Sexual dysfunction is not a subject you hear women talk about, even with their best friends. Many women find it embarrassing or too personal to discuss, believing that sexual difficulties reflect badly on themselves or their sexual partners. Unable to share their concerns, they often end up feeling alone, helpless, and doomed.
But sexual dysfunction—characterized by low sexual arousal, vaginal atrophy or dryness, painful intercourse, or lack of orgasm—is more pervasive than many realize.
In a 2008 survey of over 32,000 women conducted by the Massachusetts General Hospital, 43 percent of the women surveyed across all age groups reported some kind of sexual problem in their life, the most common being low sexual desire. In fact, a full 39 percent of the women surveyed reported experiencing low desire, while 26 percent had low levels of arousal, and 21 percent had difficulties with orgasm.
While many physical ailments can affect sexual response, researchers have found that psychological factors often play a bigger role in creating sexual dysfunction, especially in cases of low libido. According to Lori Brotto, a professor of gynecology at the University of British Columbia, mood, interpersonal relationships, and general wellbeing are much more central to a woman’s lack of sexual desire than physiological factors.
Even when physiological factors do affect sexual functioning—like in menopause, where vaginal dryness can make intercourse uncomfortable without lubricants—the low self-esteem, poor body image, and relationship problems that often accompany these are what’s often most devastating to a women’s sexual self, she says.
But Brotto has been researching a new treatment for sexual dysfunction that may promise relief for millions of affected women…and men, too: mindfulness.
Brotto’s studies have shown that mindfulness—the ancient Buddhist practice of paying attention to one’s moment to moment experience without judgment—can help women with sexual dysfunction increase their sexual desire by helping them to become more attuned to their body’s sexual response and learn to accept their body’s physical limitations. And, not only that, mindfulness can help decrease stress and alleviate depression, helping women to feel better and enjoy sex more.
Mapping women’s arousal
Researchers have known for decades that a women’s sexual response has both physical and psychological components. While women respond physically to sexual stimuli in much the same way as men—for example, lubrication in the genital area when viewing erotic films—they won’t always experience these body sensations as arousing.
According to Brotto, stress, mood, self-judgment, and other worries can prevent women from feeling sexually aroused, and women who suffer from physical ailments (like cancer) or emotional traumas (like child sexual abuse) are particularly prone to these.
Inspired by the work of Jon Kabat-Zinn—whose Mindfulness-Based Stress Reduction program had been used to decrease stress, pain, anxiety, and depression in patients suffering from illness, including cancer—Brotto wondered if mindfulness might hold the key to helping women with sexual dysfunction.
In a 2008 pilot study, Brotto provided three sessions of mindfulness-based cognitive behavioral therapy (MB-CBT) to cancer survivors with severe sexual desire and arousal problems. Mindfulness exercises included focusing on the breath, paying attention to body sensations, and watching thoughts come and go without judgment. These were coupled with sexual arousal exercises, general information on sexual functioning, and cognitive therapy to challenge negative thinking patterns. The women were asked to practice exercises mindfully for five to seven hours per week to increase their awareness of and acceptance of their own sexual feelings.
When compared to a group of women waiting for treatment, the women receiving the MB-CBT had significant increases in sexual desire and arousal, and less sexual distress, with these positive effects lasting six months post-treatment. In follow up interviews with the women, many expressed that they found the mindfulness exercises to be the most helpful part of their treatment.
“The women seemed to respond positively to the mindfulness,” she said. “They really started to incorporate it into their lives.”
In addition, the women in the study were tested in a laboratory setting before and after treatment to see how well they could tune into their own physiological sexual response. After being shown an erotic film, the women were measured on levels of vaginal swelling and then asked to describe any sexual sensations they noticed and to rate how sexually aroused they felt. Those who’d received the MB-CBT became significantly more aware of their physiological sexual response and experienced it as more arousing than women in the control condition.
“We were pleasantly surprised [by these results],” says Brotto. “We expected some reduction in distress (as this is common no matter what treatment modality is given) but the significant increases in self reported desire and arousal were a nice bonus.”
To help make sure that mindfulness and not other factors were what caused this effect, Brotto conducted another study in which 22 women with a history of child sexual abuse and self-reported sexual dysfunction were assigned to either CBT or mindfulness group therapy. The women were then compared on many of the same sexual function measures as in the first experiment, as well as on agreement between their subjective arousal and their physiological response to explicit material.
Although both groups experienced reductions in sexual distress, only the mindfulness group also experienced greater agreement between subjective and physiological responses, suggesting that women using mindfulness techniques were better able to tune into their body’s response and experience it as pleasurable. For Brotto, these results were huge.
“In cases of sexual abuse there is often a disconnect between the mind and the body, because when you experience unwanted sexual acts, you learn to dissociate from what’s happening to you,” she says. “But mindfulness seemed to help the women to anchor their experience so that they could stay with pleasant sensations.”
Brotto thinks that mindfulness targets the negative self-talk that many women with sexual dysfunction experience. Too busy worrying about how their bodies look, evaluating their ability to sexually “perform,” or feeling too stressed, anxious, or depressed, can prevent women from really being engaged in sex, she says, while mindfulness appears to help people let go of these distractions.
“Mindfulness allows you to surf the difficult thoughts without being swept away by them,” she says.
Changing the experience of pain
From the time she was 19 years old, Meredith M. has suffered from provoked vestibulodynia (PVD), a condition in intercourse causes severe pain in the vaginal opening. PVD interfered with her relationships, her health, and her peace of mind, sometimes driving her to self-medicate with alcohol in order to deal with the pain.
“Nothing I did helped,” she said. “I just dealt with it for a long time.”
Meredith was one of 200 women who became part of Brotto’s most recent study focusing on how mindfulness might help women with PVD cope. At first, Meredith thought the idea of using mindfulness sounded like a “silly new age thing”—but she was desperate to try anything at that point in her life, she says.
In the treatment group, Meredith learned how to become more aware of sensations in her body and to develop curiosity about those sensations without recoiling from them. After weeks of practicing tuning into different sensations—her breath, sounds in the room, and feelings in her body—and cultivating an accepting attitude toward those sensations, Meredith was encouraged to practice these techniques while provoking a little cervical pain using a dilator.
Although it was difficult at first, Meredith found that she was able to tolerate the pain better using mindfulness. As she continued to practice over the months following treatment, she saw continued improvement in her condition, including more flexibility in her vaginal opening. She also has a much more positive outlook on life, in general, with less self-judgment and more acceptance of her negative feelings.
“Mindfulness was very helpful to me,” says Meredith. “I’ve improved a lot. I’m still in pain; but now I feel like it’s not the end of the world.”
Although mindfulness may seem an unusual treatment for PVD, pain researchers have known for years that one’s experience of pain can be exacerbated by stress and anxiety, often due to catastrophic thinking about the pain—for example, worrying that it will never go away or becoming hyper-vigilant around potentially painful situations. Indeed, functional resonance imaging of the brain has shown that emotional and cognitive centers in the brain light up when one is in pain, supporting the theory that feelings and thoughts play a key role amplifying or de-amplifying pain.
When Brotto measured the effects of the mindfulness treatment on the group of PVD sufferers like Meredith, she found that the women experienced decreased pain during intercourse, decreased hyper-vigilance and catastrophizing, decreased distress and anxiety, and increased mood, when compared to women waiting for treatment. Six months later, these symptoms appeared to improve even further.
Though Meredith is happy with her progress, she still finds it challenging to stay focused on the present and to not start wishing for her pain to dissipate completely.
“It can be hard to accept the point you’re at,” she says. “You have to remember to stay in the moment and remain curious.”
Brotto is careful with patients to not promise their pain will end; but she does promise that mindfulness can change one’s experience of the pain. Meredith recounts how, before she entered the group, she was getting intravenous vitamin infusions and experiencing tremendous pain from having a needle stuck in her arm. But after the mindfulness group, she had an experience where a technician had to prick her ten times to find a vein, and it hardly bothered her.
“The difference in my pain tolerance was amazing,” she says.
Results like Meredith’s have made Brotto shift from feeling optimistic about mindfulness as a treatment for sexual dysfunction to being sure that it’s helpful.
“I’m very convinced by the data and also with the clinical feedback I get from patients,” says Brotto. “If you’d asked me five years ago, I would have been much more tentative.”
Brotto’s success has prompted others to look at how mindfulness may help with sexual dysfunction. Alex Iantaffi, at the Center for Sexual Health at the University of Minnesota, has been working as a sex therapist for years and has found that mindfulness helps his patients—both men and women—to communicate better with their partners around sex. He uses it in conjunction with other treatment tools to help people become more aware and accepting of their experience.
“It helps people to expand their tolerance of themselves and their partners, to look non-judgmentally at their condition, and to make better choices,” he says.
He and colleague Sara Mize recently did a pilot study to see how mindfulness approaches might augment group treatment for women patients with sexual dysfunction. They incorporated mindfulness techniques and exercises into their usual treatment protocol, and then studied its effects on the patients’ sexual functioning.
Measurements taken pre- and post-treatment showed that the group members had less self-judgment and better body awareness after the mindfulness treatment. In addition, Iantaffi found that in post-treatment focus groups the women were more willing to express themselves in ways that could benefit them—i.e. talking to their partners more openly, communicating with health practitioners more effectively, sharing challenges with group members, etc.
“Without mindfulness, it can be hard to engage people in treatment,” says Iantaffi. “Mindfulness helps them to open up.”
For Nettonya R., another woman in Brotto’s PVD study, mindfulness helped her to become more aware of her body and to pay more attention to her pain threshold, learning how to honor it rather than just pushing through it as she sometimes did. She began to talk to her husband more openly about what was going on for her, making him an active participant in her treatment.
“It helped me to talk to him and it strengthened our relationship,” says Nettoyne. “In that regard, I’m very grateful.”
However, in spite of that, Nettonya was disappointed in Brotto’s mindfulness program, saying that it didn’t make much of an impact on her vaginal pain.
“We did a number of sessions of meditation and learned how to relax in the program, but that doesn’t help when you’re in the middle of a sexual encounter,” she says.
She regrets not getting a more “physical” intervention for her problem from the group and is currently seeking hormone treatment therapy that she hopes will be more effective for her condition.
Though Brotto is sympathetic to women like Nettonya who want a cream or a pill to take away their pain, she finds that many of her patients have already tried multiple treatments—including hormones—without getting significant relief. Mindfulness may be the best course for these women, she says, because it can help uncouple the stress and the worry around the pain from the actual experience of the pain, giving at least some respite to the women.
Still, this can be hard for patients to accept.
“People don’t want to be told that their pain is made up in their head,” says Brotto. “The idea that your mind can impact your experience of pain is counter-intuitive.”
Brotto notes that, even though mindfulness seems to help, many people have trouble continuing with mindfulness after learning the techniques, deciding they just don’t have the time. In addition, patients can get confused about the purpose of mindfulness and become discouraged.
“Improvement in pain is not necessarily a primary goal of mindfulness; it is a secondary goal,” says Brotto. “We are encouraging non-judgmental experiencing of the pain. Continued practice, in our experience, then results in reduction of pain,” though there is no guarantee.
Nettonya admits that she has stopped practicing meditation, and it’s unknown how much that has affected treatment outcomes. But, she has found that the mindfulness training has helped her to become a calmer, more grounded person. She uses it on a daily basis to try to experience more pleasure in her life, she says, even in mundane activities like walking her dog, which now she finds she enjoys much more.
Brotto often hears similar stories from her patients about how mindfulness affects other aspects of their lives—not just their sexual health. She points to how ubiquitous mindfulness programs have become in schools and in hospitals around the country, many of which report positive impacts on emotional and social health of those who practice, and to the fact that mindfulness has been practiced for millennia in the Eastern world.
“It seems almost dangerous to say how much mindfulness seems to help,” she says. “Here in the Western world, though, we still need proof.”