I remember very vividly a young woman who came to my psychiatric unit after her first psychotic break and spent much of the admission trying to punish herself for what her body had done during a rape.
She had been assaulted by a college classmate after her sophomore year. During the rape, she became intensely aroused. She could barely say this aloud, and when she finally told me, she spoke as though she were confessing to something criminal. She watched my face carefully. I had heard this story many times, more times than I wish I had, and perhaps because she did not see surprise or judgment, she kept coming back to me with the same question.
Her body had responded. Did that mean some part of her had wanted it?
Around the same time, memories began returning of sexual abuse by her stepfather when she was a child. The rape in college had opened something she had managed not to know for years, and the two experiences became almost impossible for her to separate. She remembered being abused as a child, remembered becoming aroused during the later rape, and began using her own body as evidence against herself.
“I became my abuser,” she told me. “Rape scenes arouse me. There is something wrong with me. Can you medicate me until I become a vegetable?”
She said this without drama. She looked exhausted.
I wish I could say this was an unusual conversation in psychiatry. I have heard versions of it from women who became lubricated during an assault, from men who had erections while being abused, and from people who reached orgasm and then carried the shame of it for years. Most of them had never told anyone. They sat across from me watching my face in the same careful way.
I understood her immediately, not only as a psychiatrist and a former neurologist, but as a woman who had also been abused.
Her shame stayed with me because I had heard it too many times in rooms where people spoke quietly and looked at the floor. I have also heard it from partners.
The husband of one of my patients once told me that his wife had described being sexually abused when she was young, but sometimes asked him to be cruel during sex.
“Was it really abuse?” he asked. “Or was it something she invited?”
He was not trying to be cruel when he said it. He was trying to make sense of something he could not reconcile, and in doing so, he arrived at the same accusation she had already made against herself.
The body remembers in associations, not moral categories
The brain does not store experience according to the language we later use to explain it. It does not file one event under love, another under abuse, one sensation under pleasure, another under fear, and then keep those categories cleanly separated. It learns by timing. What repeatedly happens together begins to become connected, particularly in childhood, when the systems governing arousal, fear, attachment, memory, and bodily regulation are still developing.
When sexual stimulation occurs together with fear, pain, immobilization, secrecy, or the anticipation of what another person may do next, those experiences can become linked without the child understanding any of them. The body may later respond to one element of the original situation because it has learned the entire pattern. A tone of voice, a position, the feeling of being watched, the loss of control, or even humiliation can acquire sexual charge, not because the person chose that meaning, but because the brain encountered them together often enough.
This is ordinary associative learning, though its consequences are anything but ordinary for the person living with them. The same mechanism allows a smell to bring back a childhood kitchen before we have consciously identified it, or a song to produce grief years after the relationship attached to it has ended. Sexual conditioning is not exempt from this process. Repeated pairing changes what later captures attention and what the body begins to anticipate.
Memory also depends on state. A person may appear to have no access to an earlier experience for years, then suddenly recover fragments of it during another assault, during sex, after childbirth, while intoxicated, or in a period of severe sleep deprivation. The later state does not need to reproduce the original event in every detail. It only needs to resemble it enough in the body. The same fear, loss of movement, genital sensation, or altered level of consciousness may reopen material that was inaccessible in ordinary life.
This was part of what happened to the young woman on my unit. The rape by her classmate did not hand her a coherent childhood memory with a beginning and an end. It returned pieces. Bodily sensations arrived before explanation. Images appeared without sequence. She knew something before she could tell herself what she knew, and the effort to force those fragments into a single story contributed to the collapse that brought her to the hospital.
Fear and sexual arousal activate some of the same physiological systems. Both can increase heart rate, narrow attention, heighten vigilance, and pull awareness toward the body. That overlap does not make terror erotic or transform assault into desire. It does mean that the body can become highly activated during an experience the person does not want, and genital tissue can respond to direct stimulation even while the person is frightened or mentally absent.
Dissociation complicates this further. Under overwhelming stress, perception may become fragmented. A person may register pressure, pain, warmth, or orgasm without experiencing the event as something happening to a continuous self. Later, the body remembers what the narrative mind cannot organize. Some patients describe watching the assault from the ceiling. Others remember only one object in the room, the pattern on a wall, or the sound of a television in another part of the house. The rest returns years later through dreams, sex, panic, or impulses they do not understand.
There is also the matter of relief. Intense sexual stimulation can interrupt psychic pain for a few minutes. Orgasm can quiet intrusive thoughts, reduce tension, or cut through numbness, and the person may return to it for the same reason another patient returns to alcohol, self-injury, or compulsive exercise. Pleasure may be present, but pleasure is not always the primary aim. Sometimes the person is trying to stop thinking. Sometimes the person is trying to feel anything at all.
Returning to the scene
Long before I had enough clinical experience to understand any of this, I watched a Russian film called Twilight Portrait. I was in my early twenties, and the woman in the film disturbed me because after being raped by three policemen, she went back looking for the one who had led them.
Not to report him. Not exactly to kill him, although at first she seemed to want revenge. She found his apartment and began returning there, having sex with him, recreating something that had already destroyed her once.
At that age, I thought the film was showing a woman who had become sick after rape. I could not understand why she moved toward the man she should have feared most.
Years later, while listening to patients in psychiatric rooms in the United States, I began recognizing the same return in lives that otherwise had little in common with Marina’s.
Why trauma repeats itself through sex
Freud called it repetition compulsion, a phrase that has become so familiar that it risks sounding more orderly than the thing itself. In practice, repetition rarely announces itself as repetition. A patient describes a new partner, a new sexual arrangement, a new reason for remaining, and only gradually does the old scene become visible beneath it. The details have changed enough for the person to experience the encounter as chosen, although the position they occupy inside it may be painfully familiar.
Freud believed that returning to what had once overwhelmed us could represent an attempt at mastery. An experience first endured in helplessness is approached again with some control over its conditions. The person chooses whom to meet, where to go, what will be done, and how far the encounter may proceed. Even cruelty can feel different when it has been requested rather than imposed. The distinction is real, although it does not always settle the psychological question as cleanly as people hope it will.
I know that logic from my own life. Three months before my dissertation defense, during a conference in Greece, I invited the supervisor who had repeatedly raped me into my hotel room. I feared him more than anyone I had ever known. That night, I chose the room, decided what would happen, and when it was over, told him I needed to rest and he had to leave. I had already decided it would be the last time. I did not tell him. My dissertation defense was still in his hands. The pleasure was not in the sex. It was in watching him leave without knowing that he would never touch me again.
Ferenczi wrote about the child’s identification with the aggressor, describing how a frightened child may become extraordinarily attentive to the abuser’s wishes, moods, and expectations. Survival depends on understanding the person who holds the power. Over time, the child may take in that person’s view of the event and even of the child herself. What began as adaptation can later appear inside sexuality as compliance, submission, fascination with power, or the wish to occupy the aggressor’s position rather than remain the one acted upon. The adult may know perfectly well that the original abuse was wrong and still find that desire has grown around some of its conditions.
Patients do sometimes repeat an experience while hoping, without fully knowing it, that the ending will change. The new partner will notice fear before being asked. The person who humiliates them will become tender afterward and remain present. Someone will finally enter the old arrangement and behave differently inside it. Psychoanalysis has often understood this as a wish for repair, although the wish may be carried through the body long before it can be spoken.
There are also repetitions that do not seem to be moving toward repair at all. Familiar suffering can be easier to organize around than unfamiliar care. One patient may need sexual intensity to interrupt hours of numbness, while another uses the same intensity to become less present. Pain can bring someone sharply back into the body, but it can also allow the person to leave it. In clinical language, both may be described as regulation, although that word conceals how different the experiences can be.
Reenactment is another term we use, particularly when an earlier relationship or traumatic position is recreated rather than consciously remembered. The person may not be recalling the past in images or words. They may be arranging it with another human being. Psychoanalysts sometimes call this enactment when an unspoken conflict appears through action and relationship instead of reflection. Sex is especially suited to this because it can carry power, surrender, fear, tenderness, shame, and bodily memory without requiring any of them to be named.
The wish to reclaim what happened can be difficult to separate from the compulsion to return to it. An encounter that once occurred without permission is restaged with permission, and that new consent may genuinely alter the experience. The person can speak, negotiate, stop, or ask to be held afterward. Yet there are occasions when the permission functions mainly as an entrance into the old position. The person chose the door, but not everything that becomes psychologically active after crossing it.
Some survivors describe a private logic that is almost impossible to explain to anyone who has not lived inside it: if I select the man, know what he will do, and ask for the humiliation, then perhaps it no longer belongs to the person who first did it to me. The scene becomes mine because I arranged it. Whether that is mastery, repetition, self-punishment, or several of these at once may not be apparent even to the person repeating it.
Another version of this is also common. A woman I knew had survived years of physical violence in her marriage. Later, she slept with many men and took particular pleasure in telling them to leave as soon as she was finished. For once, she chose the man, controlled the encounter, and closed the door.
I understood what she was taking back. I have also met the people left on the other side of that door, and I have seen this in both women and men. Being wounded does not prevent us from wounding someone else.
I am not interested in judging how another person lives. We remain responsible for what we do, and my work is to help people understand it and heal. But one person’s freedom ends when another human being is used to punish everyone who resembles the person who caused the original injury.
The woman who returned to the man with the drug
This past winter, I was sitting in the Dominican Republic, looking out at a view so beautiful it barely seemed real, when I read an essay on Substack by a woman who kept returning to the same man in a bar. She knew he would drug her. By morning, she would wake with bruises across her body and no memory of what he had done to her during the night.
Then she would return.
I kept thinking about that detail after I finished reading, because she was not describing an assault that repeated itself by accident. She went back to the same place and the same man while knowing that he would erase her from the experience. She could choose to enter the bar, sit beside him, and accept the drink, but everything after that belonged to him. By the time the violence began, she could no longer speak, change her mind, remember, or leave.
Perhaps this was her way of approaching an earlier trauma under conditions she could name in advance. She knew who he was. She knew what he would do. In her own telling, that knowledge gave her power. She had chosen the man, the bar, the drink, and the return, and she experienced that choice as liberating because the event no longer arrived without warning. It belonged to her decision before it belonged to him.
The difficulty was that her power ended when the drug took effect. She could choose to enter the scene, but she could not remain conscious inside it, alter what happened, or withdraw the permission she believed she had given.
What stayed with me was the peculiar cruelty of the arrangement she had created for herself. She returned in order to make the experience hers, but each time she returned, she arranged for herself not to be there. In the morning, the bruises told her what her mind could not.
I would not use her story to explain every survivor who returns to danger, and I do not know enough about her life to reduce it to a diagnosis. I only know that I recognized the movement. She was trying to come closer to something by disappearing from it.
BDSM: what choice can and cannot change
There is a scene in The Americans that says more about sexual reenactment than many psychiatric explanations I have read. Elizabeth Jennings becomes curious about “Clark,” the false identity her husband Philip uses with another woman. She knows that Clark is rougher, less tender, perhaps less recognizably her husband, and she asks Philip to have sex with her as that man.
At first, he cannot quite do it. He is still Philip with her, and she notices. She keeps pushing him to show her the man he becomes elsewhere, until something in him gives way and he turns her over with a force that changes the room immediately.
Elizabeth had asked for it. She had pursued it. She had objected when he was too gentle.
Afterward, she is curled on the bed crying while Philip stands in the bathroom, pulling off the wig and staring at himself in the mirror. He looks angry, although much of the anger appears directed at the man he has just allowed himself to become. Elizabeth does not look released or newly in possession of her sexuality. Later, she asks him whether he is angry with her.
The scene is difficult because consent is present and still does not rescue either of them from what happens. Elizabeth had been raped as a young KGB trainee by the officer who was supposed to be preparing her for service. Her body had already learned what it meant for a powerful man to turn sex into domination. Years later, she invited that position into bed with the husband she loved, perhaps believing that love, knowledge, or choice would change it enough.
For a few minutes, she could decide who the man would be and when the encounter would begin. She could ask for the aggression instead of having it forced upon her without warning. Yet once Philip entered the role she had demanded, the experience became larger than the request. Her tears did not mean she had never consented. They showed that conscious consent had reached something in her that consciousness could not control.
I have seen people approach BDSM with a similar hope, although they rarely describe it in those terms. They may believe that returning voluntarily to restraint, pain, humiliation, or physical overpowering will allow them to take possession of what once belonged to an abuser. Sometimes the encounter is carefully planned, with a trusted partner who knows the history and understands that a frightened face is not decorative scenery. The person expects that choosing the act will make the old helplessness feel different.
It may feel different. It may also bring the person directly back to it.
BDSM does not require a history of abuse, and it would be absurd to treat every interest in dominance or submission as a psychiatric symptom. Human sexuality has always included power, pain, performance, and the wish to surrender control, often without any history of trauma behind it. Psychiatry has caused enough trouble by treating whatever made it uncomfortable as evidence of illness.
The clinical problem appears when a survivor enters the scene hoping it will repair something and discovers afterward that the body has not accepted the new arrangement as evidence that the past is over. The partner may have followed every agreed rule. The safe word may have been available. Nothing illegal may have happened. The person can still find themselves crying in the bathroom, unable to explain why an encounter they requested has left them feeling used.
A safe word cannot always reach the part of a person that has gone silent. Someone who survived by complying may continue to monitor the dominant partner’s pleasure while losing track of their own fear. They may technically retain the right to stop and remain unable to use it, because stopping another person still feels more dangerous than enduring what comes next. The scene may be negotiated between two adults while an older obedience quietly directs one of them.
I pay attention to what happens when the scene departs from the fantasy. Can the person tolerate changing their mind after asking for something? Does the partner notice when speech becomes mechanical or the body goes strangely still? Can either of them stop without turning the interruption into failure? What does the person remember afterward, and how long does it take before they feel entirely present again?
Some people do experience the return as transformative. They remain awake inside the surrender, feel protected rather than abandoned, and discover that restraint no longer means being trapped with someone indifferent to their terror. Others keep increasing the force because the promised sense of mastery never arrives. The next scene becomes harsher, more elaborate, or more dangerous, while healing remains permanently scheduled for the encounter after that one.
Elizabeth did not become healed because she made Philip reproduce the force of another man. Philip did not become the safe replacement for her rapist simply because he loved her. For those few minutes, they entered the old arrangement together, and afterward each was left alone with what it had made of them: she crying on the bed, he unable to meet his own eyes in the mirror.
Elizabeth’s tears do not mean that every survivor who returns to force, restraint, or submission has returned to the abuse itself. They mean that the meaning assigned to an encounter beforehand may not survive contact with what the encounter awakens. She asked Philip for something real, and when he gave it to her, both of them discovered that they had entered a scene neither fully understood.
There are other outcomes. I have known survivors who did not want sexuality reduced to gentleness after what had happened to them. They were not searching for a permanently careful partner who treated them as though one firm touch might break them. Some wanted intensity and understood perfectly well that wanting it did not revise the history of how they were first hurt.
What changed the experience was not that the sex became mild. The partner remained capable of force, but did not become unreachable while using it. He could notice the difference between surrender and absence. She could ask for more without losing the right to want less a minute later, and neither change became a referendum on her sanity, her trauma, or whether she had been telling the truth about the past.
This is one reason sexual reenactment cannot be interpreted from the visible act. A woman may ask to be restrained because she is returning compulsively to helplessness, or because restraint now excites her in a body that is entirely her own. She may discover both meanings in the same encounter. People are rarely considerate enough to organize their sexuality into categories that make psychiatry comfortable.
Healing does not always look like losing the desire for darkness. Sometimes it appears in the ability to enter it without becoming confused about who chose it, who can stop it, and whether the person beside you is still listening. A survivor may remain drawn to intensity while no longer needing pain to prove anything about her worth or to repeat an old verdict against herself.
The pleasure is not less real because trauma once occupied nearby territory. Neither does pleasure make the trauma less real.
Why some men who were abused become compulsive pornography users
When I first started my Instagram account, a woman who also wrote about trauma and sexual abuse contacted me and suggested that we create a collaboration post about pornography. She wanted the post to shame men who watched it.
The request made me feel almost physically ill.
By then, I had already sat in too many rooms with men who could barely look at me while telling me how much of their lives pornography had taken from them. Their marriages were failing. Some could no longer become aroused with a real partner. They stayed awake for hours watching material they no longer even liked, arrived late to work, spent money they could not afford, and promised themselves each morning that they would stop. By evening, they were back in front of the screen.
I treat addiction. I would no more shame one of these men than I would shame an alcoholic for continuing to drink after alcohol had begun destroying his liver, his family, and his ability to recognize himself. People do terrible things under the pressure of addiction, and responsibility does not disappear, but humiliation has never been much of a treatment.
I declined the collaboration.
This is not an article about pornography addiction in general, which has its own physical, sexual, relational, and psychiatric consequences and deserves a separate discussion. I am writing here about one group I repeatedly encountered in clinical practice: men whose compulsive pornography use existed alongside a history of childhood sexual abuse. They are not the only people who develop this addiction, but they are among those least helped by being told that their symptom proves they are disgusting.
Many of the men who spoke to me about compulsive pornography use had been sexually abused as boys. They did not always tell me this at the beginning. Pornography was easier to confess than what an adult had done to them, although even that confession often took several appointments. They usually began with the amount of time they were losing, the material becoming more extreme, or the fact that ordinary sex no longer produced enough response. The childhood history came later, sometimes almost reluctantly, as though it could not possibly have anything to do with the problem they were describing.
For some, pornography had become less about pleasure than about changing their mental state. They watched when they could not sleep, after an argument, when they felt rejected, or during the empty hours when there was nothing immediate enough to keep old thoughts away. Once the sequence began, the room receded, time became unreliable, and for a while they did not have to be the man whose marriage was ending or the boy who had once been trapped with an adult.
The screen also gave them control that the original abuse had not. They decided what appeared, how long it remained, when the image changed, and when everyone vanished. No one on the screen could demand tenderness, become disappointed, notice fear, or ask what they were feeling. A person who had learned sexuality through another person’s power could remain physically aroused without having to tolerate the uncertainty of another mind.
Some became increasingly drawn to scenes of coercion or group rape and were horrified by it. They brought this to me as proof that they were dangerous men. Often they had spent years moving toward more extreme material because what once produced enough intensity had become ordinary. The popular explanation is dopamine, which is not entirely wrong, but it is too small for what I heard in those rooms. Novelty and habituation were involved, but so were numbness, old fear, and the need to reach a state powerful enough to shut everything else down.
There were men who watched from the position of the aggressor after having once been the child who could not escape. Others seemed to identify with the person being overpowered, though they found that much harder to admit. Sometimes the same man moved between both positions. The pornography allowed him to control the scene while remaining attached to the helplessness inside it.
Afterward came disgust. They deleted files, cleared histories, prayed, confessed to a partner, or swore that the next time would be different. The shame did not interrupt the cycle for long. It often returned them to the same isolation in which the urge became strongest.
I cannot write about compulsive pornography use as though it were merely evidence of male selfishness or depravity. I have seen too much damage caused by it to romanticize it, and too much suffering underneath it to turn it into a public shaming campaign. Sometimes pornography is the most visible part of an addiction that began years before the man ever saw a screen.
Eleven Minutes: when pain is mistaken for revelation
Paulo Coelho is one of my favorite writers, but Eleven Minutes has never been one of my favorite books. I understand what he was trying to do with Maria, and there are passages in the novel I have remembered for years, but I have always felt that he made pain far more cooperative than it is in real life.
Maria is hired by an English client who introduces her to sex built around domination and pain. During that encounter, she has her first orgasm. Coelho gives the moment the atmosphere of discovery, as though the body has finally been forced through a locked door and found some hidden truth on the other side. The scene is memorable because it touches something real. Intensity can break through inhibition. Pain can narrow attention so completely that ordinary self-consciousness disappears. A person who has lived at a distance from her own body may suddenly feel herself with an almost frightening clarity.
An orgasm, however, does not explain what has happened.
Maria’s body responds, but the response does not tell us whether she has found freedom, crossed into another form of submission, or simply encountered stimulation powerful enough to overwhelm whatever had previously kept pleasure out of reach. Coelho allows the orgasm to carry too much authority. Bodies are less philosophical than writers sometimes want them to be. They can respond inside tenderness, terror, humiliation, boredom, or an experience the person will later wish had never occurred.
Later, Maria tells Ralf what happened with the English client, and he takes her to a path covered in sharp stones. He asks her to remove her shoes and jacket and continue walking through the cold while he remains beside her, distant enough that she begins longing for him to notice her effort and tell her she can stop. He believes he is teaching her the difference between pain used for degradation and pain imposed by nature, the lesson that once freed him from his own attraction to sadomasochism.
Maria keeps walking after her feet begin to hurt, after she feels sick, and after coherent thought becomes difficult. Eventually she loses awareness of her body and enters the peaceful, almost transcendent state Coelho has been moving toward. The next thing she knows, Ralf is lifting her from the ground. She appears to have fainted from the cold.
I had remembered this as the gentler answer to the English client, perhaps because Ralf loves her and later carries her home. Reading it again, I am less certain. He is trying to release her from one experience of pain by leading her through another, and she once again remains in it while waiting for a man to recognize that she has endured enough. The language has changed. The pain is now spiritual rather than sexual, and the man beside her is supposed to be wise rather than cruel. Her body still has to disappear before he decides that she has reached the place she needed to reach.
Perhaps that is what has always bothered me about the novel. Coelho knows that pain can produce ecstasy, relief, and an unusual sense of freedom. Maria’s experience with Terence is not merely imposed on her; she becomes deeply interested in it and writes that she wants to go further. Ralf answers by giving the same bodily extremity a more acceptable explanation. One man calls it submission, the other calls it liberation, and Maria reaches an altered state with both. The book seems satisfied that love has clarified the difference. I am not.
I understand why this part of the book appeals to people. Maria is not treated as ruined by what excites her. Coelho allows her curiosity, her appetite, and even her attraction to humiliation without making her a psychiatric specimen. I value that more than I value his explanation. Where I part company with him is the speed with which experience becomes wisdom. Maria enters pain, reaches orgasm, walks over stones, loses consciousness, and emerges with a lesson. Real people are often left with the experience long before they know what, if anything, it has taught them.
Maria’s orgasm is important because it is real. It is not a verdict on whether the encounter freed her, harmed her, or opened something she would later understand differently. The body had an orgasm. The rest still required a life.
Behind closed doors
I have heard these stories in psychiatric offices from people who had spent years punishing themselves before they ever said a word aloud. They carried them into marriages, workplaces, bedrooms, bathrooms, and long sleepless nights while continuing to look entirely functional to everyone around them. Some believed they were damaged. Others believed they were dangerous. Most had already judged themselves more harshly than anyone else could.
There is always someone ready to explain another person’s sexual life from a safe distance. A survivor’s body responded, so perhaps the assault was not really an assault. A man watches violent pornography, so he must be depraved. A woman asks for cruelty during sex, so perhaps she wanted what happened to her years earlier. These conclusions arrive quickly, usually before anyone has listened long enough to understand the question.
Psychiatry has taught me how much is whispered after the door closes. People tell me things they have not told a spouse of twenty years. They ask me if an orgasm means they participated in what happened, if their fantasies have made them resemble the person who hurt them. Some are frightened that what excites them now will make others doubt what was done to them then. Most begin studying my face before they have finished speaking.
We are comfortable with sexual freedom only while it remains easy to approve of. The moment desire becomes contradictory, frightening, or difficult to explain, freedom gives way to suspicion. People are told to speak, and then punished when what they say is not the expected story.
I am not arguing that every desire is harmless or that every choice should be called liberation. I have seen people use others while trying to recover from being used themselves. We remain responsible for what we do. But judgment rarely makes anyone more honest, and shame has never been a particularly effective treatment.
People spend years defending themselves against meanings assigned to their bodies by strangers, partners, families, and sometimes clinicians. By the time they finally speak, they are often less afraid of the memory than of what another person will decide it says about them.
I have watched someone tell the whole story and wait for disgust that never came. Nothing miraculous happened. The past remained the past, and the work ahead was still there. But for the first time, the person was no longer alone with the accusation.
Vera Hart, MD, PhD
@verahartmdphd on Instagram
Wow, what a piece. Thank you for sharing and sorry for what you yourself have gone through. I was raped in my 4th year of uni by a powerful man 9 years my senior, he threatened and nearly choked me, stating how much and for how long and which pieces he wanted my body. I never reported it but I took a 2 hour shower and took hours to cry and then went to the library as it was midterms. A lot of this resonates. The body does keep the score. What matters, I think, is your body also knows, if you are giving into pressure or desire. If it's pressure, get out. It will absolutely haunt you if you don't. Desire feels like a force that envelops you in him.
This stayed with me. The body can remember what words cannot hold. A response is not consent, and arousal is not desire. Trauma rarely fits into neat categories. Sometimes repetition carries both pain and an attempt at agency. What helps is curiosity without judgment or shame. And sometimes healing begins simply by being heard differently.