Twenty years after Viagra was approved to treat erectile issues in men, we still don’t have any quick fixes for the primary sexual struggle of women: low sexual desire. In this podcast interview, Dr. Lori Brotto shares what has been the most promising treatment for women who struggle with sexual desire – mindfulness.
Mindfulness based sex therapy is not a quick fix, but instead is an ongoing practice and lifestyle that offers profound and lasting benefits for a wide range of sexual struggles.
In her new book Better Sex Through Mindfulness: How Women Can Cultivate Desire, Lori Brotto gives an illuminating overview of the past fifteen years of research on applying mindfulness based interventions for sexual concerns. Along the way, she challenges many of the cultural narratives that drive so many of these struggles: a misunderstanding of the nature of sexual desire, the scripts and routines that drive so many sexual encounters, and the culture of distraction and stress we all live in. Meanwhile, Lori Brotto outlines several of the mindfulness practices that she uses in her clinic so readers can immediately begin applying these concepts to their own sexual experience.
The take-home message is this: mindfulness teaches women to become more aware of their internal bodily sensations, including sexual sensations, and this may improve their motivations for sex and increase their tendency to notice sexual arousal and have that arousal trigger sexual desire.
Could it really be this simple – that teaching women to tune into their body, to the signs that their body is already producing, and making them aware of these sensations can be enough to trigger sexual desire? I offer a tentative “yes” to this question. Why tentative? Because awareness of internal bodily sensations is only one of potentially many different ways that mindfulness exerts its beneficial effects on sexual desire. Without a doubt, when we pay attention to the body in a kind, compassionate, nonjudgemental and present-oriented way, it offers us a new way of being in the world. And that new way of being might just be critical for the sexual satisfaction that so many women crave. ~ Lori Brotto, Ph.D.
A full transcript of the podcast interview with Lori Brotto is below.
If you are ready to begin exploring the frontiers of Mindful Sex, join our online course on Mindful Sex! Our Mindful Sex course is the perfect complement to Lori’s brilliant book, and we will be discussing the book in depth within the course community.
Full Transcript of Pleasure Mechanics Interview With Lori Brotto:
[00:00:00] – Chris Rose
Lori Brotto, welcome to Speaking of Sex.
[00:00:04] – Lori Brotto
Thanks so much for having me today Chris.
[00:00:06] – Chris Rose
Can you introduce yourself and the work that you do.
[00:00:09] – Lori Brotto
Sure. So I’m Lori Brotto. I am a registered psychologist by training, a researcher in the Department of Gynecology at the University of British Columbia and the executive director of Women’s Health Research Institute in the province of B.C. and my research has been focusing mostly over the last decade or so on the development and treatment of sexual concerns in women using mindfulness meditation based approaches
[00:00:39] – Chris Rose
In the book you lay out this beautiful story, but how did you come to focus on mindfulness after the development of viagra, what is that link?
[00:00:48] – Lori Brotto
So this was really a pivotal moment not only in my own career but I think for the field of sexuality and sex research more broadly and that was the year 1998 when Viagra was approved for men and suddenly men had an effective easy to use low risk, low adverse event, very accessible medication to treat their sexual concerns- so erectile dysfunction in men which affects probably between 10 to 15 percent of men. And shortly after that in the same year there was a large study based on several thousand American men and women and it found that actually the prevalence of sexual difficulties in women was far greater than the prevalence of sexual concerns in men. And it reached somewhere around the neighborhood of about 40 percent. So around 40 percent of women over the last year reported that they had some type of sexual difficulty. The most common of which was low sexual desire. So that sort of got me started down the path of looking into – well we’ve got this effective and easily accessible treatment for men’s sexual concerns.- What is there for women.? And I quickly discovered that my literature search took all of about one minute and discovered that there were very very few treatments available. There were no medications approved. There were a handful of more psychological types of interventions but really very little research looking at effective ways of improving women’s sex response and sexual satisfaction.
And that really led to the path that I took after that point I was an animal researcher focused on animal models of sexual dysfunction and very soon after reading that paper I made the switch over to studying women’s sexual response in the laboratory. Then I was introduced to mindfulness a few years after that when I was living and working as a post-doctoral fellow at the University of Washington in Seattle and learned about mindfulness because it was a very effective part of treatment for individuals who engaged in cutting behaviour or parasuicidal behaviors and mindfulness essentially helped those patients cope. It helped them cope with the ups and downs of their emotions, their tendency to want to hurt themself and basically it taught them – if they could remain in the present and really focus on what it felt like, including all of the distressing emotions they were feeling, that they could ride it out almost like as if they were on a surfboard. So that again another pivotal turn in my career that introduced me to mindfulness. I began my own personal practice and rather intensive training and learning about mindfulness and really the rest is history so to speak.
[00:03:52] – Chris Rose
And here we are 15 years later and this treatment has proven to not only effectively help women with low sexual desire and other sexual struggles but create lasting changes. And again 15 years later we don’t have the pink Viagra. So what is it – your book is called Better Sex Through Mindfulness. So let’s start with the basics, what is it about mindfulness that can lead to a better sexual experience?
[00:04:24] – Lori Brotto
So mindfulness is essentially a way of being. It includes paying attention in the present moment moment by moment and doing so non-judgemental and compassionately. So it’s more than just paying attention or concentration training but rather it’s about how we pay attention. And one of the things we know is that individuals who have sexual concerns and in particular women who have low desire are often struck by myriad negative thoughts about their own performance, concerns about whether or not they will respond, worries and fears about how a partner may respond or or not approve about their sexual activities or outcomes, and there’s compelling data that shows that this sort of onslaught of negative thoughts and negative self judgements and essentially women be very very hard on themselves can directly and negatively affect their ability to become sexually aroused and have sexual desire. And so one of the ways that we believe mindfulness is helpful for women with sexual concerns is it teaches them to just be in the moment, to notice sensations without that tendency to jump into the future and worry about “Am I responding enough? Is this going to upset my partner? is this going to lead to disaster? Am I not going to reach an orgasm?”
And so mindfulness really allows them to really tune into sensations and really stay with the sensations so that they might still have those negative thoughts but they’re not dominating the field of their awareness. And our research has shown that that’s probably one of the important ways. There are certainly other ways as well that mindfulness is helpful but that’s really one of the key ways is really targeting that negative self judgment.
[00:06:26] – Chris Rose
The work of a lifetime.
[00:06:28] – Lori Brotto
Yeah sure is
[00:06:30] – Chris Rose
So when we think about so many women having low sexual desire do you feel like we need to rethink how we culturally talk about desire? What are your thoughts about how we reframe the human the notion of desire in the first place?
[00:06:47] – Lori Brotto
Yeah absolutely and this has been an area of work that I’ve been pretty actively involved with as along with several others and that is how do we define sexual desire? And I think that there are many cultural stereotypes around what sexual desire is and one of them being this notion that you either have desire or you don’t. And when you have it it’s something that just exists within you it lives somewhere within your body you feel it physically and it always compels you towards sexual activities. So you know you feel horny, you feel butterflies, you feel some kind of internal physical trigger that moves you towards sex. And one of the things we know is yeah that might that might express sexual desire for some people or maybe for some people some of the time depending on their context, their age, what kind of relationship there and how long that relationship is, a host of other factors. But we also know that there are other ways that desire is expressed and one of the more helpful ways of thinking about desire is as if it were an emotion just like sadness or happiness. Now we feel happy when positive things happen to us when things in our environment or people we interact with say or do things that make us feel happy so happiness happens in response to something and it can be really helpful to think about sexual desire in the same way. So we feel desire when there are triggers for desire. And the research suggests that that’s probably a much more common manifestation of desire than this idea that desire something just is or is not within you. And when we think about desire in that way, as something that can be triggered or elicited, then suddenly we feel far more empowered to explore – well what are those cultivators of desire? And if I don’t have desire or my desire is less than it used to be maybe this is an opportunity to explore the triggers and the context that would be more likely to elicit desire for me.
[00:09:11] – Chris Rose
And part of that exploration is paying attention. So how does mindfulness help us pay attention to what’s already going on in our body and tuning in rather than tuning out?
So in our own work and of course our work is heavily influenced by the much larger field of work exploring mindfulness based interventions for other issues like stress and anxiety and depression and chronic pain.
And so the way that we do that with sexual concerns is we start with introducing a formal practice. So in our groups this means that we bring groups of about eight to 10 women together we have a facilitator who is well versed in both mindfulness space practice as well as in sex therapy and we spend really the first hour of our two hour group engaged in a mindfulness practice where the facilitator will provide instructions for the participants something along the lines of – pay attention to the breath, notice where in the body the breath is experienced, notice what sensations are associated with breathing, notice any sounds or smells or thoughts or other sensations that go along with breathing. That’s just a really really quick short snippet of a much longer exercise that we do called mindfulness of breath – but essentially we encourage women to adopt a regular formal mindfulness practice in their lives where they might practice a formal meditation every day for you know 20 to 30 minutes and then we gradually tailor these exercises to more sexual contexts. So in that sense we might first encourage the women to engage in some self touch and while they’re touching themselves alone they can practice mindfulness at the same time. So what does it actually feel like these sensations as I’m touching myself head to toe including the more erogenous parts of her body – the nipples, the breasts, the vulva, the labia, et cetera. And then we also talk quite specifically about how they might incorporate these new found skills when they’re sexual together with a partner.
[00:11:41] – Chris Rose
I love that. So we released our mindful sex course about four months ago. And one of the things we include is the aroused body scan, because I think there’s different information to be gained from paying attention in a state of arousal. And I love that in your book you include all these exercises of mapping the mindful practice into the sexual encounter either alone or with a partner. What are some of the issues. So a lot of women report this disconnect between the body and the brain. Right. And in the book you talk about arousal concordance and interoception – these are big words, so how do we explain these concepts and think about this unification of the mental and physical experience of sex?
[00:12:27] – Lori Brotto
Right. So I’ll maybe just start with a bit of a real example of one of the first groups that I I worked with when I was a fellow at the University of Washington Seattle to adapt and test mindfulness and this was at a time when I was working quite closely in research with cancer survivors. And these specifically were women survivors of gynecologic cancer where their treatment involved rather radical removal of some of the the internal reproductive structures, so with a radical hysterectomy they had their uterus or cervix and the upper part of the vagina removed and many of these women described a complete lack of any any pleasure any sensation with genital contact. They often talked about it as feeling as though my partner’s touching my elbow. So rather than having that specific sexual pleasure related quality they could feel touch but it was not pleasurable for them whatsoever and it was really a potent example of this kind of disconnect because what we learned was when we taught women to really pay attention, to really notice the sensations that were there while they were engaged in erotic touch or sexual contact, that they realized that there were still sensations of pleasure that they could by focusing on them and really tuning into them could then amplify. So that’s one example of how and why paying attention can really amplify a response that maybe women are not noticing or that has been greatly reduced. Now there’s also been quite a large body of research led by Meredith Chivers, a fantastic Canadian sex researcher as well as others, that shows when you bring women into a right into a sexual psychophysiology research lab and you show them a series of erotic videos and you measure their physical response, typically by the use of a vaginal probe that measures their genital blood flow. And then you also ask them how turned on or how sexually aroused they are, that far more often than not what those studies will find is that there might be a strong physical sexual arousal response. And yet at the same time women are self reporting either minimal sexual arousal or not being sexually aroused or frankly being turned off and we often find that in our samples of women with sexual dysfunction. So the body is responding in the mind is simply not. And that’s what we mean by either low concordance or frankly discordance. And that what that means is that when exposed to a sexual trigger the body’s responding and the mind is not and sometimes you can have the opposite you might have the mind that sexually excited and turned on and the body that’s not responding. So one of the things that we’ve been very interested in in our research is how does mindfulness impact this concordance or this mind body agreement in sexual response. And we’ve now found in a few studies that essentially what mindfulness does is it increases the amount of communication between the brain’s arousal pathways and the body’s sexual response such that as women are becoming aroused in their body they’re far more likely to be tuned in also in their mind and therefore state that they feel sexually excited.
[00:16:13] – Chris Rose
And is this a function of strengthening neural pathways? Do we know yet how this functions?
[00:16:21] – Lori Brotto
Yeah. So this is really where the research needs to go next and we speculate on how and why that is and one of the kind of leading explanations that I believe is going on is we’re strengthening women’s ability to become interoceptive aware. So interception or interoceptive awareness, this is just our general ability to know what’s going on in our body.
So you might know folks who are acutely aware of their own heart rate and accurately aware of their own heart rate or those women who can actually sense when they are they ovulate or sense other internal physical sensations. That is interception and we measure interoception in our studies, both through self report questionnaires as well as through a heart rate accuracy test that women do before the mindfulness groups and after. And what we’ve found is that as women become more interoceptively aware this is also associated with their increased ability to tune into those sexual sensations as well.
[00:17:32] – Chris Rose
So in the moment of receiving sensation you are aware of how you’re feeling, then you can map the emotional response onto it and then comes the piece of nonjudgment, right. So we live in a culture that has nothing but judgment, especially around female sexual desire. How does this piece of practicing non-judgment and self compassion play out in your groups? What kind of transformations are possible there?
[00:18:04] – Lori Brotto
Yeah so this this has been really in my mind probably one of the most critical ingredients in our mindfulness based intervention. So I mentioned the awareness of the breath practice. We also have body awareness practice, awareness of thoughts, awareness of sounds and then we also have specific practices that are designed to cultivate compassion towards one’s self. And typically in the group what that looks like is there’s a lot of emotion that goes along with realizing and recognizing that we can be really hard on ourselves. And when you do a formal practice with women where your instructions invite them to cultivate a sense of love and compassion to them self and they realize just how challenging that is – so you have no difficulties at all cultivating love towards other people that they know, even other people that they don’t know. But when it comes to really channeling that love and compassion towards them self there is great great difficulty in doing that. And immediately the women realize what role that this plays in perhaps perpetuating some of their sexual concerns so because they’re constantly faced with a fear of disapproval and concerns about not being good enough sexually as well as otherwise. And when we start to really confront that in the group and send women home with practices that are designed to cultivate compassion they immediately feel transformed in fact many of the women when we follow up with women and engage them in some interviews after they do the group they’ll often tell us how that was one of the most challenging parts of of the eight week intervention is really cultivating that love towards themself.
[00:20:03] – Chris Rose
Especially when we live in the world we do right now.
[00:20:06] – Lori Brotto
[00:20:07] – Chris Rose
I know you you mentioned you worked with cancer survivors. You’ve also worked with trauma survivors. What has working with this population taught you?
[00:20:17] – Lori Brotto
Yeah. Wow what an opportunity that has been to offer to these women, who have in some cases really quite tragic and horrific histories of sexual abuse and assault, many of them as children. And one of my motivations in working with that group using mindfulness specifically are that these the women that we worked with had already undergone fairly extensive psychotherapy to deal with the aftermath the psychological aftermath of their abuse histories and most of them felt like they were resilient and they got past that until they found themselves in consensual sexual relationships again where engaging in sex or feeling sexual arousal triggered many of the past intrusive thoughts and nightmares and distress and dissociation as it had done in their past and their abusive situations. So very very distressing because these were women who were now in happy and consensual relationships. They wanted to be sexual. And yet they had this kind of recurrence of their their past PTSD and trauma symptoms. And so we believed that a mindfulness approach teaching women to really tune into the arousal and notice that the building sensations of arousal and staying with it, without getting pulled away into dissociation, was really quite key and we found in one study that we did where we compared this approach to another effective psychological approach Cognitive Behavioral Therapy, that the women who received the mindfulness training were able to have far less distressed sex related distress and moreover they were really able to tune into their body and experience both their body getting aroused as well as their mind getting aroused. So for me it was really after working with those women who who had experienced histories of sexual abuse that it convinced me that wow, this was really a tool and a practice that finally could make a lasting impact on women’s sexuality.
[00:22:43] – Chris Rose
And while most of your work has been around women’s sexuality, what are your thoughts on how this research translates to the male sexual experience?
[00:22:52] – Lori Brotto
Yeah I’ve been often asked that question particularly since the book has women in the title. And yet our research over the last two to three years has also adapted these same strategies, our same groups to different populations of men with some really fantastic outcomes. So for example one of the studies we did involved men who have situational premature ejaculation which essentially means that these are guys who had no difficulty with their ejaculation or their erection when they were on their own but when they’re with a partner they might ejaculate too early or the men with situational erectile dysfunction have no difficulty getting erection on their own but when they’re with a partner because of concerns and fears and worries and and concern about performance failure they might lose their erection. And so we found mindfulness to be really a powerful tool, a powerful strategy for helping them gain better control over their erections and for dealing specifically with the premature ejaculation. We’ve much more recently been delivering mindfulness based strategies also to prostate cancer survivors together with their partners.
Now this is a bit of a different population because one of the things we know is that prostate cancer treatment whether it’s the surgery or the chemotherapy or the radiation produces lasting and permanent sexual difficulties for the vast majority of men who survive their prostate cancer. So our use of mindfulness with this population is not so much focused on getting their sexual function back but rather on expanding their repertoire. Their – what we call “a buffet menu” of different ways of being sexual that don’t focus on having an erect penis.
So that work’s been very interesting because typically this is a population who’s really really distressed and very focused on getting their erection back and that also probably speaks to bigger societal notions of what it means to be a masculine man and to be a masculine man means to have a rock hard erection when one wants it, when one wants to need it. So mindfulness and in particular the compassion practice of mindfulness has been very useful for that population of men in expanding the different ways that they might be sexual.
[00:25:32] – Chris Rose
So important, I love that. Recently on the podcast we were talking about performance anxiety and the idea that excitation and anxiety are both arousal responses. How does mindfulness allow us to grow our capacity for arousal and excitation without flipping into anxiety?
[00:26:00] – Lori Brotto
That is a great question and I’m going to write that down because that would be a great future research study. And you know one of the things we know is that among women with low desire, individuals with low desire more generally, that there may be different kind of patterns for sort of their reasons for their low desire.
So it may be the case that one woman has a low capacity for becoming sexually excited so a low excitation ability and for other women they might be much higher on the inhibition domain. So they might have kind of internal structures in their brain that constantly put the brakes on and prevent them from becoming sexually excited. So in our own research we have measures of this inhibition and excitation tendency and we’re now starting to look at how mindfulness might specifically impact those two different systems the excitation and inhibition system. So we don’t quite know exactly how that happens yet but we can speculate that one of the things that mindfulness does is by tuning in and reducing avoidance tendencies that it probably does have an impact on lessening some of those inhibitory barriers that are preventing women from getting sexually excited. Now how it impacts the excitatory pathways we don’t know quite yet what the answer to that is.
[00:27:33] – Chris Rose
I look forward to it. Thank you. And when we released our mindful sex course and when we talk about mindfulness on the podcast, sometimes the response we get is “I’m all ready to self conscious during sex. I’m already too much in my head” and there’s this confusion that mindfulness means overthinking. How do you talk about the specific qualities of mindful attention that are different from everyday cognitive function?
[00:28:03] – Lori Brotto
Yeah that’s also a very common concern expressed by women in our group which is “I’m already hyper vigilant to my own function and I actually think that that’s actually getting in the way of my sexual arousal.” And so there are different ways of paying attention and in the woman who’s hyper vigilant. There can be a tendency to misinterpret what’s happening as signaling some kind of negative or disastrous or catastrophic outcome. So by hyper focusing on “am I getting aroused, am I wet yet, am I excited, what’s happening in my body, what’s happening in my vulva, what’s happening with my nipples” It’s not a hypervigilance that we’re cultivating but rather it’s an awareness and an observing. One of the other really important things that we practice with mindfulness is something that mindfulness experts call “open monitoring” and that is our ability to just kind of notice everything that is happening without attaching to any one particular experience. And so in our groups when we lead the mindfulness practice there’s really two things that we focus on. One is notice what’s happening. Notice the sensations. And then secondly notice if you have a tendency to become overfocused on those so to attach to experience attachment and simultaneously notice if there’s a tendency to want to move away from or experience some aversive reaction to those sensations. So we fold in this practicing practice of noticing attachment and aversion while we’re also noticing sensations and that can be a really useful concept for those women who tend to be hyper vigilant about their sensations.
[00:30:00] – Chris Rose
Oh yeah I know that well from being mindful during chronic pain. And to map that onto how we move away from or towards pleasure that is really powerful. So of all of your research findings over the past decade plus what has been most surprising to you?
[00:30:19] – Lori Brotto
I think one of the pleasantly surprising outcomes has been that when we invite women back six months and one year later that they continue to experience the benefits. They’re continuing to practice the mindfulness maybe not in the same kind of intensive way that they did when they participated in our groups but because they’ve experienced lasting improvements not only in their sexual response unsatisfaction but on those other important parts of quality of life like mood and ability to cope with stress ability to just engage more in life and enjoy their meals and pay attention to their conversations that they actually want to continue to do these practices in their in their life. So it’s been a really positive observation is to see that we are planting a seed but then that seed continues to be cultivated and it grows into women’s ongoing practice long after they leave our our center. So that’s been a great finding. I think one of the other maybe somewhat surprising findings is that the benefits of mindfulness were not specific to those women who already bought into the idea of Mindfulness being useful.
So basically what I mean by that is that we include baseline measures for women engaged in the groups around “how much do you think that this is going to help you” and “how much do you really agree with this kind of a mindfulness based approach” and “how skeptical are you of these strategies and whether they will work for you?” And what we found is that women’s baseline level of confidence in the mindfulness treatment and in their level of skepticism had no bearing whatsoever on whether they benefited from the mindfulness or not. So this is great news because one of the the concerns that I’ve certainly read about in the larger mindfulness literature is you know maybe this is only for a small segment of the population who practice yoga and are open to integrative and contemplative practices. Maybe these are folks who you know are have an openness to Buddhist meditation more generally. And our research finds that actually it’s not specific to that population that really cuts across different segments of the population regardless of their baseline level of belief or not.
[00:32:58] – Chris Rose
Thanks so much to your work, we have a developing new field of mindfulness based sex therapy. What do you see coming down the road for the future? What questions are you excited to ask next?
[00:33:14] – Lori Brotto
So we know that sexual difficulties are common. They cut across different ages, different demographics, different cultural groups, different relationship status, sexual orientations, and although my work has focused mostly on women and on the most common concerns being low desire and lack of sexual satisfaction, what I would love to see is kind of an exporting of these approaches for much broader groups. So perhaps individuals who are grappling with sexual identity or who are experiencing stigma or face prejudice as they’re contemplating coming out of the closet and revealing their sexual orientation. So I would love to see kind of an adaptation of these strategies for much broader populations of individuals who are again kind of confronting with different aspects in that broad field of sexuality.
[00:34:17] – Chris Rose
Thank you so much for this conversation and thank you so much for this book.
[00:34:22] – Lori Brotto
Thank you so much for the opportunity. It’s been a real treat to talk to you today.
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