Group mindfulness-based therapy significantly improves sexual desire in women

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Highlights

  • To date there are no Food and Drug Administration or Health Canada approved treatments.

  • 4-session mindfulness-based group intervention significantly improved sexual desire, arousal, sexual satisfaction.

  • Positive effects of mindfulness were retained from the post-treatment to the 6-month follow-up assessment point.

  • Increases in women's ability to be mindful significantly predicted changes in sexual desire with treatment.

Abstract

At least a third of women across reproductive ages experience low sexual desire and impaired arousal. There is increasing evidence that mindfulness, defined as non-judgmental present moment awareness, may improve women's sexual functioning. The goal of this study was to test the effectiveness of mindfulness-based therapy, either immediately or after a 3-month waiting period, in women seeking treatment for low sexual desire and arousal. Women participated in four 90-min group sessions that included mindfulness meditation, cognitive therapy, and education. A total of 117 women were assigned to either the immediate treatment (n = 68, mean age 40.8 yrs) or delayed treatment (n = 49, mean age 42.2 yrs) group, in which women had two pre-treatment baseline assessments followed by treatment. A total of 95 women completed assessments through to the 6-month follow-up period. Compared to the delayed treatment control group, treatment significantly improved sexual desire, sexual arousal, lubrication, sexual satisfaction, and overall sexual functioning. Sex-related distress significantly decreased in both conditions, regardless of treatment, as did orgasmic difficulties and depressive symptoms. Increases in mindfulness and a reduction in depressive symptoms predicted improvements in sexual desire. Mindfulness-based group therapy significantly improved sexual desire and other indices of sexual response, and should be considered in the treatment of women's sexual dysfunction.

Introduction

Despite over a decade of a costly and intense search for the “female Viagra”, there are no medications approved by the Food and Drug Administration or Health Canada for treatment of women's most common type of sexual difficulty, namely low sexual desire and arousal – these two phases being indistinguishable for perhaps the majority of women (Brotto et al., 2009, Goldhammer and McCabe, 2011). This is perhaps not surprising given the abundance of data indicating that low sexual desire is strongly influenced by a woman's relationship satisfaction (Burri et al., 2013, Dennerstein et al., 1999, Dennerstein et al., 2007), mood (Dennerstein et al., 2007, Shifren et al., 2008), self-esteem (Hartmann, Heiser, Rüffer-Hesse, & Kloth, 2002), body image (Pujols et al., 2010, Seal et al., 2009), psychiatric symptoms (Kalmbach et al., 2012, Kennedy et al., 1999), and age (Dennerstein, Dudley, & Burger, 2001), while both desire and subjective arousal are minimally impacted by genital blood flow and genital congestion (Chivers & Rosen, 2010).

According to one of the largest national probability studies focused on women's sexual function, low sexual desire is experienced by the majority (75%) of older women, 39% of women aged 45-64, and 22% of younger women (Shifren et al., 2008). Among the smaller proportion of this group who are distressed and therefore meet diagnostic criteria for Hypoactive Sexual Desire Disorder (HSDD), safe, effective treatment, ideally addressing factors known to negatively influence sexual desire, is very much needed.

In the absence of pharmacotherapy options, psychological and behavior-based methods (typically small group cognitive behavioral therapy (CBT), sex therapy or both), have been the mainstay of treatment to enhance sexual desire and response. Outcome data are sparse but recent systematic reviews and meta-analysis identified evidence of benefit in both symptom severity and sexual satisfaction for women with low desire. However, quality of method, outcome measures, and of reporting was variable, mostly low (Berner and Günzler, 2012, Günzler and Berner, 2012, Frühauf et al., 2013). Mindfulness-based therapies have become increasingly used and valued since the seminal work of Kabat-Zinn in the late 1970s and 1980s, which showed benefit to chronic stress and pain from an eight week program to learn mindfulness meditation (Kabat-Zinn, 1982). Mindfulness is an age-old practice that involves paying attention, in the present moment, and in a way that cultivates non-judgment. Mindfulness-Based Stress Reduction (MBSR) has been shown to benefit many medical, psychological, and behavioral ailments (Grossman et al., 2004, Merkes, 2010) as well as physiological parameters including vagal tone (a proxy for general health) (Kok et al., 2013) and epigenetic changes (Bhasin et al., 2013). Of particular relevance, Mindfulness-Based Cognitive Therapy (MBCT) (Segal, Williams, & Teasdale, 2002) has been shown to benefit current anxiety (Evans et al., 2008), depression (Sipe & Eisendrath, 2012) and prevent depression relapse (Teasdale et al., 2000). Depressive symptoms are strongly linked to HSDD, and even when women with Major Depression are excluded, compared to controls, women with HSDD have more depressed and anxious thoughts, more emotional instability, and lower self-image (Hartmann et al., 2002).

As well as benefiting mood, the attention to and acceptance of the present moment (considered the fundamental premise of mindfulness) lessens both the tendency to self-criticize and to evaluate one's sexual responsiveness, and the tendency to follow distracting thoughts. A circular model of sexual response (Basson, 2000) reflects the multiple factors underlying desire for sex. Included are the recognition and attention to sexual stimuli, the ability to manage distractions (including those pertaining to self-criticism and concerns about a possible unsatisfactory outcome), and freedom from anxiety, guilt, and shame that, collectively, may inhibit sexual arousal (Laan & Janssen, 2007). Women experiencing dysfunctional arousal and desire often deny awareness of responses to sexual stimuli (subjective excitement, sexual sensations, body heat, pelvic muscle tone, etc.), even despite measurable genital response in a laboratory setting (Laan, van Driel, & van Lunsen, 2008). Mindfulness practices can not only increase awareness of sexual responses unfolding moment by moment, but also lessen judgment that the latter are insufficiently intense or in some way sub-standard. Given that distractions are major inhibitors of women's sexual arousal (Adams et al., 1985, Carvalho, 2010, Carvalho and Nobre, 2010, Dove and Wiederman, 2000, Salemink and van Lankveld, 2006), a mindfulness approach can encourage women that distractions – often anxious or other negative thoughts arising with arousal (Nobre and Pinto-Gouveia, 2006a, Nobre and Pinto-Gouveia, 2006b) – can be treated as “mental events”; in other words, as “products of the mind” that are not necessarily accurate or needing to be believed and pursued. Instead, the erotic stimulus can be attended to. Women's need for certain requirements, recently termed contingency factors (Sanders, Graham, & Milhausen, 2008), to be met before sexual stimuli can be attended, may lessen with mindfulness practice as acceptance of the present situation, just as it is, develops. Being generally more present through the day also allows recognition of sexual cues and triggers of desire that are typically rare for women with low desire (McCall and Meston, 2006, McCall and Meston, 2007). Continued mindfulness practice may enable women to resist dwelling on the unrewarding nature of past sexual experiences that had previously contributed to ongoing unsatisfactory sexual arousal (Basson, 2001, Basson, 2003). As self-acceptance increases, it may be that the insidious pervasive harm from low body-image (Nelson and Purdon, 2011, Wiederman, 2000) and the commonly identified negative or critical self-focused attention (van Lankveld & Bergh, 2008) may also lessen.

Recent research confirms benefit to sexual difficulties from mindfulness training (as reviewed by Brotto, 2013). This has been shown not just in relatively healthy women, but also in female survivors of gynecologic cancer (Brotto et al., 2008a, Brotto et al., 2008b) and women with a history of childhood sexual abuse (Brotto, Seal, & Rellini, 2012).

To explore the mechanisms by which mindfulness may affect sexual function, Silverstein and colleagues enrolled sexually-healthy women in either a 12-week mindfulness program or an education control (Silverstein, Brown, Roth, & Britton, 2011). Women were assessed on interoceptive awareness and three categories of psychological barriers (i.e., attention, self-judgment, and clinical symptoms) that interfere with attention. Low body awareness was associated with women's levels of self-judgment and clinical symptoms, and mindfulness meditation significantly improved each of these domains. On a test of reaction time, there was evidence of improved interoceptive awareness with mindfulness training that correlated with improvements in women's clinical symptoms and self-judgment. Although this was a nonclinical group, the authors concluded that when applied to the treatment of sexual dysfunctions, mindfulness might promote a more direct access to body sensations by training attention and reducing negative self-evaluation. Recent evidence that sexual arousal can be deliberately modulated depending on the focus of attention (de Jong, 2009) further supports the utility of mindfulness in sexual functioning.

The goal of the present study was to test the effectiveness of a four-session mindfulness-based cognitive behavioral sex therapy (MBCST) administered to women seeking treatment for distressing low or absent sexual desire and/or sexual arousal. Much of the previous literature on which our treatment is based stems from applications of mindfulness to other (non-sexual) clinical populations. Grossman et al. (2004) discuss a number of human characteristics that support the usefulness of mindfulness meditation as a treatment. These include: (1) that we are often unaware of our moment-to-moment experiences; (2) that we have the capacity for developing awareness of mental content; (3) that development of this sustained attention requires practice; (4) that the development of such awareness will improve lives because it can replace unconscious reactiveness; (5) that persistent non-judgmental observations of mental content will lead to greater accuracy of perceptions; and (6) that as we gain a better awareness of our responses to stimuli, we may be able to act more effectively in the world and with a greater sense of control. Each of these concepts may be applied to the individual seeking help for sexual difficulties and therefore provide a strong rationale for the hypothesized benefits of mindfulness on sexual functioning.

Despite the apparent potential for mindfulness to enhance sexual response, we are not aware of any literature prior to 2007 (Brotto & Heiman, 2007) that specifically discussed mindfulness as a treatment for sexual dysfunction. In their description of the causes of sexual dysfunction, Masters and Johnson (1970) believed that anxiety and spectatoring played a major role for both women and men, and developed sensate focus as a core aspect of therapy. Sensate focus involved the structured and progressive touching by one partner to the other as a means of improving concentration on the sensual aspects of touch and to reduce anxiety. Although Masters and Johnson did not use the term mindfulness, in part, cultivating mindfulness. However, rather than any focus on acceptance of the present moment, during sensate focus each partner is encouraged to give on-going feedback and guidance so as to find the optimal type of stimulation.

Based on findings from a previous pilot study (Brotto, Basson, et al., 2008), our primary endpoints focused on sexual desire, since difficulties with desire represent the most common form of sexual dysfunction in women (Shifren et al., 2008), and sex-related distress—the latter of which was considered given that it is usually distress about sexual difficulties which brings women to seek treatment. For both endpoints, we predicted significant improvements with treatment. Secondary endpoints were the Female Sexual Function Index (FSFI) subscales of arousal, lubrication, orgasm, sexual satisfaction, and overall sexual functioning, as well as a more detailed assessment of arousal, mood, and relationship adjustment. We examined changes in mood, mindfulness, and amount of homework completed as predictors of change in sexual desire given the finding that changes in clinical symptoms mediate the effects of mindfulness on reaction time (Silverstein et al., 2011).

We included a delayed treatment group to test for potential expectancy effects as women waited for treatment. The therapeutic effect of an in-person detailed assessment, validation of symptoms and their sequelae on relationships and self-image, along with explanation of the many factors involved to lessen guilt and perplexity is well recognized. Whether dysfunction as well as distress would lessen was less predictable.

Section snippets

Participants

Women seeking treatment for sexual desire and/or arousal concerns, whether lifelong or acquired, were eligible to participate. Inclusion criteria included being aged 19–65, fluent in English, and willing to complete all four treatment sessions as well as assessment measures which consisted of both self-report questionnaires and in-session psychophysiological sexual arousal assessments (data from the sexual arousal assessment will be the focus of a separate manuscript). Women were eligible

Sample characteristics

Demographic comparisons among the 115 women who took part in at least one of the four treatment sessions revealed no significant pre-treatment differences between the 68 women in the immediate treatment arm and the 47 women in the delayed treatment arm on age [t(113) = −0.70], relationship status [χ2(4) = 1.53], relationship duration [t(109) = −0.73], number of children [t(109) = 1.21], ethnicity [χ2(6) = 3.80], or education [χ2(6) = 5.81], all p's > .05. Although all women reported complaints

Beneficial effects of treatment on sexual functioning

Overall, we found that compared to a delayed treatment control group, a four session group mindfulness-based therapy significantly improved sexual desire, arousal, lubrication, satisfaction, and overall sexual functioning. Arousal domains of mental sexual excitement, genital tingling, and genital pleasure also significantly improved more with treatment than the control condition. Sex-related distress, on the other hand, significantly lessened between assessments, regardless of whether treatment

Conclusion

A brief MBCST intervention was associated with significant improvements in sexual desire and other domains of sexual functioning. Benefit was maintained at six months following treatment. Distress improved with time, regardless of treatment, and may have related to positive expectancy effects for women in the delayed treatment condition as they anticipated receiving treatment in the near future. Improved sexual desire was predicted by changes in facets of mindfulness (describing sensations),

Acknowledgments

The authors wish to thank Yvonne Erskine for overall coordination of this study. We also wish to thank group facilitators Shea Hocaloski, Dr. Brooke Seal, Morag Yule, and Dr. Miriam Driscoll. Funding for this study was provided from a BC Medical Services Grant BCM07-0015 to the first author. Neither author has any conflicts of interest to disclose.

References (79)

  • A.H. Clayton et al.

    Standards for clinical trials in sexual dysfunction in women: research designs and outcomes assessment

    Journal of Sexual Medicine

    (2010)
  • A.H. Clayton et al.

    Validation of the sexual interest and desire inventory-female in hypoactive sexual desire disorder

    Journal of Sexual Medicine

    (2010)
  • L. Dennerstein et al.

    Are changes in sexual functioning during midlife due to aging or menopause?

    Fertility and Sterility

    (2001)
  • L. Dennerstein et al.

    Sexual function, dysfunction, and sexual distress in a prospective, population-based sample of mid-aged, Australian-born women

    Journal of Sexual Medicine

    (2008)
  • P. Grossman et al.

    Mindfulness-based stress reduction and health benefits: a meta-analysis

    Journal of Psychosomatic Research

    (2004)
  • C. Günzler et al.

    Efficacy of psychosocial interventions in men and women with sexual dysfunctions—a systematic review of controlled clinical trials: part 2-the efficacy of psychosocial interventions for female sexual dysfunction

    Journal of Sexual Medicine

    (2012)
  • J. Kabat-Zinn

    An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminarily results

    General Hospital Psychiatry

    (1982)
  • D.A. Kalmbach et al.

    Specificity of anhedonic depression and anxious arousal with sexual problems among sexually healthy young adults

    Journal of Sexual Medicine

    (2012)
  • S.H. Kennedy et al.

    Sexual dysfunction before antidepressant therapy in major depression

    Journal of Affective Disorders

    (1999)
  • E. Laan et al.

    Genital responsiveness in healthy women with and without sexual arousal disorder

    Journal of Sexual Medicine

    (2008)
  • J. van Lankveld et al.

    The interaction of state and trait aspects of self-focused attention affects genital, but not subjective, sexual arousal in sexually functional women

    Behaviour Research and Therapy

    (2008)
  • K. McCall et al.

    Cues resulting in desire for sexual activity in women

    Journal of Sexual Medicine

    (2006)
  • K. McCall et al.

    Differences between pre- and postmenopausal women in cues for sexual desire

    Journal of Sexual Medicine

    (2007)
  • Y. Pujols et al.

    The association between sexual satisfaction and body image in women

    Journal of Sexual Medicine

    (2010)
  • A.E. Adams et al.

    Cognitive distraction in female sexual arousal

    Psychophysiology

    (1985)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders, DSM-IV-TR

    (2000)
  • R.A. Baer et al.

    Using self-report assessment methods to explore facets of mindfulness

    Assessment

    (2006)
  • R.A. Baer et al.

    Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples

    Assessment

    (2008)
  • R. Basson

    The female sexual response: a different model

    Journal of Sex and Marital Therapy

    (2000)
  • R. Basson

    Human sex-response cycles

    Journal of Sex & Marital Therapy

    (2001)
  • R. Basson

    Biopsychosocial models of women's sexual response: applications to management of ‘desire disorders’

    Sexual and Relationship Therapy

    (2003)
  • A.T. Beck et al.

    Assessment of depression: the depression inventory

  • M.K. Bhasin et al.

    Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways

    PLoS One

    (2013)
  • W.R. Boot et al.

    The pervasive problem with placebos in psychology: why active control groups are not sufficient to rule out placebo effects

    Perspectives on Psychological Science

    (2013)
  • A. Bradford et al.

    Placebo response in the treatment of women's sexual dysfunctions: a review and commentary

    Journal of Sex and Marital Therapy

    (2009)
  • L.A. Brotto

    Mindful sex

    Canadian Journal of Human Sexuality

    (2013)
  • L.A. Brotto et al.

    Impact of an integrated mindfulness and cognitive behavioural treatment for provoked vestibulodynia (IMPROVED): a qualitative study

    Sexual and Relationship Therapy

    (2013)
  • L.A. Brotto et al.

    Mindfulness in sex therapy: applications for women with sexual difficulties following gynecologic cancer

    Sexual & Relationship Therapy

    (2007)
  • L.A. Brotto et al.

    A psychoeducational intervention for sexual dysfunction in women with gynecologic cancer

    Archives of Sexual Behavior

    (2008)
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