Arch Sex Behav (2014) 43:1219–1223 DOI 10.1007/s10508-014-0341-z
COMMENTARY ON DSM-5
Sexual Aversion and the DSM-5: An Excluded Disorder with Unabated Relevance as a Trans-diagnostic Symptom Charmaine Borg • Peter J. de Jong • Hermien Elgersma
Published online: 12 July 2014 Ó Springer Science+Business Media New York 2014
In the transition from DSM-IV-TR to DSM-5 (American Psychiatric Association, 2013), the diagnosis of Sexual Aversion Disorder (SAD) has been deleted. SAD was initially included in the DSM-III-R (American Psychiatric Association, 1987) and was defined as‘‘persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner.’’Symptoms had to not be better accounted for by another diagnosis from Axis I (e.g., mood disorder) or any other sexual dysfunction. The criteria in the DSM-IV-TR (American Psychiatric Association, 2000) were extended further and stated that (the prospect of) having any sexual contact was associated with fear, anxiety, and disgust and that there could be great variety in the type of stimuli and behaviors that evoked aversion, ranging from a very specific aspect of sex (e.g., genital fluid) to almostallstimuliorbehaviorsthatmaybeinvolvedinsex(including kissing, touching, cuddling). Symptoms of (extreme) anxiety/panic and avoidance behaviors were described as signs of severe sexual aversion. As defined originally in the DSM-III-R, SAD did not imply a complete disinterest in sex. A person diagnosed with SAD could very well have sexual fantasies and/or may masturbate to release sexual tension. Perhaps critical for the purpose of this commentary is that SAD specifically referred to the prospect of the potential or actual sexual contact with another person. In this respect, SAD also differed from the categorization given in the
C. Borg (&) P. J. de Jong Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS Groningen, The Netherlands e-mail: [email protected] H. Elgersma Accare, Institution for Child Psychiatry and Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands
DSM-IV (American Psychiatric Association, 1994)‘‘decreased sexual desire’’ (Hypoactive Sexual Desire Disorder), which is not limited to sex with someone else, but is also translated to having less sexual desire, less sexual fantasies, and less urges to touch oneself for pleasure.
Why Sexual Dysfunction and Not Specific Phobia? As discussed by Brotto (2010), the rationale behind the inclusion of SAD as a separate category rather than having it as part of the other anxiety disorders (as a specific phobia of sexual contact) remains blurred. Kaplan (1987) had already highlighted the phobic qualities involved in SAD. Consistent with this conceptualization, individuals diagnosed with SAD are typified by avoidance of all shapes and forms of sexual contact although there are large variations of what is aversive and avoided. In addition, features that seem highly relevant to phobias, like fear, anxiety, and disgust, have been considered prominent features of SAD in the DSM-IV-TR, which further strengthens the similarities between specific phobias and SAD. Kaplan further explained that people with SAD would avoid situations in which they may come in contact with SAD-relevant stimuli, which seems also highly consistent with the criteria for inclusion as a specific phobia. Accordingly, it is explicitly mentioned in the description of the DSM-IV that SAD can meet the criteria of specific phobia but no rationale was given for the decision to define SAD nevertheless as a sexual dysfunction instead of as a specific phobia. Janata and Kingsberg (2005) argued that SAD differed from specific phobia because abhorrence and disgust are critical components of SAD whereas this is not strictly the case for specific phobias. Although disgust is not included as a critical criterion for specific phobia in the DSM, by now there is sample evidence outlining the involvement of disgust in a number of
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specific phobias, such as blood-injection-injury phobia and spider phobia (e.g., Olatunji & McKay, 2009). Accordingly, it has been argued that, for instance, spider phobia essentially reflects a fear of unwanted physical contact with a disgusting stimulus (de Jong & Muris, 2002). Also in contamination fear–emetophobia (i.e., fear of vomit/vomiting) and blood-injection-injury phobia–the experienced distress upon confrontation with the phobic stimulus seems mainly driven by the disgusting features of these stimuli (e.g., Olatunji & McKay, 2007; van Overveld, de Jong, Peters, van Hout, & Bouman, 2008). Apart from the evidence that disgust is (also) involved in specific phobias, there is also ample of evidence for the involvement of panic states and anxiety in SAD. Thus, maybe the previously considered differentiating features (i.e., disgust and abhorrence vs. anxiety and fear) between specific phobias and SAD are less strong than originally assumed and provide no strong argument against the conceptualization of SAD as specific phobia. As an additional distinguishing feature, Kaplan (1987) pointed to the potentially relatively serious consequences of avoiding sex as a‘‘basic need’’when compared to the avoidance of stimuli such as small spaces, heights, animals, or blood as expressed by individuals inflicted with specific phobias. Kaplan was undoubtedly right in that the systematic avoidance of sex with others can have a huge impact on a person’s happiness and perhaps it can influence the individual’s reproduction abilities. However, it is not a priori clear that these consequences are more serious than the consequences of (other) specific phobias. For example, what should one think of the person with dental phobia who avoids all kinds of dental treatments and, as a result, starts suffering from inflammation-related bad breath and bad dental conditions? To conceal the bad breath and bad teeth this dental phobic person does not dare to laugh, or talk with others, let alone to have an intimate relationship with another person (e.g., de Jongh, 2006). Clearly, then, also such a very circumscriptive (specific) phobia may have pervasive invalidating consequences with a major impact on the overall quality of life. Besides from a clinical perspective, there seems no obvious reason to treat someone with SAD fundamentally different from someone with a specific phobia. If someone is considered to have a specific phobia of small animals and thus finds these animals or spiders intrinsically dirty/repulsive, prolonged physical exposure is the indicated evidence-based intervention that can be successfully applied to reduce the disgust-eliciting properties of these animals (de Jong & Keijsers, 2011). While there are no systematic and controlled studies on the treatment of SAD, case studies suggest that exposure with response prevention can be similarly effective in the habituation ofsexual disgust (Elgersma, 1998; Finch, 2001; Schover & LoPiccolo, 1982). Yet, one problem that can be predicted here is that in SAD the ‘‘phobic stimuli’’can be rather varied and might be way broader than in specific phobia. As a side note, it is conceivable that the avoidance and aversion experienced by people with SAD is motivated by
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transgressing strongly held moral beliefs (Borg, de Jong, & Weijmar Schultz, 2011; Ribner, 2010) or by traumatic or negative sexual experiences such as incest and/or rape (Badour et al., 2013). In the first case, exposure is likely to have no large effects because it may be hard to modify or challenge the standards that a person might have held to for a long time. On the other hand, in the second scenario, the aversion is not generated in a way to create distance away from something slimy, but rather to prevent memories of traumatic events or experiences. In the latter scenario, it fits more to classify this aversion as Post-Traumatic Stress Disorder rather than SAD (Coughtrey, Shafran, Lee, & Rachman, 2013).
Lack of Empirical Data? The decision to delete SAD from the DSM-5 is supported by the scarce research supporting SAD in the DSM-IV. Few empirical studies have been published on this topic since the inclusion of SAD in the DSM and none were provided to the Sexual Dysfunctions subworkgroup (Y. M. Binik, personal communication, June 17, 2014). Perhaps because the studies mentioned in this commentary are only published in Dutch, they offer limited accessibility. Besides, there are no rigorous crossnational data available in the literature to give clear indications of how prevalent SAD is in other countries and no large epidemiological studies have examined the boundaries or symptoms of SAD. Data from a relatively large Internet based study (N = 4,147) about sexual health among a representative sample of adults (19–69 years of age) in the Netherlands (Bakker & Vanwezenbeek, 2006) might, however, shed some light on the prevalence of sexual aversion or its symptoms. This study used a validated DSM-based questionnaire (Questionnaire for Detecting Sexual Dysfunctions) (Vroege, 1994) and gives a clear indication that SAD (at least for women) is not rare. Of the participants in this study, over 30 % reported experiencing symptoms of sexual aversion at some point in their lives and about 4 % met the criteria for SAD. These figures related to SAD in terms of prevalence were similar to those related to dyspareunia (5 %). Comparable figures were highlighted in a recent questionnaire study (N = 8,000), which focused on a representative sample of the Dutch population aged 15–71 years (Kedde, 2012). Supporting the conclusion that sexual aversion is far from being an uncommon symptom, this study also showed that about 4.5 % of women (against 2.4 % of men) experienced regular (symptoms of) sexual aversion. Moreover, women between 15 and 40 years reported significantly more often to have (symptoms of) sexual aversion than women above 40 years of age. This is in line with what one would expect, as disgust responding and corresponding avoidance will be stifled with exposure to these stimuli and thus some level of habituation may occur with (increasing) age.
Arch Sex Behav (2014) 43:1219–1223
In this study, it was also pointed out that sexual aversion seemed to go hand in hand with sexual arousal problems. Accurate understanding/estimates of the prevalence of SAD are complicated by the course and variation of symptoms as a function of age, gender, and the relationship with other symptoms of sexual dysfunction. It seems, therefore, of critical importance to complement these survey studies with further systematic (preferably international) research to estimate the severity and frequency of symptoms of SAD also in connection with other sexual problems and dysfunctions. Furthermore, when it comes to the question of how many people actually seek treatment based on symptoms of SAD, the empirical data are extremely scarce and the international literature is limited to incidental findings of certain institutions (see, e.g., Carnes, 1998). The annual reports of the combined Dutch outpatient clinics for sexual problems showed that approximately 3 % of the women who contacted an outpatient clinic had symptoms of sexual aversion (e.g., Vroege, 2002). A similar type of monitor study focusing on people who approached their general practitioner/family doctor because of sexual problems (collectedin45generalpracticesbetween2003and2008)arrivedata SAD-prevalence of 0.5 per 100,000 for men and 2.0 per 100,000 for women (Kedde, Donker, Leusink, & Kruijer, 2011). These findings seem to indicate that, compared to other sexual problems such as erectile dysfunction and dyspareunia, the frequency of people seeking treatment specifically for SAD is quite low. This seems in conflict with the finding that the prevalence of SAD is, in fact, very similar to dyspareunia (e.g., Kedde, 2012). This gap suggests that, in the context of SAD, there might be some‘‘silent suffering’’going on, because people with these symptoms may not only avoid concrete sexual contact but also might avoid seeking help (to avoid any contact with SAD related stimuli such as sexual medicine practitioners/sexologists). In addition, it is conceivable to think that people who are characterized by symptoms of SAD do not realize that these symptoms are potentially modifiable and that they can be helped. This underlines the importance of more rigorous epidemiological research on SAD symptomatology within the general population to get a clearer picture of the symptoms experienced.
Consequence for DSM Classification The finding of the Dutch epidemiological studies that the prevalence of SAD was similar to that of dyspareunia provides empirical ground for opposing the removal of SAD from the DSM. It is, therefore, important to note that the current classification of the DSM-5 still leaves room to bring in ‘‘Other Specified Sexual Dysfunction’’ (302.79) for patients who meet the initial criteria of SAD. According to the DSM-5 criteria, this latter mentioned classification applies to symptoms of sexual dysfunction that cause clinical distress, but do not meet all the
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criteria for Sexual Dysfunction Otherwise Specified. It also specifically refers to the example of sexual aversion. Moreover, in the accompanying text, it is stated that there is the possibility that SAD will eventually be re-included in the DSM as a unique category or perhaps might be included as a specific phobia. This is relevant when one considers the high prevalence of SAD or symptoms of sexual aversion indexed by the Dutch studies mentioned in this commentary and possibly by other international studies that were, as these Dutch reports, not captured or not brought to the attention of the DSM-5 Sexual Dysfunctions subworkgroup.
Future Sexual Aversion (Trans-diagnostic) Symptom Of course, the symptoms of sexual aversion do not disappear or become less relevant with the removal of SAD as a sexual dysfunction in the DSM-5 classification (see, e.g., Kedde & de Haas, 2006). In fact, there is increasing attention for the potential role of disgust in sexual problems and dysfunctions (for recent reviews, see de Jong & Borg, in press; de Jong et al. 2013). Although the current sexology textbooks still largely ignore the relationship between disgust and sex, a series of recent studies focused on disgust as a relevant factor in sex and sexual dysfunctions (e.g., de Jong, & Weijmar-Schultz, 2010; Borg et al., 2014). One of these studies showed that low sexual functioning as measured by the Female Sexual Functioning Index (Rosen et al., 2000) was associated with relatively high disgust for sexrelevant stimuli (van Overveld et al., 2013). A similar relationship appeared absent for men. Thus, consistent with clinical observations and anecdotal descriptions of sexual aversion (e.g., Carnes, 1998; Crenshaw, 1985), this seems to suggest that disgust is a prominent candidate and a relevant factor particularly for sexual dysfunctions in women. As further support for the role of disgust in sexual dysfunctions in women, a follow-up study showed that women with vaginismus (as diagnosed on the basis of DSM-IV-TR) scored higher on sexual disgust than women without sexual problems. A similar increased sexual disgust was absent in women with dyspareunia (van Overveld et al., 2013, Study 2). This may be due to fear of pain rather than aversion at the prospect of actual physical contact being the focus in dyspareunia. Consistent with the idea that disgust might play a role in vaginismus (perhaps more than dyspareunia), women with vaginismus also showed relatively strong activity of the disgust-specific levator muscle while watching an erotic movie (Borg et al., 2010). There is until now no research on the involvement of sexual disgust in the context of other sexual disorders or dysfunctions, so whether disgust is possibly involved in the issues surrounding decreased sexual desire or arousal remains an open question. In this thinking, recent research has indicated that, when sexually aroused, the impact of disgust on avoidance is attenuated (Borg & de Jong, 2012; Stevenson, Case, & Oaten, 2011). Individuals who
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have less interest in sex and/or become less easily sexually aroused will therefore be (more) prone to experience sexual aversion and thus may fall into a downward spiral, where disgust has an inhibitory effect on sexual arousal and/or pleasurable sex. In turn, thisinhibitory effect may lead to moredisgust andmorehesitation to approach. Thus, there is both empirical and theoretical support for the view that sexual disgust could be involved in various types of sexual problems, perhaps especially so for women. In consequence, it is not only important to identify how disgust contributes to what type of complaints, but it is also important to have interventions that are specifically directed to address the issue of disgust/aversion/loathing in the clinic (e.g., de Jong, 2011; de Jong, van Lankveld, & Elgersma, 2010; Mason & Richardson, 2012). Studies with such interventions could not only contribute to the improvement of the already available treatment repertoire, but may also contribute to the knowledge of the relevance of disgust, which might very well be related to the recurrence and/or the persistence of such problems.
Conclusion From thecurrently availableevidence,itseemsthat thereisinsufficient data to determine whether or not SAD warrants inclusion in the DSM and, if so, whether it should be considered a specific phobia or should be seen as a sexual dysfunction. Up until now, we do not know how often it occurs, whether it is different than a specific phobia, and whether it requires specific clinical interventions. What we do know, however, is that symptoms of sexual aversion are not uncommon and that in women these aversion symptoms are associated with the woman’s level of sexual functioning. To optimize classification/categorization, diagnosis, and treatment options, further research on the prevalence of sexual aversion and the role of sexual-disgust/aversion in sexual problems is needed. It would be beneficial to gather epidemiological data from specific institutions and health agencies that have investigated the incidence and prevalence of sexual dysfunction both in English and non-English speaking countries, in order to make a more informed choice for DSM-5.1. At this stage, given the potential impact of sexual aversion and related sexual avoidance, it seems most important to investigate the clinical significance of the effectiveness of disgust tailored treatment approaches (e.g., Mason & Richardson, 2012). In conclusion, we would like to emphasize that the deletion of SAD as a separate disorder in the DSM-5, of course, does not implythat sexual aversion wouldno longerexist. We must therefore ensure that, despite this deletion, we give proper attention to the symptoms of sexual aversion thereby preventing that with the disappearance of SAD as a diagnostic label also adequate interventions disappear from clinical practice.
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Arch Sex Behav (2014) 43:1219–1223 Acknowledgments We would like to thank Irv Binik for triggering the idea of writing this commentary, for proofreading, and for commenting on an earlier version of it.
References American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Badour, C. L., Feldner, M. T., Babson, K. A., Blumenthal, H., & Dutton, C. E. (2013). Disgust, mental contamination, and posttraumatic stress: Unique relations following sexual versus non-sexual assault. Journal of Anxiety Disorders, 27, 155–162. Bakker, F., & Vanwezenbeek, I. (2006). Seksuele gezondheid in Nederland 2006 [RNG-studies nr. 9]. Delft: Eburon. Borg, C., & de Jong, P. J. (2012). Feelings of disgust and disgust-induced avoidance weaken following induced sexual arousal in women. PLoS One, 7, e44111. doi:10.1371/journal.pone.0044111. Borg, C., de Jong, P. J., & Weijmar-Schultz, W. (2010). Vaginismus and dyspareunia: The role of automatic vs. deliberate disgust responsivity. Journal of Sexual Medicine, 7, 2149–2157. Borg, C., de Jong, P. J., & Weijmar-Schultz, W. (2011). Vaginismus and dyspareunia: Relationship with general and sex-related moral standards. Journal of Sexual Medicine, 8, 223–231. Borg, C., Georgiadis, R. J., Renken, R. J., Spoelstra, K., Weijmar Schultz, W., & de Jong, P. J. (2014). Brain processing of sexual penetration versus core and animal-reminder disgust pictures in women with genito-pelvic pain/penetration disorders. PLoS One, 9, e84882. doi:10.1371/journal.pone.0084882. Brotto, L. A. (2010). The DSM diagnostic criteria for Sexual Aversion Disorder. Archives of Sexual Behavior, 39, 271–277. Carnes, P. J. (1998). The case for sexual anorexia: An interim report on 144 patients with sexual disorders. Sexual Addiction & Compulsivity, 5, 293–309. Coughtrey, A. E., Shafran, R., Lee, M., & Rachman, S. (2013). The treatment of mental contamination: A case series. Cognitive and Behavioral Practice, 20, 221–231. Crenshaw, T. L. (1985). The sexual aversion syndrome. Journal of Sex and Marital Therapy, 11, 285–292. de Jong, P. J. (2011). Seks en walging? Tijdschrift voor Seksuologie, 35, 4–14. de Jong, P. J., & Borg, C. (in press). Self-directed disgust: Reciprocal relationships with sex and sexual dysfunction. In P. A. Powell, P. G. Overton, & J. Simpson (Eds.), The revolting self: Perspectives on the psychological and clinical implications of self-directed disgust. London: Karnac Books. de Jong, P. J., & Keijsers, G. P. J. (2011). Protocollaire behandeling van patienten met een specifieke fobie: kortdurende exposure in vivo. In G. P. J. Keijsers, A. van Minnen, & C. A. L. Hoogduin (Eds.), Protocollaire behandelingen voor volwassenen met psychische stoornissen (pp. 111–143). Amsterdam: Boom. de Jong, P. J., & Muris, P. (2002). Spider phobia: Interaction of disgust and perceived likelihood of involuntary physical contact. Journal of Anxiety Disorders, 16, 51–65. de Jong, P. J., van Lankveld, J., & Elgersma, H. J. (2010). Refractory cases in the treatment of sexual problems associated with low
Arch Sex Behav (2014) 43:1219–1223 sexual arousal. In D. McKay, J. Abramowitz, & S. Taylor (Eds.), Cognitive-behavioral therapy for refractory cases: Turning failure into success (pp. 255–275). Washington, DC: American Psychological Association. de Jong, P. J., van Overveld, M., & Borg, C. (2013). Giving into arousal or staying stuck in disgust: Disgust-based mechanisms in sex and sexual dysfunction. Annual Review of Sex Research, 50, 247–262. de Jongh, A. (2006). Angst voor de tandarts. Assen: van Gorcum. Elgersma, H. J. (1998). Geen zin meer in walgelijke seks. Verslag van een behandeling volgens gedragstherapeutische principes van een vrouw met klachten van seksuele aversie stoornis en seksuele stoornis met verminderd verlangen. Ongepubliceerde N = 1 studie in het kader van de opleiding tot gedragstherapeut. Finch, S. (2001). Sexual aversion disorder treated with behavioural desensitization [Letter to the Editor]. Canadian Journal of Psychiatry, 46, 563–564. Janata, J. W., & Kingsberg, S. A. (2005). Sexual aversion disorder. In R. Balon & R. T. Segraves (Eds.), Handbook of sexual dysfunction (pp. 43–65). Boca Raton: Taylor and Francis Group. Kaplan, H. S. (1987). Sexual aversion, sexual phobias, and panic disorder. New York: Brunner-Mazel. Kedde, H. (2012). Seksuele disfuncties in Nederland: Prevalentie en samenhangende factoren. Tijdschrift voor Seksuologie, 36, 98–108. Kedde, H., & de Haas, S. (2006). Problemen met het seksueel functioneren. In F. Bakker & I. Vanwezenbeek (Eds.), Seksuele gezondheid in Nederland 2006: RNG-studies nr 9 (pp. 123–138). Delft: Eburon. Kedde, H., Donker, G., Leusink, P., & Kruijer, H. (2011). The incidence of sexual dysfunction in patients attending Dutch general practitioners. International Journal of Sexual Health, 23, 269–277. Mason, E. C., & Richardson, R. (2012). Treating disgust in anxiety disorders. Clinical Psychology: Science and Practice, 19, 180–194.
1223 Olatunji, B. O., & McKay, D. (2007). Disgust and psychiatric illness: Have we remembered? British Journal of Psychiatry, 190, 457–459. Olatunji, B. O., & McKay, D. (2009). Disgust and its disorders: Theory, assessment, and treatment. Washington, DC: American Psychological Association. Ribner, D. S. (2010). A brief treatment approach for sexual aversions in a young, single Haredi (ultra-orthodox) Jewish female. Sexual and Relationship Therapy, 25, 160–165. Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., et al. (2000). The Female Sexual Function Index (FSFI): A multidimensional self-report instrument forthe assessment of female sexual function. Journal of Sex and Marital Therapy, 26, 191–208. Schover, L. R., & LoPiccolo, J. (1982). Treatment effectiveness for dysfunctions of sexual desire. Journal of Sex and Marital Therapy, 8, 179–197. Stevenson, R. J., Case, T. I., & Oaten, M. (2011). Effect of self-reported sexual arousal on responses to sex-related and non-sex-related disgust cues. Archives of Sexual Behavior, 40, 79–85. van Overveld, M., de Jong, P. J., Peters, M. L., van Hout, W. J. P. J., & Bouman, T. K. (2008). An internet-based study on the relation between disgust sensitivity and emetophobia. Journal of Anxiety Disorders, 22, 524–531. van Overveld, M., de Jong, P. J., Peters, M., van Lankveld, J., Melles, R., & ter Kuile, M. M. (2013). The Sexual Disgust Questionnaire: A psychometric study and a first exploration in patients with sexual dysfunctions. Journal of Sexual Medicine, 10, 396–407. Vroege, J. A. (1994). Vragenlijst voor het signaleren van seksuele dysfuncties (VSD) (5de versie). Utrecht: Academisch Ziekenhuis Utrecht, Afdeling Medische seksuologie/Nederlands Instituut voor Sociaal Sexuologisch Onderzoek. Vroege, J. A. (2002). LOPS-registratie 2000. Utrecht: Landelijk Overleg van Poliklinieken Seksuologie/Rutgers Nisso Groep.
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COMMENTARY ON DSM-5
Sexual Aversion and the DSM-5: An Excluded Disorder with Unabated Relevance as a Trans-diagnostic Symptom Charmaine Borg • Peter J. de Jong • Hermien Elgersma
Published online: 12 July 2014 Ó Springer Science+Business Media New York 2014
In the transition from DSM-IV-TR to DSM-5 (American Psychiatric Association, 2013), the diagnosis of Sexual Aversion Disorder (SAD) has been deleted. SAD was initially included in the DSM-III-R (American Psychiatric Association, 1987) and was defined as‘‘persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner.’’Symptoms had to not be better accounted for by another diagnosis from Axis I (e.g., mood disorder) or any other sexual dysfunction. The criteria in the DSM-IV-TR (American Psychiatric Association, 2000) were extended further and stated that (the prospect of) having any sexual contact was associated with fear, anxiety, and disgust and that there could be great variety in the type of stimuli and behaviors that evoked aversion, ranging from a very specific aspect of sex (e.g., genital fluid) to almostallstimuliorbehaviorsthatmaybeinvolvedinsex(including kissing, touching, cuddling). Symptoms of (extreme) anxiety/panic and avoidance behaviors were described as signs of severe sexual aversion. As defined originally in the DSM-III-R, SAD did not imply a complete disinterest in sex. A person diagnosed with SAD could very well have sexual fantasies and/or may masturbate to release sexual tension. Perhaps critical for the purpose of this commentary is that SAD specifically referred to the prospect of the potential or actual sexual contact with another person. In this respect, SAD also differed from the categorization given in the
C. Borg (&) P. J. de Jong Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS Groningen, The Netherlands e-mail: [email protected] H. Elgersma Accare, Institution for Child Psychiatry and Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands
DSM-IV (American Psychiatric Association, 1994)‘‘decreased sexual desire’’ (Hypoactive Sexual Desire Disorder), which is not limited to sex with someone else, but is also translated to having less sexual desire, less sexual fantasies, and less urges to touch oneself for pleasure.
Why Sexual Dysfunction and Not Specific Phobia? As discussed by Brotto (2010), the rationale behind the inclusion of SAD as a separate category rather than having it as part of the other anxiety disorders (as a specific phobia of sexual contact) remains blurred. Kaplan (1987) had already highlighted the phobic qualities involved in SAD. Consistent with this conceptualization, individuals diagnosed with SAD are typified by avoidance of all shapes and forms of sexual contact although there are large variations of what is aversive and avoided. In addition, features that seem highly relevant to phobias, like fear, anxiety, and disgust, have been considered prominent features of SAD in the DSM-IV-TR, which further strengthens the similarities between specific phobias and SAD. Kaplan further explained that people with SAD would avoid situations in which they may come in contact with SAD-relevant stimuli, which seems also highly consistent with the criteria for inclusion as a specific phobia. Accordingly, it is explicitly mentioned in the description of the DSM-IV that SAD can meet the criteria of specific phobia but no rationale was given for the decision to define SAD nevertheless as a sexual dysfunction instead of as a specific phobia. Janata and Kingsberg (2005) argued that SAD differed from specific phobia because abhorrence and disgust are critical components of SAD whereas this is not strictly the case for specific phobias. Although disgust is not included as a critical criterion for specific phobia in the DSM, by now there is sample evidence outlining the involvement of disgust in a number of
123
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specific phobias, such as blood-injection-injury phobia and spider phobia (e.g., Olatunji & McKay, 2009). Accordingly, it has been argued that, for instance, spider phobia essentially reflects a fear of unwanted physical contact with a disgusting stimulus (de Jong & Muris, 2002). Also in contamination fear–emetophobia (i.e., fear of vomit/vomiting) and blood-injection-injury phobia–the experienced distress upon confrontation with the phobic stimulus seems mainly driven by the disgusting features of these stimuli (e.g., Olatunji & McKay, 2007; van Overveld, de Jong, Peters, van Hout, & Bouman, 2008). Apart from the evidence that disgust is (also) involved in specific phobias, there is also ample of evidence for the involvement of panic states and anxiety in SAD. Thus, maybe the previously considered differentiating features (i.e., disgust and abhorrence vs. anxiety and fear) between specific phobias and SAD are less strong than originally assumed and provide no strong argument against the conceptualization of SAD as specific phobia. As an additional distinguishing feature, Kaplan (1987) pointed to the potentially relatively serious consequences of avoiding sex as a‘‘basic need’’when compared to the avoidance of stimuli such as small spaces, heights, animals, or blood as expressed by individuals inflicted with specific phobias. Kaplan was undoubtedly right in that the systematic avoidance of sex with others can have a huge impact on a person’s happiness and perhaps it can influence the individual’s reproduction abilities. However, it is not a priori clear that these consequences are more serious than the consequences of (other) specific phobias. For example, what should one think of the person with dental phobia who avoids all kinds of dental treatments and, as a result, starts suffering from inflammation-related bad breath and bad dental conditions? To conceal the bad breath and bad teeth this dental phobic person does not dare to laugh, or talk with others, let alone to have an intimate relationship with another person (e.g., de Jongh, 2006). Clearly, then, also such a very circumscriptive (specific) phobia may have pervasive invalidating consequences with a major impact on the overall quality of life. Besides from a clinical perspective, there seems no obvious reason to treat someone with SAD fundamentally different from someone with a specific phobia. If someone is considered to have a specific phobia of small animals and thus finds these animals or spiders intrinsically dirty/repulsive, prolonged physical exposure is the indicated evidence-based intervention that can be successfully applied to reduce the disgust-eliciting properties of these animals (de Jong & Keijsers, 2011). While there are no systematic and controlled studies on the treatment of SAD, case studies suggest that exposure with response prevention can be similarly effective in the habituation ofsexual disgust (Elgersma, 1998; Finch, 2001; Schover & LoPiccolo, 1982). Yet, one problem that can be predicted here is that in SAD the ‘‘phobic stimuli’’can be rather varied and might be way broader than in specific phobia. As a side note, it is conceivable that the avoidance and aversion experienced by people with SAD is motivated by
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transgressing strongly held moral beliefs (Borg, de Jong, & Weijmar Schultz, 2011; Ribner, 2010) or by traumatic or negative sexual experiences such as incest and/or rape (Badour et al., 2013). In the first case, exposure is likely to have no large effects because it may be hard to modify or challenge the standards that a person might have held to for a long time. On the other hand, in the second scenario, the aversion is not generated in a way to create distance away from something slimy, but rather to prevent memories of traumatic events or experiences. In the latter scenario, it fits more to classify this aversion as Post-Traumatic Stress Disorder rather than SAD (Coughtrey, Shafran, Lee, & Rachman, 2013).
Lack of Empirical Data? The decision to delete SAD from the DSM-5 is supported by the scarce research supporting SAD in the DSM-IV. Few empirical studies have been published on this topic since the inclusion of SAD in the DSM and none were provided to the Sexual Dysfunctions subworkgroup (Y. M. Binik, personal communication, June 17, 2014). Perhaps because the studies mentioned in this commentary are only published in Dutch, they offer limited accessibility. Besides, there are no rigorous crossnational data available in the literature to give clear indications of how prevalent SAD is in other countries and no large epidemiological studies have examined the boundaries or symptoms of SAD. Data from a relatively large Internet based study (N = 4,147) about sexual health among a representative sample of adults (19–69 years of age) in the Netherlands (Bakker & Vanwezenbeek, 2006) might, however, shed some light on the prevalence of sexual aversion or its symptoms. This study used a validated DSM-based questionnaire (Questionnaire for Detecting Sexual Dysfunctions) (Vroege, 1994) and gives a clear indication that SAD (at least for women) is not rare. Of the participants in this study, over 30 % reported experiencing symptoms of sexual aversion at some point in their lives and about 4 % met the criteria for SAD. These figures related to SAD in terms of prevalence were similar to those related to dyspareunia (5 %). Comparable figures were highlighted in a recent questionnaire study (N = 8,000), which focused on a representative sample of the Dutch population aged 15–71 years (Kedde, 2012). Supporting the conclusion that sexual aversion is far from being an uncommon symptom, this study also showed that about 4.5 % of women (against 2.4 % of men) experienced regular (symptoms of) sexual aversion. Moreover, women between 15 and 40 years reported significantly more often to have (symptoms of) sexual aversion than women above 40 years of age. This is in line with what one would expect, as disgust responding and corresponding avoidance will be stifled with exposure to these stimuli and thus some level of habituation may occur with (increasing) age.
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In this study, it was also pointed out that sexual aversion seemed to go hand in hand with sexual arousal problems. Accurate understanding/estimates of the prevalence of SAD are complicated by the course and variation of symptoms as a function of age, gender, and the relationship with other symptoms of sexual dysfunction. It seems, therefore, of critical importance to complement these survey studies with further systematic (preferably international) research to estimate the severity and frequency of symptoms of SAD also in connection with other sexual problems and dysfunctions. Furthermore, when it comes to the question of how many people actually seek treatment based on symptoms of SAD, the empirical data are extremely scarce and the international literature is limited to incidental findings of certain institutions (see, e.g., Carnes, 1998). The annual reports of the combined Dutch outpatient clinics for sexual problems showed that approximately 3 % of the women who contacted an outpatient clinic had symptoms of sexual aversion (e.g., Vroege, 2002). A similar type of monitor study focusing on people who approached their general practitioner/family doctor because of sexual problems (collectedin45generalpracticesbetween2003and2008)arrivedata SAD-prevalence of 0.5 per 100,000 for men and 2.0 per 100,000 for women (Kedde, Donker, Leusink, & Kruijer, 2011). These findings seem to indicate that, compared to other sexual problems such as erectile dysfunction and dyspareunia, the frequency of people seeking treatment specifically for SAD is quite low. This seems in conflict with the finding that the prevalence of SAD is, in fact, very similar to dyspareunia (e.g., Kedde, 2012). This gap suggests that, in the context of SAD, there might be some‘‘silent suffering’’going on, because people with these symptoms may not only avoid concrete sexual contact but also might avoid seeking help (to avoid any contact with SAD related stimuli such as sexual medicine practitioners/sexologists). In addition, it is conceivable to think that people who are characterized by symptoms of SAD do not realize that these symptoms are potentially modifiable and that they can be helped. This underlines the importance of more rigorous epidemiological research on SAD symptomatology within the general population to get a clearer picture of the symptoms experienced.
Consequence for DSM Classification The finding of the Dutch epidemiological studies that the prevalence of SAD was similar to that of dyspareunia provides empirical ground for opposing the removal of SAD from the DSM. It is, therefore, important to note that the current classification of the DSM-5 still leaves room to bring in ‘‘Other Specified Sexual Dysfunction’’ (302.79) for patients who meet the initial criteria of SAD. According to the DSM-5 criteria, this latter mentioned classification applies to symptoms of sexual dysfunction that cause clinical distress, but do not meet all the
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criteria for Sexual Dysfunction Otherwise Specified. It also specifically refers to the example of sexual aversion. Moreover, in the accompanying text, it is stated that there is the possibility that SAD will eventually be re-included in the DSM as a unique category or perhaps might be included as a specific phobia. This is relevant when one considers the high prevalence of SAD or symptoms of sexual aversion indexed by the Dutch studies mentioned in this commentary and possibly by other international studies that were, as these Dutch reports, not captured or not brought to the attention of the DSM-5 Sexual Dysfunctions subworkgroup.
Future Sexual Aversion (Trans-diagnostic) Symptom Of course, the symptoms of sexual aversion do not disappear or become less relevant with the removal of SAD as a sexual dysfunction in the DSM-5 classification (see, e.g., Kedde & de Haas, 2006). In fact, there is increasing attention for the potential role of disgust in sexual problems and dysfunctions (for recent reviews, see de Jong & Borg, in press; de Jong et al. 2013). Although the current sexology textbooks still largely ignore the relationship between disgust and sex, a series of recent studies focused on disgust as a relevant factor in sex and sexual dysfunctions (e.g., de Jong, & Weijmar-Schultz, 2010; Borg et al., 2014). One of these studies showed that low sexual functioning as measured by the Female Sexual Functioning Index (Rosen et al., 2000) was associated with relatively high disgust for sexrelevant stimuli (van Overveld et al., 2013). A similar relationship appeared absent for men. Thus, consistent with clinical observations and anecdotal descriptions of sexual aversion (e.g., Carnes, 1998; Crenshaw, 1985), this seems to suggest that disgust is a prominent candidate and a relevant factor particularly for sexual dysfunctions in women. As further support for the role of disgust in sexual dysfunctions in women, a follow-up study showed that women with vaginismus (as diagnosed on the basis of DSM-IV-TR) scored higher on sexual disgust than women without sexual problems. A similar increased sexual disgust was absent in women with dyspareunia (van Overveld et al., 2013, Study 2). This may be due to fear of pain rather than aversion at the prospect of actual physical contact being the focus in dyspareunia. Consistent with the idea that disgust might play a role in vaginismus (perhaps more than dyspareunia), women with vaginismus also showed relatively strong activity of the disgust-specific levator muscle while watching an erotic movie (Borg et al., 2010). There is until now no research on the involvement of sexual disgust in the context of other sexual disorders or dysfunctions, so whether disgust is possibly involved in the issues surrounding decreased sexual desire or arousal remains an open question. In this thinking, recent research has indicated that, when sexually aroused, the impact of disgust on avoidance is attenuated (Borg & de Jong, 2012; Stevenson, Case, & Oaten, 2011). Individuals who
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have less interest in sex and/or become less easily sexually aroused will therefore be (more) prone to experience sexual aversion and thus may fall into a downward spiral, where disgust has an inhibitory effect on sexual arousal and/or pleasurable sex. In turn, thisinhibitory effect may lead to moredisgust andmorehesitation to approach. Thus, there is both empirical and theoretical support for the view that sexual disgust could be involved in various types of sexual problems, perhaps especially so for women. In consequence, it is not only important to identify how disgust contributes to what type of complaints, but it is also important to have interventions that are specifically directed to address the issue of disgust/aversion/loathing in the clinic (e.g., de Jong, 2011; de Jong, van Lankveld, & Elgersma, 2010; Mason & Richardson, 2012). Studies with such interventions could not only contribute to the improvement of the already available treatment repertoire, but may also contribute to the knowledge of the relevance of disgust, which might very well be related to the recurrence and/or the persistence of such problems.
Conclusion From thecurrently availableevidence,itseemsthat thereisinsufficient data to determine whether or not SAD warrants inclusion in the DSM and, if so, whether it should be considered a specific phobia or should be seen as a sexual dysfunction. Up until now, we do not know how often it occurs, whether it is different than a specific phobia, and whether it requires specific clinical interventions. What we do know, however, is that symptoms of sexual aversion are not uncommon and that in women these aversion symptoms are associated with the woman’s level of sexual functioning. To optimize classification/categorization, diagnosis, and treatment options, further research on the prevalence of sexual aversion and the role of sexual-disgust/aversion in sexual problems is needed. It would be beneficial to gather epidemiological data from specific institutions and health agencies that have investigated the incidence and prevalence of sexual dysfunction both in English and non-English speaking countries, in order to make a more informed choice for DSM-5.1. At this stage, given the potential impact of sexual aversion and related sexual avoidance, it seems most important to investigate the clinical significance of the effectiveness of disgust tailored treatment approaches (e.g., Mason & Richardson, 2012). In conclusion, we would like to emphasize that the deletion of SAD as a separate disorder in the DSM-5, of course, does not implythat sexual aversion wouldno longerexist. We must therefore ensure that, despite this deletion, we give proper attention to the symptoms of sexual aversion thereby preventing that with the disappearance of SAD as a diagnostic label also adequate interventions disappear from clinical practice.
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Arch Sex Behav (2014) 43:1219–1223 Acknowledgments We would like to thank Irv Binik for triggering the idea of writing this commentary, for proofreading, and for commenting on an earlier version of it.
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