Question 1

What led to your interest in women's sexual health and mindfulness-based interventions?

Lori Brotto · Accepted Answer

I’ve been interested in women’s sexual health since Viagra was approved in Canada in 1999. It was the year I started my PhD and I was ready for a change after studying rat models of sexual dysfunction for the previous six years. My introduction to mindfulness was in 2002 while I was a fellow at the University of Washington. I learned about mindfulness as a component of treatment for borderline personality disorder. The women with sexual dysfunction that I was doing research with described a profound disconnect from their bodies, a lack of pleasure, extremes of emotions, and as a result, a change in how they viewed themselves. It struck me that mindfulness, which had been working so well for other patient populations, might also be useful for this group. I carried out a small pilot study of mindfulness with cervical cancer survivors who also had a lack of sexual arousal. I immersed myself in the practice and study of mindfulness, and as I was learning, I was teaching the young cancer survivors too. The data I collected on this group was extremely promising. They had an increase in their physiological sexual arousal response when measured in a laboratory, and also their self-reports of sexual arousal. The findings were promising enough that I started to apply for grants and test this in much larger samples of women.

Question 2

How do you define mindfulness? And how does it relate to sex?

Lori Brotto · Accepted Answer

Jon Kabat-Zinn defined mindfulness in 1991 as present-moment, non-judgmental awareness. It is about paying attention in the present moment, and doing so non-judgmentally and compassionately. It is more than just concentration training, it is also about how you’re paying attention. It relates to sex because so often people are multitasking during sex. They might be having benign thoughts such as “did I turn the stove off?” or more judgmental thoughts like “what happens if this does not go well and my partner leaves me?” Particularly for women, the body might be responding to touch with signs of arousal, but the mind is not registering the arousal because it is elsewhere. Mindfulness is about unifying the mind and the body response, which heightens desire and makes for a much more satisfying encounter.

Question 3

What everyday mindfulness exercises can you do to improve your sex life?

Lori Brotto · Accepted Answer

I do recommend a daily formal practice, even if it is 5-10 minutes of a formal guided meditation like mindfulness of breath or a brief body scan. In addition, I recommend that people bring mindfulness into activities of their day such as: while walking, while standing in line, while having a shower, while kissing a partner, and most definitely during sexual activity. We have evidence that after just 8 weeks of a regular mindfulness practice, women with a sexual desire disorder experience significant improvements in sexual desire and relationship satisfaction, and significant decreases in sexual distress and rumination, and moreover that these benefits are retained when they are assessed a year later.

Question 4

Can a low libido be a sign of relationship problems, and is mindfulness alone enough to fix these?

Lori Brotto · Accepted Answer

Yes, among the various causes of a low or absent libido is relationship problems. There is a fair bit of research showing the strong relationship between sexual satisfaction and relationship satisfaction. Certainly as a sex therapist, one of the key domains we assess for a person presenting with low desire is their relationship. In our research, we showed that 8 weeks of mindfulness significantly improved relationship satisfaction. However, we have never assessed whether mindfulness along is sufficient to fix relationship problems. If there is significant conflict, a breakdown in communication, and a betrayal of trust, it is likely that couples therapy may be needed in addition to using mindfulness as a tool for coping with extreme emotions. That said, I would also recommend couples-focused mindfulness exercises (like the ones described in my book) to couples who are facing relationship discord and low desire.

Question 5

How can mindfulness improve sexual desire within longer term relationships where sexual desire has reduced over time?

Lori Brotto · Accepted Answer

One of the things we’ve assessed in our own research is whether mindfulness is only effective for partnered vs single people, and also whether it works differently depending on how long one has been experiencing their low desire. It turns out that neither relationship status nor duration of difficulty impact how well mindfulness works. This means that even for those individuals (or couples) who’ve had a longstanding low sexual desire, mindfulness might still be useful for them. One determining factor is how regularly does one practice mindfulness. There is some evidence that a regular, daily practice, if even just for a few minutes, is more effective than a once per week longer mindfulness practice. We also want to acknowledge that declining sexual desire is a very normal feature in many (and perhaps even most) long term relationships. Therefore, while we do want to use evidence-based strategies, like mindfulness, to address distressing low desire, we also do not want to pathologize normative declines in sexual desire.

Question 6

What would you suggest for a woman experiencing postpartum depression if trying to increase her pleasure in sexual interactions? Desire seems to be intact but enjoying experiences is difficult.

Lori Brotto · Accepted Answer

Firstly, sleep is a major contributor to overall vitality and mood. During the postpartum period, a woman is very likely to be sleep deprived as her clock is catering to her newborn. On top of that, postpartum depression (and anxiety) impact 1 in 5 women and can reduce interest in any sexual activity. The best thing she can do for herself (in addition to trying to sneak in naps whenever possible) is to ensure she is getting the help she needs for postpartum depression and anxiety. Sometimes the improvement in mood can directly contribute to improvements in sexual pleasure. We also need to make sure her partner is contributing equally to the caretaking or she will develop resentment towards that person, which is also a significant impediment to desire.

Question 7

How can sexual trauma of one partner be handled in romantic relationships?

Lori Brotto · Accepted Answer

Unfortunately sexual trauma is very common, and the consequences of it can linger for many years even when a person is in a healthy and loving and consensual relationship. Symptoms of sexual trauma are best managed with a qualified health care provider, ideally a psychologist or counsellor with expertise and training in this area. In my own work, I routinely use mindfulness to manage symptoms of re-experiencing and hypervigilance which can be consequences of sexual trauma. In addition, sexual arousal during an encounter can trigger dissociation or other negative mood states, and again, mindfulness can be very helpful for keeping the person in the present moment, and encouraging them to stay with the safety of the present moment. Our research has shown mindfulness to be a very effective tool for helping women with a history of trauma to enjoy their current sexual encounters again.

Question 8

Are there any mindfulness resources for men with sexual dysfunction due to autonomic nervous system imbalance? They are already enrolled in eight-week mindfulness therapy. Could something be added to the group to address mindful sex?

Lori Brotto · Accepted Answer

If a person is already enrolled in an 8-week mindfulness based cognitive therapy or mindfulness based stress reduction program, this means that they are learning and practicing the foundations of mindfulness and acquiring those critical skills in present-moment non-judgmental awareness. To integrate these skills into sexual activity, I recommend starting slow. Begin during masturbation by using the same breath awareness and body awareness exercises they’ve been practicing in their 8-week program. Slow down the touching and really pay attention to the emerging sensations. Distraction or fantasy or viewing erotica should not be used during this exercise in order to really facilitate that awareness with emerging sensations and to settle into the relaxation that is needed to counter a revved up stress response system.

Question 9

I am wondering if you have any tips for a woman who can no longer access penetrative sex due to having surgeries/trauma to their vulva. Do you have any ideas on how they can find pleasure in others ways/how they can pleasure their partners in ways other than penetrative sex?

Lori Brotto · Accepted Answer

Surgeries or other treatments to the vulva, such as removal of vulvar tissue due to vulvar cancer, or other diagnoses such as vulvar skin conditions, can have a disfiguring effect on women and persons with vulvas. They may be embarrassed to have a partner see their vulva or touch the area, and it indeed may be quite painful for them. The good news is that there are many areas of the body that are responsive to erotic touch and this can be a time to set out exploring, either alone or with a partner, where those areas are, and what kinds of touch feel sensual for them. If the clitoris has not been impacted by the treatment, then retaining clitoral stimulation by hand or mouth should continue as it is a major source of stimulation and pleasure for women. But other sensual areas include the earlobes, back of the neck, inner thighs. In fact, individuals who have experienced a spinal cord injury where they may not feel any sensation below the waist or neck can even learn to experience pleasure (and orgasm) from stimulating areas of the head or even purely by engaging in fantasy! I recommend working with a qualified sex therapist who can coach the person and their partner to engage in this exploration while simultaneously addressing any body image concerns or fears that arise.

Question 10

What broad advice for maintaining desire would you give women going through menopause?

Lori Brotto · Accepted Answer

Firstly, ensure that the vagina is adequately moisturized. There are non-hormonal over the counter products that can be used safely in the vagina to maintain moisture and reduce friction and pain, which are common during the perimenopausal transition. If the non-hormonal products are not helping, then speak to a physician about a hormonal moisturizer, which come in cream, gel, pill, or ring form. They are safe to use, even among breast cancer survivors and help to restore moisture and elasticity of the vagina to reduce pain with penetration. In addition to a moisturizer, now is the time to introduce a lubricant each and every time you engage in sexual activity. Lubricants make sexual activity more pleasurable and feel better. They do nothing to improve vaginal dryness or pain, which is why they’re often used in conjunction with a moisturizer for menopausal women who may be experiencing dryness. If sexual activity feels good, then desire for it will continue. If it hurts, desire will wane. In addition to these physical aids, there may be sleep changes or mood changes during the perimenopause that can contribute to a reduction in desire. This is a time to take a full-body wellness approach and explore ways of sleeping better, managing mood, and keeping on top of other aches and pains that may arise with age. Having regular appointments with your healthcare team can be essential for preventing some of these age-related issues from taking a toll on sexual desire. Finally, it might be a good time to speak with a sex therapist about communication tips and other strategies (like mindful sex) to keep the desire spark alive.

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