Giving In to Arousal or Staying Stuck in Disgust? Disgust-Based Mechanisms in Sex and Sexual...

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Giving In to Arousal or Staying Stuck in Disgust? Disgust-Based Mechanisms in Sex and Sexual DysfunctionPeter J. de Jong a , Mark van Overveld b & Charmaine Borg aa Department of Clinical Psychology, University of Groningenb Rotterdam School of Management, Erasmus University RotterdamVersion of record first published: 12 Mar 2013.

To cite this article: Peter J. de Jong , Mark van Overveld & Charmaine Borg (2013): Giving In to Arousal or Staying Stuck inDisgust? Disgust-Based Mechanisms in Sex and Sexual Dysfunction, Journal of Sex Research, 50:3-4, 247-262

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Giving In to Arousal or Staying Stuck in Disgust? Disgust-BasedMechanisms in Sex and Sexual Dysfunction

Peter J. de JongDepartment of Clinical Psychology, University of Groningen

Mark van OverveldRotterdam School of Management, Erasmus University Rotterdam

Charmaine BorgDepartment of Clinical Psychology, University of Groningen

Sex and disgust seem like strange bedfellows. The premise of this review is that disgust-basedmechanisms nevertheless hold great promise for improving our understanding of sexual beha-vior, including dysfunctions. Disgust is a defensive emotion that protects the organism from con-tamination. Accordingly, disgust is focused on the border of the self, with the mouth and vaginabeing the body parts that show strongest disgust sensitivity. Given the central role of theseorgans in sexual behavior, together with the fact that bodily products are among the strongestdisgust elicitors, the critical question seems not whether disgust may interfere with sex but ratherhow people succeed in having pleasurable sex at all.We argue that sexual arousal plays a criticalrole in counteracting disgust-induced avoidance via lowering the threshold for engaging in ‘‘dis-gusting sex.’’ Following this, all mechanisms that interfere with the generation of sexual arousalor enhance the disgusting properties of sexual stimuli may hamper the functional transition froma sex-avoidance into an approach disposition. Since prolonged contact is the most powerfulmeans to reduce disgust, disgust-based mechanisms that counteract sexual approach may giverise to a self-perpetuating cycle in which enhanced sexual disgust becomes a chronic feature.

Current models of sexual behavior, such as the dual con-trol model (Bancroft & Janssen, 2000), propose that sexualresponses involve an interaction between sexual excitatoryand sexual inhibitory processes. From such a perspective,the generation of sexual responses may be compromisedwhen sexual inhibition outweighs sexual excitation(Bancroft, Graham, Janssen, & Sanders, 2009). Accord-ingly, relatively weak excitatory and relatively stronginhibitory tendencies may interfere with functional sexualbehaviors, and may give rise to sexual problems such aserectile dysfunction and low sexual desire.

Many different interpersonal and intrapersonal pro-cesses may fuel inhibitory tendencies in sexual contexts,such as relational worries or difficulties (e.g., feelinglack of trust) (Graham, Sanders, Milhausen, & McBride,2004) and concerns about one’s actual sexual functioning(e.g., worries about not getting an erection) (Janssen,Vorst, Finn, & Bancroft, 2002). Also, negativemood states(e.g., depression and anxiety) as well as negative emotional

reactions such as fear (e.g., due to the anticipation of painor performance failure) are typically associated withdecreases in sexual interest or responsiveness (e.g., Barlow,1986; Janssen & Everaerd, 1993; Janssen et al., 2002).Although disgust and disgust-related preoccupations alsoseem obvious candidates for being involved in the inhi-bition of sexual responses, it seems disgust has thus farbeen largely overlooked as a potentially relevant factorthat may compromise the generation of ‘‘healthy’’ sexualresponses. Underlining the more general negligence of dis-gust as a potentially relevant factor in human sexuality,there is no single reference to disgust in the subject indicesof current textbooks on human sexuality (e.g., Hock, 2011;McAnulty & Burnette, 2004; Rathus, Nevid, &Fichner-Rathus, 2005).

In this article we argue that disgust has great promisefor improving our understanding of (dys)functionalsexual behaviors andmay also provide potentially interest-ing avenues for treatment. Yet because many if not mostaspects of the link between sex and disgust are still await-ing empirical scrutiny, the present article relies heavily ontheoretical speculation instead of empirical data. We firstdefine disgust and discuss both its critical features andits proposed functional properties. In doing so, we also

Correspondence should be addressed to Peter J. de Jong, Depart-

ment of Clinical Psychology, University of Groningen, Grote

Kruisstraat 2=1, 9712 TS Groningen, The Netherlands. E-mail: p.j.de.

jong@rug.nl

JOURNAL OF SEX RESEARCH, 50(3–4), 247–262, 2013

Copyright # The Society for the Scientific Study of Sexuality

ISSN: 0022-4499 print=1559-8519 online

DOI: 10.1080/00224499.2012.746280

speculate on how disgust-based mechanisms may play arole in common sexual behavior and how these samemechanisms may contribute to the generation of sexualproblems. In the second section, we discuss how disgustmight be involved in sexual dysfunctions, with a particularfocus on vaginismus. In the final part of this review, we dis-cuss the clinical implications of a disgust conceptualizationfor the treatment of particular sexual problems andsummarize important lacunae that still call for furtherinvestigation.

Disgust and Sex

Disgust has long been acknowledged as one of thebasic emotions that are recognized across cultures (Dar-win, 1872=1989; Ekman, 1972). Although disgust is gen-erally considered a universal emotion, the exactconditions that elicit disgust are highly variable and seemshaped by societies over the life span of an individual(Sawchuk, 2009). The emotion of disgust is characterizedby a typical facial expression, including wrinkling of thenose and raising of the upper lip; it motivates escape andavoidance tendencies, and upon undesirable contact orincorporation of disgusting stimuli it may give rise todefensive reflexes (for reviews, see Rozin & Fallon,1987; Olatunji & Sawchuk, 2005). Although there isconsiderable variation in the concrete stimuli people finddisgusting, the whole range of disgusting stimuli seems tocluster in three coherent domains of disgust: pathogendisgust, sexual disgust, and moral disgust (e.g., Tybur,Lieberman, & Griskevicius, 2009)1. Each of these threedomains has been proposed to relate to a qualitatively

different adaptive problem that humankind faced in itsphylogenetic history. In the following section we describethe various types of disgust, and for each of these types ofdisgust we discuss how it might play a role in sexualbehaviors and contribute to sexual problems.

Pathogen Disgust

The first type of disgust concerns stimuli such asspoiled foods and body products, which share commonfeatures somehow implicated in an increased risk of thetransmission of infectious disease. It has been proposedthat this pathogen disgust evolved as a first line ofdefense to protect humans from contamination by infec-tious agents (Curtis, de Barra, & Aunger, 2011; Oaten,Stevenson, & Case, 2009). Via eliciting the overwhelmingurge to withdraw from the disgusting cue, pathogen dis-gust facilitates the avoidance of physical contact withand ingestion of pathogens. Consistent with such adisease-avoidance conceptualization, (pathogen) disgustis typically focused on the intersection between the bodyand the environment and concentrates on the skin andbody apertures (Fessler & Haley, 2006; Rozin, Nemeroff,Horowitz, Gordon, & Voet, 1995).

Providing further indirect support for the view that(pathogen) disgust may guard against disease, it has beenshown that women’s disgust propensity (i.e., their gen-eral tendency to respond with the emotion of disgust toany given situation) varies as a function of their men-strual cycle, with highest scores during the luteal phasewhen the vulnerability to disease is relatively high dueto a down-regulation of inflammatory immune responses(Fleischman & Fessler, 2011). In a similar vein it hasbeen shown that disgust propensity is also relatively highduring the first trimester of pregnancy, when mother andfetus are most vulnerable to disease (Fessler, Eng, &Navarette, 2005). Thus, the behavioral disease avoidancesystem seems to adjust the level of disgust propensity as afunction of biological immunocompetence.

Sexual behavior represents an obvious threat for thetransmission of disease. The close physical contact, bodyapertures, and exchange of bodily fluids that are impliedin sexual behavior provide ample opportunity for thetransmission of pathogens. From the starting point thatpathogen disgust has evolved to protect humans fromcontamination by infectious agents, the link betweensex and disgust seems immediately obvious. Accordingly,many aspects of sexual behaviors may promote the gen-eration of disgust. First of all, some of the strongestdisgust-eliciting stimuli, such as saliva and sweat (Rozin& Fallon, 1987), are part and parcel of sexual behaviorand present universal disgust stimuli. In addition, thestrength of the disgust-eliciting properties of a particularstimulus has been shown to increase as a function of itsproximity and the sense of inclusion (Rozin et al.,1995). Moreover, pathogen disgust concentrates on theskin and body apertures, with the mouth, vagina, and

1It should be noted that this particular division into three domains

(i.e., pathogen, sex, and morality) is not beyond dispute and other dif-

ferentiations of disgust domains have been proposed that track different

theoretical viewpoints. Most important in this respect is the seminal and

widely applied theory of Rozin and Fallon (1987) that was also used as

the starting point for the Disgust Scale (Haidt et al., 1994). In their

approach, Rozin and colleagues differentiate among four domains:

core, animal-reminder, interpersonal, and sociomoral disgust. One of

the most salient differences between both approaches concerns the

domain of animal-reminder disgust. Rozin and colleagues argue that

this type of disgust is elicited by stimuli and=or behaviors that remind

us of our animal nature. This type of disgust-mediated rejection of

our animal nature would serve as a defensive function by maintaining

the hierarchical division between humans and animals through distan-

cing the self from animals and animal properties. Yet the evolutionary

relevance of such mechanism has recently been challenged (see Tybur

et al., 2009). Moreover, although empirical data provide evidence for

the relevance of differentiating between animal-reminder and core dis-

gust (e.g., in terms of differential relationships with symptoms of psy-

chopathology), scores on the animal-reminder and core disgust scales

of the widely used Disgust Scale (Haidt et al., 1994) are typically highly

correlated. In addition, content analysis suggests that many of the items

on the animal-reminder scale share with core items that they both may

somehow be linked to the transmission of disease. Therefore, we eventu-

ally decided to take the three domains of disgust approach as our start-

ing point in this review. See Tybur and colleagues (2009) for a more

elaborate discussion of this issue.

DE JONG, VAN OVERVELD, AND BORG

penis being the body parts holding the highest subjectivedisgust sensitivity (Rozin et al., 1995). Given the centralrole of these body parts in sexual behavior, together withthe fact that sex-related body products and smells areamong the strongest disgust elicitors (Rozin & Fallon,1987), it is highly conceivable that pathogen-based dis-gust may arise during sex (during its initiation as well asduring actual sexual engagement). In further support ofthe close link between (pathogen) disgust and sex, recentneuroimaging studies showed large overlap between brainnetworks that were activated in processing stimuli depict-ing sexual (penile-vaginal) penetration and disgustingstimuli such as rotten food items, when controlling forneural visual stimulation (Borg, de Jong, & Georgiades,2012; Karama, Armony, & Beauregard, 2011).

Once elicited, disgust may exert its influence in variousways. First, the subjective experience or feelings of dis-gust may affect the subjective appreciation of the relevantstimuli. Second, in line with its function to prevent thecontamination by pathogens (e.g., Oaten et al., 2009),disgust will logically elicit all kinds of avoidance andescape behaviors to enhance distance from the disgustingstimuli and to prevent or neutralize the potential impactof physical contact with these stimuli. Third, for the samereason, the sudden prospect of being touched by a (per-ceived) disgusting stimulus may elicit automatic defens-ive reflexes (e.g., Yartz & Hawk, 2002). Obviously,these processes are not mutually exclusive but might wellact in concert. For the sake of clarity these variousaspects are nevertheless separately discussed in the sub-sequent paragraphs.

Feelings. First of all, particular sexual stimuli andbehaviors may elicit subjective feelings of disgust (e.g.,Carnes, 1998; Koukounas & McCabe, 1997; Tyburet al., 2009). These feelings of disgust may well underminesexual pleasure and disrupt the development of sexualarousal. In line with this, laboratory studies showed thatthe level of experienced disgust when watching an eroticvideo correlated negatively with positive feelings, sexualarousal, and absorption (Borg & de Jong, 2012; Koukou-nas & McCabe, 1997). This finding suggests that feelingsof disgust may interfere with the generation of sexualarousal. An important next step would be to experimen-tally manipulate the state of disgust to more critically testthe alleged causal influence of feelings of disgust onreducing sexual arousal and pleasure. Moreover, the stu-dies mentioned above were restricted to female parti-cipants; thus, it remains to be examined whetherfeelings of disgust also attenuate sexual arousal in men.

Avoidance. Disgust may also elicit avoidance ten-dencies motivated to create distance from the disgustingsituation or object. Accordingly, disgust may give rise toescape behavior and withdrawal of attention (e.g.,closing one’s eyes or plugging one’s nose). There is con-siderable evidence from experimental laboratory studies

in the context of disgust-related psychopathologies, suchas spider phobia, blood-injection distress, and washingcompulsions, that feelings of disgust are strongly relatedto subsequent avoidance behavior (e.g., de Jong & Peters,2007; Olatunji, Huijding, de Jong, & Smits, 2011; Olatunji,Lohr, Sawchuk, & Tolin, 2007; van Overveld, de Jong, &Peters, 2010; Woody, McLean, & Klassen, 2005). In asimilar vein, disgust may motivate withdrawal of parti-cular sexual behaviors or avoidance of particular sex-related stimuli, which in turn may inadvertently influencethe generation and maintenance of sexual arousal.

These avoidance behaviors may also be motivatedto minimize the duration, intensity, or impact of thephysical contact with a disgusting stimulus (e.g., Woodyet al., 2005). For example, people may immediately startwiping semen away from their bodies, immediately takea shower following sexual intercourse, or clean theirmouths after oral sex. Apart from the fact that thesetypes of ‘‘neutralizing’’ behaviors may have a negativeinfluence on the sexual arousal=pleasure of the personhimself or herself, they may also have undesirable effectson the person’s sex partner, who might, for example,interpret these cleaning behaviors as a rejection or asevidence indicating that he or she was not fully involvedin the sexual encounter.

Defensive reflexes. Disgust may also elicit defensivereflexes to prevent contaminants from entering the body.These types of reflexes may also be elicited in sexual con-texts and may logically cause disrupting effects e.g.,when disgust elicits retching during kissing or oral sex,or flinching of the pelvic floor muscles during attemptsat sexual intercourse. In support of the latter example,there is evidence that contraction of the pelvic floor mus-cles is part of a general defense mechanism that can beelicited in the context of physical threat (e.g., van derVelde, Laan, & Everaerd, 2001). It seems reasonable toassume that similar defensive contractions can also beelicited by the prospect of physical contact with disgust-ing stimuli (e.g., Yartz & Hawk, 2002). If so, the mereprospect of physical contact with the genital area maylead to enhanced activity of the pelvic floor muscles. Inthe context of sexual penetration, such defensive contrac-tions of the pelvic floor muscles would obviously enhancethe friction between penis and vulvar skin, eventuallygiving rise to genital pain or contributing to makingintercourse unlikely to occur. Similar mechanisms mayalso be involved in (attempts at) anal sex or manualstimulation of the vaginal area.

Facial expression. Disgust is usually accompaniedby a distinct facial expression (e.g., Darwin, 1872=1989;Vrana, 1993). However, in the context of intimate inter-personal (sexual) behavior, displaying disgust may beconsidered highly undesirable because of the signalingproperties of such facial display. For example, one’smate may interpret the facial display of disgust as a sign

DISGUST-BASED MECHANISMS IN SEXUAL DYSFUNCTION

of disapproval or rejection. Therefore, people may useemotion regulation strategies to hide their (expressionsof) disgust in a sexual context (e.g., de Jong, van Lank-veld, Elgersma, & Borg, 2010). Although experimentalresearch has shown that people are generally well ableto reduce expressions of disgust (Gross & Levenson,1993), such emotional suppression may come at a cost.That is, attempts at inhibiting the expression of disgustmay have unfortunate rebound effects, since suppressionwill enhance activation of disgust-related concepts inmemory (e.g., Wegner, 1994). Accordingly, people mayend up in a vicious cycle that further intensifies theemotion of disgust, thereby disrupting sexual arousal.It would be interesting in future research to explorewhether people indeed use emotion regulation strategiesto reduce or hide disgust in sexual contexts—and howthis might impact on their sexual arousal.

Sexual Disgust

The second domain of disgust elicitors consists of aparticular class of sexual stimuli and behaviors. For thistype of disgust the link with sex is already implied by itslabel. Yet the label sexualmight be somewhat misleading,as this type of disgust does not refer to any disgust thatmay arise during sex but specifically to disgust elicitedby potential sexual mates. It has been proposed that thistype of disgust evolved to facilitate avoidance of sexualpartners and behaviors that challenge long-term repro-ductive success (Tybur et al., 2009). One important factorthat might jeopardize reproductive success is high geneticsimilarity. Accordingly, people typically respond withdisgust when asked to imagine having sex with a siblingor any other close genetic relative (e.g., Lieberman,Tooby, & Cosmides, 2007). In these cases, disgust mighthelp prevent having sex with a potential sex partner whois characterized by too high genetic similarity, which thusmight interfere with reproducing healthy offspring.

Another dimension that is relevant for reproductivesuccess is the so-called intrinsic quality of the potentialsex mate. This intrinsic quality is typically expressed inphysical features, such as facial symmetry, that are alsoused to (implicitly) judge attractiveness (e.g., Thornhill &Gangestad, 2006). For those considering them as potentialsex partners, people with low intrinsic quality as reflectedin their physical appearance (e.g., body asymmetry) mightelicit disgust, thereby reducing the risk of a poor matechoice. Similarly, people will typically respond with dis-gust when asked to imagine having sex with, for example,someone who is extremely obese, with a 12-year old child,or with an animal (e.g., Ariely & Loewenstein, 2006).

Very different from the pathogen-disgust elicitors,sexual disgust will typically be elicited via (the prospectof) physical contact with another person, instead ofthrough being in contact with particular products. Inaddition, the disgust-eliciting properties of these otherpeople seem restricted to the sexual context. Whereas

the disgust-eliciting properties of pathogenic individuals(i.e., people who show signs of a transmittable disease)will be largely context independent, sexual disgust willtypically arise only in the context of mating. Thus,although a person may elicit disgust as a potential sexpartner, the same person may still be a highly esteemedfriend, colleague, team member, etc. Due to these specificfeatures of sexual disgust, it may give rise to sexual prob-lems when two people enter a close relationship (e.g.,marriage) because they feel attracted to many featuresof the partner but are not physically or sexually attractedto each other. Sexual disgust may also emerge if impor-tant physical features of the partner change significantly,for example, due to an accident, illness, or surgical inter-vention, such as stoma surgery (e.g., Manderson, 2005).

Once elicited, sexual disgust may disrupt sexual arousaland undermine sexual pleasure via the same processes asoutlined in the previous section about pathogen disgust.Yet the disgust-induced avoidance and withdrawal beha-vior will not so much involve cleaning and neutralizingactivities but be predominantly driven to prevent sexualinteraction with the source of disgust. However, whenavoidance strategies are not successful in preventing ‘‘dis-gusting’’ sex, or when people have been forced to haveunwanted sex, sexual disgust may elicit cleaning behavior,just as pathogen disgust does.

Yet such cleaning behaviors might not be sufficient toneutralize disgust following unwanted or undesired sex,because these types of aversive sexual experiences willprobably not only elicit feelings of physical pollutionbut also feelings of a more symbolic, ideational type of‘‘mental’’ pollution (Rachman, 1994). In line with this,a study among female victims of sexual assault foundthat a majority of them reported feelings of mentalpollution. Deliberate recall of the assault not onlyresulted in stronger feelings of dirtiness but also elicitedthe urge to wash, and a substantial proportion of thesewomen reported washing their hands in response todeliberate recall of the assault (Fairbrother & Rachman,2004). In a similar vein, a subsequent experimental studyshowed that undergraduates who were asked to imagineexperiencing a nonconsensual kiss at a party reportedsignificant feelings of mental pollution together with anurge to wash (Fairbrother, Newth, & Rachman, 2005).However, whereas washing may be highly effective inreducing concrete traces of physical pollution, it is nota helpful strategy to undo the more ideational form ofmental pollution. The more ideational feelings of dirti-ness may thus remain and may continue to elicit the urgeto wash. This may also explain why victims of sexualabuse often engage in elaborate washing rituals or mayeven get stuck in persistent cleaning compulsions.

Moral Disgust

The third and final domain of stimuli that may triggerdisgust reflects sociomoral transgressions (Kelly, 2011).

Cooperation for mutual benefit was a major evolution-ary challenge, and avoiding free-riders or defectorswho violate important social norms by cheating andlying would have (had) important survival value. Moraldisgust has been proposed to be evolved to motivateavoidance of social relationships with norm-violatingindividuals (e.g., Kelly, 2011; Tybur et al., 2009). Thus,the defensive mechanism of disgust originally evolvedto protect the (physical) integrity of the individual seemsextended to also secure the integrity of individuals’ socialnetworks (Rozin, Haidt, & Fincher, 2009; Rozin, Haidt,& McCauley, 1999). Moral disgust might motivate notonly avoidance but also punishment of norm violators(e.g., Kurzban, DeScioli, & O’Brien, 2007). Moreover,there is evidence that the experience of disgust may bol-ster already internalized sociomoral rules (Wheatley &Haidt, 2005), which might help the actor prevent theoccurrence of future infringements; in other words, theexperience of disgust may, just as shame and embarrass-ment, help people stay on a moral path (cf. Levenson,1999; Ferguson & Stegge, 1995).

This more ideational type of disgust may be elicitedby sexual behaviors that violate important and deeplyingrained sociomoral rules (Rozin et al., 1999). Thoseholding more restrictive sociomoral standards would bemore likely to experience a particular sexual behavioras a transgression (‘‘wrongdoing’’) and thus elicit disgust.In line with this, it has been shown that women with rela-tively restrictive attitudes toward sexual behavior experi-enced more disgust when they viewed erotic slides orvideos than women with more liberal values (Koukounas& McCabe, 1997). In a similar vein, it has been shownthat people’s judgments about the abnormality of parti-cular consensual sexual behaviors were closely associatedwith their ratings of elicited disgust (Giner-Sorolla,Bosson, Caswell, & Hettinger, 2012).

Thus, individuals’ adherence to strict moral rules con-cerning sexual behaviors may influence their subsequentemotional responding toward particular sexual behaviorsand may contribute to disrupted sexual arousal. It hasbeen argued that parents’ expressions of disgust inresponse to their children’s behavior is an importantmeans of learning to adhere to dominant sociomoral rules(e.g., concerning ‘‘proper’’ sexual behavior). Accordingly,disgust is seen as a major force for negative socializationin children: ‘‘a very effective way to internalize culturallyprescribed rejections (perhaps starting with feces) is tomake them disgusting’’ (Rozin et al., 1999, p. 439). Ithas been speculated that elicited feelings of disgust mayalso further confirm the importance of adhering to certainsociomoral rules. Emotional reasoning such as ‘‘If I feeldisgusted, then it must be inappropriate behavior’’ (e.g.,Rachman, 2004, p. 1252) will logically result in furtherinhibiting individuals’ motivation to get involved in theseparticular disgust-eliciting sexual behaviors or, moredrastically, motivate people to refrain from (and avoid)particular sexual behaviors.

As the counterpart of people with relatively restrictivestandards, people with extreme liberal values may experi-ence minimal disgust or no disgust at all, even when actu-ally violating widely held sociomoral rules. In such cases,the threshold for getting involved in social behavior that istotally unacceptable (e.g., sex with children) may be low-ered by the absence of experiencing disgust. What is mor-ally correct and what is not, of course, is a very subjectiveand sensitive issue that may differ widely across culturesand individuals, and may also change during the life span.Therefore, it is possible that a specific sexual activity willelicit strong feelings of disgust in one person because heor she feels that it is not ‘‘right’’ (e.g., sexual masochism,transvestism, homosexual behaviors), whereas the sameactivity may elicit positive feelings in other persons (orin the same person when given a different context) (e.g.,Olatunji, 2008; Ahmed & Bhugra, 2007).

Disgust and Sexual Arousal: Opposing Forces?

In light of the intimate link between sex and disgust,and the multiple ways in which sexual behavior mightgive rise to disgust, the critical question seems not somuch whether disgust may have inhibitory propertiesand may give rise to sexual problems but how peoplegenerally succeed in having pleasurable sex at all. Howcan it be explained that sexually mature people generallyshow a strong appetite for sexual activities in spite of thisstrong emotional barrier that works against it?

Obviously sexual behavior has critical phylogeneticrelevance; thus, some mechanism must have beenevolved to balance the opposing forces of the adaptivegoal of transmitting (optimal) genes to future genera-tions versus the adaptive goal of disease avoidance. Toallow sexual behavior while minimizing health risks, ithas been argued that sexual arousal might temporarilyreduce the disgust-eliciting properties of otherwise dis-gusting stimuli or behaviors (Stevenson, Case, & Oaten,2011). As an additional mechanism, sexual engagementmight also just weaken the hesitation to approachdisgust-eliciting stimuli, even in spite of unchangeddisgust properties of the stimuli. Obviously, bothmechanisms could also act in concert.

To test the proposed disgust-reducing effect of sexualarousal, a group of male students was presented with dis-gusting stimuli in the absence or presence of experimen-tally induced sexual arousal (Stevenson et al., 2011). Toelicit sexual arousal, the experimental group watchederotic female images, whereas the control group watchedneutral pictures. The participants were then exposed to aseries of sex-related and non-sex-related disgust elicitorsthat were drawn from various sensory modalities (i.e.,visual, tactile, auditory, and olfactory). For example,as tactile disgust elicitors, participants were asked toplace their dominant hand through a small opening (sothe content was not visible) in a bucket containing either

four lubricated condoms (sex-related) or cold pea andham soup (not sex-related). Supporting the view thatsexual arousal might indeed have an inhibitory effecton disgust, participants in the sexual arousal conditionreported being less disgusted by sex-related disgustelicitors than participants in the control condition. Asubsequent study among female (student) participants(Borg & de Jong, 2012) similarly showed that experimen-tally induced sexual arousal attenuated the subjectivefeelings of disgust when presented with various sex-related and non-sex-related disgust elicitors. In thisstudy, film clips were used to elicit the relevant moodstate: A female-friendly erotic film (de Gast by Christinele Duc) was selected to induce sexual arousal. To controlfor the influence of general positive arousal, the designalso included a sports=high-adrenalin arousal clip (e.g.,rafting=skydiving=mountain climbing). Finally, a neu-tral film consisting of a train ride with different sceneriesserved as the baseline condition. Participants were ran-domly allocated to one of three groups (sexual arousal,nonsexual positive arousal, neutral control), andengaged in 16 behavioral tasks, involving sex-related(e.g., lubricate a vibrator) and not sex-related (e.g., takea sip of juice with a large insect in the cup) stimuli, tomeasure the impact of sexual arousal on feelings of dis-gust and actual avoidance behavior. In line with the find-ings of Stevenson and colleagues (2011), the sexualarousal group rated the sex-related stimuli as less dis-gusting compared to the other groups. A similar tend-ency was evident for the non sex-related disgustingstimuli. Importantly, the study showed that this effectwas not restricted to subjective changes but also resultedin less disgust-induced avoidance. For both the sex-related and non sex-related behavioral tasks, the sexualarousal group showed less avoidance behavior in theseries of disgust-relevant behavioral approach tasks.

In a similar vein, the original repulsion in male parti-cipants when asked, for example, to consider having sexwith a woman who is extremely obese, was greatlyreduced when they were sexually aroused (Ariely & Loe-wenstein, 2006). As further evidence for the role of sexualarousal in reducing sexual avoidance, other studies haveshown that sexual motivation can lower the subjectiveprobability of contracting a sexually transmitted diseaseand more generally lower the threshold for risk-takingbehaviors (Ditto, Pizarro, Epstein, Jacobson, & MacDo-nald, 2006) and impair decision making (Van den Bergh& Dewitte, 2006). Together, this evidence indeed sug-gests that sexual arousal may counteract all kinds ofmechanisms that otherwise promote avoidance of parti-cular sexual behaviors or stimuli—be they general repul-sion, moral borders (e.g., having sex with a 12-year-old),or contamination risk (e.g., condom use). Thus, sexualarousal may undermine mechanisms that normally helppeople avoid certain (disgusting) stimuli.

Figure 1 presents a heuristic model that visualizesthe proposed interrelationship between disgust and sexual

arousal. If people encounter a sex-relevant stimulus, thismay elicit both sexual arousal and disgust. The strengthof the elicited response will be moderated by individuals’disgust propensity as well as individuals’ propensity forsexual excitation. The experience of disgust will motivateavoidance of the sexual stimulus and inhibit sexualarousal. The elicited sexual arousal, on the other hand,facilitates approach behavior and inhibits the tendencyto experience disgust. If disgust outweighs sexualarousal, an individual may enter a negative loop thatinterferes with the generation of sexual responses,whereas an individual will enter a positive feedback loopif sexual arousal outweighs disgust.

For both men and women, there is evidence thatandrogens have an activating effect on sexual behavior.For example, it has been shown that serum androgenlevels are a strong predictor of sexual motivation andbehavior in adolescent boys (Udry, Billy, Morris, Groff,& Raj, 1985). Also, androgen replacement in men withlow testosterone levels has been shown to increase sexualdesire and the frequency of sexual intercourse (Seftel,Mack, Secrest, & Smith, 2004). Similarly, evidencesuggests that the addition of testosterone to estrogenreplacement therapy in oophorectomized women has afavorable effect on the sexual interest and enhances theenjoyment of sex (e.g., Floter, Nathorst-Boos, Carlstrom,& von Schoultz, 2002). Consistent with this, research hasshown that women with low libido have lower androgenlevels compared to age-matched normal control groups(Turna et al., 2005). Moreover, it was found that femaleandrogen levels correlated positively with their sexualfunctioning (Turna et al., 2005). Providing further sup-port for the relevance of androgens in stimulating sexualapproach behavior, longitudinal research has shown thatthe pubertal rise in testosterone in adolescent girls is asso-ciated with subsequent increases in female sexual interest

Figure 1. This model illustrates how sexual disgust may counteract

the generation of sexual arousal resulting in a dysfunctional loop

(B), and sexual arousal may counteract sexual disgust resulting in a

functional loop (A).

and activity (Halpern, Udry, & Suchindran, 1997). Per-haps, then, the physiologically low level of androgens inchildren may help explain the typical sex-avoidance dis-position in prepuberty (eliciting such reactions from themas ‘‘Yuck! They are kissing mouth to mouth!’’). From thestart of puberty, the disgust-induced avoidance of sexstimuli might be reduced or counteracted by the presenceof (or increased sensitivity for) androgens, which mightlower the threshold for engaging in ‘‘disgusting sex’’(see Figure 1, left part of the model, filled arrow). It couldbe speculated that perhaps androgens also have a direct(sex-relevant) disgust-inhibiting effect (see Figure 1, leftpart of the model, striped arrow). Because prolongedphysical contact is a powerful means to reduce disgust(e.g., Rozin, 2008), this may help explain the functionaltransition from a sex-avoidance disposition in prepubertyinto an approach disposition during adolescence (i.e., theproposed ‘‘healthy’’ loop presented in the lower part ofthe model).

If individuals for some reason (e.g., low levels ofandrogens; high disgust propensity; strict moral stan-dards) refrain from such habituation experiences, theymay enter a self-perpetuating cycle in which sexual dis-gust becomes a chronic feature (i.e., the proposed dys-functional loop presented in the upper part of themodel). In terms of the dual-control model, the propen-sity for disgust-induced sexual inhibition may then per-sistently outweigh the propensity for sexual excitation,which may give rise to various sexual problems and pro-mote the development of sexual dysfunctions. In thenext section we evaluate in more detail how disgustmay be involved in sexual dysfunctions.

Disgust-Based Mechanisms in Sexual Dysfunctions

The categories of sexual dysfunctions as describedin the Diagnostic and Statistical Manual of Mental Disor-ders, Fourth Edition, Text Revision (DSM-IV-TR;American Psychiatric Association [APA], 2000), closelyfollow Kaplan’s three-stage model of the sexual responsecycle, which consists of desire, excitement, and orgasm.Accordingly, dysfunctions are defined on the basis ofproblems involving desire (hypoactive sexual desiredisorder; sexual aversion disorder), excitement (femalesexual arousal disorder; male erectile disorder), andorgasm (female orgasmic disorder; male orgasmic dis-order; premature ejaculation). As an additional category,theDSM-IV-TR refers to sexual pain disorders, includingdyspareunia and vaginismus. In this section we discusshow disgust and disgust-based mechanisms may helpimprove our understanding of the processes involved inthe various sexual dysfunctions. Obviously many differ-ent factors may be involved in the development of sexualdysfunctions in addition to disgust-based mechanisms,such as problematic relational factors, dysfunctionalinterpersonal processes, insufficient knowledge, lack of

proper sexual stimulation, fearful preoccupations, (fearof) pain, and physiological problems, among others. Thus,we do not intend to provide a comprehensive overview ofthe potential mechanisms involved in sexual dysfunctionsbut specifically focus on the potential relevance ofdisgust. Because empirical research on the putative roleof disgust in sexual dysfunctions is thus far largely restric-ted to the sexual pain disorders (vaginismus and dyspareu-nia), we speculate only very briefly about the potential roleof disgust in the other main categories of sexual dysfunc-tions described in theDSM-IV-TR (APA, 2000). We focuson vaginismus to more concretely illustrate how a disgustconceptualization might help improve our understandingof sexual problems.

As previously argued, anticipated feelings of disgustwill logically motivate sexual avoidance and withdrawal,whereas cognitive biases, such as emotional reasoning,may further confirm the negative appreciation of sex.Accordingly, enhanced feelings of disgust may well con-tribute to hypoactive sexual desire disorder and sexualaversion disorder. In support of this, clinical evidencesuggests that disgust-related appraisals are prominentin these conditions (e.g., Carnes, 1998). This led Kaneko(2001) to argue that it would be important to more fullyappreciate the potential role of disgust in the diagnosticprocess. However, thus far the particular role of disgustin these disorders has not been anywhere close to thefocus of empirical research. Therefore, it remains forfuture research to determine what type of disgust orcluster of disgust stimuli is most prominently involved(pathogen, sexual, or moral disgust elicitors), whetherthe particular disgust-related preoccupations vary acrossindividuals, and whether disgust should be considered asa cause, a consequence of the complaints, or both. Ontheoretical grounds it seems reasonable to argue thatany factor that may enhance individuals’ disgust pro-pensity—or the particular sensitivity of the body partsthat are involved in sexual behavior, or enhance theanticipated contamination potency of relevant bodyparts or body products of sexual partners—may putpeople at risk for developing sexual disorders linked toreduced sexual desire (e.g., Rempel & Baumgartner,2003).

As argued previously (de Jong & Peters, 2009), a verysimilar line of reasoning can be followed for other sexualdysfunctions, with the addition that feelings of disgustand disgust-related appraisals will logically oppose thegeneration of sexual arousal (see also Figure 1). Disgustmay thus contribute to problems associated with reducedsexual arousal (e.g., erectile dysfunction) as well as tomale or female orgasmic disorder. It may be the interac-tion of disgust with other factors that eventually deter-mines the exact phenomenology of an individual’ssymptoms. Although the level of disgust propensity tendsto be higher in women than in men (Olatunji & Sawchuk,2005), disgust appraisals may well affect sexual behaviorin both men and women. Disgust and disgust-related

appraisals may perhaps be best considered as transdiag-nostic phenomena (see Harvey, Watkins, Mansell, &Shafran, 2004). Following from this, it may well be thata more thorough appreciation of the role of disgust in thevarious complaints may help to improve the currentdiagnostic categories (see, e.g., Basson, 2002) and pro-vide specific clues for more tailored interventions (e.g.,de Jong, van Lankveld, & Elgersma, 2010).

Disgust and Vaginismus

Disgust may not only be relevant for the sexual dys-functions associated with the sexual response cycle butmay also improve our understanding of primary (life-long) vaginismus, perhaps the most perplexing andpoorly understood of the sexual dysfunctions (Leiblum,2000). In this section we therefore more fully addressthe potential role of disgust in the generation of vaginis-tic response symptoms. The core symptom of primaryvaginismus is the persistent inability to allow vaginalentry of a penis, finger, or object, despite the woman’sexpressed wish to do so (e.g., Basson et al., 2003;Weijmar-Schultz & van de Wiel, 2005). Obviously, thesetypes of symptoms may be similar for dyspareunia,although avoidance in the latter group is less pronounced(e.g., in gynecological examinations and in attempts atpenile-vaginal penetration) (Reissing, Binik, Khalife,Cohen, & Amsel, 2004). This might help explain the cur-rent dispute about the relevance of differentiatingbetween dyspareunia and vaginismus (e.g., Binik,2010). Not all research has differentiated betweenprimary and secondary vaginismus, which might havebiased the literature to find large overlap between dys-pareunia and vaginismus (Hanema, de Jong, Borg &Weijmar-Schultz, 2012). Yet it may well be that differentetiological mechanisms are involved in women who havenever been able to allow vaginal entry of a penis, finger,or object versus those who acquired this symptom fol-lowing past (e.g., painful) experiences associated withsexual intercourse. In the following discussion we there-fore reserve the label vaginismus for primary (lifelong)vaginismus.

Current views on vaginismus emphasize the role ofpain catastrophizing (Binik et al., 2002; Borg, Peters,Weijmar-Schultz, & de Jong, 2012; Reissing et al., 2004)and fear of penetration (ter Kuile et al., 2009). However,disgust and fear of contamination might also play a criti-cal role here. More specifically, it has been proposed thatthe involuntary contraction of the pelvic floor muscles inwomen with vaginismus may be elicited by the prospectof penetration by a potential contaminant (e.g., penis)rather than by the prospect of harm or pain per se (deJong, van Overveld, Weijmar-Schultz, Peters, & Buwalda,2009). Such a disgust conceptualization of vaginismuswould give rise to at least three testable hypotheses. First,if disgust does indeed play an important role in vaginis-mus, women who are extremely sensitive to disgust and

contamination would be at risk for developing symptomsassociated with vaginismus. Such enhanced disgust pro-pensity could reflect a general tendency to respond withthe emotion of disgust to any given stimulus or a morefocused tendency to respond with extreme disgust that isrestricted to sexual stimuli. Second, women with vaginis-mus may be characterized by restricted moral values ingeneral or with respect to sexual behaviors in particular,which may result in moral disgust-induced defensiveresponses at the prospect of sexual intercourse (e.g., Rozinet al., 1999). Third, women with vaginismus may be char-acterized by a particular individual physiological responsestereotype to react with extreme contraction of the pelvicfloor muscles in response to acute feelings of threat ordisgust (for a test of a conceptually similar hypothesis inthe context of chronic low back pain, see Vlaeyen et al.,1999).

Potential Factors in Vaginismus

Enhanced disgust propensity. As a first explorationof the possible role of disgust in vaginismus, we examinedwhether women with primary (lifelong) vaginismusshowed an enhanced trait disgust propensity comparedwith patients with dyspareunia (concisely defined asrecurrent genital pain associated with [attempts of] sexualintercourse) and women without sexual complaints (deJong et al., 2009). In support of the notion that disgustmay indeed be involved in vaginismus, women with pri-mary vaginismus reported heightened levels of disposi-tional disgust propensity (i.e., a tendency to experiencedisgust more readily) compared to women without sexualproblems and compared to patients with dyspareunia, asindexed by the Disgust Scale (DS, developed by Haidt,McCauley, & Rozin, 1994). The difference between thevaginistic response group, on one hand, and the dyspar-eunia and control groups, on the other hand, was mainlyin their differential scores on the Hygiene and Death sub-scales of the Disgust Scale (Haidt et al., 1994). The itemson these scales represent disgust elicitors capable of pro-ducing contaminating agents (see also Olatunji, Saw-chuk, Lohr, & de Jong, 2004). High scores on theseitems seem therefore to suggest some aversion toward,and avoidance of coming into contact with, objects thatmay transmit contaminating agents (e.g., from DSHygiene: ‘‘I never let any part of my body touch the toiletseat in a public washroom’’; DS Death: ‘‘It would botherme tremendously to touch a dead body’’). In otherwords, the high levels of disgust propensity in the vaginis-tic response group seem to reflect a fearful preoccupationwith contamination. This pattern of findings seems toreflect a robust phenomenon, as it was recently replicatedin an independent study covering different clinical sites(van Overveld, de Jong, Peters, van Lankveld, Melles,& ter Kuile, 2012).

This finding—women with vaginismus showing agenerally enhanced aversion toward coming into contact

with stimuli that are capable of producing or transmit-ting contaminating agents—points to the possibility thathigh levels of disgust and contamination sensitivity are apremorbid characteristic making these women liable todevelop symptoms associated with vaginismus. That is,intercourse-related stimuli (e.g., vaginal fluid, semen,the penis) are more likely to acquire inflated contami-nation potency in women with high levels of disgust pro-pensity than they are in women with low levels of disgustpropensity. In a similar vein, the vagina is more likely toacquire strong contamination sensitivity in women withhigh disgust propensity (e.g., Davey, Forster, &Mayhew, 1993). Both characteristics will logically facili-tate the generation of disgust-motivated avoidance ten-dencies, such as the contraction of the pelvicmusculature at the prospect of penetration. In addition,enhanced trait sensitivity may more generally promotepeople to enter the dysfunctional loop (see Figure 1) byenhancing the ‘‘push’’ factor away from sexual arousal.People with enhanced disgust propensity would logicallyrequire a stronger ‘‘pull’’ factor to facilitate the transitioninto the functional loop. Accordingly, this characteristicmay heighten the chance that people get stuck in disgust.

One way to further explore the potential role ofenhanced disgust and contamination sensitivity in thedevelopment of vaginismus would be to test whetherthe generally enhanced disgust and contamination sensi-tivity (e.g., as indexed by the DS) is affected by treat-ment. If indeed strong contamination sensitivity putswomen at risk for developing vaginismus rather thanbeing a consequence of these complaints, one wouldexpect an individual’s general contamination sensitivityto remain largely unaffected by successful treatment(de Jong et al., 1997).

Enhanced disgust-eliciting properties of sexual stimuli.The finding that women with vaginismus displayed heigh-tened levels of disgust propensity does not necessarilyimply that disgust per se is also involved in sexual dys-functions. To arrive at more solid conclusions in thisrespect, it would be critical to more directly examine thedisgusting status of sexual stimuli. Therefore, we recentlydeveloped the Sexual Disgust Questionnaire (SDQ; deJong et al., 2009). The SDQ was based on the DisgustQuestionnaire (DQ), which was originally designed byRozin, Fallon, and Mandell (1984) to assess food rejec-tion tendencies following trace (or pure ideational)contamination of these food items by certain animalproducts. This approach was based on the central featureof disgusting stimuli, namely, that they readily transfertheir offensive characteristics to other stimuli by briefcontact (Rozin & Fallon, 1987; Tolin, Worhunsky, &Maltby, 2004). The original DQ consisted of items suchas ‘‘Imagine your favorite soup. How much would youlike to eat this soup after it has been stirred by a usedfly swatter?’’ This questionnaire was modified in a wayto test the strength of individuals’ tendencies to avoid

physical contact with certain objects (e.g., a towel) afterthey have been in contact with certain sexual by-products(e.g., semen from their partner). Because the contami-nation potency of particular sexual stimuli may vary asa function of the source of the potential contaminants,we differentiated between familiar (partner or self) andunfamiliar sources (unknown persons). Providing furthersupport for the role of disgust in vaginismus specifically,women with primary vaginismus reported higher levels ofdisgust for sexual by-products related to familiar persons(van Overveld et al., 2012).

As a conceptual replication and an even more directtest of the role of disgust in vaginismus, we also investi-gated whether individuals with symptoms associated withvaginismus reacted with (enhanced) feelings of disgust inresponse to erotic slides and video materials displayingsexual intercourse (Borg, de Jong, & Weijmar-Schultz,2010). In support of the idea that disgust and fear of con-tamination is somehow involved in vaginismus, womenwith vaginistic response complaints reported consider-ably higher levels of experienced disgust than did womenwithout these complaints.

The results discussed thus far exclusively relied onexplicit self-report measures. Current dual-process mod-els emphasize the importance of differentiating betweenmore deliberate, reflective attitudes that can be assessedby self-reports and the more automatic reflexive associa-tions in memory (e.g., Gawronski & Bodenhausen, 2006).Both types of cognitions are believed to have differentfunctional qualities. Explicit attitudes are assumed toreflect the outcome of the weighting of propositions andtheir corresponding ‘‘truth’’ values (i.e., validation pro-cesses), while automatic associations are assumed to fol-low from the direct activation of simple associations inmemory, independent of their truth value. Explicit cogni-tions tend to predict more deliberate behaviors, whereasautomatic associations seem to play an important rolein guiding relatively spontaneous (reflexive) behaviors,the kind of behaviors that also seem critically involvedin disgust- and threat-induced defensive reflexes (e.g.,Huijding & de Jong, 2006). Following this, it seemsreasonable to assume that especially this type of moreautomatically activated association may be relevant ineliciting the characteristic defensive reactions in womensuffering from vaginismus. We therefore tested whetherwomen with vaginismus would also show relativelystrong sex-disgust associations at the more automaticlevel. Using a single target Implicit Association Task(st-IAT; Wigboldus, Holland, van Knippenberg, denHartog, & Belles, 2002), women suffering from vaginis-mus indeed also showed stronger automatic sex-disgustassociations than women without sexual problems or dys-functions. Attesting to the specificity of the sex-disgustassociation, a similar pattern was absent with regard tosex-threat associations, or the more general automaticaffective appraisals of penetration pictures (Huijding,Borg, Weijmar-Schultz, & de Jong, 2011). However, the

relatively enhanced automatic sex-disgust associationswere not restricted to women with vaginismus; they werealso evident in women suffering from dyspareunia (Borget al., 2010). This pattern of findings may explain theshared difficulties associated with vaginal penetration(either completely impossible or partially possible butwith pain).

As a further (more implicit) test of the role of disgustresponsivity, we also recorded facial electromyography(EMG) of the levator labii muscle as a physiologicalmarker of disgust (Vrana, 1993). To minimize demandand self-presentational concerns, we used pictorial andvideo materials that did not directly refer to the patient’spartner. Underlining the potential importance of reflex-ive disgust responsivity in vaginismus, the vaginisticresponse group specifically responded with an increaseof levator activity in response to the erotic stimulation(Borg et al., 2010).

Restricted (sexual) standards. To examine whetherenhanced moral disgust may also be involved in vaginis-mus, we recently tested whether women with vaginismuswould show a strong adherence to conservative moralsand strict sexual standards (Borg, de Jong, &Weijmar-Schultz, 2011). To tap into the individual’sgeneral values, the Schwartz Value Survey (SVS;Schwartz & Bilsky, 1987) was used. As an indirect mea-sure of participants’ more specific sex-related moral stan-dards, we also assessed their willingness to performcertain sexual activities that may violate the sociomoralrules of particular subgroups, such as ‘‘Watching a videoshowing your partner while he=she is masturbating’’ (seealso de Jong et al., 2009). The vaginismus group showedrelatively low scores on liberal values together with com-paratively high scores on conservative values. Inaddition, the vaginismus group was more restricted intheir readiness to perform or participate in particularsex-related behaviors (such as watching the video) thanthe control group without sexual problems.

This pattern of findings seems consistent with thehypothesis that women with vaginismus are character-ized by relatively restrictive moral standards that alsoapply to their sexual repertoires. Restricted sexual valuesmay put people at risk for experiencing disgust duringsexual behaviors (e.g., as a result of some norm violation;see also van Overveld et al., 2012). Perhaps, then, theperceived ‘‘immorality’’ of particular sexual behaviorsand the perceived moral impurity of specific sexual stim-uli may contribute to the defensive reflexes of the pelvicfloor muscles that characterize vaginismus. To gain moreinsight into the alleged causal influence of relativelyrestrictive (sexual) standards on the generation of vagi-nistic response symptoms, it would be interesting to seewhether challenging the strong devotion=adherence ofindividuals’ sexual morals and learning a more flexibleattitude toward the full range of socially acceptable sex-ual behaviors has a favorable influence on the intensity

of vaginistic response symptoms. If so, this would notonly be of theoretical interest but may also provide arelatively unexplored starting point for the treatment ofvaginismus (see Borg et al., 2011).

All in all, there is considerable evidence supportingthe view that disgust might indeed be a relevant factorin the etiology of vaginismus. Women suffering fromvaginismus showed several characteristics that wouldlogically lower the threshold for experiencing disgust inresponse to sexual advances, such as heightened traitdisgust propensity and relatively restrictive (sexual) stan-dards. In addition, they showed relatively strong disgustresponses when confronted with sexual stimuli, both atthe subjective and the behavioral level. In light of themodel proposed in Figure 1, the core problems of vagi-nismus may not only be due to enhanced disgust respon-sivity but also to a lack of sufficient sexual arousal tocounteract the negative impact of disgust on sexualapproach behavior. It would be interesting to examinewhether perhaps the (first) sexual experiences of womenwith vaginismus were not (sufficiently) arousing or werefor some reason postponed to an age range in which thehormonal ‘‘pull’’ factor was suboptimal (Longcope,1986). Since reduced sexual arousal will logicallyheighten the threshold for engaging in ‘‘disgusting’’sexual behaviors, this may thus have prevented theoccurrence of disgust-reducing and arousal-sensitizingsexual encounters, eventually resulting in getting stuckin disgust.

In line with the suggestion that perhaps an insufficientstrength of the ‘‘pull’’ factor might also be involved,anecdotal evidence from clinical practice shows thatwhen women with lifelong vaginismus change relation-ships they sometimes manage to have intercourse withlittle or no problem. From this angle one can also specu-late on a default disgust that has never been desensitizedor neutralized. For instance, if a person postpones thedesensitization or habituation of sex-related disgust, itcan consequently be reflected as enhanced disgust (i.e.,disgust that has never been neutralized). Following thisperspective, it would also be interesting to look at strictChristian or Muslim populations, or other cultureswhere sex is postponed until after marriage, to examinewhether in these populations the prevalence of vaginis-mus is relatively high compared to other cultures wherethis is not the case (e.g., Dogan, 2009).

Clinical Implications: The Treatment of Disgust

In this section, we discuss potential leads for interven-tions that might be integrated in current treatments tospecifically target the disgust component of sexual prob-lems. A consistent finding from the limited research onthe (un)learning of disgust is that once acquired, disgustresponses are quite difficult to eliminate. Laboratory stu-dies using a differential conditioning paradigm in which

an originally neutral conditional stimulus (CSþ) issystematically paired with an unconditional disgustingstimulus (US) has shown that the CSþ readily acquiresa disgusting status, whereas disgust only slowly declinesfollowing unpaired CSþ presentations during asubsequent extinction procedure (Olatunji, Forsyth, &Cherian, 2007; Mason & Richardson, 2010). In line withthis, a series of treatment studies focusing on individualssuffering from enhanced pathogen disgust in the contextof anxiety disorders (e.g., spider phobia, obsessive-compulsive disorder [OCD]) showed that exposure invivo was much faster and more effective in reducing fearthan in reducing disgust (e.g., Olatunji, Wolitzky-Taylor,Willems, Lohr, & Armstrong, 2009).

Interestingly, delayed extinction in laboratory researchwas especially pronounced in individuals with habituallyenhanced trait disgust propensity (Mason & Richardson,2010). This finding suggests that people with heightenedtrait disgust propensity may not only be at risk forenduring disgust responsivity because of a heightenedsusceptibility to disgust conditioning, but also becauseof a relative insensitivity to extinction of already-acquired disgust. In line with this, it has been shown thatarachnophobic individuals with heightened levels of traitdisgust propensity profited less from exposure treatmentthan did phobic individuals with relatively low levels ofdisgust propensity (Merckelbach, de Jong, Arntz, &Schouten, 1993; de Jong, Andrea, & Muris, 1997). Themore general finding that disgust responses cannot be eas-ily unlearned by CS-only experiences may be functionalfrom the perspective that the very source of infection isoften rather unclear and usually impossible to detect with-out additional aids (e.g., microscope, immune tests).Thus, in the absence of explicit positive information indi-cating that the stimulus is now actually safe, the CS maytend to retain (part of) its disgusting properties, followinga ‘‘better safe than sorry’’ heuristic (de Jong, 2013).

Prolonged exposure to the disgusting stimulus isnevertheless considered the most effective strategy tounlearn disgust (e.g., Meunier & Tolin, 2009; Rozin &Fallon, 1987). For example, when cleaning toilets is partof one’s job, aversion to dirty toilets is assumed to gradu-ally decline in that person because of consistent andrepeated contact with the disgusting item that is inherentin the cleaning role. In a similar vein, preliminary evi-dence suggests that repeated prolonged exposure maybe helpful in the modification of food aversions (de Silva,1988). In addition, there is ample evidence that prolongedexposure with response prevention is an effective treat-ment in the context of disgust-based psychopathologysuch as OCD (Abramowitz, 1996; McKay, 2006).

As for disgusting items in general, individuals experi-encing disgust in the context of sexual behavior will ordi-narily avoid opportunities that would provide the contextfor the extinction or habituation of the disgust response.They are likely to use all kinds of so-called safetybehaviors, such as distracting attention, withdrawing

particular behaviors, or avoiding sustained contact withparticular sexual products, and so forth (Frank, Noyon,Hofling, & Heidenreich, 2010). It is therefore importantto identify these influences of disgust and to incorporatethem into the functional analysis of the individual’s(sexual) problems. Such a functional analysis can betaken as the starting point for designing interventionsthat might help prevent (emotional) avoidance and facili-tate mood-incongruent action tendencies (e.g., Barlow,Allen, & Choate, 2004).

As one global example, it could be useful to arrangehomework assignments that help the clients force them-selves to tolerate prolonged direct physical contact withdisgusting stimuli, because only prolonged contact whileabstaining from concurrent safety behaviors may eventu-ally neutralize the perceived disgusting properties of thetarget stimuli (e.g., Frank et al., 2010). It may be mostefficient to arrange these assignments in a gradual man-ner (disgust hierarchy) from stimuli or situations that areonly mildly disgusting or aversive to stimuli or situationsthat are maximally disgusting (see ter Kuile et al., 2009).In addition, one could speculate that mindfulness-basedinterventions might also be helpful in reducing theimpact of disgust on sexual dysfunction. Mindfulness-based therapies generally aim at improvements in atten-tion, acceptance, and awareness (Segal, Williams, &Teasdale, 2002). Accordingly, such an intervention mayhelp patients direct their attention specifically towardthe ‘‘giving into arousal’’ component, while no longerbeing distracted and caught up in the inhibiting disgustresponse. Moreover, via learning to accept and allowthe ‘‘disgusting’’ sexual acts and stimuli (e.g., a partner’ssexual fluids) as they present themselves in the currentmoment, patients could simultaneously learn to preventthe cascade of catastrophical, sex-related thoughts that,for them, would normally be associated with sexualbehaviors.

In their review, Rozin and Fallon (1987) reported twoadditional mechanisms that may help to counteract dis-gust responses. These mechanisms may be integratedinto treatment. The first mechanism concerns theinitiation of accepting expressions by others toward therelevant object or action. Following this, the framingof homework assignments, as well as the therapist’sexpressed attitudes toward the ingredients of the assign-ments may well contribute to a positive change in theevaluation of particular stimuli or behaviors. Althoughtheoretically it seems plausible that such a strategy mighthelp correct overly negative evaluations (see de Jong,Vorage, & van den Hout, 2000), its efficacy is still await-ing empirical scrutiny.

As the second additional mechanism, Rozin andFallon (1987) mentioned conceptual reorientation. Thisnotion refers to the phenomenon that the disgustresponse can disappear when, for example, a person dis-covers that what he or she thought was rotting milk isactually fresh yogurt. Such a cognitive switch may also

be of relevance in the context of sexual complaints. Forexample, for a woman who indicated that she felt dis-gusted by ‘‘this slimy stuff’’ in her vagina, the statementthat in the absence of lubrication a penis would feel likesandpaper appeared quite successful in the conceptualreorientation of vaginal lubrication from being a highlyaversive (bad-smelling and bad-tasting) fluid to a veryhelpful and positively valenced supporting substance.This type of conceptual reorientation might also be help-ful to correct dysfunctional views about sex organs.Homework assignments aimed at forming a more elabo-rated and accurate view of the sex organs and theirchanges based on the various stages of the sexualresponse cycle may, for example, contribute to a reorien-tation of a penis from being an atrocious, uncontrollable,dirty monster toward its conception as a cute, caringbody part that can share love and sexual pleasure witha loved sex partner. Similarly, conceptions of the vaginalarea might change from being an ugly tangle of folds,slime, and secretions that stinks and cannot be kept cleantoward conceptions that ‘‘My labia are a normal part ofmy organ that protects my vagina, and the presence ofvaginal fluids is a normal response of the body to keepthe vagina clean’’ (for more detailed examples, see deJong, van Lankveld, Elgersma, & Borg, 2010).

To the extent that (pathogen) disgust does indeedplay a role in the development or maintenance of sexualproblems, it might also more generally be worthwhilein cognitive-behavioral therapy to add a focus oncontamination-related preoccupations and to includeexposure exercises aimed at reducing the subjectivecontamination potency of sexual products and the sensi-tivity to contamination of the individual’s body parts(e.g., de Jong et al., 2000). In addition, a disgust concep-tualization of sexual problems suggests that it might behelpful to include exposure exercises to more generallyreduce individuals’ disgust propensity irrespective ofthe particular domain of sex-related stimuli.

As far as moral disgust is involved, it might be helpfulto use techniques from cognitive-behavioral therapy tofacilitate change of a dysfunctional conception of sexas being dirty, sinful, or immoral into a more functionalconception of sex (e.g., Borg et al., 2011). Of course thistechnique may also be applied to particular forms ofsexual behaviors that people might initially find disgust-ing because of restricting thoughts about the range ofacceptable sexual behaviors.

Recapitulation and Remaining Issues

Disgust is probably not the first thing that comes tomind when most people think about sex. Perhaps thisexplains why disgust has received scant attention in sexresearch and has been largely overlooked as a relevantfactor in sexual dysfunctions. The present review showsthat disgust-based mechanisms may nevertheless be a

significant factor in the generation and persistence ofsexual dysfunctions and may provide fresh clues forimproving current treatment options. Since few studiesin the literature directly address the role of disgust insexual behavior, many issues remain to be empiricallytested.

As a starting point, it seems critical to improve ourinsight into the role of disgust in the common develop-ment of sexual approach behavior from childhood to lateadolescence, also in connection with the development ofindividuals’ domain-specific disgust propensity (e.g.,Stevenson, Oaten, Case, Repacholi, & Wagland, 2010).Thus far, both the role of disgust in normal sexualdevelopment and in the development of individuals’domain-specific disgust propensity is largely unknown.As a more specific issue, it would be helpful totest whether the increase in androgens during pubertyis indeed associated with a lowered threshold forapproaching=touching disgusting stimuli and, if so,whether this is restricted to sex-relevant stimuli or reflectsa more generally reduced disgust propensity. Moreover, itwould be highly relevant to consider potential gender dif-ferences in this respect.

Along the same lines, it would also be important toexamine whether the influence of sexual arousal on thewillingness to approach disgusting stimuli might varybetween people with particular types of sexual dysfunc-tions (e.g., hyposexual desire disorder or sexual aversiondisorder) and people without sexual complaints. To theextent that sexual arousal may have less impact onsex-induced disgust, this could help explain why somepeople may bemore likely to develop these types of sexualdysfunction; moreover, it would provide concrete startingpoints to further improve available treatment options.

In addition, it would be valuable to gain a morecomprehensive insight into the role of disgust acrossthe various male=female disorders. It would also beimportant to complement the cross-sectional observa-tions regarding the relationship between enhanced dis-gust and sexual dysfunctions, such as vaginismus, withlongitudinal and experimental studies to get insight intothe direction and meaning of the relationship betweendisgust and the presence of these disorders. If, forexample, enhanced disgust propensity is a risk factorfor the development of vaginismus instead of a conse-quence, trait disgust propensity should remain enhancedeven following successful therapy. In addition, if (state)disgust is causally involved in the maintenance of symp-toms, specifically reducing sex-related disgust shouldresult in a reduction of symptoms.

Another interesting avenue for future research wouldbe to test the neurophysiological underpinnings of dis-gust in connection to those of sex. Preliminary evidencehas already shown that, in nonsymptomatic men andwomen, the brain networks activated by disgust andsex pictures were similar (Borg, de Jong, & Georgiades,2012; Karama et al., 2011). It would be interesting to

examine whether the overlap between sex responsivityand disgust is especially pronounced in individuals suf-fering from sexual dysfunctions (e.g., vaginismus, erectiledysfunction) and to examine how this overlap evolves asa function of successful treatment.

Finally, the previous section discussed several con-crete leads to develop fresh treatment options that followfrom a disgust conceptualization of sexual dysfunctions.Future efforts to further develop and test interventionstargeted at reducing disgust-related feelings and apprai-sals may lead to welcome contributions to the currentlyavailable treatment options. Recent work in the contextof OCD showed that computerized training to promoteautomatic approach tendencies to dirty=disgusting stim-uli was highly successful in reducing OCD symptoma-tology (Kuckertz & Amir, 2011). Given the allegedimportance of automatic sex-disgust associations in vagi-nismus and perhaps also other dysfunctions, it would behighly interesting to test whether a conceptually similarcomputerized approach training covering generally dis-gusting stimuli or sex-related disgusting stimuli mightalso be a helpful approach to efficiently overcome disgustreflexes in response to sexual stimuli=behaviors (see alsoMarch, 2010).

To conclude, as illustrated in this article, it is still farfrom clear exactly how disgust is involved in commonsexual behaviors and in sexual dysfunctions, and manyaspects of the link between sex and disgust are still wait-ing for empirical scrutiny. Accordingly, the presentreview and model concerning the role of disgust in(dysfunctional) sexual behaviors relied heavily on theor-etical speculation instead of empirical data. We hope thatthis overview is nevertheless helpful in illustrating thatdisgust-based mechanisms hold great promise forimproving the understanding of sexual dysfunctionsand provides inspiration for future research tofurther investigate the role of disgust in sex and sexualdysfunctions.

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