Week 4 Discussion Response to Classmates

ORIGINAL PAPER

Mindfulness-Based Sex Therapy Improves Genital-Subjective Arousal Concordance in Women With Sexual Desire/Arousal Difficulties

Lori A. Brotto1 • Meredith L. Chivers2 • Roanne D. Millman3 • Arianne Albert4

Received: 3 February 2015/ Revised: 3 November 2015/ Accepted: 30 December 2015/ Published online: 26 February 2016

� Springer Science+Business Media New York 2016

Abstract Thereisemergingevidencefortheefficacyofmind-

fulness-basedinterventionsforimprovingwomen’ssexualfunc-

tioning. To date, this literature has been limited to self-reports of

sexualresponseanddistress.Sexualarousalconcordance—the

degree of agreement between self-reported sexual arousal and

psychophysiologicalsexualresponse—hasbeenofinterestdue

tothespeculationthatitmaybeakeycomponenttohealthysex-

ualfunctioninginwomen.Weexaminedtheeffectsofmindful-

ness-basedsextherapyonsexualarousalconcordanceinasample

ofwomenwithsexualdesire/arousaldifficulties(n =79, M age

40.8 years) who participated in an in-laboratory assessment of

sexualarousalusingavaginalphotoplethysmographbeforeand

afterfoursessionsofgroupmindfulness-basedsextherapy.Genital-

subjective sexual arousalconcordance significantlyincreasedfrom

pre-treatment levels, with changes in subjective sexual arousal

predicting contemporaneous genitalsexual arousal (but not the

reverse). These findings have implications for our understand-

ingofthemechanismsbywhichmindfulness-basedsextherapy

improvessexualfunctioninginwomen,andsuggestthatsuchtreat-

ment may lead to an integration of physical and subjective arousal

processes.Moreover,ourfindingssuggestthatfutureresearch

mightconsider theadoption of sexual arousal concordance as a

relevant endpoint in treatment outcome research of women with

sexual desire/arousal concerns.

Keywords Sexual desire � Sexual arousal � Vaginal photoplethysmography � Mindfulness � DSM-5 � Sexual dysfunction

Introduction

Lack of motivation for sex affects up to 40% of women aged

16–44 (Mercer et al., 2003; Mitchell et al., 2013) and is the

most common reason prompting women to seek sex therapy.

Whenclinicallysignificantdistressaccompaniesthelossofsex-

ualdesire,estimatesrevealthatupto12%ofwomenareaffected

(Shifren,Monz,Russo,Segreti, & Johannes,2008).The 5th edi-

tion of the Diagnostic and Statistical Manual of Mental Disor-

ders (DSM-5)definesthissyndromeas‘‘FemaleSexualInterest/

ArousalDisorder’’(SIAD;AmericanPsychiatricAssociation,

2013) and a diagnosis is made when any threeof six criteria are

met for a minimum duration of 6 months and accompany clin-

icallysignificantdistress.Thecriteriainclude:(1)lackofdesire

for sex, (2) lack of sexual thoughts/fantasies, (3) lack of initia-

tionandreceptivityofsexualactivity,(4)lackofsexualpleasure,

(5)inabilityforsexualstimulitotriggerdesire,and(6)animpaired

physical sexual arousal response.

Todate,themostwidelystudiedtreatmentforlowsexualdesire

inwomenhasbeentestosterone.Alargenumberofrandomized

controlledstudieshavedemonstratedtheefficacyoftopicaltestos-

terone in surgically menopausal women (reviewed by Davis,

2013). Moreover, estimates suggest that 4.1 million prescrip-

tions for off-label testosterone are made annually in the U.S.

alone(Davis&Braunstein,2012).Nonetheless,testosteroneremains

unregulated,andalthoughitwasapprovedforuseinpatchform

in Europe (for surgically menopausal women with low sexual

desire), it is currently unavailable in North America. Various

other pharmaceutical agents have been the subject of clinical

& Lori A. Brotto [email protected]

1 Department of Gynaecology, University of British Columbia,

2775LaurelStreet,6thFloor,Vancouver,BCV5Z1M9,Canada

2 Department of Psychology, Queen’s University, Kingston, ON,

Canada

3 Department of Psychology, Simon Fraser University, Burnaby,

BC, Canada

4 Women’s Health Research Institute, Vancouver, BC, Canada

123

Arch Sex Behav (2016) 45:1907–1921

DOI 10.1007/s10508-015-0689-8

trialsfortreatmentoflowsexualdesire,butasofOctober2015,

flibanserin is the only medication approved in the U.S. for this

condition.

Despiteconsiderableinterestintestingpharmacologicaloptions

forwomen’slowsexualdesire,psychologicaltreatmenthasbeen

themainstayoftherapyforwomenwithsexualdesiredifficulties.

Because cognitive distraction during sexual activity is prevalent

among women with sexual dysfunction, and negatively impacts

theirsexualsatisfactionanddesire(Nobre&Pinto-Gouveia,2006),

this provides justification for the application of cognitive chal-

lenging strategies (i.e., identifying, challenging, and replacing

irrationalthoughts)inherenttocognitivebehavioraltherapy(CBT).

Trudeletal.(2001)comparedtheeffectsofCBT(whichincluded

bothcognitivechallengingaswell as behavioral strategies) toa

wait-list control in 74 couples in which women met criteria for

HypoactiveSexualDesireDisorder(HSDD).After12weeks,74%

of women no longer met diagnostic criteria for HSDD, andthis

stabilized to 64% after 1-year follow-up. In addition to signifi-

cantlyimprovedsexualdesire,womenalsoreportedimproved

quality ofmaritallife andperception ofsexualarousal,butthe

groupcoupletherapyformatmaynotbefeasibleintypicalclini-

cal settings. Another treatmentoutcome study of10sessions of

CBT,2–3ofwhichincludedthepartner,foundonlya26%reduc-

tion in the proportion of women who had significant concerns

withlowsexualdesire(McCabe,2001).Takentogether,thesestud-

iessuggestthatCBTiseffectiveforaproportionofwomenwith

lowsexualdesire,butsuchanapproachmayalsohavelimitations.

Specifically,becauseofthe often-noteddistractibility,anxiety-

proneness,judgmentalintrusions,andinattentiondescribedby

womenwithlowsexualdesire(Meston,2006),andalsobecause

ofthevariedwaysinwhichdesireisexperienced(Meana,2010;

Sand&Fisher,2007),otherskill-basedapproachesmaybenec-

essaryforwomenwhodonotbenefitfromcognitivechallenging.

Toaddressthesegaps,third-generationCBTapproaches,suchas

mindfulness-basedcognitivetherapy,havebeengainingtraction

in many domains of physical and psychological health.

Mindfulnessmeditationhasa3500yearhistoryandfornearly

thepastfourdecadeshasmadeitswayintoWesternmedicine.

Defined as present-moment, non-judgmental awareness with

curiosity,openness,andacceptance(Bishopetal.,2004),mind-

fulness meditation has been a major addition to the psycholog-

icaltreatmentarsenalforthetreatmentofanxiety,depression,sub-

stance use,childhoodbehavior problems,andahost of medical

concerns, includingpain, irritable bowelsyndrome, fibromyal-

gia,and highbloodpressure (Grossman, Niemann, Schmidt,&

Walach,2004;Merkes,2010).Althoughtheprecisemechanisms

by which mindfulness is associated with symptom relief is not

fullyunderstood,itsbenefitsmaybeassociatedwithanincrease

inmetacognitiveawareness,ortheabilitytoexperiencethoughts

merely as mental events (Teasdale et al., 2002). Over the past

10 years, mindfulness has beenapplied to and found effective

for the treatment of sexual dysfunction in women (Brotto,

Basson,&Luria,2008a;Brottoetal.,2008c,2012a;Brotto,Seal,

& Rellini, 2012b).

Themechanismsbywhichmindfulnessledtotheseimprove-

ments in women with sexual dysfunction are not entirely clear

andmayrelatetoadecreaseinspectatoring—definedbyMasters

andJohnson(1970)astheprocessofwatchingoneselfduringsex-

ual activity from a third person perspective—a decrease in anx-

iety, encouraging an attitude of acceptance and non-judgment,

and/or an increasein perception ofphysical sexual response. In

supportofthelatter,onelaboratory-basedstudyinwhichfemale

studentswithoutsexualdifficultieswererandomizedtoeitheran

8-weekmindfulnessmeditationgrouportoanactivecontrolrated

theintensityoftheirphysiologicalresponsesafterviewingemo-

tionalphotos(Silverstein,Brown,Roth,&Britton,2011).Thepri-

maryanalysisfocusedon interoceptive awareness,thecapacityto

accuratelydetectphysicalsensations,afterthemindfulnessinter-

vention. Interoception has long been of interest to emotion research-

ers,andisknowntocorrespondtoanafferentpathwayfromparts

ofthebodytothespinalcord,brainstem,andultimatelytothe

rightanteriorinsularcortex(Craig,2002).Studyparticipantswere

shown a series of 31 pictures containing sexual and non-sexual

imagesandwereaskedtoindicatetheirlevelofphysiologicalarousal

(calm,excited,andaroused).Reactiontime,orhowquicklyanindi-

vidualratedtheintensityofarousalintheirbody,wasusedasanindex

ofgreaterinteroceptiveawareness.Womeninthemeditationgroup

hadsignificantlyfasterreactiontimesthanwomeninthecontrol

group,andthequickerreactiontimesignificantlycorrelatedwith

increasesinmindfulness,attention,non-judgment,self-acceptance,

andwell-being,andwithdecreasesinself-judgmentandanxiety.Sil-

versteinetal.inferredthistomeanincreasedinteroceptiveawareness

followingmindfulnesstrainingthatmaycorrespondwithactivityin

the insula cortex.

Thereismarkedindividualvariabilityintheabilitytodetectinter-

nalphysicalsensations,withsomeindividualsbeinghighlyintero-

ceptivelyaware,andothersbeingrelativelynaı̈ve tochangesin

bodilyreactions.Furthermore,there ismarkedvariationinsex-

ualconcordanceamongwomen.Intheirmeta-analysisofthesex-

ualpsychophysiologyliterature,Chiversetal.(2010)found,using

apooledsampleof n = 2345women,thatvariationinwomen’s

sexualconcordancewasnotaccountedforbyavarietyofmethod-

ological factors such as the number of stimulus trials in a given

experiment,theuseoffemale-centeredversusmale-centerederotic

stimuli,orstimuluslength;however,highersexualconcordance

was associated with using stimuli that varied in content, inten-

sity,ormodality(r = .49)andmethodofcalculatingcorrelations

(between-subjects[r = .29]versuswithin-subjects[r = .43]).

Chivers et al. also found that concordance among women was

relatedtomethodofassessinggenitalresponse,withgenitaltem-

perature (e.g., labial thermistors and thermographic imaging)

yieldinghigherestimatesofsexualconcordancethanvaginalpho-

toplethysmography (.55 vs. .26, respectively), although thermo-

graphic methods of assessing genital response also produce wide

1908 Arch Sex Behav (2016) 45:1907–1921

123

inter-individual variation in sexual concordance, similar to vagi-

nalphotoplethysmography(Kukkonen,Binik,Amsel,&Carrier,

2010). Regardless of measurement method, broad variation in

sexualconcordancesuggeststhepresenceofmoderators,ofwhich

sexualfunctioningmaybeone(Boyer,Pukall,&Chamberlain,

2013).

Low sexual concordance can manifest in one of two ways:

increasesingenitalsexualresponseintheabsenceofgenitalaware-

nessorsexualaffect,ortheconverse.Consistently,itistheformer

thatisthecaseforsexuallyfunctionalwomen;genitalresponseto

sexualstimuliisrapidlyandautomaticallyevokedbyprocessing

ofsexualstimuli(Chivers&Bailey,2005),butgenitalawareness

or sexual affect may not be simultaneously reported (Chivers

et al., 2010). This pattern is also common among women with

FemaleSexualArousalDisorder(FSAD)—whichtheformer

DSM-IV-TR characterized as self-reported impairments in

genital vasocongestion (American Psychiatric Association,

2000)—suchthattheyself-reportedlowersexualaffecttosexual

stimuli in the laboratory but showed a robust genital response,

similar to women without sexual arousal problems (Laan, van

Driel, & van Lunsen, 2008; Meston, Rellini, & McCall,2010).

In their meta-analysis, Chivers et al. reported the average cor-

relationforwomenwithvarioussexualdifficulties(n =235)as

.04(-.10to.17),whereasforwomenwithoutsexualdifficulties

(n =1144), the correlation was .26 (.21 to .37).

Sexualconcordancemayberelatedtosexualfunctioningamong

healthywomen,suchthatgreaterconcordanceisassociatedwith

morefrequentexperienceoforgasm(Adams,Haynes,&Brayer,

1985;Brody,2007;Brody,Laan,&vanLunsen,2003).Coupled

withdatashowinghighersexualconcordanceamongwomenwith-

outasopposedtowithasexualdysfunction,thesedatasuggestthat

sexualconcordancemaybeakeycomponenttohealthysexual

functioninginwomen.Currenttreatmentsforsexualdysfunction,

however,donotfocusonskillsthatmayenhancewomen’ssexual

concordancenorhavetreatmentefficacystudiesusedsexualcon-

cordance as a primary outcome.

In light of mounting evidence that mindfulness improves

women’sself-reportofsexualfunctionandawarenessofbodily

sensations, and that concordance between genital and self-re-

portedarousalmayberelevanttowomen’ssexualinteroceptive

awareness,thecurrentstudywasdesignedwiththese themesin

mind.Specifically,thegoalswereto:(1)examinetheeffectsofa

group mindfulness-based sex therapy (MBST) on concordance

between genitalandsubjectivesexualarousal; (2)examine the

effects of treatment on self-reported sexual arousal and, sepa-

rately, on genital arousal; and (3) test the relationship between

changesinconcordanceandimprovementsinclinicalsymptoms

(i.e., sexual desire and sex-related distress) with treatment. A

separatepublicationdocumentsthesignificantbeneficialeffect

of this MBST compared to a delayed treatment control group

ontheprimaryendpointofself-reportedsexualdesire(Cohen’s

dtreatment=0.97; dcontrol =0.12) (Brotto & Basson, 2014). Sex-

related distress also significantly improved with treatment, and

did not significantly differ from the control group (Cohen’s d

full sample=-0.56).

Inthisarticle,wefocusedonchangesinconcordancebetween

genitalsexualresponse(vaginalpulseamplitude;asmeasuredby

vaginalphotoplethysmography)(Sintchak&Geer,1975)andcon-

tinuouslyreportedsubjectivesexualarousal(Rellini,McCall,

Randall,&Meston,2005)followingtreatment.Giventhatthe

MBSTencouragedthedailypracticeoffocusingonandexperi-

encinggeneral and genital arousal responsesnon-judgmentally,

weexpectedtreatmenttobeassociatedwithsignificantincreases

ingenital-subjectiveconcordance.Sinceparticipantswereencour-

agedtopracticemindfulnessexercisesdailybetweengroupses-

sions,wepredicteddegreeofhomeworkcompliancewouldmod-

eratetheincreasedconcordanceaftertreatment.Asanexploratory

analysis, we also included age, diagnosis of FSAD, andarousal

scoresfromavalidatedmeasure(bothsubjectivearousalaswell

aslubrication)tomoderateimprovementsinconcordance.Fur-

thermore,wehypothesizedanincreaseinself-reportedsexual

arousalwithtreatment,consistentwithpreviousfindings.Wedid

notexpecttofindaneffectoftreatmentongenitalsexualresponse

perse,givenevidencethatvaginalpulseamplitudemaynotdif-

ferbetweenwomenwithandwithoutsexualdysfunction(Laan

etal.,2008).Finally,wepredictedchangesinconcordancetobe

associatedwithimprovementsinsexualdesireandwithdecreases

in sex-related distress.

Method

Participants

Participants werepart ofa largerstudy evaluatingoutcomesof

groupmindfulness-basedsextherapyonvariousindicesofsex-

ualdesire,sexualresponse,andaffect(Brotto&Basson,2014).

Womenseekingtreatmentforsexualdesireand/orarousalcon-

cerns from the British Columbia Centre for Sexual Medicine,

whetherthedifficultieswerelifelongoracquired,wereeligible

to participate. Inclusion criteria included: age between 19 and

65years,fluentinEnglish,andwillingtocompleteallfourgroup

sessions,regularhomework,aswellasassessmentmeasures(con-

sistingofbothself-reportquestionnairesandalaboratory-based

psychophysiological sexual arousal assessment) at three time

points. Women with difficulties in achieving orgasm were also

includedaslongasthosewerenotexperiencedasmoredistressing

thanthedesireand/orarousalconcerns.Weexcludedanywoman

with dyspareunia (chronic genital pain not resolved with a per-

sonal lubricant).

Theoriginalstudydescribingtreatmentefficacyincluded117

women who provided pre-treatment assessment data. The data

herefocuson79womenwhohadcompletedatafromtheirpsy-

chophysiologicalassessments(bothgenitalandsubjectivearousal)

atallthreetimepoints—immediatepre-treatment,post-treatment,

and6-monthfollow-up.Thesampleincluded41(51.9%)women

Arch Sex Behav (2016) 45:1907–1921 1909

123

who were assigned to the immediate treatment group and 38

(48.1%)womenwhoreceivedtreatmentafteraninitial3-month

wait-list period. Only pre- to post-treatment data for women in

thecontrolgroupwereincluded(i.e.,theirwait-listdatawerenot).

Also,inthisarticle,wedidnotincludedatafromthecontrolgroup

for their two pre-treatment assessments, so the present analyses

did not compare the effects of treatment versus wait-list control

onconcordance.Themeanage ofthesample was40.8years(SD

11.5, range 20–65). A total of 84.6% were in a committed rela-

tionship, 6.4% were casually dating, and 9.0% were single. The

mean relationship length was 13.2years (SD 10.7). Most partic-

ipantswereofEuro-Canadiandescent(81.0%)followedbyEast

Asian (7.6%) and South Asian (2.5%). This was a highly edu-

catedgroupin that 67.1% hadsome post-secondary education,

and 22.8% had an advanced graduate degree.

Althoughallparticipantsself-reporteddifficultieswithsexual

desireand/orarousalandmetcriteriafortheDSM-5diagnosisof

SIAD,33(41.8%)womenmetDSM-IV-TR(AmericanPsychi-

atric Association, 2000) diagnostic criteria for HSDD and 24

(30.4 %) women met criteria for FSAD. The remaining 22

(27.8 %) women met criteria for both HSDD and FSAD.

Measures

Assessment of Psychophysiological Sexual Arousal

Genital response was measured with a vaginal photoplethys-

mograph(Sintchak&Geer,1975)consistingofatampon-shaped

acrylic vaginal probe, inserted in private by the participant. The

probe (Behavioral Technology Inc., Salt Lake City, UT) contin-

uouslymeasuredvaginalpulseamplitude(VPA)duringtheneu-

tralanderoticfilmsegments.VPAwasrecordedusingapersonal

computer(HPPentiumMLaptop)thatcollected,converted(from

analog to digital, using a Model MP150WSW data acquisition

unit [BIOPAC Systems, Inc.]), and transformed psychophysi-

ological data, using the software program AcqKnowledge III, Ver-

sion3.8.1(BIOPACSystems,Inc.,SantaBarbara,CA).Thesignal

wassampledat200Hzandbandpassfiltered(0.5–30Hz).Atrained

research assistant performed artifact smoothing of the signal fol-

lowingvisualinspectionofthedataandbeforedatawereanalyzed.

VPAdataweresubsequentlydividedinto30-sepochs,producing

sixdatapointsfortheneutralfilmand13datapointsfortheerotic

film for each sexual arousal assessment.

Contemporaneous Assessment of Subjective Sexual Arousal

Subjectivesexualresponsewasmeasuredcontinuouslyduring

the neutral and erotic films with an arousometer that was con-

structedbyalocalengineermodeledaftertheonedescribedby

Rellini et al. (2005). This device consisted of a computer optic

mouse mounted on a plastic track with 10 intervals, and was

affixedtothearmrestofthereclinersothattheparticipantcould

easily move the mouse, while simultaneously reclining and

viewing stimuli. Women were instructed to move the mouse

up and down the track over the course of the film to indicate

theirlevelofsubjectivesexualarousal,from7to-2,with7 =

Highest Level of Sexual Arousal, 0 = No Sexual Arousal, and

-2= Sexually Turned Off.Wehavepreviouslyusedthisdevice

intreatmentoutcomestudiesonwomenwithsexualdysfunction

(Brottoetal.,2012b).LikeVPAdata,themeancontemporaneous

sexual arousal response was obtained every 30-s, producing six

datapointsduringtheneutralfilmand13datapointsduringthe

erotic film, corresponding with the 30-s epochs of VPA data.

Discrete Measure of Sexual Response and Affect

The Film Scale, a 33-item self-report questionnaire, was used

toassesssubjectivearousalandaffectivereactionstotheerotic

films.ThisscalewasadaptedfromHeimanandRowland(1983)

andassessedsixdomains:subjectivesexualarousal(1item),

perceptionofgenitalsexualarousal(4items),autonomicarousal

(5items),anxiety(1item),andpositiveandnegativeaffect(11items

each). The scale has been found to be a valid and sensitive mea-

sureofemotionalreactionstoeroticstimuli.Itemswereratedon

a 7-point Likert scale from Not at All (1) to Intensely (7). Pre-

treatmentreliability for the Film Scale duringthe neutral phase

wasverygood(Cronbach’salpha=0.82)andexcellentfollowing

the erotic phase (Cronbach’s alpha = 0.94).

Homework Compliance

Homeworkcompliancewasratedbythegroupfacilitatorsona

Likertscalefrom0(did not complete homework/did not attend

sessions)to2(notable efforts at completing homework/attend-

ing sessions).Aratingwasgivenforeachparticipantateachof

thefourgroupsessions,andthenameanscoreacrossthesessions

was derived.

Female Sexual Arousal Disorder symptoms

Subscales of‘‘Arousal’’and‘‘Lubrication’’on the Female Sex-

ualFunctionIndex(FSFI)(Rosenetal.,2000)wereusedinmod-

eration analyses. The FSFI is a 19-item self-report questionnaire

considered to be the gold standard measure of sexual function in

women.Therewere4itemsintheArousaldomainand4itemsin

theLubricationdomain;responseswerecodedona5-pointLikert

scale.Arespondentwhohadnotengagedinsexualactivityforthe

past4weekswasexcludedfromthoseitems.Cronbach’salphafor

these two domains was excellent (a=0.89 and a=0.93, respec- tively) for the current sample.

Sexual Desire was measured with the 14-item Sexual Inter-

est/DesireInventory(SIDI)(Claytonetal.,2006).Possibletotal

scores range from 0 to 51, with higher scores indicating higher

levelsofsexualinterestanddesire.TheSIDIhasexcellentinter-

nal consistency (Cronbach’s a=0.90). Item-total correlations

1910 Arch Sex Behav (2016) 45:1907–1921

123

were high for‘‘Receptivity,’’‘‘Initiation,’’‘‘Desire-frequency,’’

‘‘Desire-satisfaction,’’‘‘Desire-distress,’’and‘‘Thoughts-positive’’

(r[.70), good for‘‘Relationship-sexual,’’‘‘Affection,’’‘‘Arousal- ease,’’and‘‘Arousal-continuation’’(r[.50),butpoorfortheorgasm item(r =.10)(Claytonetal.2006).Cronbach’salphaforthecurrent

sample was a=0.76. Sexual Distress was measured with the 12-item Female Sex-

ual Distress Scale (FSDS) (DeRogatis, Rosen, Leiblum, Burnett,

& Heiman,2002).Scorescan rangefrom0to48,where higher

scores represent higher levels of distress. The FSDS has been

shown to have good discriminant validity in differentiating

between sexually dysfunctional and sexually functional women,

with 88% correct classification rate, and found to have satis-

factory internal consistency (ranging from 0.86 to 0.90) (DeRo-

gatis etal.,2002).Reliabilityfor the current samplewas excel-

lent at a =0.92.

Procedure

Followingacomprehensiveassessmentbyanexperiencedsexual

medicineclinician,eligiblewomenwereinformedaboutthe

study.Ifinterested,theywereprovidedwithaone-pagebrochure

outlininginformationaboutthestudyandcontactinformationfor

thestudy’scoordinator.Next,theytookpartinatelephonescreen

thatfurtherexplainedthestudyprocedures,providedsomeinfor-

mation about the treatment content, and informed women about

upcomingschedulesfortheMBSTgroups.Theywerethenmailed

a consent form. The return of a signed consent form indicated

informed consent, at which time women were assigned to par-

ticipate in either the immediate treatment group or the delayed

treatment group. Whenever possible, we utilized random assign-

ment to group; however, in cases where participants’ schedules

werenotflexible,weassignedwomentothegroupthataccommo-

datedtheirschedules.Participantswerethenscheduledforabase-

line sexual arousal assessment to take place in a sexual psy-

chophysiologylaboratory.Womenwerealsomailedapackageof

questionnaires and asked to return them completed at the time of

their sexual arousal assessment. These same questionnaires and

sexual arousal assessment were repeated 2–4 weeks after the

completion of their MBST group as well as 6 months later. The

duration between baseline and the two subsequent assessments

was relatively equal across all participants, with no more than

2-week variation, typically at the follow-up assessment.

The sexual arousal assessment took place in a sexual psy-

chophysiologylaboratory,locatedintheuniversityhospital,and

housed a comfortable reclining chair, a large screen TV, and an

intercom. A thin blanket was placed over the seating area of the

chair. Following written consent, participants were tested by a

female researcher. Women were first shown the vaginal photo-

plethysmographandencouragedtoaskanyquestionsabouthow

to insert it. The female researcher then left the room, while

participants inserted the probe and informed the researcher via

intercom of their readiness. In order to habituate to the testing

environment, participants were encouraged to relax on a com-

fortable reclining chair for a 10-min period after the probe was

inserted. Subjective sexual arousal and affect were assessed at

the end of the adaptation period using the Film Scale, which

servedasthediscreteassessmentofarousalandaffectbeforethe

erotic film sequence.

Before the film sequence began, women were reminded to

use the arousometer to capture their subjective sexual arousal

throughout the film sequence. The researcher instructed partic-

ipants to:‘‘Monitor your subjective feelings of sexual arousal to

the film by using this device. By ‘subjective feelings of sexual

arousal,’ we mean how mentally sexually aroused you are in

your mind while you’re watching the film.’’Further instructions

were given on the numerical demarcations on the device and

whattheupper(mostsexualarousalyouhaveexperiencedorcan

imagine) andlower (sexually turned off) anchorsreflect. Partic-

ipants practiced moving the arousometer in the presence of the

researcher and any questions on its operation were addressed

before the film sequence began.

The researcher then initiated the video sequence from the

adjoining room. The audio component was delivered via wire-

less headphones to the participant. Women watched a 3-min

neutral documentary about Hawaii followed by a 7-min erotic

film that depicted a heterosexual couple engaging in foreplay,

oral sex, and penile–vaginal intercourse. There were three dif-

ferent film sequences counterbalanced across women and ses-

sions so that participants viewed the same film only once over

thethreetestingsessions.Immediatelyafterthevideosequence,

participantscompletedtheFilmScaleasecondtime,whichasked

them to evaluate their subjective sexual arousal and affect to

theeroticfilm.Theyweretheninstructedtoremovetheprobeand

meet the researcher in a separate room. After a debriefing period,

the researcher disinfected the probe in a solution of Cidex OPA

(ortho-phthalaldehyde 0.55%), a high level disinfectant (Advanced

Sterilization Products, Irvine, CA, USA), promptly following

each session.

All procedures were approved by the Clinical Research

EthicsBoardattheUniversityofBritishColumbiaandtheVan-

couver Coastal Health Research Institute. All procedures were

carriedoutinaccordancewiththeprovisionsoftheWorldMed-

ical Association Declaration of Helsinki.

Mindfulness-Based Sex Therapy

TheMBST(Brotto,Basson,&Luria,2008b)was based onan

integration of psychoeducation, sex therapy, and mindfulness-

based skills, the latter of which have received extensive empir-

ical support in other populations (Grossman et al., 2004). Stem-

ming from evidence that women with sexual desire/arousal dif-

ficulties are often distracted during sexual activity and/or judg-

mental(ofthemselvesortheirpartners),mindfulnessskillswere

primarily aimed at orienting the woman to the present experi-

ence,whilesimultaneouslynotingnegativethoughtsas‘‘mental

Arch Sex Behav (2016) 45:1907–1921 1911

123

events’’—something to be noticed but not focused on. Consis-

tentwithmindfulness-basedcognitivetherapyforpreventionof

depression relapse (Teasdale et al., 2000), MBST aims to help

womendevelopawarenessinallareasoftheirlife,includingreal

andanticipatedsexualsituations.Atleast4weekswerespentencour-

aging women to practice mindful self-awareness in non-sexual sit-

uationsasameansofdevelopingtheskillofmoment-by-moment

awareness.In-session‘‘inquiries’’followingmindfulness practice

wereintendedtoallowparticipantstoviewtheirpracticeasadepar-

ture fromtheir typicalmodeof being,whichmayhave beenchar-

acterizedasfuture-oriented,multi-tasking,and/orruminativeabout

pastevents.Atlaterstagesofthegroup,womenwerethenencour-

agedtoapplytheirnewskillsinprogressivelymoresexualsitua-

tions—firstontheirown(followingexposuretoaneroticstimulus

suchasavibratororeroticfilm),andnexttogetherwithapartner

(ifapplicable,duringactualsexualactivity).Theaimofthehome

practice was to encourage participants to develop a regular mind-

fulnesspracticeandacquireexperienceobservingthoughts,espe-

ciallynegativeones,asmentalevents,beforeintroducingpractice

togetherwithapartner,orapplyingmindfulnessduringat-home

sexualactivities.Althoughsensatefocusshareswithmindfulness

thegoalofpresent-momentawareness,theformerrequiresapartner

tobepresentanddoesnothavetheadvantageofportabilitythat

mindfulnesshas(i.e.,inhomeworkactivitieswomenwereenco-

uragedtouseinformalmindfulnesspracticethroughouttheirdays

tocomplementtheformalpractices).Concurrentwiththeprinciples

ofmindfulness,womenwereencouragedatthestartofSession1to

‘‘letbe’’strongwishesforchange,andforthedurationofthesessions

to focus instead on being fully in the present. Goals for the group

were not elicited.

In the current study, treatment was delivered by two group

facilitators (selected from a trained pool of six sexual medicine

physicians, psychologists, and upper-level residents/graduate

students)togroupsconsistingof4–7women.Sessionstookplace

inalargegrouproomattheBCCentreforSexualMedicine,and

each 90min session was spaced 2 weeks apart.

Contents

Session 1 provided educational information on the prevalence

andknown etiologyof low desire and arousal. Mindfulness was

thenintroducedthroughin-sessionpractice of the‘‘BodyScan,’’

which is also the foundational practice in mindfulness-based

therapies (Teasdale et al., 2000). By orienting attention to var-

ious parts of the body, women were encouraged to become

aware of sensations in that region and any subsequent‘‘mental

events’’(thoughts,beliefs,emotions,othercognitiveactivity)that

followontheawarenessofsensations.Afteraguidedin-session

practice,participantswereencouragedtopracticetheBodyScan

daily at home, and were provided an audio-recorded guide.

Session 2 provided an opportunity for in-depth homework

review, followed by psychoeducation on sexual anatomy and

physiologyandthecircularsexualresponsecycle(Basson,2001).

In-session mindfulness practice centered on‘‘Breath and body’’

as the focus of attention. Like the Body Scan, participants were

guided to notice and attend to various parts of the body, includ-

ing sensations associated with breathing and the breath itself. In

mindfulness-based therapy for depression (Basson, 2001), this

practicealsotypicallyfollowsafoundationofpracticeusingthe

BodyScan.Forhomework,participantswereencouragedtodoa

‘‘seeing meditation’’with their genitals as the focus of the prac-

tice. They were asked to observe their genitals with a hand-held

mirror, and in addition to noticing moment-by-moment visual

and bodily sensations, they were also asked to take note of any

follow-on thoughts, emotions, or beliefs as a result of the seeing

practice.

Session 3 began with an in-depth review of the home body-

oriented mindfulness practice, and participants were encour-

aged to start to think about the relevance of this practice to their

sexuality more broadly. Next, there was in-session psychoedu-

cation on Gottman’s principles for lasting relationships (Gott-

man& Silver,1999).The guidedin-sessionpractice utilized

mindfulnessofthoughts,andthepracticewasfollowedbyadis-

cussion on the high prevalence of automatic thoughts/logical

errors of thinking, and using the cognitive behavioral model to

illustrate the association between thoughts, emotions, and beh-

aviors. The discussion also highlighted how mindfulness skills

are aimed at simply bringing awareness to negative/judgmental

thoughts and were contrasted with CBT skills, which are aimed

at identifying and challenging problematic thoughts. For home

practice, women were encouraged to repeat the mindfulness of

genitals exercise from the previous 2 weeks in which they obs-

ervedtheirgenitalsmoment-by-momentandnon-judgmentally,

but this time were also encouraged to incorporate the sensation

of touch. This was framed as a non-masturbatory exercise

designed to enhance mindful awareness of genital sensations.

Session 4 was devoted to home practice review followed by

an introduction of sensate focus to be used with a partner (if

available). The facilitator explained the first (of three) phase of

sensate focus as originally defined by Masters and Johnson

(1970). Specifically, sensate focus was described as having the

goals of: tuning into sensations (and in this way, women were

encouraged to use the mindfulness skills they had been devel-

oping),relaxation,andprovidingfeedbacktoapartneraboutthe

receivedtouch.In-sessiontrouble-shootingaroundcommonbar-

riers,suchasfindingthetimeforthehour-longpractice,thenfol-

lowed.Sensatefocuswasdescribedspecificallyasanon-demand

exercise(Weiner&Avery-Clark,2014);ifwomen(ortheirpart-

ners)experiencedsexualexcitement,theywereencouragedtonotice

theaccompanyingsensationsinthesamewaytheyhadpracticed

noticingsensationsduringtheBodyScan.Thesecondhalfofthe

finalsessionprovidedanoverviewontheuseofcognitiveandtactile

toolstoaugmentsexualresponse(e.g.,fantasy,erotica,andvibrators)

duringmindfulnesspractice.Specifically,instructionswerepro-

vided to womentoelicita sexualarousal response usingone of

these tools, and then use those sensations as the focus during a

1912 Arch Sex Behav (2016) 45:1907–1921

123

mindfulness practice, and they were encouraged to try this at

leasttwotimesathome.Byelicitingastrongerbodilyresponsewith

these erotic aids, we hypothesized greater facilitation of inte-

roceptiveawareness.Thegroupendedfollowingadiscussionof

strategiesformaintainingmindfulnesspracticeathome,andwith

theencouragementtoviewthesefoursessionsaspotentiallythe

beginningofalifelongpracticeusingmindfulnessbothinsexualand

non-sexual aspects of their lives. Whenever possible, the facilita-

tors referenced published findings on the efficacy of mindful-

nesstherapyinother populations,andintegratedemergingknowl-

edgeontheimpactofmindfulnesspracticeonneuralplasticityand

brain function. All materialwas compiled intoa facilitator and

participant manual that included space for personal practice

notes and observations (Brotto et al., 2008b).

Data Analyses

Hypothesis 1

We predicted a significant effect of MBST on increasing con-

cordance between genital and subjective sexual arousal. Mul-

tilevel methodology was used to assess this question as it allows

for the examination of changes within an individual (rather than

averages across individuals) and has specifically been used to

examinechangesinsexualconcordance(Clifton,Seehuus,&Rellini,

2015;Rellinietal.,2005).WeusedtheHierarchicalLinearModeling

software program (HLM 6.08) (Raudenbush, Bryk, & Cong-

don,2004)totestwhetherconcordancesignificantlyincreased

from pre-treatment to post-treatment, and again at six-month

follow-up.

We used a two-level model with repeated measures modeled

atLevel1toestimateintercepts(meanoftheoutcomevariableat

the start of the erotic film) and trajectories of change (slopes) in

theoutcome.WestandardizedallLevel1variablesacrosswaves

priortoanalyses,allowingfortheinterpretationofthecoefficients

asstandardized betas. All coefficientswere modeled as random

(Nezlek, 2001).

First, we assessed the effect of the intervention on the con-

temporaneous(e.g.,T30s ?T30s,T60s?T60s,andsoon)relation between genital and continuous subjective arousal (i.e., whether

genital arousal predicted contemporaneous subjective arousal,

andwhethersubjectivearousalpredictedcontemporaneousgenital

arousal).Themodeltestedthesimpleslopesofsexualconcordance

ineachtimeperiodseparately(i.e.,againstaslopeofzero).Dummy

codedtimevariableswereincludedtocontrolforanymeandif-

ferences in the outcome of interest at the different assessment

points.

Second, we conducted five Level 2 moderation analyses to

determine if age, homework compliance, or FSAD status [asse-

ssed in two ways; firstly, as a dichotomous variable according to

whetherthe womanhadaclinicaldiagnosisof FSADornot,and

secondly using continuous scores on the lubrication and arousal

subscalesoftheFSFI(Rosenetal.,2000)]changedthedegreeof

concordance between genital and subjective sexual arousal at

each of the time points.

To aid in the interpretation of the magnitude of concordance

betweengenitalandsubjectivesexualarousal,wealsocarriedout

within-subjects and between-subjects Pearson r correlation coef-

ficients on VPA and continuous self-reported arousal during the

eroticsegmentofthefilmonly.Inthisway,concordanceestimates

could be compared to the mean concordance values from a

meta-analysisofseveralpsychophysiologicalstudies(Chivers

et al., 2010).

Hypothesis 2

We predicted that treatment would be associated with significant

improvements in self-reported sexual arousal and affect but not

with any significant changes in genital sexual response measured

in-laboratory.Wetookdifferencescoresfromresponsesfollowing

the erotic stimulus minus mean scores during the baseline period,

asperCliftonetal.(2015).Wenextcarriedoutarepeatedmeasures

analysisofvariance(ANOVA)acrossthethreeassessmentpoints

onthese difference scores.Toexamine the effectsof treatmenton

genital sexual response, a similar mixed within-between repeated

measuresANOVAwascarriedoutonVPApercentchangescore,

which was calculated as follows: (mean erotic VPA minus mean

neutral VPA) divided by mean neutral VPA, as per Clifton et al.

(2015).

Hypothesis 3

Wepredictedanassociationbetweenconcordanceandclinical

symptoms—namely, sexual desire,and sex-related distress.

Firstly,Spearman’srankcorrelationcoefficient(rho)wasusedas

the estimate of concordance between VPA and subjective aro-

usalforeachwomanat eachtime point(pre-,post-treatment,and

follow-up)separately.Theseconcordanceestimateswerethen

used as a fixed variable in a mixed-effects model examining the

relationshipbetweeneitherSIDIscores(measuringsexualdesire)

and concordance over time points, or FSDS scores (measuring

sex-related distress) and concordance. The models included con-

cordance, time point (pre-, post-treatment, and follow-up), and

their interaction, as well as participant ID as a random nesting

effect.

Results

Concordance Between Genital and Continuous

Subjective Sexual Arousal (Hypothesis 1)

Results ofthecontemporaneous analysesare shown inTable 1

and indicated that genital and subjective arousal covaried

Arch Sex Behav (2016) 45:1907–1921 1913

123

throughouttreatment.Specifically,increasesinsubjectivearousal

predicted contemporaneous increases in genital arousal, and

increasesingenitalarousalpredictedcontemporaneousincreases

in subjective arousal.

Subjective Arousal Predicting Genital Arousal

When examining the association between subjective arousal

and contemporaneous genital arousal, SAPre-treatment (tophalf of

Table1) represents this association during pre-treatment. This

coefficient was significant, indicating that for every one stan-

dardized unit of subjective arousal increase, women showed an

average corresponding increase of 0.008 millivolts in VPA,

equivalent toa 0.16standarddeviationincrease inVPA.SAPost-

treatment and SAFollow-up were also statistically significant, indi-

cating that for every one standardized unit of subjective arousal

increase, women showed an average corresponding increase of

0.00525 millivolts in VPA at post-treatment and 0.00501 mil-

livoltsinVPAatfollow-up,respectively.Thiscorrespondstoan

average increase of 0.15 standard deviations in VPA at post-

treatment and 0.12 standard deviations at follow-up.

To examine whether sexual concordance significantly dif-

fered at pre-treatment, post-treatment, and follow-up, we

examined the model with no constraints and compared this to

models constraining every unique pair of concordance ratios to

be equal. The models were compared using standard v2 differ- ence tests in which the goodness-of-fit for two models is differ-

enced(Schermelleh-Engel,Moosbrugger,&Müller,2003).If

themodelwithmoreconstraintsresultsinasignificantincreasein

theoverallv2,thisisindicativeofapoorerfit,andthemodelwith no constraints is retained. After applying the conservative Bon-

ferroni correction for multiple tests (a=0.05/3= .017), results

of all v2 difference tests comparing the unconstrained and con- strained models, pre-treatment=post-treatment, v2(1)=10.40, p = .001; pre-treatment= follow-up,v2(1)= 10.34, p = .001; post-treatment=follow-up,v2(1)=12.30, p\.001,showedthat theunconstrainedmodelfitsthedatasignificantlybetter.Inother

words,thedegreeofconcordancebetweensubjectiveandgenital

arousalateachtimepointwassignificantlydifferentfromevery

other time point. Further, these differences were in the expected

directionsuchthatbetavaluesdecreasedovertime(i.e.,therewas

lesschangeingenital arousal associatedwith thesame level of

subjective arousal over time).

Genital Arousal Predicting Subjective Arousal

In examining the association between genital arousal and con-

temporaneoussubjective arousal, VPAPre-treatment (bottom half of

Table1) represents this association during pre-treatment. This

coefficient was significant, indicating that for every one stan-

dardized unit of genital arousal increase, women showed an

average corresponding increase of 1.79 units of subjective arou-

sal, equivalent to a 1.16 standard deviation increase in subjective

sexual arousal. VPAPost-treatment and VPAFollow-up were also sta-

tistically significant, indicating that for every one standardized

unitofphysiologicalarousalincrease,womenshowedanaverage

correspondingincreaseof1.37unitsofsubjectivearousalatpost-

treatmentand1.08unitsofsubjectivearousalatfollow-up,respec-

tively. This corresponds to an average increase of 0.76 standard

deviations in subjective sexual arousal at post-treatment and 0.64

standard deviations at follow-up.

Toexaminewhethersexualconcordancesignificantlydiffered

at pre-treatment, post-treatment, and follow-up, we again exam-

ined the model with no constraints and compared this to models

Table1 Contemporaneous reciprocal associations between genital and subjective arousal

Coefficient SE t ratio p

SA ? VPA

Pre-treatment 5.71910 -2

0.005 10.92 \.001 Post-treatment 6.40910

-2 0.004 16.68 \.001

Follow-up 5.98910 -2

0.005 12.85 \.001 SAPre-treatment 8.12910

-3 0.004 1.99 .05

SAPost-treatment 5.25910 -3

0.001 3.50 .001

SAFollow-up 5.01910 -3

0.001 3.40 .001

VPA ? SA

Pre-treatment 1.82 0.26 6.87 \.001 Post-treatment 1.88 0.23 8.22 \.001 Follow-up 1.70 0.19 8.97 \.001 VPAPre-treatment 1.79 0.50 3.58 .001

VPAPost-treatment 1.37 0.28 4.96 \.001 VPAFollow-up 1.08 0.26 4.20 \.001

df =78

VPA Vaginal pulse amplitude (genital arousal), SA subjective arousal

1914 Arch Sex Behav (2016) 45:1907–1921

123

constraining every unique pair of concordance ratios to be equal.

Results of all v2 difference tests comparing the unconstrained modelwithconstrainedmodelsshowednostatisticallysignificant

difference in fit, pre-treatment= post-treatment, v2(1) = 0.71, p = .40;pre-treatment=follow-up,v2(1)=-0.56,p = .46;post- treatment=follow-up, v2(1)=1.49, p = .22, indicating that the degree of concordance between genital and subjective arousal at

eachtimepointwasnotsignificantlydifferentfromanyothertime

point.

Wecalculatedbothwithin-subjectscorrelationsandbetween-

subjects correlations and these are shown in Table 2. Across

time points,themagnitudeofthecorrelationbetweengenitaland

subjective sexual arousal was larger for within-subjects correla-

tions (range .28 to .33) than for between-subjects correlations

(range.13to.22).Usinga pairedsamples t test comparingpre- to

post-treatment,andaseparateonefrompost-treatmenttofollow-up

revealednostatisticallysignificantdifferencesforwithin-subjects

concordanceestimates.Thesamenon-significantresultswerefound

usingFisher’sr-to-z transformationforthebetween-subjectscon-

cordance estimates (Table2).

Focusing specifically on the within-subjects correlations, the

rangeofconcordanceestimatesatpre-treatmentwas-.90to?.91.

A total of 19.1% had negative concordance (defined here as

r B -.25), 10.6% had noconcordance (definedhereas-.24\ r\.24), and 70.2% had positive concordance (defined here as r C .25).Atpost-treatment,therangewassimilarlylarge:-.80

to.94with15%havingnegativeconcordance,20%havingno

concordance, and 65% having a positive concordance.

Moderation of the Association Between Genital and

Continuous Subjective Arousal

Five separate Level 2 moderation analyses were conducted to

determine if age (n =79), homework compliance (n =78), or

FSAD status (assessed dichotomously according to whether

women had a clinician-determined diagnosis of FSAD or not;

n = 79), and using mean scores on the lubrication (n = 62) and

arousal(n = 62)domainsoftheFSFI(measuredcontinuously)

changed the degree of concordance between genital and sub-

jectivesexualarousalateachofthetimepoints.Alltimepoints

were included in the moderation analyses for age and FSAD

status, while only post-treatment and follow-up were included

in the moderation analyses involving homework compliance

(homework had not yet been assigned at pre-treatment).

Neither age, diagnosis of FSAD, continuous FSFI scores on

the lubrication and arousal domains, nor homework compliance

moderated the association between contemporaneous subjective

and genital arousal as an outcome (ps ranged from .21 to .79).

Similarly, neither age nor FSAD status (assessed dichotomously

andcontinuouslywiththeFSFI)moderatedthecontemporaneous

(ps ranged from .35 to .92) association between genital and sub-

jective sexual arousal as an outcome. Degree of homework com-

pliance was, however, found to moderate this association, such

thatgreaterhomeworkcompliancewasassociatedwithanincrease

inthenumberofsubjectivearousalunitsassociatedwithastan-

dardized unit increase in genital arousal (Table3). Specifically,

foreverystandardizedunitincreaseofgenitalarousal,womenshowed

a marginally significantly greater increase in subjective arousal

withmorehomeworkcomplianceatpost-treatment(t =1.67,p =

.10)andasignificantlygreaterincreaseinsubjectivearousalwith

greaterhomeworkcomplianceatfollow-up(t = 2.13, p = .04).

Effects of Erotic Film and Treatment on Self-Reported

Sexual Arousal and Affect (Hypothesis 2)

To test the ability of the erotic film to significantly increase self-

reportedsexualarousalandaffect,apairedsamplesttestwasused

tocomparemeanscoresonFilmScaledomainsbeforetheneutral

film and after the erotic film at post-treatment. There was a sig-

nificant increase in perception of genital sexual arousal, t(78)=

-10.53, p\.001, d = 1.93;subjectivesexualarousal, t(78) = -8.66, p\.001, d = 1.38; positive affect, t(78) = -6.43, p\.001, d =1.20; autonomic arousal, t(78)=-7.36, p\.001, d =1.23;negativeaffect,t(78)=-3.47,p = .001,d =0.59,anda

significant decrease in self-reported anxiety, t(78)=2.62, p =

.011, d =-0.42,followingtheeroticfilm.Thesefindingssuggest

that the erotic film was effective at eliciting a subjective sexual

response at post-treatment (Table4).

A repeated measures ANOVA didnot find a significant effect

of treatment on subjective sexual arousal difference scores, F(2,

156)\1, p = .861, d =0.05frompre-topost-treatment;d =0.06 from post-treatment to follow-up. Perception of genital sexual

arousalsimilarlydidnotsignificantlychangewithtreatment, F(2,

156)\1, p = .747, d =0.07frompre-topost-treatment;d =0.05 from post-treatment to follow-up.

Focusingonaffect,arepeatedmeasuresANOVAdidnotfinda

significant effect of treatment on the change in positive affect

Table2 Concordance between genital and continuous subjective sexual arousalcalculatedwithwithin-subjectscorrelationsandbetween-subjects

correlations across three time points

Pre-treatment Post-treatment Follow-up

Within-subjects

correlations

.30 (.54)

n =47

.33 (.47)

n =60

.28 (.47)

n =76

Between-subjects

correlations

.22

n =79

.13

n =79

.14

n =79

Within-subjects correlations used responses during the erotic segment of

the film only and continuous measures of subjective sexual arousal.

Sample sizes vary due to missing data. Paired samples t test revealed no

significant difference from pre- to post-treatment, t(46)=-0.21, p =

.835;orfrompost-treatmenttofollow-up, t(58)=0.76, p = .448.Between-

subjectscorrelationswerecalculatedwithpercentchangeingenitalsexual

arousal from neutral to erotic film conditions, and using the difference

between neutral to erotic film conditions for discrete self-reported sexual

arousal.Fisher’s r-to-z transformationfoundnosignificantdifferencefrom

pre- to post-treatment, z =0.61, p = .542; or from post-treatment to fol-

low-up, z =-0.06, p = .952

Arch Sex Behav (2016) 45:1907–1921 1915

123

fromneutraltoeroticfilmconditions, F(2,156)=2.54, p = .082,

d =0.14 from pre- to post-treatment; d =0.08 from post-treat-

menttofollow-up.Asimilarpatternwasfoundfornegativeaffect,

with no significant effect of treatment, F(2, 156)\1, p = .948, d =0.00 from pre- to post-treatment; d =0.04 from post-treat-

ment to follow-up.

EffectsofEroticFilmandTreatmentonGenitalSexual

Arousal (Hypothesis 2)

Totesttheabilityoftheeroticfilmtosignificantlyincreasegenital

sexualresponseateachtimepoint,apairedsamplesttestwasused

tocomparemeanVPA(inmV)fromtheneutraltotheeroticfilm.

A paired samples t test revealed that the erotic film significantly

increasedVPAatpre-treatment, t(78)=-2.00, p = .049;atpost-

treatment, t(78) = -2.00, p = .049;atpost-treatment, t(78) =

-2.78, p =.007; and at follow-up, t(78)=-2.19, p =.032, veri-

fying the sexually arousing properties of our erotic stimuli

(Table4).

To examine the effects of treatment on VPA percent change

scores, a repeated measures ANOVA across all three time points

wascarriedoutandfoundnottoreachstatisticalsignificance,F(2,

156) = 2.58, p = .079; d = 0.28 from pre- to post-treatment;

d = -0.34 from post-treatment to follow-up.

Association Between Sexual Concordance and Clinical

Symptoms Using the Sexual Interest/Desire Inventory

and the Female Sexual Distress Scale (Hypothesis 3)

Significance of the interaction term and the main effects were

estimated using likelihood-ratio tests comparing the fit of the

modelcontainingthetermversusthefitofthemodelwiththeterm

removed. p-values\.05 were considered as indicating a signifi- cant relationship between the term of interest and the outcome

variable. There was no significant interaction between time and

concordanceforeitherSIDIorFSDS(Likelihood-ratioteststatis-

tic [LRT]=3.9, p = .15, and LRT=3.2, p = .21, respectively).

This suggests that any relationship between concordance and the

clinical symptoms of desire (SIDI) and distress (FSDS) did not

differ significantly over the time periods. If the interaction terms

were removed, there wasstill no significant relationship between

either SIDI or FSDS and concordance (LRT=0.2, p = .68, and

LRT=0.0, p = .99, respectively); however, there was a signifi-

cant effect of time period for both outcomes (SIDI: LRT=17.3,

p=.0002;FSDS:LRT=9.0, p =.01),withSIDIscoresincreasing

significantly post-treatment and remaining high at follow-up,

and FSDS scores decreasing significantly at post-treatment

and remaining low at follow-up.

Table3 Homeworkcomplianceasamoderatoroftheassociationbetween genital and contemporaneous subjective arousal as an outcome

Coefficient SE t ratio p

VPA(T) ? SA(T) Post-treatment

Low HC 1.76 0.20 8.94 \.001 High HC 2.79 0.36 2.83 .006

Follow-up

Low HC 1.45 0.14 10.46 \.001 High HC 2.50 0.33 3.22 .002

VPAPost-treatment

Low HC 0.94 0.23 4.16 \.001 High HC 1.57 0.38 1.67 .10

VPAFollow-up

Low HC 0.59 0.12 5.06 \.001 High HC 1.14 0.26 2.13 .04

df =76

VPA vaginal pulse amplitude (genital arousal), SA subjective arousal, HC

homework compliance

Table4 Effectsoferoticfilmondiscretemeasuresofsubjectivesexualarousal,perceptionofgenitalarousal,positiveaffect,negativeaffect,autonomic arousal, anxiety, and vaginal pulse amplitude (VPA) from neutral to erotic films at pre-treatment, post-treatment, and follow-up

Pre-treatment Post-treatment Follow-up

Neutral Erotic Neutral Erotic Neutral Erotic

Subjective arousal 2.91 1.14*** 4.27 1.41 3.04 1.19*** 4.47 1.30 2.97 1.10*** 4.32 1.34

Perception of genital arousal 1.45 0.58*** 2.80 1.31 1.51 0.66*** 2.93 1.36 1.46 0.59*** 2.83 1.29

Positive affect 1.71 0.64*** 2.49 1.41 1.63 0.66*** 2.57 1.46 1.54 0.53*** 2.57 1.38

Negative affect 1.38 0.44*** 1.52 0.57 1.26 0.36*** 1.40 0.50 1.28 0.35*** 1.43 0.53

Autonomic arousal 1.58 0.54*** 2.25 0.92 1.56 0.62*** 2.37 1.00 1.52 0.61*** 2.35 0.96

Anxiety 2.06 1.08** 1.66 1.19 1.68 0.87** 1.39 0.90 1.59 0.81 1.41 0.84

VPA (mV) .044 .063* .058 .037 .043 .063** .063 .029 .044 0.67* .060 .043

Data represent means and SD

* p\.05, ** p\.01, *** p\.0001 paired samples t test from Neutral to Erotic conditions. All variables, except VPA, have a 1–7 range

1916 Arch Sex Behav (2016) 45:1907–1921

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Discussion

We examined the effects of a group mindfulness-based sex

therapy on concordance between genital and subjective sexual

arousalinwomenseekingtreatmentforconcernsofsexualdesire

and/or arousal using a series of hierarchical linear models, first

with subjective arousal predicting genital response and then the

reverse. We found evidence of significant sexual concordance at

all time points, with subjective arousal predicting contempora-

neous genital arousal, and significant increases from pre- to post-

treatment, such that there was less change in genital arousal

associated with the same level of subjective arousal, suggesting

greater coherence between these two aspects of the sexual res-

ponse(Brottoetal.,2012b).Incontrast,althoughgenitalresponse

predicted significant increases in subjective arousal contempo-

raneouslyatalltimepoints,wefoundnochangeinthismeasureof

sexual concordance as a function of treatment. Within-subjects

correlations revealed the magnitude of the association (between

.28and.33)tobewithintherangefoundamongseveralotherpsy-

chophysiologicalstudiesofwomen(Chiversetal.,2010).These

resultssuggestthatincreasesinsexualconcordanceassociatedwith

mindfulness-basedsextherapymaybedrivenbychangesinsubjec-

tive sexual response rather than genital response.

Interestingly, although the erotic film significantly increased

self-reportedsexualarousal,affect,andgenitalsexualresponseat

each time point, there was no significant effect of treatment on

eitherself-reportedorgenitalresponsecomparedtobaseline,sug-

gesting that the change in sexual concordance following treat-

ment was not a straightforward consequence of increases in self-

reported or genital response. Clifton et al. (2015) also found

similareffects,withwomenhigherinSESIIexcitationscoresand

passionate-romantic scores showing higher genital-subjective

concordance, despite no significant association between individ-

ual predictors and genital or subjective sexual response sepa-

rately;womenwhoratethemselvesasmoreeasilyarousablemay

be more in tune with their body’s physiological responses to sex-

ual stimuli, even though the magnitude of their actual physio-

logical or subjective sexual response is no different from women

withlowerexcitationscores.Similarly,wefoundasignificanteffect

of mindfulness treatment on concordance (compared to pre-

treatment levels) but not on genital or subjective sexual response

separately, suggesting that treatment may have contributed to

women’s capacity to detect and integrate their experience of

sexual excitation.

FSAD diagnostic status and FSFI lubrication and arousal

domainscoresdidnotsignificantlymoderatesexualconcordance

at any of the time points. This was a surprising result, given both

clinical domains improved after treatment (Brotto & Basson,

2014), and other research has notedrelationships between sexual

functioning and sexual concordance in healthy women (Brody

et al., 2003) andin women with sexual difficulties(Chivers et al.,

2010). Our findings suggest, perhaps, that sexual concordance

and self-reported clinical symptoms of (low) desire and sexual

distress reflect different, unrelated aspects of the female sexual

response, accounting for their lack of significant association.

Conversely,homeworkcompliancedidsignificantlymoderate

sexualconcordance,suchthat,foreverystandardizedunitincrease

ofgenitalarousal,womenshowedasignificantlygreaterincrease

insubjectivearousalwithgreaterhomeworkcomplianceatfollow-

up. This suggests that recommended daily at-home mindful-

nesspractices,designedtocultivatebetterintegrationofawareness

andphysicalsensations,mayhavecontributedtotheincreasein

concordance.Ofnote,thismoderationwassignificantatfollow-up,

butnotatimmediatepost-treatment,suggestingcumulativeeffects

ofmindfulnesspracticeoverthe6-monthfollow-upperiod.Other

datashowingadose–responserelationshipbetweendurationof

mindfulnesspracticeandimprovementsinsymptomsofdepression

andanxietysupportsthisinterpretation(Krusche,Cyhlarova,&

Williams,2013).Othershavealsofoundthatamountofat-home

mindfulnesspracticeisassociatedwithself-reportmeasuresof

affect and well-being, but not with indices of medical health

(Carmody&Baer,2008).Ourhomeworkcompliancescores

were assignedbygroupfacilitators;therefore,future studies

could haveparticipantsmonitor amountofat-home practiceto

correlate mindfulness practice with changes in outcomes.

Sexual Concordance as a Potential Study Endpoint?

Our findings suggest that skills aimed at enhancing a woman’s

concentration training and compassionate self-acceptance may

be associated with greater integration of physical and mental

sexual responses to erotic stimuli in a laboratory setting. Con-

sidered in the context of prior research showing similar effects of

attention training on sexual arousal (Meston, Rellini, & Telch,

2008), and the specificity of mindfulness interventions (versus

cognitive behavioral sex therapy) on changes in sexual concor-

dance (Brotto et al., 2012b), we propose that sexual concordance

beconsideredameaningfulstudyendpointinsexualpsychophys-

iologyresearch.Intreatmentoutcomeresearch,itisnotuncommon

toseethetreatmenteffectsonself-reportedbutnotgenitalresponse

(Diamondetal.,2006).Elsewhere,wehaveproposedthatsexual

concordancemayrevealtreatmenteffectsthatmightotherwise

be overlooked when examining only self-reported or psychophysi-

ologicalsexualresponsealone(Chivers&Rosen,2010).Others

haveshownthatsexualconcordanceismeaningfullyassociated

withcognitiveandschematicaspectsofwomen’ssexualfunctioning,

suchashighersexualexcitationandpassion-andromance-related

cognitiveschemas,intheabsenceofdirecteffectsbetweenthese

variables(Cliftonetal.,2015).Inthecurrentstudy,wedemonstrated

asimilarpatternwithsexualconcordanceincreasingaftertreatment

butnodetectablechangeineitheraspectofsexualresponsethrough-

outtreatment.Takentogether,thesefindingsprovidepreliminary

support for the possibility of sexual concordance being a more

relevant and sensitive study endpoint.

Arch Sex Behav (2016) 45:1907–1921 1917

123

Mechanisms of Action

The direction of concordance effects, with subjective arousal

predictingcontemporaneousgenitalarousal(butnotthereverse),

suggests that mechanisms underlying change in sexual concor-

dance are predominantly, as expected, top-down, as opposed to

bottom-up.Aswomendeliberatelyguidedtheirattentionontodif-

ferent foci—whether the breath, body, sounds, or thoughts—this

may have translated into an improved ability to detect sensations

inthebodyassociatedwithsexualarousal.Silversteinetal.(2011)

founddecreasedreactiontimetoratingbodilyreactionstosexual

stimuli in women following mindfulness training. Given that the

insular cortex mediates interoceptive ability (Critchley, Wiens,

Rotshtein,Öhman,&Dolan,2004),andisassociatedwithincreased

thicknessfollowingmindfulnesspractice(Hölzeletal.,2010),itis

possiblethatinsula-mediatedincreasesininteroceptiveabilityfrom

the various mindfulness exercises contributed to the improved

concordance between genital and subjective arousal.

Because sexual concordance was not significantly different

with treatment when genital arousal predicted subjective sexual

arousal, this suggests that it was unlikely that genital sensations

ledwomentoexperiencemoresubjectivearousal,therebydriving

concordance.Furthermore,ithasbeenarguedthattreatmentsaimed

atimprovinggenitalresponsemaybeineffectivewithoutthecapacity

todetectandpositivelyappraisethosephysiologicalchanges(Chivers

& Rosen,2010).Thegenitalarousalresponsetoeroticcuesisrela-

tivelyautomatic(Chivers&Bailey,2005;Chivers,Rieger,Latty,

&Bailey,2004;Laan,Everaerd,vanBellen,&Hanewald,1994),

regardlessofwomen’sageorsexualdysfunctionstatus;indeed,

womenwithadiagnosisofFSADhadthesamemagnitudeofVPA

assexuallyhealthycontrols(Laanetal.,2008).Inthecurrentstudy,

therewasnoimmediateeffectoftreatmentonVPA.Therefore,

itisnotlikelythatourtreatmentledtochangesingenitalresponding,

which then drove an increase in concordance. A top-down mecha-

nisminwhichwomendeliberatelyfocusedattentiononemerging,

moment-by-moment sensations over the course of treatment,

likelyledtotheircontemporaneousdetectionofgenitalarousal

inthelaboratorysetting,therebyincreasingsexualconcordance.

In addition to mindfulness practice increasing awareness of

visceral (and likely genital) cues, current models of the mecha-

nismsofmindfulness(Teper,Segal,&Inzlicht,2013)suggestthat

increasesinacceptanceandself-compassionmayhavecultivated

anopennesstoallelementsofourparticipants’experienceofsexual

response withoutattemptingtoalter them.Teperetal.surmised

thatwhenoneobservesandacceptscurrentemotions,thismay

facilitateemotionregulation.Givenevidencethatnegativeaffect

during sexual encounters may significantly predict sexual diffi-

culties(Nobre&Pinto-Gouveia,2006),itispossiblethatwomen

experiencedanimprovedabilitytoregulatesuchemotionsand

thereby tune into and accept their visceral sensations.

Limitations

Therewerelimitationsinthisstudythatmustbeconsidered.Firstly,

treatment included a combination of (primarily) mindfulness exer-

cises,psychoeducation,andsextherapy.Itisunknownwhether

benefits were due to one specific component of treatment or to

theirsynergisticeffects.Ofnote,however,previousresearchtesting

asimilar(butnotidentical)treatmentprotocolfoundthatpartici-

pantsself-reportedthemindfulnesscomponenttobethemosteffec-

tiveaspectoftreatment(Brotto&Heiman,2007).Futureresearch

thatdismantlesthesecomponentsandteststhemagainstoneanother

isneededinordertoempiricallysubstantiatetheseobservations.

Secondly,ourmeasureofsexualfunctioning(i.e.,theFSFI)was

limitedbecauseitexcludedwomenwhowerenotsexuallyactive

inthepreceding4weeks,andassessedonlytheintensityandfre-

quencyofsexualarousal,withoutconsiderationforthemultiple

waysinwhichsexualarousalmaybeexperiencedinwomen.Our

abilitytodetectassociationsbetweenchangeinsexualconcordance

andchangeinclinicalsymptomsmayberelatedtotheselimitations.

Relatedly,wewerealsounabletoexaminecorrelationsbetween

concordance and the orgasm domain given the large proportion

ofmissingdataintheFSFI.Importantly,thissamplerepresentsonly

asmallcross-sectionofwomenwithsexualdesiredifficulties,and

we limited the upper age to 65 in recognition of the large hetero-

geneityinthewayswomenexperience(lossof)sexualdesire(Meana,

2010).Itispossiblethatsuchaninterventionwouldhaveyielded

differentresultsinamuchlarger,morerepresentativesampleof

women with sexual desire complaints.

Thirdly,ourcapacitytodetectassociationsbetweenchangein

sexual concordance and sexual functioning was limited by

examining these relationships in a clinical sample only, such that

range restriction in sexual functioning may have hampered the

detectionofanassociationthatmayhavebeenobservedifwomen

withoutsexualdysfunctionwere included.Tothatend,therewas

considerable variability in the range of concordance estimates

acrossparticipants,bothatpre-andatpost-treatment,butwiththe

majorityofparticipantsshowingapositiveconcordanceestimate.

Also, in the absence of a no-treatment control group, the magni-

tude of any change in subjective or genital sexual response with

treatment cannot be established and should be the focus of future

research.

To examine whether sexual concordance changed during two

pre-treatment assessments before treatment was administered,

genitalarousalandcontinuousself-reportedsexualarousalduring

the erotic film segment were analyzed for 25 women who

receivedtwopre-treatmentassessments.Within-subjectscorrela-

tions were calculated, then statistically compared using a depen-

dent samples t test. There was no significant difference between

the concordance estimates at the two pre-treatment assessment

points (data not shown), suggesting that the repeated assessment

1918 Arch Sex Behav (2016) 45:1907–1921

123

of concordance does not significantly impact the concordance

estimates themselves. Furthermore, this finding strengthens our

conclusion that the increases in sexual concordance observed

with treatment are not likely attributable to the passage of time.

Implications

The incentive motivation model (Both, Everaerd, & Laan, 2007)

proposesthatsexualdesireistriggeredbysexualarousal,whereas

previously, sexual desire and arousal were viewed as distinct and

sequential phasesof sexual response (Masters & Johnson, 1966).

Accordingtotheincentivemotivationmodelthatinformscurrent

DSM-5definitionsofSIAD,sexualdesireandarousalarereciprocally

reinforcing,suchthatsexualdesireemergesfromexperiencingsexual

arousal(Toates,2009).Genitalresponsesalonemaynot,however,

besufficientforgeneratingsexualdesire;instead,theintegration

ofphysiologicalandpsychologicalsexualresponse(presumably

capturedwithaconcordanceestimate)maybemorestronglyassoci-

atedwith triggeredsexualdesire.Likewise,consciousawareness

and positive appraisal of physiological response may be integral

totheexperienceofsexualdesire.Inthisway,sexualconcordance

as a study endpoint may be fruitful for disambiguating the long-

debated relationship between sexual arousal and desire.

Theincentivemotivationmodelfurtherproposesthatlowdesire

andarousalmaybetheresultofweakassociationsbetweenasexual

stimulusandrewardorthatitmaybeassociatedwithamorenarrow

rangeofstimulithatareconsideredrewarding(McCall&Meston,

2006,2007).Thisviewproposesthatwomenwithlowarousaland

desirearecapableofaphysicalsexualresponse,butstimuliare

appraisedasneutralornegative,andthusfailtotriggersexualdesire.

Anotherpossiblecontributortolowarousalanddesiremaybean

inabilitytoconsciouslyexperienceandrecognizeastateofsexual

arousal.Inthecurrentstudy,cultivationofattentiontorawsensations

improvedconcordanceandfosteredgreatermind–bodyintegration.

Thesefindingsprovidesupportfortreatmentsaimedatincreasing

sexualinteroceptionandnon-judgementalawarenessofsexual

responding.

Overall, the present findings contribute to an emerging liter-

ature supporting the clinical application of mindfulness for the

treatment of sexual dysfunction in women (Brotto, 2013; Brotto

& Goldmeier, 2015). Given women’s frequent claims of‘‘feel-

ingdisconnectedsexually’’whenpresentingforsextherapy,our

data suggest that mindfulness may improve the integration

betweengenitalandself-reportedsexualarousal.Althoughthis

study did not identify individual differences predicting treat-

ment-related improvementsinsexualconcordance,thewiderange

inconcordanceestimates across participants suggests that future

research could identify characteristicsassociated with treatment

response.Inthelong-run,andgiventherecentapprovalofthefirst-

ever medication for the treatment of women’s sexual desire (fli-

banserin; http://www.fda.gov/NewsEvents/Newsroom/Press

Announcements/ucm458734.htm),thereisanopportunityfor

identifying individual patient characteristics predictive of a

positive response to treatment such that therapies (whether psy-

chological or pharmacological) can be individually tailored to

women’s needs.

Acknowledgments The authors wish to thank Yvonne Erskine for overallcoordinationofthisstudy.Wealsowishtothankgroupfacilitators

MiriamDriscoll,SheaHocaloski,GailKnudson,BrookeSeal,andMorag

Yule.OurthankstoDr.RosemaryBassonandDr.MijalLuriafordeveloping

thetreatmentmanualusedtodeliverthemindfulnessintervention.Funding

forthisstudywasprovidedbyaBCMedicalServicesGranttoLoriBrotto.

Compliance with Ethical Standards

Conflictofinterest Noneoftheauthorshaveanyconflicts ofinterest to disclose.

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