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The DSM Diagnostic Criteria for Sexual Aversion Disorder

Authors:

Abstract

Sexual Aversion Disorder (SAD) is one of two Sexual Desire Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and is defined as a "persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner" which causes distress or interpersonal difficulty. This paper reviews the short history of the diagnosis of SAD as well as the existing literature on its prevalence and etiology. Kaplan (1987) emphasized the phobic qualities of individuals with SAD who are highly avoidant of all forms of sexual contact. Much has also been written about the overlap between SAD and panic states, and the more obvious similarities between SAD and anxiety as opposed to sexual desire are described. There has been very little new published data on SAD since the publication of DSM-IV and the precise prevalence remains unknown. This paper critiques the placement of SAD as a Sexual Dysfunction and argues that it might more appropriately be placed within the Specific Phobia grouping as an Anxiety Disorder.
ORIGINAL PAPER
The DSM Diagnostic Criteria for Sexual Aversion Disorder
Lori A. Brotto
!American Psychiatric Association 2009
Abstract Sexual Aversion Disorder (SAD)is one of twoSex-
ual Desire Disorders in the Diagnostic andStatistical Manual of
Mental Disorders (DSM) and is defined as a ‘‘persistent or
recurrent extreme aversion to, and avoidance of, all or almost
all, genital sexual contact with a sexual partner’’ which causes
distress or interpersonal difficulty. This paper reviews the short
history of the diagnosis of SAD as well as the existing literature
on its prevalence and etiology. Kaplan (1987) emphasized the
phobic qualities of individuals with SAD who are highly
avoidant of all forms of sexual contact. Much has also been
written about theoverlap betweenSAD and panicstates, andthe
more obvious similarities betweenSAD and anxiety as opposed
to sexual desire are described. There has been very little new
published data onSAD since thepublication of DSM-IVand the
precise prevalence remains unknown. This paper critiques the
placement of SAD as a Sexual Dysfunction and argues that it
might more appropriately be placed within the Specific Phobia
grouping as an Anxiety Disorder.
Keywords Sexual Aversion Disorder !Sexual phobia !
Sexual avoidance !DSM-IV-TR !DSM-V
Introduction
In the book, Sexual Aversion, Sexual Phobias, and Panic Dis-
order, published in the same year that DSM-III-R (American
Psychiatric Association, 1987) was released, Kaplan (1987) re-
marked that‘‘sexual panicstateshave received surprisingly little
professional attention, and students in the field are hard put to
find literature on this topic’’ (p. 3). The state of the science some
20-plus years later has not changed much and there are stilllittle
empirical data on Sexual Aversion Disorder(SAD). SAD isone
of two Sexual Desire Disorders in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR; American Psychi-
atricAssociation,2000) (the otherone being HypoactiveSexual
Desire Disorder (HSDD)), and the most recent addition to the
list of Sexual Dysfunctions in the DSM (American Psychiatric
Association, 1987). Relative to the research done on HSDD,
much less is known about the prevalence, etiology, and treat-
ment of SAD.
Diagnosis
The original diagnostic criteria for SAD (302.79) required a
‘persistent or recurrent extreme aversion to, and avoidance
of, all or almost all, genital sexual contact with a sexual part-
ner’’ and that this symptom did not occur ‘‘during the course
of another Axis I disorder (other than a Sexual Dysfunction),
such as Major Depression’’ (American Psychiatric Associa-
tion, 1987, p. 293).
In the DSM-IV-TR (American Psychiatric Association,
2000), Criterion A did not change from that listed in the DSM-
III-R. The only addition to the diagnostic criteriawas Criterion
B–that the disturbance cause marked distress or interpersonal
difficulty (Table 1). The DSM-IV-TR text indicates that anx-
iety, fear,or disgust when confronted with a sexualopportunity
are featuresof SAD. Moreover, the scope of the sexual stimuli
producing the aversion can range from a specific aspect ofthe
sexual encounter (e.g., genital secretions) to any and all sexual
stimuli (including kissing, touching, and hugging). The text
goes on to describe symptoms of anxiety (e.g., panic attacks)
and avoidance behavior as signs of severe SAD.
L. A. Brotto (&)
Department of Obstetrics and Gynaecology, University of British
Columbia, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada
e-mail: lori.brotto@vch.ca
123
Arch Sex Behav
DOI 10.1007/s10508-009-9534-2
Sexual aversion was described by Kaplan as being persistent
andirrational as well as ego-dystonic, with thephobic avoidance
causing significant distress to theindividual. She also indicated
that it may or may not be co-morbid with other sexual dys-
functions. Kaplan describedtotaland situationalforms of sexual
aversion: total aversion involved any and all erotic sensations,
feelings, thoughts, and opportunities whereas situational was
limited to a specific aspect of sex (e.g., genitalia, being pene-
trated, fantasies, orgasm, oral sex, etc.). Kaplan noted an inter-
esting feature of individuals with situational sexual aversion in
that they could enjoy many aspects of sexual activity as long as
avoidance of their circumscribed phobic stimulus could be
maintained. Kaplan also described enormous variability across
individuals with sexual aversion in their willingness to be sex-
ually active, with some who were able to push past their reluc-
tance of sex and, once engaging in sexual activity, to experience
satisfaction. Others, however, were more severely phobic such
that they could not feel any erotic sensations. Some of these indi-
viduals also experience panic attacks (‘‘discrete period of intense
apprehension,fearfulness,orterror,often associatedwithfeelings
of impending doom’’ [American Psychiatric Association, 2000]
with symptoms of autonomic activation). What makes sexual
aversion so distressing is that, unlike other phobias (e.g., snakes,
heights), it is possible to avoid the phobic stimulus with little
interference in the individual’s life. However, with sexual pho-
bias, Kaplan noted that ‘‘its avoidance can be profoundlydestruc-
tive’’ given that sexuality is a core feature of human existence.
Aversion itself is not actually defined in the DSM-IV (orDSM-
III-R). In other contexts, it is conceptualized as an emotion (e.g.,
feelings of repugnance or extreme dislike) (Toronchuk & Ellis,
2007). Other aversions (e.g., conditioned taste aversion) may em-
phasize thebehavioral correlates of aversion and not the emotional
aspects. However, given that the DSM criteria indicatethat there is
aversion and avoidance, this implies that the definition of aversion
focuses on the affective aspects and not on the behavioral aspects
(as the latter is captured by ‘‘and avoidance’’).
It is likely (although this cannot be verified due to the unavail-
ability of DSM-III-R Sourcebooks) that the empirical justifica-
tion for including SAD as a new disorder in DSM-III-R stem-
med from Kaplan’s own patients and observations. Kaplan
(1987) reportedon the characteristicsof 373 patients with sexual
avoidance who were seen at the Human Sexuality Program of
the Payne Whitney Clinic as well as a private clinic between
1976 and 1986. Kaplan found that 9% of those who avoided sex
also met criteria for Panic Disorder and, as such, suggested that
pharmacotherapy for the Panic Disorder would improve the
sexual aversion. The proportion of those with Panic Disorder
was even higher (25%) among those individuals who avoided
sex and also had a phobia of sex. Another 25% of those with
phobic avoidance of sex experienced emotional signs and symp-
toms of Panic Disorder but did not meet full criteria.
It is noteworthy that Kaplan (1987) originally described SAD
as a sexual phobia. A considerable portion of Kaplan’s book was
spent on describing the panic experienced by these individuals
and describing therapeutic approaches to phobias (in general) as
well as PanicDisorder. Kaplan (1988) noted thatindividualswith
Panic Disorder were particularly prone to SAD because of their
personality traits of separation anxiety, rejection sensitivity, and
overreaction to criticism from significant others such as lovers.
The placement of SAD as a Sexual Dysfunction as opposed to
a Specific Phobia at the time seems to have been related to the
type of stimulus responsible for the phobic reaction (i.e., a sexual
stimulus). However, the other Specific Phobias (then classed as
Simple Phobias) were not similarly categorized according to the
type of stimulus that provoked symptoms (e.g., public speaking
phobia is not characterized as an Interpersonal Disorder, and fear
of heights is not placed in a different category of related syn-
dromes). Kaplan (1987) presented the DSM-III criteria for Sim-
plePhobia(300.29)and pointed out the similarity to the proposed
DSM-III-R criteriaforSAD,stating:‘‘It isnotclearto mewhether
sexual phobia and aversion are two discrete disordersor whe-
ther aversion is simply a form of sexual panic with especially
intense autonomic reactions. At this time, I tend to conceptualize
sexual aversion and phobic avoidance of sex as two clinical
variations of sexual panic states’’ (p. 11). The DSM-IV-TR text
on the Differential Diagnosis section of SAD indicates that
‘Although sexual aversion may technically meet criteria for
Specific Phobia, this additional diagnosis isnot given.’’ Theratio-
nale for why this was the case was not provided and there was no
information in theDSM-IV Sourcebook justifyingthis disclaimer.
On the other hand, the Differential Diagnosis section of Specific
Phobia makes no mention of SAD.
Despite the apparent similarities between sexual aversion
and Specific Phobia, Janata and Kingsberg (2005) noted that a
critical difference between the two was that the former was
characterizedby abhorrence anddisgust whilethe latter was not.
To explore the potential similarities between SAD, HSDD, and
Table 1 DSM-IV-TR diagnostic 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)
Specify type
Lifelong type
Acquired type
Specify type
Generalized type
Situational type
Specify
Due to psychological factors
Due to combined factors
Arch Sex Behav
123
worry (the latter was assessed because it is associated with
many DSM-IV-TR disorders including anxiety disorders), 138
college students completed questionnaires such as the Sexual
Aversion Scale (Katz, Gipson, Kearl, & Kriskovich, 1989), the
Hurlbert Index of Sexual Desire(Apt & Hurlbert, 1992), and the
Penn State Worry Questionnaire (Meyer, Miller, Metzger, &
Borkovec, 1990). Worry was only weakly associated with both
sexual aversion and sexual desire scores, leading Janata and
Kingsberg to conclude that worry was nota centralfeature ofthe
sexual desire disorders.
In the DSM-IV-TR, SAD is diagnosed as lifelong or ac-
quired. Crenshaw (1985) noted that occasionally sexual aver-
sion is specific to a certain relationship and that outside of that
relationship the person is able to function normally sexually.
This would be deemed a situational SAD. Janata and Kingsberg
(2005) prefer the categories ofprimary andsecondaryto refer to
the acquisition of fear and anxiety before or after, respectively,
the development of a healthy sexual relationship. A lifelong
SAD is senseless for the individual who, perhaps, had their
sexual debut in their teens, 20s, or even later. Secondly, because
of the leading theory of SAD as being a conditioned and, there-
fore, acquired response, this also implies that it could never have
been lifelong for conditioning would have had to take place at
some point in time.
Interestingly, there was no change to the essential criterion
for SAD (extreme aversion to and avoidance of sexual contact)
from DSM-III-R to DSM-IV.It is also interesting to note that in
the DSM-IVSourcebook(Schiavi,1996), therewas referenceto
only two published empirical papers on SAD and both were
published prior to DSM-III-R (American Psychiatric Associ-
ation, 1987). One study compared 20 sexually aversive indi-
viduals with 35 controls. The DSM-IV Sourcebook noted that
no reliability information were provided, but that those with
SAD scored significantly higher on the State-Trait Anxiety
Inventory (Spielberger, Gorusch, & Lushene, 1970). The only
conclusion drawn by theSexual Dysfunctions Work Groupwas
that there was no evidence to support ‘‘narrowing the diagnosis
of sexual aversion disorder to include individuals with aver-
sions limited to one or a few components of the sexual inter-
action’ (Schiavi, 1996, p. 1100). However, there was also no
mention of justification for why SAD should continue to
remain a diagnosable sexual dysfunction.
Prevalence
The precise prevalence of SAD is unknown and difficult to
establish given that individuals avoid sexual encounters and
therefore seldom present to sex therapy clinics. Based on
clinical experience, Crenshaw (1985) believed that sexual
aversion syndrome was the most common sexual dysfunction;
however, Crenshaw noted that most clinicians ‘‘miss’’ the
diagnosis because they are inexperienced in identifying it. In
one of the few empirical studies of SAD, 382 college under-
graduates completed a survey assessing the DSM-III-R diag-
nostic criteria for SAD (Katz et al., 1989). The 30-item Sexual
AversionScale (SAS) assessed fearsabout AIDS, social evalu-
ation, pregnancy, and sexual trauma. Katz et al. found high
internal, test-retest, and item-total reliability of the scale. Katz
et al. estimated the prevalence of sexual aversion severe en-
ough to warrant treatment seeking to be approximately 10%,
although 29% reported avoidance of nearly all genital contact.
Among thosewith sexual aversion,there were significantfears
about AIDS, and Katz et al. predicted that such a question-
naire would be important if AIDS were to spread to the het-
erosexual population. In a subsequent validation study of the
SAS (Katz, Gipson, & Turner, 1992), scores on this measure
were significantly correlated with scores on the Fear Survey
Schedule (Wolpe & Lang, 2007), and individuals with a his-
tory of sexual abuse had higher scores of aversion. Since the
articles by Katz et al. 20 years ago, I could not locate any
additional published studies using the SAS.
Despite the large number of recent population-based epi-
demiological studies on sexual symptoms and distress, none
have asked about the prevalence and associated features of
sexual aversion. One exception is the large epidemiological
Zurich Cohort Study, of which a subset of the questions fo-
cused on sexual symptoms in 363 participants. A total of 12
(3.3%) individuals reported feeling ‘‘constantly or once in a
while extreme aversion to genital sexual contact’’ which
caused ‘‘distinct suffering or relationship conflicts’’ (J. Angst,
personal communication, February 23, 2009). Because of the
small sample size, analyses of the associated correlates of
sexual aversion were not possible.
Knowledge about gender differences in sexual aversion is
virtually non-existent. However, Kingsberg and Janata (2003)
noted that SAD primarily affects women and that men with
SAD are more likely to avoid relationships and, therefore,
distress due to sexual contact is less frequent than it is for
women. In the college student sample studied by Katz et al.
(1989), scores on the SAS were significantly higher for women
than they were for men. Women also worried significantly
more about being evaluated sexually by partners, were more
avoidant, and were more fearful of intercourse than men.
Causal Mechanisms
Janata and Kingsberg (2005) asserted that SAD is likely best
conceptualized as a conditioned aversion according to Mow-
rer’s (1947) two-factor theory. It is possible that sexual stimuli
were paired with painful or traumatic sexual stimuli, produc-
ing the aversive conditioned response. There is clinical (Janata
& Kingsberg, 2005) and limited empirical (Noll, Trickett, &
Putnam, 2003) support for a role for child sexual abuse in the
Arch Sex Behav
123
etiology of SAD. There are no empirical data supporting the
speculation that SAD is due to a partner forcing sex upon an
individual, despitewhat is claimed in some pop culture sources
(www.marriagebuilders.com). Avoidance behavior then rein-
forces the conditioned avoidance. Because systematic desen-
sitization has been found effective in two published case stud-
ies of women with SAD (Finch, 2001; Kingsberg & Janata,
2003), SAD was speculated to be similar to other anxiety
disorders which respond quite well to systematic desensitiza-
tion (Choy, Fyer, & Lipsitz, 2007). For women, it has been
noted that, in general, SAD is less responsive to behavioral
treatment than is HSDD (Schover & LoPiccolo, 1982); how-
ever, there are no published studies comparing behavior ther-
apy in HSDD versus SAD. There have been no published
longitudinal studies exploring the etiology of SAD so state-
ments about proposed mechanisms are based on assertion
only. Moreover, there are no published efficacy studies or case
reports on treatment of SAD in men.
Kaplan (1987) also believed that Mowrer’s (1947) two-fac-
tor theory explained the etiology of sexual aversion but added
that reinforcement processes were responsible for its mainte-
nance. Specifically, Kaplan argued that the sexual aversion was
maintained because of a vicious cycle of avoidance and rein-
forcement of theavoidancebehavior. Becauseavoidance allows
the individual to be free of the significant sexual anxiety and
distress, avoidance becomes self-perpetuating and therefore
reinforcing.
Kaplan (1987) noted that psychoanalytic theories also at-
tempt to explain the etiology of SAD in that the phobic anxiety
is activated among those individuals with unresolved oedipal
conflicts. For those 4–5 year old boys who do not mature from
the stage of having sexual feelings for their mothers and being
fearful of castration by their fathers, neurotic anxiety (and sex-
ual aversion) may develop. Treatment is therefore aimed at
resolving the oedipal complex. Unfortunately, this particular
theory has never been tested directly nor have there been
empirical tests of the efficacy of psychoanalysis for SAD.
Is Sexual Aversion Disorder a Sexual Desire Disorder?
Although SADislistedasoneof thetwo Sexual Desire Disorders,
there appear to be fewsimilarities between HSDD and SAD—the
former being characterized by the absence of desire and the latter
as the presence of fear and avoidance. Although Schover and
LoPiccolo (1982) conceptualized SAD and HSDD as being at
opposite ends of the same spectrum, Kaplan (1987) disagreed
with this conceptualization, noting thatindividuals with SAD can
continue to experience normal sexual desire, fantasize, and often
masturbate to orgasm. Indeed, internet advice columns (e.g.,
psychcentral.com/ask-the-therapist) present queries from indi-
viduals with SAD symptoms despite apparent normal levels of
sexual desire:
I’ma 24 year old female, and I believeI sufferfrom sexual
aversion disorder. I find the thought of all genital contact
quite repulsive, and on occasions in the past when guys
havetried to touch me below thewaist I have become very
panicky and upset. It’s not that I have no sexual desire, I
do, and I masturbate to orgasm around once a week.
In a sample of 376 patients who avoided sex, Kaplan (1987)
found that 21% also met criteria for Inhibited Sexual Desire
Disorder (now classified as HSDD). In an empirical test of the
association between SAD and HSDD, although sexual desire
and sexual aversion scores were significantly correlated (r=
.33, p\.001), sexual aversion scores accounted for only 11%
of the variance in sexual desire scores (Katz & Jardine, 1999).
Research on the distinction between desire and aversion is ex-
tremely limited to outdated studies with poor methodological
design. However, among those seeking treatment for sexual
concerns, anxiety was significantly higher among those with
sexual aversioncomparedto those with low sexual desire (Murphy
& Sullivan, 1981). There was no information in the DSM-IV
Sourcebook (Schiavi, 1996) justifying SAD as a Sexual Desire
Disorder.
Overlap Between Sexual Aversion Disorder
and Vaginismus
As reviewed by Binik (2009), there is some overlap between
SAD and vaginismus, the latter of which is defined in DSM-IV
by a recurrent or persistent involuntary vaginal muscle spasm.
The International Consultation Committee sponsored by the
American Urological Association Foundation refined the defi-
nition of vaginismus in recognition of the finding that vaginal
muscle spasm was not universally present among women with
vaginismus whereas fear of penetration was. This group de-
scribed vaginismus as ‘‘The persistent or recurrent difficulties of
the woman to allow vaginal entry of a penis, a finger, and/or any
object, despite the woman’s expressed wish to do so. There is
often(phobic)avoidanceand anticipation/fear of pain’’ (Basson
et al., 2003). Basson et al. highlighted the phobic qualities of
vaginismus and concluded that it was fear of penetration that
characterized vaginismus more than vaginal spasm. Because
women with vaginismus are fearful of (painful) vaginal pene-
tration, this often results in avoidance behavior and even in
aversion in severe cases. It is possible, therefore, that some cases
of aversionare due tovaginismus,although both disorders can be
diagnosed simultaneously. Although there are no empirical data
that have sought to differentiate these two disorders, vaginismus
is classified as a sexual pain disorder because of the overlap with
dyspareunia.If the aversionis exclusively dueto fearof pain,then
the diagnosis indeed would be one of vaginismus and not SAD.
Thus, there appears to be enough of a difference in the diagnostic
descriptions of the two disorders to justify their assignment to
different classes of sexual dysfunction.
Arch Sex Behav
123
Overlap Between Sexual Aversion Disorder
and Specific Phobia
The DSM-IV-TR (American Psychiatric Association, 2000)
criteria for Specific Phobia are listed in Table 2. If one were
to consider these criteria in the context of the feared sexual
stimulus, it is readily apparent that the individual with SAD
could meet criteria for a Specific Phobia. Although the text on
SAD indicates that ‘sexual aversion may technically meet
the criteria for Specific Phobia, this additional diagnosis is
not given’’ (American Psychiat ric Association, 1994, p. 499),
paradoxically the text on Specific Phobia makes no mention
of SAD. It might be inferred from these criteria that the
Anxiety Disorders Work Group had not considered the fact
that SAD could technically overlap with the criteria for
Specific Phobia and therefore did not list it as a Differential
Diagnosis. The rationale for why SAD should be classified as
a Sexual Dysfunction and not an Anxiety Disorder is simi-
larly not clarified. The limited empirical data available sug-
gest that SAD is similar to Specific Phobias in that (1) it likely
follows Mowrer’s (1947) two-factor theory of pathogenesis
and (2) it responds optimally to behavior therapy in the form
of systematic desensitization.
Recommendations
It is perhaps no coincidence that Sexual Aversion Disorder
was added to the DSM-III-R (American Psychiatric Asso-
ciation, 1987) under the influence of Kaplan in the same year
that Sexual Aversion, Sexual Phobias, and Panic Disorder
(Kaplan, 1987) was published. Kaplan was a major proponent
for including SAD into the DSM based on clinical observa-
tions. However, its inclusion into the diagnostic taxonomy
has not translated into increased research on the topic (as it
perhaps was originally hoped). Instead, there are only a few
case studies published on SAD and, since the publication of
DSM-IV-TR in 2000, there have been no published epide-
miological studies on the topic.
There are three possible alternatives for dealing with SAD
in DSM-V. The APA draft guidelines for making changes to
DSM-V (DSM-V Task Force Document, 2009) provides a list
of five principles to consider when proposing a change to the
DSM. These include: (1) to distinguish between psychiatric
syndromes for purposes of guiding the most effective treat-
ment and management; (2) to reduce confusion of syndromes
with each other; (3) to take into account co-morbid symptoms
which affect the outcome of treatment in the most effective
manner;(4) to facilitate easeof use and promote clinical utility;
and (5) to demonstrate validity on as many levels as possible.
Among the principles that are most relevant to SAD is one that
states that the goal is to distinguish among psychiatric syn-
dromes for purposes of treatment. Changes should also reduce
confusion among syndromes. Both of these points are relevant
to the diagnostic category of SAD given its apparent overlap
with phobias and possibly with vaginismus. Thus:
Option 1 is to removeSAD from the DSM-V and expandthe
definition of vaginismus to encompass women with sexual
aversion. As noted earlier in this review, some women with
vaginismus experience aversion to sexual activity. Crenshaw
(1988) noted that there is a high correlation between primary
sexual aversion and vaginismus in women, but this claim has
never been empirically verified. The potential benefit of sub-
suming sexual aversion under the category of vaginismus is
that women with vaginismus would not be further patholo-
gized by having an additional disorder if they were aversive of
sex. However, in women with SAD, the aversive stimulus is
typically genital sexual contact with a partner, not necessarily
fear/anticipation of pain, as in the case of vaginismus. More-
over, many (if not most) women with vaginismus also expe-
rience comorbid sexual pain, and this isnot a clinical feature of
women withSAD. One might speculatethat the aversion to sex
among women with vaginismus is, therefore, adaptive since
Table 2 DSM-IV-TR diagnostic criteria for Specific Phobia (300.29)
A. Marked and persistent fear that is excessive or unreasonable, cued by
the presence or anticipation of a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood)
B. Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response, which may take the form of a
situationally bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying,
tantrums, freezing, or clinging
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent
D. The phobic situation(s) is avoided or else is endured with intense
anxiety or distress
E. The avoidance, anxious-anticipation, or distress in the feared
situation(s) interferes significantly with the person’s normal routine,
occupational (or academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia
F. In individuals under age 18 years, the duration is less than 6 months
G. The anxiety, Panic Attacks, or phobic avoidance associated with the
specific object or situation are not better accounted for by another
mental disorder, such as Obsessive–Compulsive Disorder (e.g., fear
of dirt in someone with an obsession about contamination),
Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated
with a severe stressor), Separation Anxiety Disorder (e.g., avoidance
of school), Social Phobia (e.g., avoidance of social situations because
of fear of embarrassment), Panic Disorder With Agoraphobia, or
Agoraphobia Without History of Panic Disorder
Specify type
Animal type
Natural environment type (e.g., heights, storms, water)
Blood–Injection–Injury type
Situational type (e.g., airplanes, elevators, enclosed spaces)
Other type (e.g., phobic avoidance of situations that may lead to
choking, vomiting, or contracting an illness; in children,
avoidance of loud sounds or costumed characters)
Arch Sex Behav
123
they are avoiding painfulsexual activity.This appears not to be
the case with SAD. Thus, although some women with vagi-
nismus do experience aversive or phobic-like reactions to
vaginal penetration, this is not the same group of women
originally conceptualized by Kaplan (1987) as being sexually
aversive. I am not in favor of subsuming sexual aversion under
the category of vaginismus.
Option 2 is to remove SAD from the DSM-V and make the
recommendation that cases of genital contact phobia be cap-
tured under the diagnosis of Specific Phobia. This would in-
volve adding to the text description of Specific Phobia that
aversion to sexual contact is one manifestation of phobia in the
‘Other Type’’ category. It would not be necessary to change
the diagnostic criteria for Specific Phobia itself to account for
sexual aversion given that, as outlined earlier, if one were to
substitute ‘‘sexual stimulus’’ for ‘‘specific object’’ or ‘‘stimu-
lus’’ in the criteria, this description captures the entity of SAD
already. It is unclear why the DSM-IV-TR text description of
SAD indicatesthat a diagnosis of Specific Phobia shouldnot be
given if one has SAD, particularly as a parallel statement is not
made in the text description of Specific Phobia. Option 2 is in
line with the Draft Criteria for proposing change to DSM in
that it circumvents the problem of making a false distinction
between Specific Phobia and SAD and therefore reduces con-
fusion. A potential disadvantage of including phobia of sexual
contact as a Specific Phobia is that patients mightseek treatment
for this problem in Anxiety Disorder clinics and not by sex
therapy experts, thus shifting the focus of the problem away
from the sexual/interpersonal aspects and focusing more on the
anxiety-related aspects. This is a downside only on face-value
given that the most efficacious treatment approaches for SAD
have involved techniques borne out of the anxiety disorders
literature (e.g., systematic desensitization). Just as the clinician
treating public speaking phobias is not an expert in communi-
cation, it is not necessaryfor the clinician treating sexual phobia
to be a sex therapist.
Option 3 is to retain SAD in the DSM-V as a Sexual
Dysfunction. Given that there have not been any empirical
publications to suggest improving the criteria, no recom-
mendations can be made for doing so. However, the lack of
research in this area, the absence of epidemiological and
pathophysiological research, and the apparent overlap with
Specific Phobia make this option the least desirable. More-
over, the current classification implies a false distinction
between these two disorders and maintains confusion among
clinicians about whether a sexual or an anxiety disorder is
most appropriate. If the criteria set out in the Draft Guidelines
for making changes to DSM-V had been used when SAD was
considered for inclusion into DSM-III-R, it would not have
passed the test. Reliability and validity data on the diagnostic
criteria were not available, diagnostic validity of the syn-
drome was unknown, there were insufficient data published on
a range of topics related to SAD, and epidemiological and
services data, course, and treatment outcome data were non-
existent. Moreover, the requirement that the disorder in
question is sufficiently distinct fromother disorders to warrant
designation as a separate disorder was not met and it could
have been captured as a subtype of another disorder (Specific
Phobia). It is possible that the historical influence of Kaplan
overshadowed the lack of empirical data justifying SAD as a
new diagnostic entity. With DSM-V and the emphasis placed
on any changes being based on empirical science, SAD clearly
would not have made its way into the DSM.
Acknowledgments The author is a member of the DSM-V Work-
group on Sexual and Gender Identity Disorders. I wish to acknowledge
the valuable input I received from members of my Workgroup (Yitzchak
Binik, Cynthia Graham, R. Taylor Segraves) and Kenneth J. Zucker.
Feedback from DSM-V Advisors Richard Balon and Sheryl Kingsberg
is greatly appreciated. Reprinted with permission from the Diagnos-
tic and Statistical Manual of Mental Disorders V Workgroup Reports
(Copyright 2009), American Psychiatric Association.
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... Sexual Aversion (SA) disorder is defined as a persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner, causing distress or interpersonal difficulties (American Psychiatric Association, 2000). Aversive sexual cues can include aspects of partenered sexual activities (e.g., penetration, bodily fluids, sexual intimacy), perceptions surrounding sexuality (e.g., nudity, sexual communication, fantasies, sexual health messages), or masturbation (Borg et al., 2014;Brotto, 2010). SA is associated with psychological and sexual distress (Bodenmann & Ledermann, 2008;Hendrickx et al., 2016), reduced sexual and relationship satisfaction (Tripoli et al., 2011;Vaillancourt-Morel et al., 2015), as well as other sexual difficulties (e.g., sexual desire disorders; Borg et al., 2014;Hendrickx et al., 2016). ...
... The experimental scenario was designed for the purpose of the present study using Unity software, and assets (e.g., characters, clothes, body fluids) were selected from Daz 3D, Unity, and specialized websites for photorealistic body parts (e.g., genitals; https://www.renderotica.com). The virtual scenario was developed based on: (a) characteristics of virtual environments used in related disorders or experiences (e.g., social anxiety, sexual assault; Bouchard et al., 2017;Dechant et al., 2017;Loranger & Bouchard, 2017); (b) documented anxiety/disgust-provoking sexual situations or behaviors characteristic of SA (Borg et al., 2020;Brotto, 2010) such as nudity, signs of sexual interest (lengthy eye contact, approach behaviors), arousal, and orgasm (e.g., erection, body fluids, vocalizing); and (c) the evaluation of the research team (i.e., three experts in clinical sexology). ...
... Another hypothesis is that SA is not necessarily a reflection of a lack of sexual interest or of low sexual desire, although they are sometimes related (Basson, 2010;Brotto, 2010;Kaplan et al., 1987). In summary, results indicate that eye-tracking may not be a good discriminating measure to assess the level of avoidance in SA. ...
Article
Full-text available
This study focused on sexual aversion (SA) – namely the experience of fear, disgust, and avoidance when exposed to sexual contexts or cues – and aimed to validate a virtual environment’s ability to progressively trigger the typical emotional responses of SA. Thirty-nine participants (16 low-SA and 23 high-SA individuals) were immersed in a virtual room and then successively exposed to six scenarios in which a synthetic character showed erotic behaviors of increasing sexual intensity. Throughout immersion, subjective measures of anxiety and disgust (Subjective Units of Discomfort Scale; SUDS), skin conductance, heart rate, cardiac output, and eye movements were recorded. The changes in SUDS and physiological variables were examined through repeated measures analyses of variance. SUDS scores significantly increased as the levels of exposure progressed among the high-SA participants, who also reported significantly more anxiety and disgust than the low-SA group. Significant large time effects were found for cardiac output and eye fixation (on face, chest, and genitals), but no significant group*time interactions were found for physiological variables. Results show that this virtual environment may be a promising tool for research and practice, and its efficacy as part of a virtual reality exposure-based treatment for SA should be tested.
... The fourth, text-revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defined Sexual Aversion Disorder as a persistent or recurrent extreme aversion to, and avoidance of, all or almost all genital sexual contact with a sexual partner (Criterion A), causing marked distress or interpersonal difficulties (Criterion B). 4 In other terms, individuals with SA may experience fear, anxiety, or disgust at the prospect of having sexual contact, and exhibit avoidance behaviors in sexual contexts. Beyond genital contact, types of stimuli and behaviors that could provoke aversion vary greatly [4][5][6] and can include aspects of partnered or solo sexual activity (eg, penetration, masturbation, sexual intimacy, sexual fluids, body odors) or sexual cues and contexts (eg, nudity, sexual communication, cuddling, sexual fantasies). In severe SA cases, exposure to sexual cues may also cause somatic symptoms of extreme anxiety (eg, heart palpitations, shortness of breath). ...
Article
Background: Sexual aversion (SA) is a chronic difficulty impacting sexual, relational and psychological wellbeing. Yet, there is a dearth of studies exploring its prevalence and associated factors. Aims: To estimate the prevalence of SA and examine its correlates among a community sample of Canadian adults. Methods: A large web-based sample of the Quebec (Canada) adult population (n = 1,935) completed an online survey on sexual wellbeing. Prevalence rates were estimated for SA and other sexual difficulties. Multivariate logistic regression analyses were used to identify correlates of SA. Outcomes: Demographics (e.g., gender, employment status), self-reported experiences of sexual difficulties (low sexual desire and arousal, vaginal dryness, pain during sexual intercourse, erectile difficulties, premature or delayed ejaculation, and orgasm difficulties), and markers of psychosexual wellbeing (e.g., psychological distress, performance anxiety) according to the presence or absence of SA were assessed. Results: The prevalence of SA was 9.7% (95% CI: 8.5-11.2) in the present sample (6.9% [95% CI: 5.1-8.9] in men, 11.3% [95% CI: 9.4-13.4] in women and 17.1% [95% CI: 9.4-27.4] in nonbinary/trans individuals). The multivariate logistic regression model explained 31% of the likelihood of experiencing SA. SA was related to psychological distress (aOR: 1.77, 95% CI: 1.33-2.38), sexual satisfaction (aOR: .59, 95% CI:.49-.70), sexual performance anxiety (aOR: 2.08, 95% CI: 1.45-2.98), and discomfort with sex-related information (aOR: 1.02, 95% CI: 1.01-1.04). Clinical implications: Several psychosexual correlates of SA were documented and could be targeted by practitioners during the assessment and treatment of individuals living with SA. Strengths and limitations: The study’s strengths include its large, gender diverse sample and use of comprehensive diagnostic criteria for SA. Probability-based sampling methods and longitudinal studies should be conducted to address the current study’s limitations. Conclusions: SA research is critical to document its prevalence in different sociodemographic groups, explore additional intrapersonal and interpersonal mechanisms involved in SA etiology, and ensure that the needs of people living with SA are met with tailored interventions.
... It was defined as "a persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a partner, which causes distress or interpersonal difficulty." It was deleted from DSM-5 because of its overlap with other anxiety disorders and the lack of research supporting its existence as a unique disorder (Brotto, 2010). ...
Chapter
A critical feature of sexual aversion, according to the authors of this chapter, is that “sex is experienced as inherently disgusting.” While historically classified as a sexual desire disorder, present diagnostic nosology has subsumed sexual aversion into the category of genito-pelvic pain/penetration disorder (DSM-5), or a sexual pain/penetration disorder, or a phobia (ICD-11). However, Borg, Both, ter Kuile, and de Jong make a strong case in Chapter 10 that the decision to eliminate a separate diagnosis of sexual aversion was misguided, observing: “When individuals who are disgusted by sex are nonetheless forced to engage in it, this may give rise to fear and pain, but this does not imply that such individuals can best be categorized as suffering from a phobia or from GPPPD.” They point out that because of the universality of the emotion of disgust, there are strong theoretical reasons to believe that this emotion can interfere with sexual function. They support this contention through case histories and empirical studies. They point out that sexual aversion disorder may not only exist as a separate disorder but in fact, may also be a primary underlying issue for many individuals suffering from reduced desire and arousal or vaginismus. Unfortunately, there are no systematic treatment studies for sexual aversion, but clinical experience and theory suggest that prolonged and hierarchical exposure is an important first treatment step.
... *,6 (NEW) 1.7 Sexual aversion disorder: Persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner which causes distress or interpersonal difficulty. 8 (NEW) 1.8 Hypogonadism: A term introduced to signify low testosterone levels associated with infertility, sexual dysfunction, and systemic alterations (such as decreased muscle mass, depressed mood, sleep disturbances, loss of body hair, lethargy). It has more recently been used interchangeably with the idea of low testosterone production alone. ...
Article
Introduction The terminology for sexual health in men with lower urinary tract (LUT) and pelvic floor (PF) dysfunction has not been defined and organized into a clinically based consensus terminology report. The aim of this terminology report is to provide a definitional document within this context that will assist clinical practice and research. Methods This report combines the input of the members of sexual health in men with LUT and PF Dysfunction working group of the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 18 rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus). The Committee retained evidence-based definitions, identified gaps, and updated or discarded outdated definitions. Expert opinions were used when evidence was insufficient or absent. Results A terminology report for sexual health in men with LUT and PF dysfunction, encompassing 198 (178 NEW) separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different speciality groups involved. Conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5–10 years) review is anticipated to keep the document updated. Conclusion A consensus-based terminology report for sexual health in men with LUT and PF dysfunction has been produced to aid clinical practice and research. The definitions that have been adopted are those that are most strongly supported by the literature at this time or are considered clinical principles or consensus of experts' opinions.
... ed along a continuum ranging from lesser to greater severity; Prevalence data suggest that SA is far from uncommon, even in severe form of SA, sexual stimuli may cause symptoms of exthough epidemiological data are lacking. In a large internet treme anxiety/panic, such as palpitations, shortness of breath, or survey ( n = 4,147) about sexual health among a representative nausea (Brotto, 2010). Although SA is associated with signifi cant sample of adults (19-69 years of age) in the Netherlands, 30% of sexual and relational distress ( Dang et al., 2018), measures of SA respondents had experienced SA at some point in their lives and are currently limited and short scales to adequately assess SA are about 4% met diagnostic criteria for Sexual Aversion Disorder lacking, thus reflecting the need to develop measures meant to (a recurrent and acute form of anxiety toward sexuality; Bakker accurately screen manifestations of SA and its impacts on sexual & Vanwezenbeek, 2006). ...
Article
Full-text available
Although sexual anxiety (SA) is associated with significant sexual and relationship difficulties, to date, we lack brief scales to adequately assess SA. The aim of the present study was to develop a brief and reliable French version of the Sexual Anxiety Scale (SAS) that can be used to screen the manifestations of SA and their severity. A community sample ( n = 576) was recruited to investigate the reliability and validity of the brief form of the scale (SAS-BF). Confirmatory factor analysis was performed on the original three-factor model (SAS) and on the new, four-factor SAS-BF. Its convergent validity was tested with theoretically relevant correlates (e.g., anxiety, sexual satisfaction). The SAS-BF yielded strong psychometric properties in terms of factor structure and reliability, and was reasonably correlated with associated variables. SAS-BF can be considered a valid short scale to assess SA in studies where a brief form of the questionnaire is desirable or during clinical screening with patients experiencing variable levels of SA.
... ed along a continuum ranging from lesser to greater severity; Prevalence data suggest that SA is far from uncommon, even in severe form of SA, sexual stimuli may cause symptoms of exthough epidemiological data are lacking. In a large internet treme anxiety/panic, such as palpitations, shortness of breath, or survey ( n = 4,147) about sexual health among a representative nausea (Brotto, 2010). Although SA is associated with signifi cant sample of adults (19-69 years of age) in the Netherlands, 30% of sexual and relational distress ( Dang et al., 2018), measures of SA respondents had experienced SA at some point in their lives and are currently limited and short scales to adequately assess SA are about 4% met diagnostic criteria for Sexual Aversion Disorder lacking, thus reflecting the need to develop measures meant to (a recurrent and acute form of anxiety toward sexuality; Bakker accurately screen manifestations of SA and its impacts on sexual & Vanwezenbeek, 2006). ...
Preprint
Full-text available
Although sexual anxiety (SA) is associated with significant sexual and relationship difficulties, to date, we lack brief scales to adequately assess SA. The aim of the present study was to develop a brief and reliable French version of the Sexual Anxiety Scale (SAS; Fallis et al., 2011) that can be used to screen the manifestations of SA and their severity. A community sample (n = 576) was recruited to investigate the reliability and validity of the brief form of the scale (SAS-BF). Confirmatory factor analysis was performed on the original three-factor model (SAS) and on the new, four-factor SAS-BF. Its convergent validity was tested with theoretically relevant correlates (e.g., anxiety, sexual satisfaction). The SAS-BF yielded strong psychometric properties in terms of factor structure and reliability, and was reasonably correlated with associated variables. SAS-BF can be considered a valid short scale to assess SA in studies where a brief form of the questionnaire is desirable or during clinical screening with patients experiencing variable levels of SA.
... The sexual aversion dysfunction has been deleted from the newly proposed ICD-11 classification due to diagnostic difficulties and in consequence difficulties in estimating the frequency of the disorder and development of therapeutic recommendations. Some researchers argue that there is a connection between sexual aversion and anxiety and phobia [12]. It is emphasised that sexual aversion may be well justified by sexual abuse experience in the past or pain as a result of penetration. ...
Article
Full-text available
In June 2018, the 11th version of the International Statistical Classification of Diseases and Related Health Problems was published effective as of 2022. This new classification introduced material changes into the classification of sexual dysfunctions to reflect contemporary conceptualisations evolving together with the scientific progress regarding pathogenesis and clinical presentation of sexual disorders. The article discusses changes in the categorisation of female sexual dysfunction in comparison with the previous, the ICD-10 classification as well as a comparison with the latest version of the classification published by American Psychiatric Association (DSM-5, Diagnostic and Statistical Manual of Mental Disorders) published in 2013.
... In fact, in previous volumes of the DSM, there was a disorder called sexual aversion disorder. This disorder was defined as "persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner" [35]. The reasoning behind the removal of this disorder was the lack of empirical support and comorbidity of this disorder with other anxiety disorders [36]. ...
Article
Full-text available
Purpose of Review The aim of this review is to examine recent literature on the relationship between sexual disgust and aspects of female sexual functioning, with consideration of how an evolutionary perspective of this important emotion may help inform treatment and intervention programs. Recent Findings Researchers have begun to link sexual disgust with sexual dysfunction in women. There is evidence to suggest that sexual disgust has an inhibitory effect on sexual arousal, and that it is involved in the development and maintenance of sexual pain disorders. While research has begun to investigate the influence of sexual disgust as it relates to female sexual arousal disorder and orgasm, the overall picture of whether or not sexual disgust facilitates sexual dysfunction in these areas is unclear. Understanding the evolutionary relevance of sexual disgust provides an important perspective for diagnosing and treating sexual dysfunction in women. Summary Sexual disgust is an emotion that evolved to coordinate a solution to the adaptive problem of avoiding negative outcomes such as disease or selecting a suboptimal mate. Although this emotion within the normal range has an adaptive function, excessively high levels are hypothesized to lead to sexual dysfunction. Understanding individual differences in trait or state-based disgust might elucidate individual differences in susceptibility of sexual dysfunction and expedite the development of interventions targeted to help resolve impediments to healthy sexual functioning.
Article
In the last years, hypersexual behavior has been broadly scientifically studied. The interest in this topic, belonging to psycho-sexology and sexual medicine, has been due to its still unclear aetiology, nature, and its manifestation in relationship with several organic and psychopathological conditions. So, the specialist (the psychologist, psychiatrist, endocrinologist, neurologist) may encounter some difficulties in diagnosing and managing this symptom. The first main objective of this position statement, which has been developed in collaboration between the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Psychopathology (SOPSI) is to give to the reader evidence about the necessity to consider hypersexuality as a symptom related to another underlying condition. Following this consideration, the second main objective is to give specific statements, for the biopsychosocial assessment and the diagnosis of hypersexual behavior, developed on the basis of the most recent literature evidence. To develop a psycho-pharmacological treatment tailored on patients' needs, our suggestion is to assess the presence of specific comorbid psychopathological and organic conditions, and the impact of pharmacological treatments on the presence of an excess of sexual behavior. Finally, a suggestion of a standardized psychometric evaluation of hypersexuality will be given.
Thesis
Full-text available
This thesis explores the experiences of ten asexual and aromantic college students at Oregon State University and the strategies they used to navigate their sexualized and romanticized campuses. The questions that guided this research were about belonging, resilience, kinship, and worldview. Did they feel they belonged to anyone or mattered to anyone at the university, were they resilient and what helped them be resilient, where and how did they find community and how did they view the world through their identities? Photovoice research was used as the methodology in this study, using photography to make visible asexual and aromantic students who have been treated as invisible (MacNeela & Murphy, 2015). This research was collaborative with the participants, they were viewed as co-researchers and they made meaning of their lives and identities together (Wang & Burris, 1997). Study data illuminated a hostile campus environment for asexual and aromantic students, where they felt excluded and othered by society, friends, family, classmates, and professors. Yet despite their invisibility they practiced resilience and found belonging and kinship as strategies to be successful in college.
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In response to our proposal that DISGUST be considered an emotional system comparable to the SEEKING system, Panksepp has argued that the inclusion of disgust would necessitate the addition of hunger, thirst, fatigue, and other affective states. Although the English word disgust may carry primarily gustatory connotations, we are not suggesting a distaste system but a broad multipurpose system comparable to SEEKING. Our proposal is that nutritionally-, sexually-, and socially-related stimuli plus ideational components are all able to activate either the SEEKING or DISGUST systems in analogous ways. Our intent is to point out this evolutionary trajectory from illness-related reactions, which include distaste reflexes, through more complex learned aversions and avoidance responses, to human core disgust, which eventually gives rise to a secondary emotion encompassing socio-moral attributes.
Article
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Article
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Article
"Sexual Desire Disorders" is a comprehensive guide to contemporary theory, research, and treatment. Containing contributions by foremost sex therapists in the field, the book addresses all aspects of sexual desire difficulties and provides a variety of treatment approaches. Offering a number of professional viewpoints, it includes actual case studies that illuminate this perplexing and challenging problem. After an introductory discussion of changing perspectives on sexual desire, including problems of definition and measurements of "normalcy," the book analyzes four basic models of desire disorders and the interventions they favor. Dr. Leiblum and Rosen have combined the fruit of their vast experience to create a compelling and enlightening volume that will be of great value to psychiatrists, psychologists, mental health and medical specialists, graduate level students, and anyone else concerned with the subject of psychosexual disorders. (PsycINFO Database Record (c) 2012 APA, all rights reserved)