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

Diagnosis

Lifelong (primary sexual aversion) Acquired (secondary sexual aversion)

Primary sexual aversion Secondary sexual aversion

Current DSM-IV-TR criteria Lifelong anxiety, fear, or disgust to sexual stimuli

Acquired anxiety, fear, or disgust to sexual stimuli

Proposed revised criteria Acquisition of fear, anxiety, or disgust before the development of healthy sexual interactions with a partner Acquisition of fear, anxiety, or disgust after the development of healthy sexual interactions with a partner 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 relatively 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 responsiveness 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 relationships, 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 dissipate. 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.

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