A Clinical Case Study in Sexual Anorexia, Dismissive-Avoidant Attachment, and the Engineered Field of Infidelity
A clinical formulation for practitioners working with untreated adult survivors of childhood sexual abuse, their spouses, and the specific relational configurations these dynamics often produce.
Author’s Note
The case material integrated below is composite and de-identified. Details have been altered to protect confidentiality while preserving the clinical structure. The formulation is offered as one framework among several — not as universal claim about survivors of childhood sexual abuse, most of whom seek treatment and do the work — but as clinical description of what specifically happens when the material remains foundationally untreated across an adult life, and the specific relational configurations that unfold when such a structure enters marriage with a spouse whose own developmental history renders him particularly susceptible to what her defenses will require.
The Foundational Fact
A woman is molested by a trusted family relative in childhood.
She never addresses it in therapy. Not in her twenties. Not in her thirties. Not in her forties. Not when her marriage begins to collapse. Not when her children are grieving. Not when the entire architecture of her adult life is visibly organized around not touching it. She refuses treatment outright. Repeatedly. Across decades.
This is not uncommon.
The literature on disclosure and help-seeking following childhood sexual abuse (CSA) documents that a substantial proportion of survivors never disclose to a professional, and among those who do, many delay for decades (Alaggia, Collin-Vézina, & Lateef, 2019).
The reasons are well-established: Shame, Fear of not being believed, Family loyalty, Protective encapsulation of the material to preserve some form of performed functional adult life.
What is less discussed in the clinical literature, and what deserves specific attention, is what happens developmentally and relationally when the encapsulation holds for a lifetime. When the survivor never opens the material. When the entire adult personality is built around the specific defensive architecture required to keep the material sealed.
This article is about that configuration. Specifically, about how untreated Childhood Sexual Abuse, specifically the type where the perpetrator was a trusted family member or family friend, can produce sexual anorexia and severely pathological dismissive-avoidant attachment in adulthood, how these defenses can often shape marriage, and how they can engineer — through structural rather than conscious mechanisms — the very infidelity that the survivor will later use as evidence of the spouse’s moral failure.
Sexual Anorexia as Defensive Structure
The term sexual anorexia was introduced clinically by Nelson Goodwin in 1975 and developed extensively by Patrick Carnes in the 1990s, describing a pattern of compulsive avoidance of sexual expression and intimate emotional engagement. Unlike simple low desire, sexual anorexia involves active, ongoing defensive work — the sustained refusal of embodiment, sexual presence, and vulnerable connection as an organizing structure of identity.
In survivors of untreated childhood sexual abuse, sexual anorexia frequently develops as protective architecture.
The specific mechanism: authentic sexual and emotional presence in adult intimate relationship requires the specific interoceptive and affective openness that would render the childhood material reachable. The survivor’s structure cannot permit this openness. The defensive solution is to eliminate the configurations that would activate it — not through conscious decision but through the reorganization of the entire adult personality around being above such configurations.
The clinical presentation is distinctive.
The woman is not merely uninterested in sex. She is specifically positioned as above sex — above beauty, above embodiment, above social performance, above ordinary emotional need, above the specific configurations of adult intimate life that she experiences as beneath her. Her sense of superiority is not incidental to her avoidance. It is the structural mechanism through which the avoidance is maintained.
This is what distinguishes sexual anorexia from low desire, from asexuality, from ordinary variation in libido. Sexual anorexia is a defensive operation. It requires the specific active rejection of the configurations it defends against. And when the defensive rejection is grounded in unresolved CSA, the structure has additional specific features — a rigidity to the position of elevation, a contempt for those who occupy the rejected configurations, and specific intolerance for anything in the relational field that threatens to activate the material.
Severe Dismissive-Avoidant Attachment in the CSA Survivor
Attachment researchers (Bartholomew & Horowitz, 1991; Mikulincer & Shaver, 2016) have documented the dismissive-avoidant pattern extensively — a positive model of self combined with negative model of others, deactivation of the attachment system, compulsive self-reliance, and defensive dismissal of the importance of close relationships.
In its non-pathological forms, dismissive attachment can function reasonably well in adult life, particularly for individuals whose careers and social configurations do not require sustained intimate vulnerability. When it develops severely, and particularly when it develops in the context of unresolved trauma, the structure becomes more rigid, more punitive, and more actively engaged in maintaining distance through specific relational operations.
The severely pathological dismissive-avoidant survivor of untreated CSA presents a specific clinical picture:
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The self is experienced as elevated and self-sufficient, but the elevation requires ongoing external confirmation and specific inferiority in others. The self-sufficiency is defensive rather than genuine.
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Others are experienced as beneath, particularly those who display the configurations of vulnerability, need, or embodied desire the survivor has spent her life refusing.
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Intimacy is not merely avoided but actively neutralized through contempt, criticism, withholding, and specific relational maneuvers that prevent the other from reaching.
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Contempt functions as a primary affect regulator. The specific act of holding others as beneath preserves the survivor’s elevated position, and the elevated position is what keeps the childhood material sealed.
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The survivor does not experience the defense as defense. She experiences her position as legitimate superiority. Her contempt feels earned. Her avoidance feels like discernment.
This configuration is highly stable in isolation. It becomes clinically vivid in the context of marriage, where the spouse’s ongoing bids for connection generate continuous defensive labor, and where the specific mechanisms the structure uses to neutralize those bids become observable across time.
The Complementary Vulnerability: The Husband with a Critical, Controlling, Neglectful, Avoidant Mother
Object relations theorists — Fairbairn (1952), Guntrip (1969), Ogden (1986) — describe how the child of a critical, unpleaseable, emotionally withholding mother internalizes the specific relational configuration as internal working model. The adult carries a specific internal object: a woman who cannot be pleased, whose approval is continuously sought and continuously withheld, whose critical distance the child experiences as evidence of his own deficiency.
The adult man formed by this childhood configuration has specific vulnerabilities in adult intimate relationship.
Bowlby’s (1979) formulation of compulsive caregiving describes one common outcome — the adult who compulsively attends to a specific unavailable other, seeking to earn what was never available in childhood. West and Sheldon-Keller (1994) extend this to the specific relational patterns of compulsive care-seeking within adult attachment.
For such a man, the woman with untreated CSA and severely pathological dismissive-avoidant attachment is specifically resonant. She replicates the specific configuration of his internal object with striking fidelity — the elevated, critical, contemptuous, unpleaseable woman whose distance he experiences as call to further effort.
The specific pathology of their bond is that his attachment system is activated by her defensive structure, and her defensive structure requires his ongoing activation. The system is stable and mutually reinforcing:
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His reaching confirms her elevation.
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Her elevation requires her refusing.
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Her refusing produces his reaching.
This is not a rare configuration. It is one of the most reliably observable dynamics in couples work with survivors of untreated CSA married to men from critical-maternal backgrounds. The specific mechanism is well-described in the object relations literature on projective identification (Ogden, 1979; Bion, 1962). Each partner’s structure requires the specific configuration the other’s structure provides.
The Marriage: What Actually Happens
The marital picture that unfolds is specific and predictable.
She performs surface where surface can be produced. The supportive wife, the mother at her kid’s sporting events, the woman visible at church functions, the public presentation of intactness. These require no interior. They can be maintained indefinitely.
She sometimes performs sex. Mechanics without presence. The specific act performed with the specific center absent, because the specific center is where the material lives. She can produce the behaviors. She cannot permit the presence.
Behind closed doors, the interior is emptiness. Depression. Contempt. The specific labor of not touching the material. He experiences this as her being emotionally unavailable, cold, dismissive, critical of everything he does or fails to do. He does not know that her structure is engaged in continuous defensive work. He experiences her withholding as personal.
He reaches for her continuously. This is what men from his developmental background do. Her withholding activates his internal working model — the unpleaseable mother whose approval he must earn. His reaching intensifies as her withholding continues. Her withholding intensifies because his reaching threatens to activate the material.
The system escalates in the specific direction of his eventual acting out.
This is the specific mechanism the clinical literature on infidelity does not adequately describe. Most treatments of infidelity focus on the moral choice of the acting-out partner, on the specific transgressions of the affair, on the specific work required for repair. What is often missed is the specific structural configuration that produced the field within which the acting out became possible — and in some cases, the specific ways the withholding partner’s structure has engineered the field.
The Engineering of the Field
The specific pattern documented in the case material integrated for this article — and observable across multiple couples with the same structural configuration — involves the withholding wife bringing specific women into the husband’s proximity.
These women are her friends. They are typically emotionally expressive, needy, dependent — occupying the specific configurations of vulnerability that the wife has spent her life refusing and holding in contempt. She degrades these women to her husband. She positions them as beneath her, as pathetic, as embodying what she is above.
And she brings them close to him.
She creates the shared time. She creates the proximity. She creates the conditions of ongoing exposure. Sometimes she leaves them alone together. Sometimes she orchestrates the specific configurations of intimate contact. In cases where a first affair has already occurred and repair is attempted, she sometimes re-creates the configuration a second time with a second friend — and clinical case material suggests that these second configurations are sometimes engineered entirely by her, with the specific proximity produced through her direct arrangement.
Then when the affair occurs, she performs horror.
This is Ogden’s (1979) formulation of projective identification with induction. The structure disowns material it cannot hold internally — in this case, the vulnerable, needy, sexually alive, emotionally dependent parts of self that would activate the CSA material if held internally. It installs the disowned material in specific external containers. The friends become the containers.
Once installed, the disowned material remains hers. Her structure requires specific mechanisms to metabolize it. Engineering her husband’s engagement with the containers accomplishes several specific structural functions:
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She produces evidence of her own moral superiority by contrast with the specifically fallen women who acted on the disowned material.
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She produces her husband as specific betrayer, giving her the specific position of specific victim.
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She produces indefinite material to hold against him, ensuring his ongoing guilt and orientation toward her.
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She punishes him for engaging with the material she disowned, using his guilt to further consolidate her elevated position.
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She confirms the childhood material by re-producing it in adult form — the specific configuration in which her body and her intimate life are violated by another, this time with her structure specifically arranging the violation to serve its defensive purposes.
Her horror at the affair is real. Her structure genuinely experiences horror. And her structure has specifically arranged the configuration in which the horror-producing event will occur. Both are true. This is what projective identification with induction produces — real affect responding to real events specifically engineered by structural operation.
The Husband’s Responsibility
Nothing in the above formulation excuses the husband’s infidelity.
He made specific choices. He violated his commitments. He caused specific harm to his wife, his children, his community, and himself. He is responsible for what he did.
And. He was operating within a specific field she had specifically engineered. His developmental vulnerability was specifically calibrated to her defensive structure. His reaching was activated by her withholding. His unmet needs were produced by her ongoing refusal. The specific women he engaged with were brought into his proximity by her active arrangement. The specific configurations of intimate contact were sometimes created by her direct engineering.
Both moral responsibility and structural formulation must be held. Neither can be collapsed into the other.
The clinical error of the past several decades of infidelity treatment has been to collapse the structural formulation into moral responsibility — to focus so exhaustively on the acting-out partner’s moral failure that the specific defensive structure of the withholding partner remains unformulated, untreated, and free to continue producing similar configurations in the next relationship.
The corrective clinical stance is to hold both. The husband is morally responsible for his choices. The wife is structurally responsible for the field she engineered. Both partners require specific treatment. And in the case where the wife refuses treatment — as untreated CSA survivors with severely pathological dismissive-avoidant structures frequently do — the marriage cannot be repaired, because one partner is not available for repair.
What the Divorce Reveals
When such a marriage ends, the specific mechanism of the ending often illuminates the structure retrospectively.
The wife files, not the husband. This is critical. The specific configuration in which she is the injured party who has removed herself from the man who betrayed her produces her structure’s maximum power position. Filing consolidates the position. She is not the wife who was left. She is the wife who chose to leave. Filing gives her both agency and victimhood simultaneously.
She does not file to be free of him. She files to punish him maximally and to arrange the ongoing configuration in which she can continue to operate on him from the position of injured party. She expects him to remain oriented toward her from the position of guilty betrayer indefinitely.
Which he often does, for a period. His compulsive-caregiver structure and his fear of losing the children combine to produce ongoing accommodation. He comes when she calls. He performs specific favors. He allows her to maintain specific access to his life. His accommodation is not attachment to her — it is attachment to the children and to the specific responsibility he holds for the affair.
Her structure misreads his accommodation as attachment. When the youngest child reaches independence and his accommodation ends, she discovers that what she had believed was his bond to her had been custody protection all along.
Her structure cannot tolerate this discovery. Everything she does subsequently is her structure’s attempt to recover the position she had believed was hers.
The Post-Cutoff Inversion
Here is the piece that deserves specific clinical attention, because it is the piece most likely to be missed.
When the husband cuts her off completely, her elevated position loses its structural support. The configuration that positioned her as elevated required his ongoing reaching. Without his reaching, she is no longer elevated. She is just alone.
Her structure cannot tolerate this. She reverses the operation. If refusing what he wanted no longer produced his reaching — because he had stopped reaching — then producing what he wanted might restore his attention. If being above the specific configurations no longer positioned her as elevated — because he was no longer looking up to her — then performing the specific configurations might position her as competitor to the new woman in his life, who has them authentically.
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She becomes the specific opposite of everything she was.
Sexy where she was anti-sexy. Beautiful where she was anti-beauty. Publicly present where she refused social media. Connected where she refused connection. Embodied where she refused embodiment. Professionally identified where she refused public identity.
This is not development. She has not touched the material. She has not done the therapy. She has reversed the operation.
The pre-divorce operation: refuse what he wants, so he reaches for you.
The post-cutoff operation: perform what he wants, so he sees you again.
Both configurations serve the same underlying function — maintain her position in his internal life. Both configurations require her not to touch the material about her uncle. Neither configuration is authentic. She always had the capacity to produce the surface performance. She specifically refused it during the marriage as operation. She specifically produces it now as operation.
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The current performance is not who she is becoming. It is what her structure now requires to reach him.
If he has consolidated a new relationship with a woman who authentically embodies what he asked her to be in the marriage, the new woman becomes the specific container for the wife’s disowned developmental complex. The wife’s structure holds the new woman in the specific contempt she held her friends in — even without ever meeting her. And the specific operations of imitation, appropriation, and competitive performance are the structure’s attempt to reclaim the disowned material by taking it back from the container.
This cannot succeed. Disowned material can only be reclaimed through the developmental work she refuses. Imitation cannot substitute. The material about her uncle sits at the center, untouched, and no amount of surface appropriation of the new woman’s configurations will reach it.
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The operation continues indefinitely because her structure cannot resolve without doing work she refuses.
Clinical Implications:
Several specific implications follow from this formulation for practitioners.
First, screen carefully for untreated CSA in the withholding partner in cases of long-standing marital conflict, particularly when the withholding partner presents with sexual anorexia and severely pathological dismissive-avoidant features. The material may not have been disclosed even to previous therapists. The specific configurations of elevation, contempt, and refusal are diagnostic. The specific rigidity of the position of superiority is diagnostic. The specific intolerance for anything that would activate the material is diagnostic.
Second, do not collapse structural formulation into moral responsibility when treating infidelity in these configurations. The acting-out partner’s moral responsibility for the affair is real and requires specific treatment. The withholding partner’s structural role in engineering the field is also real and requires specific formulation. Treating only the moral responsibility leaves the structural configuration intact and free to reproduce itself.
Third, when the withholding partner refuses treatment, recognize that the marriage cannot be repaired. No amount of work by the acting-out partner can compensate for the structural configuration his spouse’s untreated material continues to produce. This is difficult to name clinically because it appears to place unequal weight on the two partners. It does — because the underlying structure is unequal. One partner has treatable trauma he is treating. The other has treatable trauma she refuses to treat.
Fourth, when such marriages end, prepare the acting-out partner for post-cutoff operations that may extend indefinitely. The literature on post-separation abuse documents that abusive ex-partners frequently continue their operations after separation through legal, financial, familial, and social channels. What is less well-documented, and clinically important, is the specific configuration in which the untreated CSA survivor with severely pathological dismissive-avoidant structure runs post-cutoff operations designed to restore the pre-cutoff configuration through inversion of her original defensive strategy.pmc.ncbi.nlm.nih
Fifth, protect the new partner in the acting-out partner’s post-divorce life. She is likely to become the specific container for the wife’s disowned material. She is likely to experience specific operations of imitation, appropriation, and competitive performance directed at her without ever having met the wife. She will likely see the pattern before her partner does, because he is inside the specific configurations the wife’s structure is designed to reach. Her perception is not insecurity. It is accurate perception of a specific clinical configuration that the literature supports.
What Untreated Childhood Sexual Abuse Costs
The literature on treated CSA is hopeful. Trauma-focused cognitive behavioral therapy (Cohen, Mannarino, & Deblinger, 2017), EMDR (Shapiro, 2018), somatic approaches (Van der Kolk, 2014), and psychodynamic treatments (Herman, 2015) all have substantial evidence bases for producing meaningful integration of the material and restoration of adult intimate capacity.
The literature on untreated CSA is less hopeful. The specific defensive architectures that develop across an untreated adult life become increasingly rigid, increasingly consolidated, and increasingly costly to those in relationship with the survivor. The specific costs include the survivor’s own quality of life, her spouse’s, her children’s, and — as the case material integrated here demonstrates — the specific relational fields she engineers around herself throughout her adult life.
Nothing about this formulation is inevitable for survivors of CSA. Most survivors seek treatment. Most do the work. Most produce meaningful integration and go on to have fulfilling adult intimate lives.
This article is about what happens when the specific minority does not seek treatment, and what the specific clinical picture looks like when the material remains foundationally untouched across decades of adult life.
The specific piece worth being plain about, in closing: the woman in the marriage did not choose what happened to her as a child. She did choose, repeatedly, across decades, to refuse the treatment that was available. That choice is hers. The consequences of that choice have unfolded across her husband’s life, her children’s lives, and now her ex-husband’s current life with his partner.
The choice remains hers. So does the responsibility for what her refusal continues to produce.
References
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