Jeffrey W. Janata and Sheryl A. Kingsberg
Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, Ohio, USA
Crenshaw (1) has been credited for first describing the sexual aversion syndrome. Her description, published in 1985, remains one of two comprehensive manu- scripts describing this disorder, joined only by Kaplan’s 1987 book (2), Sexual Aversion, Sexual Phobias and Panic Disorder. Kaplan suggested that sexual aver- sion is best conceptualized as encompassing a dual diagnosis, sexual anxiety and panic disorder. Kaplan believed that one must treat the underlying organic panic
disorder with medication before addressing the sexual aversion. Her model served to de-emphasize the aversion elements of the diagnosis in favor of the panic component. Seen in historical context, however, she had identified the biological underpinnings of the sexual disorders in ways that current conceptual formulations take for granted. Recently, others have again underscored the relationship between sexual aversion and panic disorder (3).
Despite this early work, sexual aversion disorder is often overlooked in the spectrum of sexual disorders. Although it was first recognized as a diagnosis in 1984, with the publication of DSM-III-R (4), relatively little has been written about the etiology and treatment of sexual aversion. Often considered a variant of an anxiety disorder, sexual aversion was not included in any of the earlier DSM editions. Although it finally achieved diagnostic status as a sexual disorder in 1984, it is often ignored or pushed to a secondary status within the field of sex therapy. A review of the most widely used sex therapy handbooks rarely finds any text that devote a chapter solely to sexual aversion. Most include some explanation of aversion in the context of understanding hypoactive desire, the impact of sexual abuse, or vaginismus and dyspareunia.
Sexual aversion disorder is sometimes referred to as sexual phobia. Gold and Gold (5) argued against the latter descriptor, noting that aversion implies an element of abhorrence and disgust, while phobia does not. In our experience, sexual aversion routinely is clinically characterized by revulsion and disgust in ways that phobias only rarely are. Nonetheless, according to DSM-IV-TR (6) criteria, sexual aversion does not require the physiologic responses that we often associate with aversion. While sexual aversion typically encompasses these responses (e.g., nausea, revulsion, shortness of breath), aversion by these criteria can also be expressed as simple avoidance of partnered sexual behavior and a panic response to engaging in partnered sexual activity.
Aversion is a conditioned response that applies to many behaviors.
Aversion may be best recognized as the conditioned response that develops in response to cancer chemotherapeutic agents. In this context, aversion implies more than phobic avoidance; aversion is characterized by nausea and vomiting. In contrast, however, others writing on sexual aversion (7) maintain that sexual aversion is equivalent to sexual phobia—the essential diagnostic feature is per- sistent fear and avoidance.
From our perspective, conditioned aversion is perhaps best understood using Mowrer’s two-factor theory (8). Mowrer theorized that two separate learn- ing processes contribute to avoidance conditioning. A conditioned emotional response results from pairing a previously neutral or positive stimulus (sexual behavior) with a painful or traumatic event (and thus is classically conditioned). Having been paired with discomfort, the sexual stimuli now produce aversive emotional reactions (e.g., anxiety, revulsion, disgust) in the absence of the orig- inal painful stimulation. The later conditioned avoidance response is operantly conditioned (negatively reinforced) in that avoidance of sexual stimulation elim- inates or reduces the aversive response. Sexual aversion, from the two-factor
avoidance perspective, can be conceptualized as maintained by this avoidance response.
Sexual aversions can be general or quite specific (2). Aversions can develop in response to any sexual stimulus, overt or covert, such that a patient may present with a circumscribed aversion to a highly specific sexual thought or behavior, or may exhibit more global revulsion to sexuality in any form.
Incidence and prevalence of sexual aversion disorder are not known, despite being considered widespread by several overviews (1,5). In addition, diagnostic criteria do not address gender differences in prevalence. Gold and Gold (5) describe the typical etiologic model for the development of aversion in women to be sexual abuse, while the etiologic model for men in their view is performance anxiety. Our clinical experience is that significantly more women than men meet the criteria for sexual aversion disorder. Ponticas (9) hypothesizes that this gender distinction may be an artifact. Men with sexual aversion disorder are likely to resist entering relationships and thereby avoid the resulting relationship conflict that might lead them into therapy. Moreover, more women with sexual aversion disorder may present clinically due to the overlap in etiology and diagnostic criteria with hypoactive sexual desire disorder which has a much greater prevalence in women than in men.
Since the criteria for sexual aversion disorder overlap with symptoms of both panic disorder and hypoactive sexual desire disorder, even experts in treating sexual disorders remain somewhat unclear regarding how and when to diagnose sexual aversion.
DSM-IV-TR (6) includes sexual aversion disorder in its Sexual and Gender
Identity Disorders classification (Table 5.1).
In response to these criteria, The Sexual Function Health Council of the American Foundation for Urologic Disease convened the Consensus Develop- ment Panel on Female Sexual Dysfunction (10). Their stated belief was that DSM-IV is limited to mental disorders and thus too narrow to provide a useful, broad diagnostic classification for female sexual dysfunction.
Two of the panel’s proposed amendments to the DSM-IV criteria are rel- evant to sexual aversion. While the DSM-IV criteria emphasize “interpersonal distress,” the panel preferred to emphasize “personal distress” as critical to the
Table 5.1 DSM-IV-TR Criteria for Sexual Aversion Disorder (302.79)
A. Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner
B. The disturbance causes marked distress or interpersonal difficulty
C. The sexual dysfunction is not better accounted for by another Axis I
disorder (except another sexual dysfunction)
diagnosis. Second, the panel specifically distinguished between psychogenic and organically based disorders. This revised classification system includes sexual aversion under the category of sexual desire disorders along with hypoactive sexual desire disorders (Table 5.2).
The consensus panel developed a very detailed document to describe and justify their new classification system. Sexual aversion disorder, however, was given little attention and by virtue of being placed in the category of sexual desire disorders, is likely to be overlooked.
DSM-IV-TR distinguishes between lifelong (primary) and acquired (secondary) sexual aversion. This is a distinction that, in light of Mowrer’s two-factor theory (8), is difficult to defend. From the perspective of learning theory, aversion must, by definition, be acquired. Lifelong sexual aversion must still have been acquired at some point along the way. Crenshaw (1) defines lifelong aversion as a negative or unenthusiastic response to sexual inter- actions from earliest memories to present. However, no matter how absent the memory of life before the aversion, the aversion was certainly learned, either directly or vicariously. Crenshaw observes that patients presenting with primary aversion often were raised in strict religious and moral environments, which supports our contention that the aversion was learned, albeit vicariously. She also suggests that there may have been some history of psychosexual trauma, which again would have been learned and not lifelong.
We suggest that these early authors may have intended that “primary” refers to aversion developed so early in life that the individual did not have the opportunity to experience normal partnered sexual behavior before acquiring the aversion. Cases in the literature described as examples of primary aversion [e.g., case history of Bridgitte and Ms. C (2) and case histories 1 and 2 (1)] typically involve early, presexual negative conditioning of sex in childhood, mediated by environmental learning but specifically not by sexual abuse. Secon- dary aversion, in contrast, would be diagnosed in cases of specific recollection of childhood abuse or later negative sexual experience that is the proximate cause of current sexual aversion.
Table 5.2 1999 Consensus Classifi- cation of Female Sexual Dysfunction
I. Sexual desire disorders
A. Hypoactive sexual desire disorder
B. Sexual aversion disorder
II. Sexual arousal disorder
III. Orgasmic disorder
IV. Sexual pain disorders
C. Other sexual pain disorders
It is further possible that this “secondary” descriptor has been maintained in the taxonomies because sexual aversion has been confounded with hypoactive sexual desire. Hypoactive sexual desire may legitimately be either a biologic or a learned condition. The biologic contribution could well have been present since birth or early in life and thereby represent a “primary” or lifelong condition. Moreover, a patient with hypoactive sexual desire may become avoidant of sexual activity. Sexual disinterest in the context of the demands of a relationship could evolve into irritation or anger and appear clinically very much like aver- sion. This presentation, however, would be absent in the fear and anxiety response to sexual behavior, which is critical for the aversion diagnosis.