

    Thanks to my talented developmental and research editor, Rebecca Frey, PhD, who fine-tuned both of my texts.

    To my former NYU graduate student Greg Mann, MA, whose research ­assistance helped substantially, thank you.

    Thanks to Barry Cohen, PhD, the innovative former program head of New York University’s master’s program in general psychology, who allowed me the freedom to develop a graduate course on sexuality that helped with the framework of this book.

    My appreciation to Ray DiGiuseppe, PhD, ABPP, whose inspirational work as the director of training at the Albert Ellis Institute and President of ABCT, set the ­standard for the rational emotive and cognitive behavioral therapy described in this book.

    My thanks to Kira Abrams, who has shown that a Ramapo College undergraduate can provide substantive research and editorial assistance.

    My thanks to Carolyn Music, MA, who was very helpful in the early phases of this book, as she was with my other text.

    I offer my sincere appreciation to Kassie Graves, former publisher of SAGE, whose patient encouragement made this book possible. I am also grateful to the other professionals at SAGE, including Nathan Davidson, Abbie Rickard, Bennie Clark Allen, Lana Todorovic-Arndt, Candice Harman, Heidi Dreiling, and Carrie Montoya, who were very helpful in bringing this book to publication.

    SAGE Publishing gratefully acknowledges the following reviewers for their kind assistance:

    • Sue Becker, Teesside University
    • Judith Burnett, Stetson University
    • Kenyon Knapp, Mercer University
    • Nicolette A. Salerno, Caldwell University

    About the Author

    Portrait of Mike Abrams. Illustration by Emrazina I. Prithwa © 2015.

    Mike Abrams is a practicing psychologist with 30 years of experience. He is a board-certified Diplomate of the American Board of Professional Psychology, and a Supervisor, Fellow, and Diplomate of the Albert Ellis Institute. He is on the graduate psychology faculty of New York University, where he has taught graduate courses in sexuality and psychotherapy. His work on sex-related issues began with his work at GMHC with people with AIDS; he was the first non-gay psychologist to volunteer to do such work in the ­mid-1980s. He spent nearly 4 years helping, pro bono, afflicted individuals along with their lovers and families.

    Dr. Abrams studied under, and for 17 years collaborated with, the prolific author and founder of sex therapy, Dr. Albert Ellis, who is also the founder of cognitive behavioral therapy. Dr. Abrams is credited with extending Dr. Ellis’s theory of human personality and his methods of sex therapy. He had worked closely with Dr. Ellis in extending Ellis’s model of human sexuality to include current evolutionary psychology. Dr. Abrams also studied psychoanalysis with Robert Langs, MD.

    Dr. Abrams holds three graduate degrees in psychology, a master’s degree in business administration, a degree in educational administration, and an advanced certificate in quantitative methods. His current research includes the role of childhood sexual abuse in adult pathology, and the role of the Internet in changing sexual mores. He has ­published numerous journal articles on topics ranging from sexual problems to the cognitive ­foundations of psychoanalysis.

    In addition to his writing and teaching, Dr. Abrams practices clinical ­psychology with his wife of 25 years, Dr. Lidia Abrams. His practice centers on relationship, sexual, mood, and personality problems. He estimates that he has worked with more than 1,100 people experiencing problems with sex or intimacy. More recently, Dr. Abrams has received commendations from the Governor of New Jersey, the Hudson County Executive, and the Mayor of Jersey City for his work with chronically ill, indigent, and disabled ­persons. Prior to his professional work in psychology, Dr. Abrams earned an MBA degree and worked in organizations such as the New York Stock Exchange, Merrill Lynch, and Citigroup, where he typically performed analytical and research projects. He has also served as a consultant to numerous organizations and governmental agencies.

    Dr. Abrams lives with his wife and has two college-age daughters.


    If one observes people carefully, virtually every action one witnesses will have some connection to sexuality. Of course, many of these connections will be quite abstractly associated with the physical acts of sex, but they will be sexual nonetheless. As will be made clear in this book, sex is more than procreation. It organizes our identities, the way we perceive others, and the way others judge us. It guides our vocational efforts and our quest for status and recognition. Sexuality guides our speech, our gestures, the way we walk, our willingness to fight or flee, and even our assessment of beauty. The following are a few examples of endeavors that may not seem sexual unless one examines them at the deepest level: men who spend hours in a gym to enhance their muscularity; women who mockingly refer to an expensive sports car as a compensation for manhood; women who enlarge their breasts and sculpt their buttocks; men who routinely take drugs to increase blood flow to their penises; people of all sexes who select clothing to either enhance their attractiveness or broadcast their social status; the relatives of a new mother who emphasize the baby’s facial similarity to the father; the prosperous men who go to great lengths to make sure that other people, especially women, are aware of their elite status; women who spend hours accoutering themselves to look as youthful and fertile as possible; individuals who use social media to disseminate negative gossip about sexual competitors and positive gossip about themselves; and those who, when told of a much older man courting a younger woman, reflexively respond with, “I’ll bet he has money.”

    And I ask the reader, Do you really behave the same way with a person that you feel attracted to compared to one who does not pique your interest? In fact, sexual attraction alters perceptions such that the attractive person will seem more astute, appear emotionally more stable, be more interesting, and even smell better. These and countless other interpersonal exchanges are intimately connected to sex and reproduction. As will be made clear, these and other human behaviors that may not seem immediately connected to sexuality will be shown as deeply connected to our sexual imperative. The specific manifestation of any sexual expression will be shaped by culture, societal traditions, and even regulations. But when one peels away the veneer of norms, most of these will be found to be essential human expressions related to love, intimacy, and sexual reproduction.

    There is no contradiction that the underlying forces that shape the multiform expression of our sexuality are distinct from our expressed reasons for having sex. Like many superficially volitional acts guided by nonconscious motivations, their explanation is often confabulated. This is because we are fundamentally explaining our actions to ourselves. We are prone to evade the apprehension that we do not always have access to the crucial reasons why we do things. Cindy Meston and the renowned evolutionary psychologist, David Buss (interviewed in this book), surveyed 1,549 college students about their reasons for having sex. The respondents initially provided more than 700 reasons that were distilled into 237 core reasons. These were further reduced to 4 factors and 13 subfactors. The finding shows that the respondentsʼ core motives were centered on physical desires such as stress reduction, pleasure seeking, attaining a desirable partner; goal attainment by way of accessing the resources of their partner, increasing social status, revenge against a competitor; reasons of personal insecurity in which sex elevated self-esteem; guarding their mate against potential competitors; and lastly, emotional reasons that included sex as an expression of love. Notably, the fourth factor, love, explained the least variance in women and none in men. What is most germane about this study is that the original 715 reasons given for having sex tended to be largely superficial and hedonic. That is, most students said they wanted to have sex simply because it was fun, it felt good, and it made them feel good about themselves. But when their reasons were factor-analyzed, deeper themes like revenge, mate guarding, resource acquisition, and acquiring an ideal partner were discovered. These are some of the key motives that evolutionary psychology not only predicts as ultimate sexual motives, but also suggests that they motivate most actions in life.

    Despite the previous results in which people claim that their reasons for sex are straightforward, in actuality, sexuality is complexly insinuated into the fabric of all human striving. The universality of sexuality is the bedrock of the social nature of humans. Indeed, our social standing among others is important because it directly impacts our sexual viability. This reality belies the adage that one shouldn’t care about what others think. If people really didn’t care, BMWs would supplant ­Volkswagens, and Cadillacs would be exchanged for Chevrolets. Expensive jewelry would become quite rare. Students would be less willing to pay the costly tuitions of elite colleges, and would readily accept the education at their state university. Great poetry, literature, painting, and sculpture would be rare. And all the servers in restaurants, waiting for their big break in theatre, would instead concentrate on waiting on tables. For what purpose would fame, impressive cars, status, or impressive degrees perform if we didn’t care what the devotees think? In truth, we are deeply inclined to care what people think about everything we do; and this concern motivates us to achieve, create art, to discover scientific truths, and even climb mountains. Because fame, creativity, lavish clothing, and social status make us sexier.

    A pansexual view such as I have been discussing was proposed a century ago by a creative writer and genius in self-promotion, who set out to make himself a legend, and at this he succeeded. He constructed explanations of individual motivation and a model of the structure of the psyche. He proposed an origin of myths and religion, and he purported to explain dreams, aggression, and the nature of love. In fact, he fabricated the most comprehensive psychosocial theory that had ever existed. His work had a fascinating appeal because it made each of us a unique composite of dynamic forces worthy of years of analysis. However, over time, every essential theory of Freud has been shown to be critically flawed or simply wrong,1 except for the one that had led to the most contention. Specifically, Freud had asserted that libido, the source of all sexual drive, underlies everything we do. As we will see, he was right in principle and wrong in explanation. Sexuality does indeed inspire virtually all that we do. But it is not a result of the sexual life force called libido. Rather, sex became crucial through the natural selection of somatic and psychological traits that are all sexually conveyed. Since most of what we are and much of what we think is conveyed through sex, then sex must be the guiding force of life.

    Over the past three decades, there has been an accelerating paradigm change in psychology that is providing fascinating revelations about human behavior. Prior to this new paradigm, evolutionary psychology, human behavior was described through a collection of competing schools of thought. Personality was modeled as an amalgam of representations such as a collection of factorial traits, repressed impulses, hidden replicas of significant others, or biological impulses. Intelligence was a function of speed of neural processing, dense and efficient cortical connections, or developmental reinforcement. Social actions were understood in terms of culture and vicarious or direct learning. And disordered thinking or behavior had even more competing explanatory schemes. Indeed, virtually every aspect of the human psyche was depicted by numerous and often mutually exclusive representations. And most of these were held apart from the rest of the person in a continuing Cartesian dualism. There were in effect numerous minds and a body, but there was no convincing means to integrate them. Then gradually a concept more than a century old was revealed to be the best means to both explore and understand our species. In 1858, Charles Darwin initiated a revolution that would ultimately show that every feature of every living thing arose from chance mutations. Each of these mutations was then selected or discarded based on their respective contribution to reproductive success. Consequently, the value of any contribution was never ­absolute, but had an importance contingent on environmental settings. In essence, there are no good traits or bad ones, only traits that best fit the particular environment in which the trait arises. The shape of the beak of a finch or the size of a mammal’s brain had relevance only in the context of how that feature aided the host’s survival in a given ecosystem. And if it aided survival, such that its host could produce more offspring, then that trait would be passed along.

    From the time of Darwin, there were a few thinkers, including Darwin himself, who hinted that natural selection applied to behavioral traits; but it wasn’t until the latter part of the 20th century that people like E. O. Wilson, Michael Ghiselin, Robert Trivers, David Buss, Leda Cosmides, John Tooby, Robert Wright, ­Douglas Kenrick, and Gordon Gallup initiated a paradigmatic change in psychology, sociology, sexology, and all other social sciences. With this change, scientists of human behavior began looking to natural selection to explain all human thought, emotion, and behavior. The social sciences began to heed the declaration of biologist Theodosius Dobzhansky that nothing in biology makes sense except in the light of evolution. Now scientifically minded social scientists are increasingly ­following the allied principle that nothing in humanity makes sense except in the light of evolution. Arguably, the first sex therapist and the founder of modern psychotherapy, Albert Ellis, PhD, tacitly took an evolutionary approach to psychology and sexuality. Ellis recognized that sexual behavior has a strong innate component and that many of the thoughts or actions that are viewed as pathological are actually attributes that were adapted for earlier settings. Decades later, this principle would become the most significant scientific basis for understanding sexual behavior. And this book, while reviewing many perspectives, is research-based and will explore sexuality accordingly. Moreover, a careful review of the scientific evidence on sexuality leads one inexorably to the natural selection perspective. Quite simply, no other model explains the observations as well.

    As Albert Ellis and I explained in our text on personality, there has long been a bias found in some experts against explaining human behavior in terms of adaptations, as these writers view this as opening a slippery slope to racism, eugenics, or antihumanism. However, to deny an essential truth because some might abuse it to justify bigotry comes at a great price. It is for this reason that I include an interview with the late J. Phillipe Rushton. He was a very gentle and pleasant man, but he presented theories that were tinged with insensitivity at best and racism at worst. However, by giving a forum to someone who indeed took evolutionary psychology to the extreme most feared by its detractors, I can help clarify that such extremes present no danger so long as they can be openly refuted. For Rushton used the logic of evolutionary psychology to propose models that instantiated the very worst fears of those who find it a potential danger. And as a result, Rushton was branded a racist and his ideas were marginalized. It is clear that any fears that evolutionary psychology will be used to justify social injustice are unfounded.

    It is because our sexuality is the result of an incremental evolutionary process that it is comprised of forces both powerful and nonconscious. That is, all of us at some time in our lives will feel compelled by our sexual drives in ways that leave us chagrined by our own behavior. Surely, the reader has been in the throes of sexual arousal and made decisions in what must have seemed to be an altered state of consciousness. At the time of arousal, these decisions seemed perfectly rational. Then with the waning of the passion, many of us are left shaken or even ashamed by our behavior. In prior eras, this was explained by the unconscious forces of the libido and id. However, a research-supported model holds that our sexual drives are mediated by evolutionarily old mechanisms controlled by primeval brain centers. These ancient drives are frequently not compatible with the values embedded in the phylogenetically newer neocortex. These drives can be so alien to our self-image that we often have trouble recalling how we were feeling once we are back in a nonaroused state. In fact, as you read this, try to recall how you felt, and what you were thinking, when you were last strongly sexually excited. You may recall the source of the stimulation and where you were, but it is unlikely that you will recapture the state of mind. Clearly our sex drive is a powerful and often ­dominating force in our lives. But unlike our other appetitive drives, it has profound social, cultural, and even legal restrictions. With such dynamics being involved with it, and its being so intertwined with our psyche, the study of sex must be based on legitimate science and research, as even the best research on sexuality can be swayed by the powerful influence of sex on our thinking.

    Anything that can subvert our thoughts or social judgments cannot be trusted to intuition or memory. As Elizabeth Loftus (interviewed in this book) has shown, memory must always be treated with skepticism. And none of us can be trusted to know ourselves when forces in our lives are sufficiently strong as to lead us to self-deception. Loftus and other memory researchers have shown that each of our realities is largely constructed in the form of a personal narrative that fits best with our self-image, our worldview, and our moral values. And this construction is particularly malleable when we confront our biases, fears, and fragile self-concepts. So, although this book does somewhat rely on the observations of a practitioner who has worked with and studied sexual matters for 30 years, these observations are always subordinated to the nearly 900 sources referenced in this book. Although not a perfect path to the truth, the scientific method is the best means we have of finding it. So the vast preponderance of the exploration of sexuality presented here will be based on scientific evidence. And when the evidence and personal experience are at loggerheads, the science always wins. Complementing the data and interpretations in this book are interviews with key figures in the world of sexuality. The interviews provide perspectives from people who have acquired either comprehensive or uniquely specialized knowledge about sexual behavior. Most of the people interviewed have earned international reputations for their accomplishments. It is strongly suggested that all of these interviews should be carefully read, as they are compelling ­complements to the text, and much of their content is not found anywhere else—in this book or any other.


    1 See Ellis, Abrams, and Abrams (2008) for a comprehensive treatment of this assertion.

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