Case Study

Sexual Heroin

Variant arousal patterns are an obstacle to intimacy

Magazine Issue
November/December 2005
Sexual Heroin

When a bewildered woman finally confides to friends that her husband or partner has been avoiding sex for months, or that the couple’s rare liaisons are filled with awkwardness and self-doubt, the questions on many lips often are: Is he having an affair? Could he be gay? In our clinical experience, more often than not, the answer is no–homosexuality and extramarital affairs aren’t, by a long shot, the only explanations for the male sexual avoidance that brings couples into marital or sex therapy. Far more frequently than most people imagine, we discover the man has another sexual secret: he’s involved in a compulsive variant arousal pattern as absorbing, erotic, and hard to kick as sexual heroin.

There’s a reason why pornography is the most financially successful business on the Web, with thousands of websites catering to every conceivable fetish. According to experts in the field of male sexual behavior, including Gene Abel and Michael Metz, some two to five million men have either a variant or deviant arousal pattern. Variant patterns, like fetishistic preoccupation with high-heeled shoes, or toes, or rubber, or cross-dressing, may be secret and shame filled, but they harm nobody physically. Deviant patterns, like pedophilia, exhibitionism, and frotteurism (when a person rubs against another to high arousal or orgasm, usually on public transportation), by contrast, are either illegal, or cause harm to others, or both.

Therapists working with couples in which variant arousal patterns are a problem must move on two fronts simultaneously: the intense, secret compulsion must be confronted and the couple’s damaged sexual relationship must also be restored. This is urgent work; good therapy for sexual secrets and dysfunction can determine whether the marriage survives or fails. The adage in marital therapy is that good sex alone can’t make a marriage, but bad sex can sink it.

A Romance Gone Sour

Take, for instance, Paula and Keith. They were in their early thirties and had been together for four years and married for nearly two when they came for their first therapy session with Barry McCarthy. They were filled with self-doubt and blame, each secretly fearing that their marriage wouldn’t survive. Their relationship, they said, had begun in a bloom of romantic love and almost daily lovemaking. But after six months, Keith’s passion had dimmed markedly. Despite their deep, genuine affection for each other, their bedroom had become an awkward place. Spontaneity, playfulness, and erotic charge had given way to fumbling self-consciousness. Nothing seemed to flow. Paula worried secretly that her husband didn’t find her attractive because he avoided sex altogether and wouldn’t say why. The last time they’d made love had been on their honeymoon 20 months earlier. The more Paula asked what was wrong and looked for reassurance, the more Keith avoided not only sex, but any discussion of sex. The decline in their mutual happiness, Keith implied during that mutually blaming first session, was at least partly Paula’s fault: she’d gone from being optimistic and self-confident to pessimistic, dependent, and constantly nagging and seeking reassurance.

After our joint initial meeting, I saw Keith and Paula separately. (I find this the most efficient way of getting a client to quickly disclose sexual secrets, and to find out what meaning their mutual sexual distress holds in the narrative of their past and present lives.) Paula told me that when Keith avoided sex, she went into a spiral of self-doubt about her own attractiveness and the viability of the marriage itself. Was it her? (She had a long scar on her thigh; perhaps it turned Keith off.) Was it him? (Perhaps he was, as her friends suggested, gay.) Or was it them? (Perhaps the marriage just wasn’t viable.) And Keith’s failure to even acknowledge a problem was making her feel crazy in addition to self-doubting.

Paula very much wanted children and genuinely loved Keith, but she didn’t want to bring a child into a nonsexual marriage that she feared wouldn’t survive. She worried that she might be following in the footsteps of her mother, who’d been divorced twice from men with hidden duplicities and fragilities: one had turned out to be a compulsive gambler; the other had bragged about fantasized financial successes that never materialized.

Neither of those, it turned out, were Keith’s secrets. But he had plenty of them. When I met with him alone, he told me haltingly that, for decades, he’d been secretly arousing himself during masturbation with fantasies–and later, pornography–of being spanked. He’d never breathed a word of this to Paula, out of shame and fear of humiliation.

As an adult, his sexual relationships with women had followed a familiar pattern: first, in the novelty of a new relationship, he’d be carried along on a river of intense sexual excitement. He’d allow himself to hope that, this time, things would be different, and that this new love would allow him to leave behind his solitary sexual fetish forever. But after six months to a year, the newness would wear off, and he’d become afraid of being impotent during standard-issue “vanilla sex.” So he’d simply stop having it. Meanwhile, he’d return to his favorite cyberporn websites, which specialized in domination and spanking. Once or twice a day, he’d go online, enter his credit card number, and follow the orders of a distant dominatrix beamed onto his flatscreen by web-cam, while he masturbated to orgasm.

Such variant arousal patterns typically begin in childhood or adolescence, and are reinforced by thousands of highly ritualized, erotically charged experiences of solitary masturbation. The combination of shame, secrecy, repetition, and orgasm makes it almost impossible to stop these activities, which is why we use the metaphor of sexual heroin.

Keith, for instance, was hooked. He told me that his spanking fetish had gotten started with childhood feelings of guilt and a need for acceptance and forgiveness. He remembered trying to spank himself at the age of 10 after he’d done something wrong. He first masturbated to orgasm at age 12, while fantasizing about being spanked and then being told he was loved and a good boy. Instead of experimenting with a wide variety of sexual fantasies, as most adolescents do, he’d repeated versions of this one scenario over and over, grooving a deep, narrow channel in his neurophysiology and sexual psyche. (This is at the core of a fetish: narrow in scope, highly erotic, ritually repeated, and kept as a shameful secret.) Keith told me that he felt great love for Paula and also wanted to preserve the marriage and start a family. But he felt hopeless about changing a sexual pattern that dominated him as completely as his paid cyber-dominatrices did.

A Secret Revealed

The fourth session was a feedback session. I noted that both Keith and Paula had congruent goals, including having a satisfying and stable marriage, a sexually rewarding relationship, and a family. All were hopeful signs. Then I turned to Keith and described his secret variant arousal pattern as an “intimacy disorder.” Rather than developing an intimate and interactive sexual style with Paula, he’d retreated into his secret fetish. That gave him a predictable sexual arousal and payoff, at the cost of blocking out Paula, her sexuality, and any sense of giving himself to the unknown. Giving yourself to the unknown is the hallmark of sex with another human being–interactive sex is, by its nature, unpredictable.

Paula’s first reaction to this information, contrary to Keith’s fear, was shock, surprise, relief, and uncertainty. She could stop worrying that it was something about her. But what was expected of her now? If she spanked him, would that make everything okay?

Keith felt vulnerable, exposed, and relieved. “It’s as if a 500-pound weight is off my shoulders,” he said. “But now it’s in the middle of the room, and I don’t know what we’ll do with it.” To which Paula replied, “Now that it’s ‘we,’ we’ll figure it out.”

The couple was on the same page, and we could work together to develop a two-pronged therapeutic plan. On the one hand, they needed to rebuild the sexual relationship between the two of them and restore Paula’s sexual confidence. On the other, they needed to address the fetish and explore whether it could serve any purpose in their sex life.

Opening up the secret at first made both of them vulnerable: Paula now had a new reason for worrying that Keith could never really find her attractive, and Keith worried that Paula couldn’t really love him now that he’d revealed his fetish. So I gave them homework designed to help them rekindle their sexual confidence and intimacy. On one Saturday morning, Paula was to tell Keith all the things she found attractive about him–from his physical traits to his sexuality to his personality to his work style. Then she was to make one to three requests that would make Keith more attractive to her. These were to be requests, not demands: Keith had a choice of accepting, modifying, or rejecting them without fear of negative consequences.

When they reported back to me at the next session, Paula had told Keith that she saw him as a hardworking, caring, physically attractive guy; she particularly liked his eyes and his long fingers, with their gentle caresses. She asked that he look at and kiss her when they began a sexual encounter, and to hold her and talk afterward. Her other major request was that he be sexually honest with her. Keith agreed.

A couple of days later, it was Keith’s turn. He told Paula he found her warmth and optimism, as well as her sparkling eyes and athletic body, attractive. He also asked her to wear sexy outfits–a request she modified by suggesting they go to Victoria’s Secret and shop together, which they did. The exercise proved to be highly motivating, especially for Paula. She felt affirmed that Keith did find her both loveable and desirable, and that his commitment to the marriage and a family was high. This gave her a safe base from which she could take more personal and sexual risks–being freer in initating sexual encounters, and allowing herself to be both sensual and erotic.

Paula began the next therapy session by saying she felt closer to Keith than at any time since their wedding, and was glad that he’d shared his spanking fetish. She was committed to the marriage, but she needed to hear from Keith what he wanted. Keith was equally resolute about his love for Paula and desire for a successful marriage, but unsure of what to do about his fetishistic arousal pattern. He understood that it was a major roadblock in their intimate relationship. Could the fetish be integrated into their sexual style? Could spanking be a part of their foreplay-pleasuring scenario–a bridge to greater shared pleasure?

As I often do when dealing with a variant arousal pattern, I suggested that Keith first bring Paula into his secret sexual world, showing her the sex websites, and playing out the spanking fetish. This would help them determine whether the fetish could play a role in their shared sexuality. Keith was hesitant, embarrassed, and anxious–this had always been his secret domain. Paula, by contrast, was eager. Parts of the next two sessions were spent on clarifying guidelines for this experimental exercise. They agreed on the following: Keith was to show Paula what was erotic to him about the cybersex websites, and she was to be open and nonjudgmental. They’d discuss their feelings about the experience at their next therapy session.

Entering Keith’s World

That Saturday, they sat down in Keith’s home office and linked up to one of the websites he frequently accessed. Paula watched as Keith played out the cybersex spanking ritual with the dominatrix, including masturbating to orgasm. This proved to be a very powerful experience for both of them. Despite her best efforts to be nonjudgmental, Paula found the ritual mechanical and antierotic, utterly lacking in either intimacy or playfulness. She simply couldn’t imagine incorporating it into their sex life. Keith’s reaction was even more dramatic. Enacting the ritual in front of Paula made it much less sexy: the excitement was so inextricably bound up with its illicitness and secrecy.

In their next session, Paula told Keith: “This is really not about me or us. It’s your secret childhood world. I want to really be with you sexually. The fetish is a wall, not a bridge, for us sexually.” It was clear to her that maintaining this secret world of forbidden pleasure would destroy any chance they had of marital intimacy. At this point, Keith began to get that his spanking ritual wasn’t a harmless sexual outlet. Rather it was a compulsively destructive sexual heroin, which could defeat any chance he had to maintain his marriage. This session was Keith’s moment of truth. He announced he was willing to give up his fetish.

But how? Many therapists mistakenly believe that improving the relationship dynamics within the couple alone will magically resolve the problem. It doesn’t work that way, any more than better communication alone solves one partner’s addictive involvement with alcohol, gambling, or cocaine. Without getting into the controversy over exactly what constitutes an “addiction,” it’s safe to say that compulsive habits are devilishly difficult to break, especially when they’re secret, satisfiable 24/7, and erotically charged. I didn’t want to put either Keith or Paula in the position I’ve seen couples in before, in which a man agrees to give up the fetish, but secretly returns to it until it again dominates his sexual desire, thoughts, and arousal. When this happens, the wife feels doubly betrayed: not only has her sexual self-confidence been undermined for a second time, but her partner has lied to her. The fetish alone doesn’t produce a fatally flawed marriage. But when a fetish is combined with dishonesty and a lack of effective support for change, the marriage dies. That’s why I had them make a commitment to not keeping any sexual secrets from each other.

To support change, I worked in individual sessions and in joint sessions. First, Keith and I worked together on the meaning he gave to fetishistic sex. He had to learn that “comparisons are odious” and to stop comparing the erotic charge of his fetish, in a decontextualized way, with that of couples sex. If he did, the fetish would always win out, just as a shot of heroin will always beat a stroll in the park for pure bodily pleasure. For him, the erotic intensity of the fetish was 100 on a scale of 100. Intimate, interactive sex might never become more intense than an 85.

New Scenarios

Then I worked with the couple together, creating erotic scenarios that would be inviting and pleasurable. The challenge to Paula was to stay sexually self-confident and in touch with her own desires–to find and keep her own positive sexual voice–rather than worry about Keith’s arousal. The challenge for him was to stay involved in intimate, interactive sex, and not retreat behind his fetish fantasy.

To address Keith’s fear of being insufficiently aroused, I got the couple to focus on multiple erotic stimulation, both before and during intercourse. He also started exploring a wider range of sexual fantasies, ones that had been cut off in his adolescence by his focus on his spanking fetish. Keith’s two favorite erotic scenarios in the pleasuring-foreplay period turned out to be standing while he gave his wife oral breast stimulation and Paula gave him manual stimulation. The second scenario involved kneeling, rubbing his penis between Paula’s breasts, and doing manual clitoral stimulation. During intercourse, Keith was highly responsive to testicular stimulation, enjoyed changing intercourse positions two or three times, and liked to intermix circular thrusting with in-out thrusting. Soon they were involved in an upward erotic interactional spiral: Paula got turned on when Keith stimulated her, and when she verbalized this, it turned Keith on all the more.

Changing a ritual as firmly entrenched as Keith’s spanking fetish is a challenging process. The sources of support for the change must come from a number of directions. Here these included not only Paula’s clear message about the unacceptability of Keith’s continuing the fetish and the need for ongoing couples therapy, but also the 12-step Sex Addicts Anonymous (SAA) group I referred Keith to and his sponsor from that group who supported him in abstaining completely from his fetish. The role of the sponsor, a member of SAA who had a personal experience with the power of fetishistic behavior and all the ways people who live in the grip of such rituals can try to “play the system” without really changing their sexual behavior, was especially important. Another member of the group, who was very sophisticated with computer software, installed a system to block fetish material from Keith’s computer. It also tracked his computer activity, allowing Paula to know if her husband had visited any porn sites.

More important, Keith agreed to a “24-hour rule,” wherein he’d disclose to Paula any internet, pictorial, or written use of spanking-fetish material within a day. Paula had no desire to be the “sexual police,” nor did Keith want her to play that role; he saw her as his intimate friend who was committed to helping him break the fetish pattern. Together, they worked out a system in which, once a week, Paula would conduct a five-minute check-in and ask if Keith had been in any high-risk situations. Within three months, their sexual comfort and confidence had improved so markedly that they decided to try to become pregnant, a decision that provided a special charge to their new sexual style.

I’m struck repeatedly by how, in healthy copules, sex is only a small, positive part of a good marriage, while sexual dysfunction, conflicts, secrets, and avoidance are so fatally destabilizing and draining. Problems like the one Paula and Keith faced can destroy marriages when one spouse is either unwilling or unable to face the issue, or feels so wounded or demoralized that he or she can’t maintain the motivation necessary to resolve the problem. What made treatment with Keith and Paula successful where many other men regress to their secret world or continually relapse? In this case, it became impossible for Keith not to recognize the negative consequences of not changing. He got a strong, coherent message from multiple sources–his therapist, spouse, SAA group members, and sponsor–that his fetish was an addictive “poison” that could only be dealt with through total abstinence. Beyond that, Keith had the incalculable advantage of being invested enough in making his marriage to Paula work that he was willing to undergo the soul-searching struggle needed to bring a truly intimate, interactive sexuality into his life.

Case Commentary

By David Treadway

The question Barry McCarthy and Jennifer Cintron pose in their case study is how best to treat shame-based, erotically turbo-charged, secret behavior. Can the opening up of such a secret and exposing the ritual behavior become a bridge to intimacy, or will it remain a wall blocking a couple from developing a sexual bond? It would appear that McCarthy and Cintron’s answer is that, while the couple can become more intimate by sharing their secrets and their vulnerability, sexual behavior such as Keith’s spanking fetish must be pathologized if treatment is to succeed.

But was this the only possible successful outcome for this case? Must all sexually variant behavior be treated using the addictions model McCarthy and Cintron employ here? I understood Keith’s preoccupation with spanking as a pattern growing out of childhood in which he tried to comfort himself by administering his own spanking as a prelude to reassuring himself that he was lovable. Given Paula’s initially empathic and compassionate response, I was left wondering whether, in this case, they could have found a way of incorporating Keith’s vulnerabilities and needs into their sexuality as a couple, while doing away with the secrets or shame.

McCarthy and Cintron appear to have done a good job helping this couple share their deepest vulnerabilities. But if he wanted to give this couple a chance to explore together Keith’s need for spanking and redemption with composure and empathy, then the assignment to have Paula watch him go through his ritual with a long- distance dominatrix on the internet seems almost guaranteed to insure that she’d be repelled and Keith would be shamed. I’d have preferred that McCarthy and Cintron invite them to consider trying some sexual role-play in the intimacy and privacy of their marital bed, to see whether they could have successfully helped Keith to stop using the internet and strangers for comfort.

I once treated a man who, after his mother’s death, developed secret erotic behavior using women’s lingerie for self-comfort and soothing. Before coming to see me, he’d secretly dressed in his wife’s underwear for years. However, once the shame and secret were exposed, his wife was able to let him wear her panties in their love making sometimes. She was able to indulge him, in part, because of her empathy for the yearning and grief that was expressed in his seeking solace in his mother’s lingerie drawer. Eventually, he was able to bring his sexual and emotional energy to her, rather than to get caught up in rigid rituals involving intimate clothing and other variant behavior. This achievement could never have happened if he’d been asked to show her the world of cross-dressing pornography that he regularly visited on the internet

My case example doesn’t contradict McCarthy and Cintron’s. Their article describes a thought-provoking case with a positive outcome. However, the challenge for us therapists is always to keep in mind the different-strokes-for-different-folks rule, especially in the area of sexuality, where there’s so much idiosyncratic yearning and vulnerability. I’d have preferred it if McCarthy and Cintron had helped this couple expand their sexual repertoire to include some of Keith’s yearnings, while, of course, keeping the addiction model in reserve in case he couldn’t redirect his compulsion and continued to retreat to cybersex and/or if Paula, despite her best efforts, found role-playing her husband’s scenario too repellent for her. For me, the key to the case was giving them the choice.

Authors’ Response

We appreciate David Treadway’s commentary and couldn’t agree more with the guidelines he presents for working with variant sexual behavior: increasing empathy and compassion, not reinforcing shame, and bearing in mind that in sexual matters, as elsewhere, there are always “different strokes for different folks.”

Nevertheless, in this case, and with many men and couples, the compulsive sexual behavior/sexual heroin model is actually more liberating (and truthful) than pathologizing. Keith’s ritualistic sexual pattern needed to be understood without shaming him, but both Keith and Paula realized it wasn’t a sexual scenario that could be successfully integrated into their couple sexual style. Helping the couple make a “wise” sexual choice is the crucial clinical issue.

Jennifer Cintron is a graduate student in the psychology Ph.D. program at American University. Contact:


Barry McCarthy

Barry W. McCarthy, PhD, ABPP, is a certified marital and sex therapist and a tenured professor of psychology at American University.  His clinical expertise focused on integrating sex therapy strategies and techniques into individual and couples therapy, assessment and treatment of the most common male and female sexual problems, and a special expertise in the treatment of sexual desire disorders. 

Dr. McCarthy earned his BA from Loyola University and his MA and PhD from Southern Illinois University.  His professional memberships include the American Psychological Association, American Association of Marriage and Family Therapy, Society for Sex Therapy and Research, and the Association for Behavioral and Cognitive Therapies.  He is a Diplomate in sex therapy, earning this from the American Association of Sex Educators, Counselors, and Therapists. 

As a leading expert in this field, Dr. McCarthy has presented over 350 workshops around the world, and his extensive list of publications includes over 100 professional articles, 26 book chapters, and co-authorship of 14 books, including Sex Made Simple (PESI, 2015), Enduring Desire (Routledge, 2010), Discovering Your Couple Sexual Style (Routledge, 2009), Men’s Sexual Health (Routledge, 2007), Coping with Erectile Dysfunction (New Harbinger, 2004), Getting It Right the First Time (Routledge, 2004), and Coping with Premature Ejaculation (New Harbinger, 2004).




David Treadway

David Treadway, PhD, is a therapist and trainer of 40 years.  His latest book is Treating Couples Well: A Practical Guide to Collaborative Couple Therapy. He’s also the author of Home Before Dark: A Family Portrait of Cancer and three other books.