Diagnostic Criteria

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 Development 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 relevant 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 interactions 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. Secondary 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 Classification 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

A. Dyspareunia

B. Vaginismus

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 aversion. This presentation, however, would be absent in the fear and anxiety response to sexual behavior, which is critical for the aversion diagnosis.

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