Introduction

Crenshaw (1) has been credited for first describing the sexual aversion syndrome. Her description, published in 1985, remains one of two comprehensive manuscripts describing this disorder, joined only by Kaplan's 1987 book (2), Sexual Aversion, Sexual Phobias and Panic Disorder. Kaplan suggested that sexual aversion 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 persistent fear and avoidance.

From our perspective, conditioned aversion is perhaps best understood using Mowrer's two-factor theory (8). Mowrer theorized that two separate learning 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 original painful stimulation. The later conditioned avoidance response is operantly conditioned (negatively reinforced) in that avoidance of sexual stimulation eliminates 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.

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