PROPOSED SEXUAL AVERSION CRITERIA REVISION
Given the difficulties inherent in the current classification systems for sexual aversion disorder (DSM-IV-TR and the 1999 Consensus Classification), we have proposed (11) a revised classification system that is based on a modification of these taxonomies. This proposed classification maintains the distinction between primary and secondary sexual aversion. However, this distinction will only be useful for the diagnostic differentiation of the acquisition of aversion early in life and the lifelong presence of hypoactive sexual desire (Table 5.3).
With this modified taxonomy in mind, we will describe a case of primary sexual aversion.
Case Example: Joyce
Joyce is a 38-year-old woman who has been married for 8 years. She presents with a long, intermittent history of bulimia and other features consistent with
Table 5.3 Elements of the Current Classification System (DSM-IV-TR) for Sexual
Aversion Disorder and a Proposed Revision to the Classification System
obsessive – compulsive spectrum disorder. Her bulimic symptoms responded rather readily to an exposure-based cognitive behavioral treatment strategy. Over the course of therapy she gradually was able both to cease purging and to expose herself to foods she had previously restricted and to situations she had avoided.
During the course of treatment she eventually acknowledged a history of sexual abuse as an early adolescent. She had denied any abuse history during the initial evaluation, but was able to reveal her history as she became more trusting of and comfortable with her therapist. She reported that she had never revealed her abuse to anyone other than a cousin and that her immediate family, including her husband, were unaware of her history of abuse.
Joyce is the second child in a close family that includes her and two siblings. She describes her parents as caring and involved, yet not particularly emotionally disclosing. She categorizes her family as supportive and celebrative of personal successes while tending to avoid discussion of emotionally difficult issues. Joyce reports feeling that if she had revealed her abuse, her parents would be devastated and retrospectively guilty over not having protected her better as a child.
Joyce reports that her abuse represented her first sexual experiences. When she was 12 a 17-year-old neighbor began seeking her out during neighborhood games and activities, encouraging her to spend increasing amounts of time with him. Joyce was friendly with his siblings and naturally trusting of him. He became increasingly sexually aggressive, progressing from touching her rela- tively quickly to forced fellatio and intercourse, and she recalls feeling that she did not want to resist him for fear that he would be disappointed or angry with her. The abuse continued for about 2 years until, at age 14, she threatened to inform his parents of his actions and he ceased his abuse of her. He left for college shortly thereafter.
Joyce began dating at age 15 and was sexually active “fairly quickly” in each of a succession of relationships. She describes herself as promiscuous throughout high school and college. The majority of her relationships are characterized by relatively early onset of physical intimacy, which included intercourse and oral sex (both fellatio and cunnilingus). Sexual behavior always began as pleasurable for her but fairly rapidly became unpleasant. She reports that she felt very sexually attracted to her male partners initially, but at the point in the relationship that sex became routine or expected, her respon- siveness declined and sexual behavior became aversive to her. Intercourse became painful and disgusting to her and she experienced revulsion at even the idea of sex with her current partner. Importantly, she maintained sexual drive such that she masturbated to orgasm on a regular (once a week) basis and she also continued to experience sexual attraction and desire for men other than her partner.
She met her future husband, Bill, when she was 28. As in other relation- ships, she was attracted to him and initially had a pleasurable and fulfilling sexual relationship with him. She experienced desire arousal and orgasm when they were sexual. She was frustrated when their sex became aversive to her but decided to “tough it out,” assuming, she supposes in retrospect, that her sexual response would improve given enough time and love. Joyce also hoped that the state of being married would also help her response since she had some guilt over nonmarital sex and expected to feel a postmarital reduction in the anxiety she associated with sexual behavior. She married Bill after dating for 2 years.
Joyce reports that at no point during marriage did her sexual aversion dis- sipate. On the contrary, Bill became increasingly frustrated with her avoidance of sex and demanded more frequent intercourse. Joyce’s attempts to explain her aversive response to him were not helpful and he became irritated and verbally abusive of her. At the point that she disclosed her history of sexual abuse in therapy, she and Bill were in considerable marital distress. Their frequency of intercourse had declined to roughly monthly, and then only with considerable endurance of distress from Joyce and verbal intimidation from Bill.
Joyce’s symptoms meet the DSM-IV-TR criteria for sexual aversion, evidencing persistent and recurrent avoidance of sexual genital contact with her husband, which causes marked personal and interpersonal distress and which is not better accounted for by another psychiatric disorder. Joyce also meets the Con- sensus Panel criteria that emphasize personal rather than partner distress as the relevant feature. Her symptoms are clearly related to the acquisition of fear and subsequent avoidance. Joyce did not evidence or report particular fear or avoidance of sexual interactions until sexual behavior was paired with abuse and victimization. She retained sexual drive and desire even while she felt pressured into sex in each of her relationships after her childhood sexual abuse. In each case, including her marriage, sexual interactions after the early relationship phase (limerance) became negatively conditioned. Joyce acquired an aversion response which then was maintained by sexual avoidance.
General Treatment Considerations
In Joyce’s case, effective treatment first required relating her history of sexual abuse to her husband, Bill, so that we could begin to interpret her aversion to him in the context of her adolescent experience. This revelation evoked some sensitivity to Joyce’s response from Bill and temporarily tempered his insistence on intercourse. We used this period to assess more fully their sexual history, to describe her sexual disorder to them both, and to develop a treatment plan. The theory and methods that characterize systematic desensitization were reviewed and the couple agreed to the treatment plan.
Cognitive Behavioral Treatment
The literature on treatment of sexual aversion emphasizes the usefulness of cognitive behavioral treatment approaches (9,12) and there is support for the practical and relatively brief use of systematic desensitization (13). In this case, treatment consisted first of the creation of a hierarchy of aversion- and anxiety- provoking images, ranging from masturbation, which evoked the least anxiety, to intercourse, which evoked the greatest anxiety. In addition, Joyce was taught diaphragmatic deep breathing and an autogenic relaxation technique. The least anxiety-provoking stimuli were addressed first, with Joyce imagining each situ- ation and reporting being able to remain relaxed and anxiety-free before each stimulus was subsequently approached in vivo. Importantly, sexual situations were designed to remain fully in her control; Bill had agreed to allow Joyce to determine the rate at which each of the items on the hierarchy was engaged. Fifteen sessions conducted over a period of 5 months were needed to help Joyce and Bill resume the healthier sexual life that had characterized their early history.
The persistence of avoidance behavior was first articulated by Freud (14);
Mowrer (15) subsequently described this phenomenon as the neurotic paradox. The common observation that avoidance is remarkably difficult to extinguish has been explained by the theory of conservation of anxiety. The theory suggests that individuals learn rapid avoidance over time, which prevents the elicitation of fear. It is further suggested that if fear is not elicited it will not extinguish.
The theory of conservation of anxiety explains why sexual aversion rarely abates on its own and can be so treatment resistant. Crenshaw (1) posits that the sexual aversion syndrome is progressive and rarely reverses spontaneously. Patients like Joyce are treatable in so far as they are willing to purposefully expose themselves to the anxiety accompanying sexual behavior. We have found (11) that this exposure process can be facilitated by the following:
1. the clinician’s conceptualizion of the patient’s sexual aversion in clear behavioral terms, emphasizing how aversion is acquired and maintained;
2. the patient’s ability to verbalize an understanding of the ways in which aversion is acquired and maintained. This understanding should allow her to generate specific examples of the process of exposure;
3. the patient maintaining records of anxiety and aversion symptoms during the treatment process and the clinician referring to those records frequently during sessions. We have found that patients are likely to adhere to record-keeping instructions to the degree that clin- icians make those records integral to the process of psychotherapy;
4. emphasis on maintenance and generalization as the therapy draws to a close to address relapse issues.
Psychodynamic psychotherapy, with its emphasis on deeper conflicts, defense mechanisms, and transference, is considered to be the treatment of choice for
those patients who report psychic pain as a component of their sexual aversion or who conceptualize their problems as symptomatic of early childhood issues (16). Patients who desire insight and express psychological curiosity about themselves are particularly likely to benefit from insight-oriented treatment.
There is evidence that sexual aversion may be predicted by a history of childhood sexual abuse. Noll et al. (17), utilizing a prospective design, demon- strated a relationship between childhood sexual behavior problems and sub- sequent sexual aversion, and found evidence that abuse by the biological father particularly predicted later sexual aversion. In clinical practice, patients with such a history may well benefit from desensitization approaches in conjunction with more traditional, uncovering psychotherapy.
The literature on psychodynamic approaches to sexual aversion empha-
sizes the integration of behavioral strategies and insight-oriented approaches (2). In clinical practice, this combined approach typically takes one of two forms. First, psychodynamic therapists recognize the utility of behavioral strat- egies and integrate them into their treatment regimens. Second, interestingly, it is often the case that patients who embark on a behavioral treatment will find that the process of behavior change itself begins to stimulate internal exploration. “Behavior change leads to insight” is at least as commonly observed in practice as the more familiar notion that “insight leads to behavior change.” These patients are likely to pursue psychodynamic psychotherapy after completion of a course of cognitive behavioral psychotherapy.
In the case example above, the aversion response was gradually desensi- tized and she was able to resume and maintain a healthy sexual relationship with her husband. This psychotherapeutic process stimulated her desire to better understand her history of abuse and the psychological trauma that fol- lowed. As the behavioral treatment of her sexual aversion neared its completion, the therapeutic strategy moved to the development of insight into the effects of her childhood and adolescent trauma.
Unfortunately, the usefulness of pharmacotherpay in the treatment of sexual aversion has not been adequately explored in the literature. Kaplan (2) describes the use of monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants for treating sexual aversion disorder, commenting on the well-established effi- cacy of these medications in the treatment of panic. Subsequently, of course, selective serotonin reuptake inhibitors (SSRIs) have also been demonstrated to be effective in treating panic and may, therefore, have a role in the treatment of sexual aversions. Importantly, anorgasmia is a potential side-effect of SSRIs, but patients will sometimes find it preferable to aversion.
In our case example, Sertraline was an important adjunct to Joyce’s treat- ment. She reported that the medication helped decrease her distress as she engaged in the exposure process. She felt that her use of relaxation strategies to modulate anxiety was aided somewhat when the SSRI was added, and she attributed a general improvement in her mood to the medication as well.
In practice, as illustrated in this case, cognitive behavioral, psychodynamic, and pharmacotherapeutic strategies are often integrated very effectively as each approach serves to enhance and augment the others.
Sexual aversion disorder clearly represents an overlooked topic in the sexual dis- orders literature. Our concern is that the diagnostic criteria have been sufficiently vague and overlapping with hypoactive sexual desire, to leave clinicians and researchers confused about how and when to make an accurate diagnosis. We have proposed a revision to the diagnostic criteria, which may help both to better define sexual aversion disorder and to distinguish it more clearly from hypoactive sexual desire.
In our proposed revision, primary aversion would be diagnosed when an individual’s initial sexual experience, either directly or vicariously, is negative. Secondary aversion is to be diagnosed when the patient has had normal, pleasur- able sexual development and experiences until a traumatic or painful experience, either direct or vicarious, negatively reconditions sexual interactions with a partner.
With advances in diagnostic clarity, better estimates of incidence and prevalence can be obtained. Anecdotal evidence suggests that this disorder is more prevalent than many clinicians may be aware, particularly in men, who may not be as likely to present for treatment as are women.