Arch Sex Behav
DOI 10.1007/s10508-009-9534-2
O R I G I N A L P A P E R
The DSM Diagnostic Criteria for Sexual Aversion Disorder
Lori A. Brotto
Ó American Psychiatric Association 2009
Abstract
Sexual Aversion Disorder (SAD) is one of two Sex-
professional attention, and students in the field are hard put to
ual Desire Disorders in the Diagnostic and Statistical Manual of
find literature on this topic’’ (p. 3). The state of the science some
Mental Disorders (DSM) and is defined as a ‘‘persistent or
20-plus years later has not changed much and there are still little
recurrent extreme aversion to, and avoidance of, all or almost
empirical data on Sexual Aversion Disorder (SAD). SAD is one
all, genital sexual contact with a sexual partner’’ which causes
of two Sexual Desire Disorders in the Diagnostic and Statistical
distress or interpersonal difficulty. This paper reviews the short
Manual of Mental Disorders (DSM-IV-TR; American Psychi-
history of the diagnosis of SAD as well as the existing literature
atric Association, 2000) (the other one being Hypoactive Sexual
on its prevalence and etiology. Kaplan (1987) emphasized the
Desire Disorder (HSDD)), and the most recent addition to the
phobic qualities of individuals with SAD who are highly
list of Sexual Dysfunctions in the DSM (American Psychiatric
avoidant of all forms of sexual contact. Much has also been
Association, 1987). Relative to the research done on HSDD,
written about the overlap between SAD and panic states, and the
much less is known about the prevalence, etiology, and treat-
more obvious similarities between SAD and anxiety as opposed
ment of SAD.
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
Diagnosis
placement of SAD as a Sexual Dysfunction and argues that it
might more appropriately be placed within the Specific Phobia
The original diagnostic criteria for SAD (302.79) required a
grouping as an Anxiety Disorder.
‘‘persistent or recurrent extreme aversion to, and avoidance
of, all or almost all, genital sexual contact with a sexual part-
Keywords
Sexual Aversion Disorder Á Sexual phobia Á
ner’’ and that this symptom did not occur ‘‘during the course
Sexual avoidance Á DSM-IV-TR Á DSM-V
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,
Introduction
2000), Criterion A did not change from that listed in the DSM-
III-R. The only addition to the diagnostic criteria was Criterion
In the book, Sexual Aversion, Sexual Phobias, and Panic Dis-
B–that the disturbance cause marked distress or interpersonal
order, published in the same year that DSM-III-R (American
difficulty (Table 1). The DSM-IV-TR text indicates that anx-
Psychiatric Association, 1987) was released, Kaplan (1987) re-
iety, fear, or disgust when confronted with a sexual opportunity
marked that ‘‘sexual panic states have received surprisingly little
are features of SAD. Moreover, the scope of the sexual stimuli
producing the aversion can range from a specific aspect of the
sexual encounter (e.g., genital secretions) to any and all sexual
L. A. Brotto (&)
stimuli (including kissing, touching, and hugging). The text
Department of Obstetrics and Gynaecology, University of British
goes on to describe symptoms of anxiety (e.g., panic attacks)
Columbia, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada
e-mail: lori.brotto@vch.ca
and avoidance behavior as signs of severe SAD.
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Arch Sex Behav
Table 1 DSM-IV-TR diagnostic criteria for Sexual Aversion Disorder
focuses on the affective aspects and not on the behavioral aspects
(302.79)
(as the latter is captured by ‘‘and avoidance’’).
It is likely (although this cannot be verified due to the unavail-
A. Persistent or recurrent extreme aversion to, and avoidance of, all (or
almost all) genital sexual contact with a sexual partner
ability of DSM-III-R Sourcebooks) that the empirical justifica-
B. The disturbance causes marked distress or interpersonal difficulty
tion for including SAD as a new disorder in DSM-III-R stem-
C. The sexual dysfunction is not better accounted for by another Axis I
med from Kaplan’s own patients and observations. Kaplan
disorder (except another Sexual Dysfunction)
(1987) reported on the characteristics of 373 patients with sexual
Specify type
avoidance who were seen at the Human Sexuality Program of
Lifelong type
the Payne Whitney Clinic as well as a private clinic between
Acquired type
1976 and 1986. Kaplan found that 9% of those who avoided sex
Specify type
also met criteria for Panic Disorder and, as such, suggested that
Generalized type
pharmacotherapy for the Panic Disorder would improve the
Situational type
sexual aversion. The proportion of those with Panic Disorder
Specify
was even higher (25%) among those individuals who avoided
Due to psychological factors
sex and also had a phobia of sex. Another 25% of those with
Due to combined factors
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
Sexual aversion was described by Kaplan as being persistent
spent on describing the panic experienced by these individuals
and irrational as well as ego-dystonic, with the phobic avoidance
and describing therapeutic approaches to phobias (in general) as
causing significant distress to the individual. She also indicated
well as Panic Disorder. Kaplan (1988) noted that individuals with
that it may or may not be co-morbid with other sexual dys-
Panic Disorder were particularly prone to SAD because of their
functions. Kaplan described total and situational forms of sexual
personality traits of separation anxiety, rejection sensitivity, and
aversion: total aversion involved any and all erotic sensations,
overreaction to criticism from significant others such as lovers.
feelings, thoughts, and opportunities whereas situational was
The placement of SAD as a Sexual Dysfunction as opposed to
limited to a specific aspect of sex (e.g., genitalia, being pene-
a Specific Phobia at the time seems to have been related to the
trated, fantasies, orgasm, oral sex, etc.). Kaplan noted an inter-
type of stimulus responsible for the phobic reaction (i.e., a sexual
esting feature of individuals with situational sexual aversion in
stimulus). However, the other Specific Phobias (then classed as
that they could enjoy many aspects of sexual activity as long as
Simple Phobias) were not similarly categorized according to the
avoidance of their circumscribed phobic stimulus could be
type of stimulus that provoked symptoms (e.g., public speaking
maintained. Kaplan also described enormous variability across
phobia is not characterized as an Interpersonal Disorder, and fear
individuals with sexual aversion in their willingness to be sex-
of heights is not placed in a different category of related syn-
ually active, with some who were able to push past their reluc-
dromes). Kaplan (1987) presented the DSM-III criteria for Sim-
tance of sex and, once engaging in sexual activity, to experience
ple Phobia (300.29) and pointed out the similarity to the proposed
satisfaction. Others, however, were more severely phobic such
DSM-III-R criteria for SAD, stating: ‘‘It is not clear to me whether
that they could not feel any erotic sensations. Some of these indi-
sexual phobia and aversion are two discrete disorders…or whe-
viduals also experience panic attacks (‘‘discrete period of intense
ther aversion is simply a form of sexual panic with especially
apprehension, fearfulness, or terror, often associated with feelings
intense autonomic reactions. At this time, I tend to conceptualize
of impending doom’’ [American Psychiatric Association, 2000]
sexual aversion and phobic avoidance of sex as two clinical
with symptoms of autonomic activation). What makes sexual
variations of sexual panic states’’ (p. 11). The DSM-IV-TR text
aversion so distressing is that, unlike other phobias (e.g., snakes,
on the Differential Diagnosis section of SAD indicates that
heights), it is possible to avoid the phobic stimulus with little
‘‘Although sexual aversion may technically meet criteria for
interference in the individual’s life. However, with sexual pho-
Specific Phobia, this additional diagnosis is not given.’’ The ratio-
bias, Kaplan noted that ‘‘its avoidance can be profoundly destruc-
nale for why this was the case was not provided and there was no
tive’’ given that sexuality is a core feature of human existence.
information in the DSM-IV Sourcebook justifying this disclaimer.
Aversion itself is not actually defined in the DSM-IV (or DSM-
On the other hand, the Differential Diagnosis section of Specific
III-R). In other contexts, it is conceptualized as an emotion (e.g.,
Phobia makes no mention of SAD.
feelings of repugnance or extreme dislike) (Toronchuk & Ellis,
Despite the apparent similarities between sexual aversion
2007). Other aversions (e.g., conditioned taste aversion) may em-
and Specific Phobia, Janata and Kingsberg (2005) noted that a
phasize the behavioral correlates of aversion and not the emotional
critical difference between the two was that the former was
aspects. However, given that the DSM criteria indicate that there is
characterized by abhorrence and disgust while the latter was not.
aversion and avoidance, this implies that the definition of aversion
To explore the potential similarities between SAD, HSDD, and
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Arch Sex Behav
worry (the latter was assessed because it is associated with
one of the few empirical studies of SAD, 382 college under-
many DSM-IV-TR disorders including anxiety disorders), 138
graduates completed a survey assessing the DSM-III-R diag-
college students completed questionnaires such as the Sexual
nostic criteria for SAD (Katz et al., 1989). The 30-item Sexual
Aversion Scale (Katz, Gipson, Kearl, & Kriskovich, 1989), the
Aversion Scale (SAS) assessed fears about AIDS, social evalu-
Hurlbert Index of Sexual Desire (Apt & Hurlbert, 1992), and the
ation, pregnancy, and sexual trauma. Katz et al. found high
Penn State Worry Questionnaire (Meyer, Miller, Metzger, &
internal, test-retest, and item-total reliability of the scale. Katz
Borkovec, 1990). Worry was only weakly associated with both
et al. estimated the prevalence of sexual aversion severe en-
sexual aversion and sexual desire scores, leading Janata and
ough to warrant treatment seeking to be approximately 10%,
Kingsberg to conclude that worry was not a central feature of the
although 29% reported avoidance of nearly all genital contact.
sexual desire disorders.
Among those with sexual aversion, there were significant fears
In the DSM-IV-TR, SAD is diagnosed as lifelong or ac-
about AIDS, and Katz et al. predicted that such a question-
quired. Crenshaw (1985) noted that occasionally sexual aver-
naire would be important if AIDS were to spread to the het-
sion is specific to a certain relationship and that outside of that
erosexual population. In a subsequent validation study of the
relationship the person is able to function normally sexually.
SAS (Katz, Gipson, & Turner, 1992), scores on this measure
This would be deemed a situational SAD. Janata and Kingsberg
were significantly correlated with scores on the Fear Survey
(2005) prefer the categories of primary and secondary to refer to
Schedule (Wolpe & Lang, 2007), and individuals with a his-
the acquisition of fear and anxiety before or after, respectively,
tory of sexual abuse had higher scores of aversion. Since the
the development of a healthy sexual relationship. A lifelong
articles by Katz et al. 20 years ago, I could not locate any
SAD is senseless for the individual who, perhaps, had their
additional published studies using the SAS.
sexual debut in their teens, 20s, or even later. Secondly, because
Despite the large number of recent population-based epi-
of the leading theory of SAD as being a conditioned and, there-
demiological studies on sexual symptoms and distress, none
fore, acquired response, this also implies that it could never have
have asked about the prevalence and associated features of
been lifelong for conditioning would have had to take place at
sexual aversion. One exception is the large epidemiological
some point in time.
Zurich Cohort Study, of which a subset of the questions fo-
Interestingly, there was no change to the essential criterion
cused on sexual symptoms in 363 participants. A total of 12
for SAD (extreme aversion to and avoidance of sexual contact)
(3.3%) individuals reported feeling ‘‘constantly or once in a
from DSM-III-R to DSM-IV. It is also interesting to note that in
while extreme aversion to genital sexual contact’’ which
the DSM-IV Sourcebook (Schiavi, 1996), there was reference to
caused ‘‘distinct suffering or relationship conflicts’’ (J. Angst,
only two published empirical papers on SAD and both were
personal communication, February 23, 2009). Because of the
published prior to DSM-III-R (American Psychiatric Associ-
small sample size, analyses of the associated correlates of
ation, 1987). One study compared 20 sexually aversive indi-
sexual aversion were not possible.
viduals with 35 controls. The DSM-IV Sourcebook noted that
Knowledge about gender differences in sexual aversion is
no reliability information were provided, but that those with
virtually non-existent. However, Kingsberg and Janata (2003)
SAD scored significantly higher on the State-Trait Anxiety
noted that SAD primarily affects women and that men with
Inventory (Spielberger, Gorusch, & Lushene, 1970). The only
SAD are more likely to avoid relationships and, therefore,
conclusion drawn by the Sexual Dysfunctions Work Group was
distress due to sexual contact is less frequent than it is for
that there was no evidence to support ‘‘narrowing the diagnosis
women. In the college student sample studied by Katz et al.
of sexual aversion disorder to include individuals with aver-
(1989), scores on the SAS were significantly higher for women
sions limited to one or a few components of the sexual inter-
than they were for men. Women also worried significantly
action’’ (Schiavi, 1996, p. 1100). However, there was also no
more about being evaluated sexually by partners, were more
mention of justification for why SAD should continue to
avoidant, and were more fearful of intercourse than men.
remain a diagnosable sexual dysfunction.
Prevalence
Causal Mechanisms
The precise prevalence of SAD is unknown and difficult to
Janata and Kingsberg (2005) asserted that SAD is likely best
establish given that individuals avoid sexual encounters and
conceptualized as a conditioned aversion according to Mow-
therefore seldom present to sex therapy clinics. Based on
rer’s (1947) two-factor theory. It is possible that sexual stimuli
clinical experience, Crenshaw (1985) believed that sexual
were paired with painful or traumatic sexual stimuli, produc-
aversion syndrome was the most common sexual dysfunction;
ing the aversive conditioned response. There is clinical (Janata
however, Crenshaw noted that most clinicians ‘‘miss’’ the
& Kingsberg, 2005) and limited empirical (Noll, Trickett, &
diagnosis because they are inexperienced in identifying it. In
Putnam, 2003) support for a role for child sexual abuse in the
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Arch Sex Behav
etiology of SAD. There are no empirical data supporting the
I’m a 24 year old female, and I believe I suffer from sexual
speculation that SAD is due to a partner forcing sex upon an
aversion disorder. I find the thought of all genital contact
individual, despite what is claimed in some pop culture sources
quite repulsive, and on occasions in the past when guys
(www.marriagebuilders.com). Avoidance behavior then rein-
have tried to touch me below the waist I have become very
forces the conditioned avoidance. Because systematic desen-
panicky and upset. It’s not that I have no sexual desire, I
sitization has been found effective in two published case stud-
do, and I masturbate to orgasm around once a week.
ies of women with SAD (Finch, 2001; Kingsberg & Janata,
In a sample of 376 patients who avoided sex, Kaplan (1987)
2003), SAD was speculated to be similar to other anxiety
found that 21% also met criteria for Inhibited Sexual Desire
disorders which respond quite well to systematic desensitiza-
Disorder (now classified as HSDD). In an empirical test of the
tion (Choy, Fyer, & Lipsitz, 2007). For women, it has been
association between SAD and HSDD, although sexual desire
noted that, in general, SAD is less responsive to behavioral
and sexual aversion scores were significantly correlated (r =
treatment than is HSDD (Schover & LoPiccolo, 1982); how-
.33, p \ .001), sexual aversion scores accounted for only 11%
ever, there are no published studies comparing behavior ther-
of the variance in sexual desire scores (Katz & Jardine, 1999).
apy in HSDD versus SAD. There have been no published
Research on the distinction between desire and aversion is ex-
longitudinal studies exploring the etiology of SAD so state-
tremely limited to outdated studies with poor methodological
ments about proposed mechanisms are based on assertion
design. However, among those seeking treatment for sexual
only. Moreover, there are no published efficacy studies or case
concerns, anxiety was significantly higher among those with
reports on treatment of SAD in men.
sexual aversion compared to those with low sexual desire (Murphy
Kaplan (1987) also believed that Mowrer’s (1947) two-fac-
& Sullivan, 1981). There was no information in the DSM-IV
tor theory explained the etiology of sexual aversion but added
Sourcebook (Schiavi, 1996) justifying SAD as a Sexual Desire
that reinforcement processes were responsible for its mainte-
Disorder.
nance. Specifically, Kaplan argued that the sexual aversion was
maintained because of a vicious cycle of avoidance and rein-
forcement of the avoidance behavior. Because avoidance allows
Overlap Between Sexual Aversion Disorder
the individual to be free of the significant sexual anxiety and
and Vaginismus
distress, avoidance becomes self-perpetuating and therefore
reinforcing.
As reviewed by Binik (2009), there is some overlap between
Kaplan (1987) noted that psychoanalytic theories also at-
SAD and vaginismus, the latter of which is defined in DSM-IV
tempt to explain the etiology of SAD in that the phobic anxiety
by a recurrent or persistent involuntary vaginal muscle spasm.
is activated among those individuals with unresolved oedipal
The International Consultation Committee sponsored by the
conflicts. For those 4–5 year old boys who do not mature from
American Urological Association Foundation refined the defi-
the stage of having sexual feelings for their mothers and being
nition of vaginismus in recognition of the finding that vaginal
fearful of castration by their fathers, neurotic anxiety (and sex-
muscle spasm was not universally present among women with
ual aversion) may develop. Treatment is therefore aimed at
vaginismus whereas fear of penetration was. This group de-
resolving the oedipal complex. Unfortunately, this particular
scribed vaginismus as ‘‘The persistent or recurrent difficulties of
theory has never been tested directly nor have there been
the woman to allow vaginal entry of a penis, a finger, and/or any
empirical tests of the efficacy of psychoanalysis for SAD.
object, despite the woman’s expressed wish to do so. There is
often (phobic) avoidance and anticipation/fear of pain’’ (Basson
et al., 2003). Basson et al. highlighted the phobic qualities of
Is Sexual Aversion Disorder a Sexual Desire Disorder?
vaginismus and concluded that it was fear of penetration that
characterized vaginismus more than vaginal spasm. Because
Although SAD is listed as one of the two Sexual Desire Disorders,
women with vaginismus are fearful of (painful) vaginal pene-
there appear to be few similarities between HSDD and SAD—the
tration, this often results in avoidance behavior and even in
former being characterized by the absence of desire and the latter
aversion in severe cases. It is possible, therefore, that some cases
as the presence of fear and avoidance. Although Schover and
of aversion are due to vaginismus, although both disorders can be
LoPiccolo (1982) conceptualized SAD and HSDD as being at
diagnosed simultaneously. Although there are no empirical data
opposite ends of the same spectrum, Kaplan (1987) disagreed
that have sought to differentiate these two disorders, vaginismus
with this conceptualization, noting that individuals with SAD can
is classified as a sexual pain disorder because of the overlap with
continue to experience normal sexual desire, fantasize, and often
dyspareunia. If the aversion is exclusively due to fear of pain, then
masturbate to orgasm. Indeed, internet advice columns (e.g.,
the diagnosis indeed would be one of vaginismus and not SAD.
psychcentral.com/ask-the-therapist) present queries from indi-
Thus, there appears to be enough of a difference in the diagnostic
viduals with SAD symptoms despite apparent normal levels of
descriptions of the two disorders to justify their assignment to
sexual desire:
different classes of sexual dysfunction.
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Arch Sex Behav
Overlap Between Sexual Aversion Disorder
follows Mowrer’s (1947) two-factor theory of pathogenesis
and Specific Phobia
and (2) it responds optimally to behavior therapy in the form
of systematic desensitization.
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
Recommendations
stimulus, it is readily apparent that the individual with SAD
could meet criteria for a Specific Phobia. Although the text on
It is perhaps no coincidence that Sexual Aversion Disorder
SAD indicates that ‘‘…sexual aversion may technically meet
was added to the DSM-III-R (American Psychiatric Asso-
the criteria for Specific Phobia, this additional diagnosis is
ciation, 1987) under the influence of Kaplan in the same year
not given’’ (American Psychiatric Association, 1994, p. 499),
that Sexual Aversion, Sexual Phobias, and Panic Disorder
paradoxically the text on Specific Phobia makes no mention
(Kaplan, 1987) was published. Kaplan was a major proponent
of SAD. It might be inferred from these criteria that the
for including SAD into the DSM based on clinical observa-
Anxiety Disorders Work Group had not considered the fact
tions. However, its inclusion into the diagnostic taxonomy
that SAD could technically overlap with the criteria for
has not translated into increased research on the topic (as it
Specific Phobia and therefore did not list it as a Differential
perhaps was originally hoped). Instead, there are only a few
Diagnosis. The rationale for why SAD should be classified as
case studies published on SAD and, since the publication of
a Sexual Dysfunction and not an Anxiety Disorder is simi-
DSM-IV-TR in 2000, there have been no published epide-
larly not clarified. The limited empirical data available sug-
miological studies on the topic.
gest that SAD is similar to Specific Phobias in that (1) it likely
There are three possible alternatives for dealing with SAD
in DSM-V. The APA draft guidelines for making changes to
Table 2 DSM-IV-TR diagnostic criteria for Specific Phobia (300.29)
DSM-V (DSM-V Task Force Document, 2009) provides a list
of five principles to consider when proposing a change to the
A. Marked and persistent fear that is excessive or unreasonable, cued by
DSM. These include: (1) to distinguish between psychiatric
the presence or anticipation of a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood)
syndromes for purposes of guiding the most effective treat-
B. Exposure to the phobic stimulus almost invariably provokes an
ment and management; (2) to reduce confusion of syndromes
immediate anxiety response, which may take the form of a
with each other; (3) to take into account co-morbid symptoms
situationally bound or situationally predisposed Panic Attack.
which affect the outcome of treatment in the most effective
Note: In children, the anxiety may be expressed by crying,
manner; (4) to facilitate ease of use and promote clinical utility;
tantrums, freezing, or clinging
and (5) to demonstrate validity on as many levels as possible.
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent
Among the principles that are most relevant to SAD is one that
D. The phobic situation(s) is avoided or else is endured with intense
states that the goal is to distinguish among psychiatric syn-
anxiety or distress
dromes for purposes of treatment. Changes should also reduce
E. The avoidance, anxious-anticipation, or distress in the feared
confusion among syndromes. Both of these points are relevant
situation(s) interferes significantly with the person’s normal routine,
to the diagnostic category of SAD given its apparent overlap
occupational (or academic) functioning, or social activities or
with phobias and possibly with vaginismus. Thus:
relationships, or there is marked distress about having the phobia
Option 1 is to remove SAD from the DSM-V and expand the
F. In individuals under age 18 years, the duration is less than 6 months
definition of vaginismus to encompass women with sexual
G. The anxiety, Panic Attacks, or phobic avoidance associated with the
specific object or situation are not better accounted for by another
aversion. As noted earlier in this review, some women with
mental disorder, such as Obsessive–Compulsive Disorder (e.g., fear
vaginismus experience aversion to sexual activity. Crenshaw
of dirt in someone with an obsession about contamination),
(1988) noted that there is a high correlation between primary
Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated
sexual aversion and vaginismus in women, but this claim has
with a severe stressor), Separation Anxiety Disorder (e.g., avoidance
of school), Social Phobia (e.g., avoidance of social situations because
never been empirically verified. The potential benefit of sub-
of fear of embarrassment), Panic Disorder With Agoraphobia, or
suming sexual aversion under the category of vaginismus is
Agoraphobia Without History of Panic Disorder
that women with vaginismus would not be further patholo-
Specify type
gized by having an additional disorder if they were aversive of
Animal type
sex. However, in women with SAD, the aversive stimulus is
Natural environment type (e.g., heights, storms, water)
typically genital sexual contact with a partner, not necessarily
Blood–Injection–Injury type
fear/anticipation of pain, as in the case of vaginismus. More-
Situational type (e.g., airplanes, elevators, enclosed spaces)
over, many (if not most) women with vaginismus also expe-
Other type (e.g., phobic avoidance of situations that may lead to
rience comorbid sexual pain, and this is not a clinical feature of
choking, vomiting, or contracting an illness; in children,
women with SAD. One might speculate that the aversion to sex
avoidance of loud sounds or costumed characters)
among women with vaginismus is, therefore, adaptive since
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Arch Sex Behav
they are avoiding painful sexual activity. This appears not to be
services data, course, and treatment outcome data were non-
the case with SAD. Thus, although some women with vagi-
existent. Moreover, the requirement that the disorder in
nismus do experience aversive or phobic-like reactions to
question is sufficiently distinct from other disorders to warrant
vaginal penetration, this is not the same group of women
designation as a separate disorder was not met and it could
originally conceptualized by Kaplan (1987) as being sexually
have been captured as a subtype of another disorder (Specific
aversive. I am not in favor of subsuming sexual aversion under
Phobia). It is possible that the historical influence of Kaplan
the category of vaginismus.
overshadowed the lack of empirical data justifying SAD as a
Option 2 is to remove SAD from the DSM-V and make the
new diagnostic entity. With DSM-V and the emphasis placed
recommendation that cases of genital contact phobia be cap-
on any changes being based on empirical science, SAD clearly
tured under the diagnosis of Specific Phobia. This would in-
would not have made its way into the DSM.
volve adding to the text description of Specific Phobia that
aversion to sexual contact is one manifestation of phobia in the
Acknowledgments
The author is a member of the DSM-V Work-
group on Sexual and Gender Identity Disorders. I wish to acknowledge
‘‘Other Type’’ category. It would not be necessary to change
the valuable input I received from members of my Workgroup (Yitzchak
the diagnostic criteria for Specific Phobia itself to account for
Binik, Cynthia Graham, R. Taylor Segraves) and Kenneth J. Zucker.
sexual aversion given that, as outlined earlier, if one were to
Feedback from DSM-V Advisors Richard Balon and Sheryl Kingsberg
substitute ‘‘sexual stimulus’’ for ‘‘specific object’’ or ‘‘stimu-
is greatly appreciated. Reprinted with permission from the Diagnos-
tic and Statistical Manual of Mental Disorders V Workgroup Reports
lus’’ in the criteria, this description captures the entity of SAD
(Copyright 2009), American Psychiatric Association.
already. It is unclear why the DSM-IV-TR text description of
SAD indicates that a diagnosis of Specific Phobia should not be
given if one has SAD, particularly as a parallel statement is not
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Document Outline

• The DSM Diagnostic Criteria for Sexual Aversion Disorder
  • Abstract
  • Introduction
  • Diagnosis
  • Prevalence
  • Causal Mechanisms
  • Is Sexual Aversion Disorder a Sexual Desire Disorder?
  • Overlap Between Sexual Aversion Disorder and Vaginismus
  • Overlap Between Sexual Aversion Disorder and Specific Phobia
  • Recommendations
  • Acknowledgments
  • References

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