Sexual Healing
Page 8
Mary Ann clearly did not have low sexual desire. Her observation illustrates the fact that people often feel they have low sexual desire when what they really have is a problem with the object of that desire rather than with the level of desire itself. I referred her to a marriage counselor because I didn’t really think low desire was her main problem. Her relationship with her husband was clearly a more pressing concern.
If you picked up a copy of Sexual Healing because of issues with low sexual desire, by now I probably have you really confused. What I’m trying to convey is that if you would like to benefit from the healing of your problem with desire, you will first have to figure out if that’s actually the main issue. Here are some questions to ask yourself to determine whether low sexual desire is your root problem:• Is your testosterone level low or nonexistent? This is the first thing you should have checked if you are experiencing a lack of desire.
• Are you on medications such as antidepressants, antianxiety agents, or birth control pills? Any of these could cause low desire.
• Do you have other sexual problems such as difficulties with arousal or erections? Your desire problems could be a result of other accompanying sexual problems.
• Would you desire sex if you were with a different partner? If the answer is yes, you may have relationship issues that are interfering with your desire.
• Finally, do you think you would desire sex if you knew you could function well whenever you wanted to? If so, low desire probably isn’t your most pressing sexual problem.
The program described in Chapter 28 for healing desire problems will work very well for you if desire is the main problem, if you basically have a good relationship, and if you are motivated to increase your desire. If you have examined yourself and realize that your desire issues are actually secondary to another sexual problem, then you should try healing the primary problem first. Also, recognize that your problem could be medical: the result of low testosterone, other hormone problems, or prescription drugs.
chapter 6
Sexual Aversion Disorder
According to the DSM, sexual aversion disorder (SAD) is “persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.” The DSM also says that sexual aversion disorder may range from “moderate anxiety and lack of pleasure to extreme psychological distress.”
In lifelong sexual aversion disorder, the person has experienced anxiety ever since he or she began to attempt partner sex. In acquired sexual aversion disorder, the person functioned without anxiety in sexual situations at some point, but cannot do so now. In generalized sexual aversion disorder, a person exhibits anxiety during a variety of different sexual situations, or during all sexual situations. In situational sexual aversion disorder, the person exhibits anxiety during a particular sexual behavior, or while having sexual contact with a particular person.
With sexual aversion disorder, as well as with many of the other sexual dysfunctions addressed in this book, we have some problems with the definition. As you read in Chapter 3, all of the sexual dysfunctions are caused by anxiety. A person will exhibit different symptoms depending on when in the sexual encounter the anxiety hits. With sexual aversion disorder, the anxiety symptoms are usually the entire problem. SAD is not a sexual dysfunction as such—the genitals are probably functioning fine in terms of erection, arousal, and orgasm. The problem is that the person experiences such intense anxiety in a sexual encounter or at the thought of a sexual encounter that he or she can’t function physically at all.
There’s also a definition problem with the words anxiety, aversion, and avoidance, all of which have been used interchangeably to describe this condition. In fact, these words don’t mean the same thing. In Chapter 3 I presented a definition of anxiety. It’s a mind-body phenomenon in which a person experiences physical symptoms, like rapid heart rate, and mental symptoms, like worry. It involves arousal of the sympathetic nervous system when there’s really no physical threat. I think the concept of fear is very close to the concept of anxiety. The difference is that although both fear and anxiety produce the same physical symptoms, fear occurs in the presence of a genuine threat.
Aversion is a feeling of repugnance or disgust toward something. It’s an attitude, a negative evaluation of an object or behavior. Avoidance is the behavioral manifestation of aversion. If you have a negative evaluation of something, you usually do your best to stay away from it.
Here’s our problem from the standpoint of trying to understand sexual dysfunctions: Some people have an aversion to sex. They think it’s disgusting in some way, but they don’t experience anxiety symptoms when confronted with it, and they may not even try to avoid it. They may just sort of grin and bear it, or allow their partner to have sex with them. There are other people who like the idea of sex—they don’t find it repugnant at all—yet when confronted with a sexual situation, they experience intense anxiety symptoms. Some people avoid sex for reasons that have nothing to do with anxiety, such as religious reasons. They avoid sex so they won’t be tempted, because having sexual contact with another person goes against their belief system in some way. Still other people have all three symptoms. They are disgusted by sex, they have anxiety symptoms when confronted with a sexual situation, and they try to avoid sexual situations.
To add to the confusion, there’s a personality trait called erotophobia, which is fear of sex. An erotophobe finds everything about sex fearful—not just potential sexual contact with a partner, but hearing about sex, reading about sex, viewing sexually explicit materials, or anything else having to do with sex. Erotophobia usually includes the whole gamut—fear, anxiety, aversion, and avoidance. Being a personality trait rather than a sexual dysfunction as such, erotophobia is very resistant to change. (The opposite of erotophobia is erotophilia. This personality trait describes someone who loves everything about sex.)
What’s Normal?
As I did with sexual desire, I’m going to be very broad in deciding what “normal” means. I think it’s normal for a person to have a sexual relationship that doesn’t involve any overt anxiety symptoms. I believe this is the case for most people.
However, let me add another term to our vocabulary of aversion, anxiety, and avoidance. That term is anticipation. It’s normal to feel a little bit nervous about having a sexual encounter with someone who excites you, someone with whom you’ve never had sex, or someone with whom you’re in love. Most of us have experienced that “butterflies in the stomach” sensation. It’s perfectly normal to feel that sensation when you’re in love or when you’re anticipating your first sexual encounter with a new lover. It doesn’t mean you have an anxiety problem. When you’re in love, it’s also normal to feel negative sensations, such as anxiety, at the thought of possibly losing your partner. Again, this doesn’t mean you have sexual aversion disorder.
So what constitutes the problem known as sexual aversion disorder? Having worked for many years with people with sexual dysfunctions, I believe that sexual aversion disorder should be referred to as sexual anxiety disorder or sexual phobia. I think the problem is best described by using the terminology of anxiety symptoms. One of the reasons I believe this is because, from a treatment standpoint, working with overt anxiety symptoms is better than trying to deal with aversion or avoidance. But for the purposes of this book, I’ll call this condition sexual aversion disorder because the DSM does. As you read, keep in mind that I’m describing anxiety.
Types of Anxiety
There are many different types of anxiety, any of which could be associated with sexual aversion disorder. These forms of anxiety are not unique to sexual concerns; people can develop any of them in response to any stimulus they learn to be afraid of. Here’s a list of the most common forms of anxiety. In my experience, these are the forms that are most often associated with sexual problems.
• Generalized anxiety disorder (GAD)
• Posttraumatic stress disorder (PT
SD)
• Panic attack
• Specific phobia
• Social phobia or social anxiety
• Obsessive-compulsive disorder (OCD) or obsessive-compulsive personality disorder
In generalized anxiety disorder, a person experiences a low to moderate anxiety level most of the time. Sometimes this is called free-floating anxiety because it’s so pervasive that it seems to be able to attach itself to just about any stimulus. People with generalized anxiety disorder are afraid of a lot of different things and are pretty much anxious all the time. Sex is a very common source of anxiety for these people. Symptoms are mainly rapid heart rate and worry.
Posttraumatic stress disorder is caused by being the victim of an unusually serious source of stress, the type that most people don’t experience in their lifetime. Examples would be wars, plane crashes, violent crimes, sexual trauma, or natural disasters. Symptoms of posttraumatic stress disorder include insomnia, hypervigilance, and flashbacks to the original trauma. You can see that these would all interfere with the ability to be intimate with another person, which could certainly have an effect on one’s sex life. Rather than causing sexual aversion disorder, posttraumatic stress disorder is likely to cause difficulty with arousal and orgasm.
Panic attack or panic disorder is a very severe, debilitating form of anxiety. A person with panic disorder experiences rapid heart rate, sweating, dizziness, a feeling of choking, chest pain, shortness of breath, chills or hot flashes, feelings of unreality, and fears of losing control, going crazy, or dying. Panic attacks can be so severe that they can cause nausea, vomiting, or diarrhea. I have seen many clients who had panic attacks in sexual situations. Panic attacks also involve what’s called anticipatory anxiety. This means the person learns to fear having the panic attack itself, rather than just fearing the stimulus (in this case, a sexual encounter).
A phobia is a specific, irrational fear. The following is a list of some common sexual phobias. I got this list from Sexual Aversion, Sexual Phobias, and Panic Disorder, by Helen Singer Kaplan. I have seen all of these phobias in clients.
• Fear of the genitalia of the opposite sex
• Fear of the patient’s own genitals
• Fear of being penetrated
• Fear of penetrating
• Fear of heterosexual activity
• Fear of homosexual activity
• Fear of sexual fantasies
• Fear of sexual secretions and odors
• Fear of sexual failure
• Fear of sexual arousal
• Fear of orgasm
• Fear of breast touching
• Fear of kissing
• Fear of partner rejection or belittlement
• Fear of undressing or being seen nude
• Fear of seeing the partner undressed
• Fear of oral sex (giving or receiving)
• Fear of anal sex (penetrating or being penetrated)
• Fear of pleasure
• Fear of commitment
• Fear of intimacy and closeness
• Fear of falling in love or being loved
• Fear of being sexually coerced or forced to have sex
• Fear of contracting a sexually transmitted disease
• Fear of becoming pregnant
Social phobia is a specific phobia that involves fear of interacting with other people in some way. Obviously, sexual aversion disorder involves a component of social phobia for most individuals. People generally are more afraid of aspects of sex with another person than they are of sex with themselves. The main features of social phobia are a fear of being observed by other people and being humiliated, or a fear of one’s performance being judged. Other forms of social phobia, besides sexual fears, include a fear of public speaking and stage fright.
Obsessive-compulsive disorder is characterized by obsessions (uncontrollable disturbing thoughts) and compulsions (uncontrollable disturbing behaviors, such as counting, cleaning, or repeating words). The obsessions cause anxiety and the compulsions relieve it. I have seen obsessive-compulsive disorder most often associated with fears of touching or fears of body odors or secretions. Obsessive-compulsive personality disorder (OCPD) is somewhat different. The anxiety symptoms are not as overt, and the person is more preoccupied with perfectionism or organization. This could manifest itself in problems such as only being able to have sex a certain way, and it also interferes with intimacy in interpersonal relationships.
I know this is a lot of information to throw at you. For our purposes, I’ll simplify it as much as I can and say that from my standpoint the most important issue with sexual aversion disorder is the level of the anxiety symptoms. In my experience, most cases of sexual aversion disorder involve either mild to moderate levels of anxiety (as in GAD) or severe levels of anxiety (as in panic attacks). This distinction is important because it helps a clinician decide whether or not a person needs medication and, if so, what kind. A person with sexually derived panic disorder often can’t even experience psychological treatment without some type of antianxiety medication.
Also important is whether you are having active anxiety symptoms because of sexual activity or have avoided sex for a long time. People with fears tend to avoid the situations that cause the fears. An analogy would be fear of flying. If you never fly because you are afraid to, you can’t actually say that you experience fear in a flying situation, can you? The same thing is true of sex. Before attempting to heal yourself of sexual aversion disorder, you need to recognize whether you have avoided sex for so long that you don’t really know what sensations to expect in terms of anxiety. Believe it or not, it’s actually easier to treat someone with overt anxiety (including panic attacks) than it is to treat someone who has avoided sex for a long period of time. It just takes longer to treat the person who has avoided sex.
The sexual healing program described for sexual aversion disorder in Chapter 29 can be adapted for different levels of anxiety. The level of anxiety is more important in determining the specific treatment course than the specific phobia is. You can use the treatment program in Chapter 29 for any sexual phobia.
Causes of Sexual Aversion Disorder
Simply saying that anxiety causes sexual aversion disorder doesn’t tell us a lot, does it? Anxiety is the most obvious proximal cause, but what caused the anxiety in the first place? A number of factors could be relevant. One is that anxiety disorders tend to be hereditary. They run in families. This is especially the case for generalized anxiety disorder and panic disorder. There seems to be some genetic predisposition for panic disorder. People with panic disorder appear to have an abnormally elevated startle response and a tendency to pay excessive attention to body states such as rapid heart rate. They are oversensitive to bodily cues that many of the rest of us ignore.
Physical or biological factors can also trigger anxiety, which can manifest itself in sexual situations. The use of stimulants, even relatively mild ones like caffeine and nicotine, can cause anxiety. Hyperthyroidism (an overactive thyroid gland) can cause it. Any cardiovascular problem that causes irregular heart rate can trigger anxiety. So can heavy alcohol use, due to withdrawal symptoms.
Family background and upbringing can often predispose a person to sexual aversion disorder. People who grow up in families that don’t show affection often develop phobias about touching. A strict religious background in which sex is forbidden or not mentioned at all can also predispose a person to sexual aversion disorder. Sexual trauma is a huge cause of fear of sex. Childhood sexual abuse can cause lifelong sexual aversion disorder, and rape or sexual assault as an adolescent or adult can cause acquired sexual aversion disorder.
Of course, it’s also possible that some factor in a person’s current interpersonal relationship could contribute to sexual aversion disorder. Fear of intimacy or fear of commitment can trigger it. If someone’s sexual partner becomes particularly unattractive in some way, this could cause aversion to that particular p
artner. We would call this situational sexual aversion disorder since it only applies to the one partner. It might actually be better treated as a low sexual desire issue or as a relationship issue.
In Chapter 1, I briefly discussed the difference between a psychoanalytic approach to treating sexual dysfunctions and a behavioral approach. Obviously, this book describes a behavioral approach to healing sexual problems. However, just for your information, you should know that in the psychoanalytic approach, anxiety is a very important concept. Psychoanalysts believe that people can learn to become afraid of almost any stimulus, especially sexual stimuli, because sexuality is an area that is threatening to many of us due to a restrictive upbringing. Other psychologists believe that sexual anxiety actually begins in childhood with separation anxiety: the fear of separating from our primary caregiver.
Alan
In my practice as a surrogate partner, I treated many clients with different levels of sexual anxiety. One of the most severe cases I saw was Alan, age fifty-two. He had several very strong phobias about sexual activity. I counted ten separate phobias, including fear of nudity and fear of being touched. He also had many nonsexual phobias, including a fear of going barefoot. His anxiety was on the level of panic disorder. He often became nauseous at the thought of sexual intercourse and suffered incapacitating stomach cramps. I took him through the program described in this book, starting with intensive daily relaxation exercises. It took several months, but he was finally able to have sexual intercourse without overt anxiety symptoms.