Week 4 Assignment

ORIGINAL PAPER

Mindfulness-Based Sex Therapy Improves Genital-Subjective Arousal Concordance inWomenWith 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 NewYork 2016

Abstract There isemergingevidencefor theefficacyofmind-

fulness-based interventions for improvingwomen’ssexual func-

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

sexual responseanddistress.Sexualarousalconcordance—the

degree of agreement between self-reported sexual arousal and

psychophysiological sexual response—hasbeenof interest due

to thespeculationthat itmaybeakeycomponent tohealthysex-

ual functioninginwomen.Weexaminedtheeffectsofmindful-

ness-basedsextherapyonsexualarousalconcordanceinasample

ofwomenwith sexual desire/arousal difficulties (n=79,M age

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

sexualarousalusingavaginalphotoplethysmographbeforeand

after foursessionsofgroupmindfulness-basedsextherapy.Genital-

subjective sexual arousal concordance significantly increased from

pre-treatment levels, with changes in subjective sexual arousal

predicting contemporaneous genital sexual arousal (but not the

reverse). These findings have implications for our understand-

ingof themechanismsbywhichmindfulness-basedsex therapy

improvessexualfunctioninginwomen,andsuggest thatsuchtreat-

mentmay lead to an integration of physical and subjective arousal

processes.Moreover, ourfindings suggest that future research

might consider the adoption of sexual arousal concordance as a

relevant endpoint in treatment outcome research ofwomenwith

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.

Whenclinicallysignificantdistressaccompanies the lossofsex-

ualdesire, estimates reveal thatup to12%ofwomenareaffected

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

tion of the Diagnostic and Statistical Manual of Mental Disor-

ders (DSM-5)defines this syndromeas‘‘FemaleSexual Interest/

ArousalDisorder’’(SIAD;AmericanPsychiatricAssociation,

2013) and a diagnosis ismadewhen any three of six criteria are

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

ically significantdistress.Thecriteria include: (1) lackofdesire

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

tionand receptivityof sexual activity, (4) lackof sexualpleasure,

(5) inability for sexualstimuli to triggerdesire,and(6)an impaired

physical sexual arousal response.

Todate,themostwidelystudiedtreatmentforlowsexualdesire

inwomenhasbeentestosterone.A largenumberof randomized

controlledstudieshavedemonstratedtheefficacyof topical testos-

terone in surgically menopausal women (reviewed by Davis,

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

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

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

unregulated,andalthough itwasapproved foruse inpatch form

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

trials for treatmentof lowsexualdesire,but asofOctober2015,

flibanserin is the onlymedication approved in the U.S. for this

condition.

Despite considerable interest in testingpharmacological options

forwomen’s lowsexualdesire,psychological treatmenthasbeen

themainstayof therapyforwomenwithsexualdesiredifficulties.

Because cognitive distraction during sexual activity is prevalent

amongwomenwith sexual dysfunction, and negatively impacts

their sexual satisfactionanddesire (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

both cognitive challenging aswell as behavioral strategies) to a

wait-list control in 74 couples in which womenmet criteria for

HypoactiveSexualDesireDisorder(HSDD).After12weeks,74%

ofwomenno longermet diagnostic criteria forHSDD, and this

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

cantly improvedsexualdesire,womenalso reported improved

quality ofmarital life andperception of sexual arousal, but the

groupcouple therapyformatmaynotbefeasible in typicalclini-

cal settings.Another treatment outcome study of 10 sessions of

CBT,2–3ofwhichincludedthepartner,foundonlya26%reduc-

tion in the proportion of women who had significant concerns

with lowsexualdesire (McCabe,2001).Taken together, these stud-

ies suggest thatCBTiseffective foraproportionofwomenwith

lowsexualdesire,but suchanapproachmayalsohave limitations.

Specifically, because of the often-noteddistractibility, anxiety-

proneness, judgmental intrusions, and inattentiondescribedby

womenwith lowsexualdesire (Meston,2006), andalsobecause

of thevariedways inwhichdesire is experienced (Meana,2010;

Sand&Fisher, 2007), other skill-based approachesmaybenec-

essaryforwomenwhodonotbenefitfromcognitivechallenging.

Toaddress thesegaps, third-generationCBTapproaches,suchas

mindfulness-basedcognitivetherapy,havebeengainingtraction

in many domains of physical and psychological health.

Mindfulnessmeditationhasa3500yearhistoryandfornearly

thepast fourdecadeshasmade itsway intoWesternmedicine.

Defined as present-moment, non-judgmental awareness with

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

fulness meditation has been amajor addition to the psycholog-

ical treatmentarsenalfor thetreatmentofanxiety,depression,sub-

stance use, childhoodbehavior problems, anda host ofmedical

concerns, includingpain, irritable bowel syndrome, fibromyal-

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

Walach,2004;Merkes,2010).Althoughtheprecisemechanisms

by which mindfulness is associated with symptom relief is not

fullyunderstood, itsbenefitsmaybeassociatedwithan increase

inmetacognitiveawareness, or theability toexperience thoughts

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

10 years,mindfulness has been applied to and found effective

for the treatment of sexual dysfunction in women (Brotto,

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

& Rellini, 2012b).

Themechanismsbywhichmindfulness led to these improve-

ments in women with sexual dysfunction are not entirely clear

andmayrelate toadecrease inspectatoring—definedbyMasters

andJohnson(1970)as theprocessofwatchingoneselfduringsex-

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

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

and/or an increase in perception of physical sexual response. In

support of the latter, one laboratory-based study inwhich female

studentswithout sexual difficultieswere randomized to either an

8-weekmindfulnessmeditationgroupor to anactivecontrol rated

the intensityof theirphysiological responsesafterviewingemo-

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

maryanalysis focusedon interoceptive awareness, the capacity to

accuratelydetectphysicalsensations,after themindfulness inter-

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

ers,and isknown tocorrespond toanafferentpathway fromparts

of thebody to the spinal cord, brain stem, andultimately to the

rightanteriorinsularcortex(Craig,2002).Studyparticipantswere

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

imagesandwereaskedtoindicatetheirlevelofphysiologicalarousal

(calm, excited, andaroused).Reaction time, or howquickly an indi-

vidualratedtheintensityofarousalintheirbody,wasusedasanindex

ofgreaterinteroceptiveawareness.Womeninthemeditationgroup

hadsignificantlyfaster reactiontimesthanwomeninthecontrol

group,andthequickerreactiontimesignificantlycorrelatedwith

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

andwell-being,andwithdecreasesinself-judgmentandanxiety.Sil-

versteinetal. inferredthistomeanincreasedinteroceptiveawareness

followingmindfulness training thatmay correspondwith activity in

the insula cortex.

Thereismarkedindividualvariabilityintheabilitytodetect inter-

nal physical sensations,with some individuals beinghighly intero-

ceptively aware, and others being relatively naı̈ve to changes in

bodily reactions. Furthermore, there ismarkedvariation in sex-

ual concordance amongwomen. In theirmeta-analysis of the sex-

ualpsychophysiology literature,Chiversetal. (2010) found,using

apooled sampleofn= 2345women, that variation inwomen’s

sexualconcordancewasnotaccountedforbyavarietyofmethod-

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

experiment, theuseof female-centeredversusmale-centerederotic

stimuli, or stimulus length;however, higher sexual concordance

was associatedwith using stimuli that varied in content, inten-

sity, ormodality (r= .49) andmethodof calculating correlations

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

Chivers et al. also found that concordance among womenwas

related tomethodofassessinggenital response,withgenital tem-

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

yieldinghigherestimatesofsexualconcordancethanvaginalpho-

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

graphicmethods of assessing genital response also producewide

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

sexualconcordancesuggests thepresenceofmoderators,ofwhich

sexual functioningmaybeone (Boyer,Pukall,&Chamberlain,

2013).

Low sexual concordance can manifest in one of two ways:

increases ingenital sexual response in theabsenceofgenital aware-

nessorsexualaffect,ortheconverse.Consistently, it is theformer

that is thecaseforsexuallyfunctionalwomen;genital responseto

sexual stimuli is rapidly andautomatically evokedbyprocessing

ofsexualstimuli (Chivers&Bailey,2005),butgenitalawareness

or sexual affect may not be simultaneously reported (Chivers

et al., 2010). This pattern is also common amongwomenwith

FemaleSexualArousalDisorder (FSAD)—which the former

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

genital vasocongestion (American Psychiatric Association,

2000)—suchthat theyself-reportedlowersexualaffect tosexual

stimuli in the laboratory but showed a robust genital response,

similar to womenwithout sexual arousal problems (Laan, van

Driel,& vanLunsen, 2008;Meston, Rellini,&McCall, 2010).

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

relation forwomenwithvarious sexualdifficulties (n=235)as

.04 (-.10 to .17),whereas forwomenwithout sexual difficulties

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

Sexualconcordancemayberelatedtosexualfunctioningamong

healthywomen, such that greater concordance is associatedwith

morefrequentexperienceoforgasm(Adams,Haynes,&Brayer,

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

withdatashowinghighersexualconcordanceamongwomenwith-

outasopposedtowithasexualdysfunction,thesedatasuggestthat

sexualconcordancemaybeakeycomponent tohealthysexual

functioninginwomen.Current treatmentsforsexualdysfunction,

however,donot focusonskills thatmayenhancewomen’ssexual

concordancenorhave treatmentefficacystudiesusedsexualcon-

cordance as a primary outcome.

In light of mounting evidence that mindfulness improves

women’s self-reportofsexual functionandawarenessofbodily

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

portedarousalmayberelevant towomen’ssexual interoceptive

awareness, the current studywas designedwith these themes in

mind.Specifically, thegoalswereto: (1)examinetheeffectsofa

groupmindfulness-based sex therapy (MBST) on concordance

between genital and subjective sexual arousal; (2) examine the

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

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

changesinconcordanceandimprovements inclinicalsymptoms

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

separate publicationdocuments the significant beneficial effect

of this MBST compared to a delayed treatment control group

on theprimaryendpoint of self-reported sexualdesire (Cohen’s

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

related distress also significantly improvedwith treatment, and

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

full sample=-0.56).

In thisarticle,wefocusedonchanges inconcordancebetween

genitalsexual response(vaginalpulseamplitude;asmeasuredby

vaginalphotoplethysmography)(Sintchak&Geer,1975)andcon-

tinuously reportedsubjectivesexual arousal (Rellini,McCall,

Randall,&Meston,2005) following treatment.Given that the

MBSTencouraged thedailypracticeof focusingonandexperi-

encing general and genital arousal responses non-judgmentally,

weexpectedtreatmenttobeassociatedwithsignificant increases

ingenital-subjectiveconcordance.Sinceparticipantswereencour-

agedtopracticemindfulnessexercisesdailybetweengroupses-

sions,wepredicteddegreeofhomeworkcompliancewouldmod-

eratetheincreasedconcordanceaftertreatment.Asanexploratory

analysis, we also included age, diagnosis of FSAD, and arousal

scoresfromavalidatedmeasure(bothsubjectivearousalaswell

as lubrication) tomoderate improvements in concordance.Fur-

thermore,wehypothesizedan increase in self-reported sexual

arousalwithtreatment,consistentwithpreviousfindings.Wedid

not expect tofindaneffect of treatment ongenital sexual response

per se, givenevidence thatvaginalpulse amplitudemaynotdif-

ferbetweenwomenwithandwithoutsexualdysfunction(Laan

etal.,2008).Finally,wepredictedchanges inconcordance tobe

associatedwith improvements in sexualdesire andwithdecreases

in sex-related distress.

Method

Participants

Participantswere part of a larger study evaluating outcomes of

groupmindfulness-basedsex therapyonvarious indicesof sex-

ualdesire, sexual response, andaffect (Brotto&Basson,2014).

Womenseeking treatment for sexual desire and/or arousal con-

cerns from the British Columbia Centre for Sexual Medicine,

whether thedifficultieswere lifelongoracquired,wereeligible

to participate. Inclusion criteria included: age between 19 and

65years,fluent inEnglish, andwilling tocomplete all fourgroup

sessions, regularhomework,aswellasassessmentmeasures (con-

sistingofbothself-reportquestionnairesandalaboratory-based

psychophysiological sexual arousal assessment) at three time

points.Womenwith difficulties in achieving orgasmwere also

includedaslongasthosewerenotexperiencedasmoredistressing

than thedesire and/orarousal concerns.Weexcludedanywoman

with dyspareunia (chronic genital pain not resolvedwith a per-

sonal lubricant).

Theoriginalstudydescribingtreatmentefficacyincluded117

womenwho provided pre-treatment assessment data. The data

here focuson79womenwhohadcomplete data from their psy-

chophysiologicalassessments (bothgenitalandsubjectivearousal)

atall threetimepoints—immediatepre-treatment,post-treatment,

and6-month follow-up.Thesample included41(51.9%)women

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

123

who were assigned to the immediate treatment group and 38

(48.1%)womenwhoreceived treatmentafteran initial3-month

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

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

Also, in thisarticle,wedidnot includedatafromthecontrolgroup

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

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

on concordance.Themean age of the samplewas 40.8years (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-

ipantswere ofEuro-Canadiandescent (81.0%) followedbyEast

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

cated group in that 67.1%had some post-secondary education,

and 22.8% had an advanced graduate degree.

Althoughallparticipants self-reporteddifficultieswith sexual

desire and/or arousal andmet criteria for theDSM-5diagnosis of

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 LakeCity, UT) contin-

uouslymeasuredvaginalpulseamplitude(VPA)duringtheneu-

tralanderoticfilmsegments.VPAwasrecordedusingapersonal

computer(HPPentiumMLaptop)thatcollected,converted(from

analog to digital, using aModelMP150WSWdata acquisition

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

ological data, using the software programAcqKnowledge III, Ver-

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

wassampledat200Hzandbandpassfiltered(0.5–30Hz).Atrained

research assistant performed artifact smoothing of the signal fol-

lowingvisual inspectionofthedataandbeforedatawereanalyzed.

VPAdatawere subsequentlydivided into30-sepochs,producing

sixdatapoints for theneutralfilmand13datapoints for theerotic

film for each sexual arousal assessment.

Contemporaneous Assessment of Subjective Sexual Arousal

Subjective sexual responsewasmeasuredcontinuouslyduring

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

structedbya local engineermodeledafter the onedescribedby

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

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

affixed to the arm rest of the recliner so that theparticipant could

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

their level of subjective sexual arousal, from7 to-2,with7=

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

-2=Sexually Turned Off.Wehavepreviouslyused this device

in treatmentoutcomestudiesonwomenwithsexualdysfunction

(Brottoetal.,2012b).LikeVPAdata, themeancontemporaneous

sexual arousal responsewas obtained every 30-s, producing six

datapointsduring theneutral filmand13datapointsduring the

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

toassess subjectivearousal and affective reactions to the erotic

films.This scalewasadapted fromHeimanandRowland(1983)

andassessed sixdomains: subjective sexual arousal (1 item),

perceptionofgenital sexual arousal (4 items), autonomicarousal

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

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

sureofemotional reactions toeroticstimuli. Itemswereratedon

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

treatment reliability for the FilmScale during the neutral phase

wasverygood(Cronbach’salpha=0.82)andexcellent following

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

Homework Compliance

Homeworkcompliancewas ratedby thegroup facilitators ona

Likert scale from0 (did not complete homework/did not attend

sessions) to 2 (notable efforts at completing homework/attend-

ing sessions).A ratingwas given for eachparticipant at eachof

the fourgroupsessions, and thenameanscoreacross thesessions

was derived.

Female Sexual Arousal Disorder symptoms

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

ualFunction Index (FSFI) (Rosenet al., 2000)wereused inmod-

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

considered to be the gold standardmeasure of sexual function in

women.Therewere4 items in theArousaldomainand4 items in

theLubricationdomain; responseswere codedona5-pointLikert

scale.A respondentwhohadnot engaged in sexual activity for the

past4weekswasexcludedfromthose items.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).Possible total

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

levelsof sexual interestanddesire.TheSIDIhasexcellent inter-

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),butpoor for theorgasm item(r= .10)(Claytonetal.2006).Cronbach’salphaforthecurrent

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

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

&Heiman, 2002). Scores can range from0 to48,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 et al., 2002).Reliability for the current samplewas excel-

lent at a=0.92.

Procedure

Followingacomprehensiveassessmentbyanexperiencedsexual

medicine clinician, eligiblewomenwere informedabout the

study. If interested, theywere providedwith a one-page brochure

outlining informationabout the studyandcontact information for

the study’s coordinator.Next, they tookpart in a telephonescreen

that further explained the studyprocedures, provided some infor-

mation about the treatment content, and informed women about

upcomingschedules for theMBSTgroups.Theywere thenmailed

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-

datedtheir schedules.Participantswere thenscheduledforabase-

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-

chophysiology laboratory, located in theuniversityhospital,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-

plethysmographandencouraged toaskanyquestionsabouthow

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

servedas thediscreteassessmentof arousal andaffectbefore the

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

yourmindwhile you’rewatching the film.’’Further instructions

were given on the numerical demarcations on the device and

whattheupper(mostsexualarousalyouhaveexperiencedorcan

imagine) and lower (sexually turned off) anchors reflect. 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.Womenwatched 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

the three testing sessions. Immediately after thevideo sequence,

participantscompleted theFilmScaleasecondtime,whichasked

them to evaluate their subjective sexual arousal and affect to

theeroticfilm.Theywere then instructed toremove theprobeand

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

EthicsBoard at theUniversityofBritishColumbia and theVan-

couver Coastal Health Research Institute. All procedures were

carriedout in accordancewith theprovisionsof theWorldMed-

ical Association Declaration of Helsinki.

Mindfulness-Based Sex Therapy

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

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 womenwith sexual desire/arousal dif-

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

mental (of themselvesor theirpartners),mindfulness skillswere

primarily aimed at orienting the woman to the present experi-

ence,while simultaneously notingnegative thoughts as‘‘mental

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

123

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

tentwithmindfulness-based cognitive therapy for preventionof

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

womendevelopawareness inallareasof their life, includingreal

andanticipatedsexualsituations.Atleast4weekswerespentencour-

agingwomen to practicemindful self-awareness in non-sexual sit-

uationsasameansofdeveloping theskillofmoment-by-moment

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

were intended to allowparticipants to view their practice as adepar-

ture from their typicalmodeof being,whichmayhave been char-

acterizedasfuture-oriented,multi-tasking,and/orruminativeabout

pastevents.Atlaterstagesofthegroup,womenwerethenencour-

aged toapply theirnewskills inprogressivelymoresexualsitua-

tions—firstontheirown(followingexposuretoaneroticstimulus

suchasavibratororeroticfilm), andnext togetherwithapartner

(if applicable,duringactualsexualactivity).Theaimof thehome

practicewas to encourage participants to develop a regularmind-

fulnesspracticeandacquireexperienceobservingthoughts,espe-

ciallynegativeones,asmentalevents,before introducingpractice

togetherwithapartner,orapplyingmindfulnessduringat-home

sexual activities.Althoughsensate focus shareswithmindfulness

thegoalofpresent-momentawareness,theformerrequiresapartner

tobepresent anddoesnothave theadvantageofportability that

mindfulnesshas (i.e., inhomeworkactivitieswomenwereenco-

uragedtouse informalmindfulnesspractice throughout theirdays

tocomplementtheformalpractices).Concurrentwiththeprinciples

ofmindfulness,womenwereencouragedat thestartofSession1to

‘‘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

ina largegrouproomat theBCCentre forSexualMedicine,and

each 90min session was spaced 2 weeks apart.

Contents

Session 1 provided educational information on the prevalence

and known etiology of lowdesire and arousal.Mindfulnesswas

then introduced through in-session practice 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

followontheawarenessof sensations.After aguided in-session

practice, participantswereencouraged topractice theBodyScan

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

physiologyandthecircularsexual responsecycle(Basson,2001).

In-sessionmindfulness 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 associatedwith breathing and the breath itself. In

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

practice also typically follows a foundationof practice using the

BodyScan.Forhomework,participantswereencouraged todoa

‘‘seeingmeditation’’with their genitals as the focus of the prac-

tice. Theywere asked to observe their genitalswith 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 onGottman’s principles for lasting relationships (Gott-

man&Silver, 1999). The guided in-session practice utilized

mindfulness of thoughts, and thepracticewas followedbyadis-

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 andwere contrastedwith 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, andproviding feedback toapartner about the

receivedtouch.In-sessiontrouble-shootingaroundcommonbar-

riers, suchasfinding the timefor thehour-longpractice, thenfol-

lowed.Sensatefocuswasdescribedspecificallyasanon-demand

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

ners)experiencedsexualexcitement, theywereencouragedtonotice

theaccompanyingsensations in the sameway theyhadpracticed

noticingsensationsduringtheBodyScan.Thesecondhalfof the

finalsessionprovidedanoverviewontheuseofcognitiveandtactile

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

duringmindfulnesspractice.Specifically, instructionswerepro-

vided towomen to elicit a sexual arousal response using one 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

the encouragement toview these four sessions as potentially the

beginningofalifelongpracticeusingmindfulnessbothinsexualand

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

tors referenced published findings on the efficacy of mindful-

ness therapy in other populations, and integrated emerging knowl-

edgeontheimpactofmindfulnesspracticeonneuralplasticityand

brain function.Allmaterialwas compiled into a 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-

tilevelmethodologywas 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) to testwhether concordance significantly increased

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

follow-up.

We used a two-levelmodel with repeatedmeasuresmodeled

atLevel1 toestimate intercepts (meanof theoutcomevariableat

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

theoutcome.WestandardizedallLevel1variablesacrosswaves

prior toanalyses,allowingfor the interpretationof thecoefficients

as standardized betas.All coefficientsweremodeled as random

(Nezlek, 2001).

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

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

genital arousal predicted contemporaneous subjective arousal,

andwhether subjectivearousalpredictedcontemporaneousgenital

arousal).Themodeltestedthesimpleslopesofsexualconcordance

ineach timeperiodseparately(i.e.,againstaslopeofzero).Dummy

coded timevariableswere included tocontrol foranymeandif-

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 twoways; firstly, as a dichotomous variable according to

whether thewomanhad a clinical diagnosis of FSADor not, and

secondly using continuous scores on the lubrication and arousal

subscales of theFSFI (Rosen et al., 2000)] changed thedegree of

concordance between genital and subjective sexual arousal at

each of the time points.

To aid in the interpretation of the magnitude of concordance

betweengenital andsubjective sexual arousal,wealsocarriedout

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

ficients on VPA and continuous self-reported arousal during the

erotic segmentof thefilmonly. In thisway, concordanceestimates

could be compared to the mean concordance values from a

meta-analysisofseveralpsychophysiological studies (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 responsemeasured

in-laboratory.Wetookdifferencescoresfromresponsesfollowing

the erotic stimulusminusmean scores during the baseline period,

asperCliftonetal.(2015).Wenextcarriedoutarepeatedmeasures

analysis of variance (ANOVA)across the three assessment points

on these difference scores. To examine the effects of treatment on

genital sexual response, a similarmixedwithin-between repeated

measuresANOVAwascarriedoutonVPApercent changescore,

which was calculated as follows: (mean erotic VPAminus 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’s rankcorrelationcoefficient (rho)wasusedas

the estimate of concordance between VPA and subjective aro-

usal for eachwoman at each time point (pre-, post-treatment, and

follow-up)separately.Theseconcordanceestimateswere then

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. Themodels 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 of the contemporaneous analyses are 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

increases ingenital arousal predicted contemporaneous increases

in subjective arousal.

Subjective Arousal Predicting Genital Arousal

When examining the association between subjective arousal

and contemporaneous genital arousal, SAPre-treatment (top half of

Table 1) 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 to a 0.16 standard deviation increase 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-

livolts inVPAat follow-up, respectively.This corresponds toan

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

themodelwithmoreconstraintsresults inasignificant increasein

theoverallv2, this is indicativeof apoorerfit, and themodelwith 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, showed that theunconstrainedmodelfits thedata significantlybetter. Inother

words, thedegreeofconcordancebetweensubjectiveandgenital

arousal at each timepointwas significantlydifferent fromevery

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

directionsuchthatbetavaluesdecreasedovertime(i.e., therewas

less change in genital arousal associatedwith the same level of

subjective arousal over time).

Genital Arousal Predicting Subjective Arousal

In examining the association between genital arousal and con-

temporaneous subjective arousal, VPAPre-treatment (bottomhalf 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

unitofphysiologicalarousal increase,womenshowedanaverage

corresponding increaseof 1.37units of subjective arousal at post-

treatment and1.08units of subjective arousal at follow-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

Table 1 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.

Wecalculated bothwithin-subjects correlations andbetween-

subjects correlations and these are shown in Table 2. Across

time points, themagnitudeof thecorrelationbetweengenital and

subjective sexual arousal was larger for within-subjects correla-

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

(range .13 to .22).Using a paired samples t test comparing pre- to

post-treatment,andaseparateonefrompost-treatmenttofollow-up

revealednostatisticallysignificantdifferencesforwithin-subjects

concordanceestimates.Thesamenon-significantresultswerefound

usingFisher’sr-to-z transformationfor thebetween-subjectscon-

cordance estimates (Table 2).

Focusing specifically on the within-subjects correlations, the

rangeofconcordanceestimatesatpre-treatmentwas-.90to?.91.

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

rB-.25), 10.6%had noconcordance (defined here as-.24\ r\.24), and 70.2%had positive concordance (defined here as rC .25).Atpost-treatment, the rangewas similarly large:-.80

to .94with 15%havingnegative concordance, 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 towhether

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

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

arousal (n= 62) domains of theFSFI (measured continuously)

changed the degree of concordance between genital and sub-

jective sexual arousal at eachof the timepoints.All timepoints

were included in the moderation analyses for age and FSAD

status, while only post-treatment and follow-upwere 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

in thenumberofsubjectivearousalunitsassociatedwithastan-

dardized unit increase in genital arousal (Table 3). Specifically,

foreverystandardizedunitincreaseofgenitalarousal,womenshowed

amarginally significantly greater increase in subjective arousal

withmorehomeworkcomplianceatpost-treatment(t=1.67,p=

.10)andasignificantlygreater increase insubjectivearousalwith

greaterhomeworkcomplianceat follow-up (t= 2.13,p= .04).

Effects of Erotic Film andTreatment on Self-Reported

Sexual Arousal and Affect (Hypothesis 2)

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

reportedsexualarousalandaffect,apairedsamples t testwasused

tocomparemeanscoresonFilmScaledomainsbefore theneutral

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; subjective sexual arousal, 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, following theeroticfilm.Thesefindingssuggest

that the erotic film was effective at eliciting a subjective sexual

response at post-treatment (Table4).

A repeatedmeasuresANOVAdid not find a significant effect

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

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

arousal similarlydidnot significantlychangewith treatment,F(2,

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

Focusingonaffect,arepeatedmeasuresANOVAdidnotfinda

significant effect of treatment on the change in positive affect

Table 2 Concordance between genital and continuous subjective sexual arousalcalculatedwithwithin-subjects correlationsandbetween-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;or frompost-treatment to follow-up, t(58)=0.76,p= .448.Between-

subjectscorrelationswerecalculatedwithpercentchangeingenital sexual

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 transformation foundno significant difference from

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

fromneutral to erotic filmconditions,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)

Totest theabilityof theeroticfilmtosignificantly increasegenital

sexualresponseateachtimepoint,apairedsamples t testwasused

tocomparemeanVPA(inmV) fromtheneutral to theeroticfilm.

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; at post-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

(Table 4).

To examine the effects of treatment on VPA percent change

scores, a repeatedmeasuresANOVAacross all three time points

wascarriedoutandfoundnot toreachstatisticalsignificance,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 andClinical

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-ratio test statis-

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, therewas still 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),withSIDI scores increasing

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

and FSDS scores decreasing significantly at post-treatment

and remaining low at follow-up.

Table 3 Homeworkcomplianceasamoderatorof theassociationbetween 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

LowHC 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

Table 4 Effects of erotic filmondiscretemeasures of subjective sexual arousal, perceptionof genital arousal, positive affect, 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 fromNeutral 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

arousal inwomenseeking treatment for concernsof sexual desire

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 frompre- 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, althoughgenital response

predicted significant increases in subjective arousal contempo-

raneouslyatall timepoints,wefoundnochangeinthismeasureof

sexual concordance as a function of treatment. Within-subjects

correlations revealed the magnitude of the association (between

.28and.33)tobewithintherangefoundamongseveralotherpsy-

chophysiological studiesofwomen(Chiversetal.,2010).These

resultssuggestthat increasesinsexualconcordanceassociatedwith

mindfulness-basedsextherapymaybedrivenbychangesinsubjec-

tive sexual response rather than genital response.

Interestingly, although the erotic film significantly increased

self-reported sexual arousal, affect, andgenital sexual response at

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

eitherself-reportedorgenital responsecomparedtobaseline,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

similar effects,withwomenhigher inSESII excitation scoresand

passionate-romantic scores showing higher genital-subjective

concordance, despite no significant association between individ-

ual predictors and genital or subjective sexual response sepa-

rately;womenwhorate themselvesasmoreeasilyarousablemay

bemore in tunewith 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 fromwomen

with lowerexcitation scores.Similarly,we foundasignificant effect

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

domainscoresdidnot significantlymoderate sexual concordance

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 noted relationships between sexual

functioning and sexual concordance in healthy women (Brody

et al., 2003) and inwomenwith 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,homeworkcompliancedid significantlymoderate

sexualconcordance,suchthat, foreverystandardizedunit increase

ofgenitalarousal,womenshowedasignificantlygreater increase

insubjectivearousalwithgreaterhomeworkcomplianceat follow-

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

nesspractices, designed tocultivatebetter integrationof awareness

andphysical sensations,mayhave contributed to the increase in

concordance.Ofnote, thismoderationwassignificantatfollow-up,

butnotatimmediatepost-treatment,suggestingcumulativeeffects

ofmindfulnesspracticeover the6-monthfollow-upperiod.Other

data showingadose–response relationshipbetweendurationof

mindfulnesspracticeandimprovements insymptomsofdepression

andanxiety supports this interpretation (Krusche,Cyhlarova,&

Williams,2013).Othershavealsofoundthatamountofat-home

mindfulnesspractice is associatedwith self-reportmeasuresof

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

(Carmody&Baer, 2008).Ourhomeworkcompliance scores

were assigned bygroup facilitators; therefore, future studies

could have participantsmonitor amount of at-homepractice to

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

beconsidered ameaningful studyendpoint in sexual psychophys-

iologyresearch.Intreatmentoutcomeresearch,itisnotuncommon

toseethetreatmenteffectsonself-reportedbutnotgenitalresponse

(Diamondetal., 2006).Elsewhere,wehaveproposed that sexual

concordancemayreveal treatmenteffects thatmightotherwise

be overlookedwhen examining only self-reported or psychophysi-

ological sexual responsealone(Chivers&Rosen,2010).Others

have shown that sexual concordance ismeaningfullyassociated

withcognitiveandschematicaspectsofwomen’ssexualfunctioning,

suchashighersexualexcitationandpassion-andromance-related

cognitive schemas, in the absenceof direct effects between these

variables(Cliftonetal.,2015). Inthecurrentstudy,wedemonstrated

asimilarpatternwithsexualconcordanceincreasingaftertreatment

butnodetectablechangeineitheraspectofsexualresponsethrough-

out treatment.Taken together, thesefindingsprovidepreliminary

support for the possibility of sexual concordance being amore

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

predicting contemporaneousgenital arousal (but not the reverse),

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)

founddecreased reaction time to ratingbodily reactions to sexual

stimuli in women followingmindfulness training. Given that the

insular cortex mediates interoceptive ability (Critchley, Wiens,

Rotshtein,Öhman,&Dolan,2004),andisassociatedwithincreased

thicknessfollowingmindfulnesspractice(Hölzeletal.,2010), it is

possiblethatinsula-mediatedincreasesininteroceptiveabilityfrom

the variousmindfulness 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, ithasbeenarguedthat treatmentsaimed

atimprovinggenitalresponsemaybeineffectivewithoutthecapacity

todetectandpositivelyappraisethosephysiologicalchanges(Chivers

&Rosen, 2010).Thegenital arousal response to erotic cues is rela-

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

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

regardless ofwomen’s ageor sexual dysfunction status; indeed,

womenwithadiagnosisofFSADhadthesamemagnitudeofVPA

assexuallyhealthycontrols(Laanetal.,2008).Inthecurrentstudy,

therewasno immediateeffectof treatmentonVPA.Therefore,

it isnotlikelythatourtreatmentledtochangesingenitalresponding,

which then drove an increase in concordance. A top-downmecha-

nisminwhichwomendeliberately focusedattentiononemerging,

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

likely led to theircontemporaneousdetectionofgenital arousal

in the laboratory setting, thereby increasing sexual concordance.

In addition to mindfulness practice increasing awareness of

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

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

increases inacceptanceandself-compassionmayhavecultivated

anopennesstoallelementsofourparticipants’experienceofsexual

responsewithout attempting to alter them.Teper et al. surmised

thatwhenoneobserves and accepts current emotions, thismay

facilitateemotionregulation.Givenevidence thatnegativeaffect

during sexual encounters may significantly predict sexual diffi-

culties (Nobre&Pinto-Gouveia, 2006), it ispossible thatwomen

experiencedan improvedability to regulate suchemotions and

thereby tune into and accept their visceral sensations.

Limitations

Therewerelimitationsinthisstudythatmustbeconsidered.Firstly,

treatment included a combination of (primarily) mindfulness exer-

cises,psychoeducation, and sex therapy. It is unknownwhether

benefitswere due to one specific component of treatment or to

theirsynergisticeffects.Ofnote,however,previousresearchtesting

asimilar (butnot identical) treatmentprotocol foundthatpartici-

pantsself-reportedthemindfulnesscomponent tobethemosteffec-

tiveaspectof treatment(Brotto&Heiman,2007).Futureresearch

thatdismantlesthesecomponentsandteststhemagainstoneanother

isneededinorder toempiricallysubstantiate theseobservations.

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

limitedbecause it excludedwomenwhowerenot sexuallyactive

in thepreceding4weeks, andassessedonly the intensityandfre-

quencyof sexual arousal,without consideration for themultiple

ways inwhichsexualarousalmaybeexperiencedinwomen.Our

ability todetectassociationsbetweenchangeinsexualconcordance

andchangeinclinicalsymptomsmayberelatedtotheselimitations.

Relatedly,wewerealsounable toexaminecorrelationsbetween

concordance and the orgasmdomain given the large proportion

ofmissingdata intheFSFI. Importantly, thissamplerepresentsonly

asmallcross-sectionofwomenwithsexualdesiredifficulties,and

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

geneityinthewayswomenexperience(lossof)sexualdesire(Meana,

2010). It is possible that suchan interventionwouldhaveyielded

different results in amuch larger,more representative sampleof

women with sexual desire complaints.

Thirdly, our capacity to detect associations between change in

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

without sexual dysfunctionwere included. To that end, therewas

considerable variability in the range of concordance estimates

acrossparticipants,bothatpre-andatpost-treatment, butwith the

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 examinewhether 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 incentivemotivationmodel (Both, Everaerd,&Laan, 2007)

proposes that sexualdesire is triggeredbysexualarousal,whereas

previously, sexual desire and arousalwere viewed as distinct and

sequential phases of sexual response (Masters& Johnson, 1966).

According to the incentivemotivationmodel that informscurrent

DSM-5definitionsofSIAD,sexualdesireandarousalarereciprocally

reinforcing,suchthatsexualdesireemergesfromexperiencingsexual

arousal (Toates,2009).Genital responsesalonemaynot,however,

besufficient forgeneratingsexualdesire; instead, theintegration

ofphysiological andpsychological sexual response (presumably

capturedwithaconcordanceestimate)maybemorestronglyassoci-

atedwith triggered sexual desire. Likewise, conscious awareness

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

desire are capable of a physical sexual response, but stimuli are

appraisedasneutralornegative,andthusfail totriggersexualdesire.

Anotherpossible contributor to lowarousal anddesiremaybean

inability toconsciouslyexperienceandrecognizeastateof sexual

arousal. Inthecurrentstudy,cultivationofattentiontorawsensations

improvedconcordanceandfosteredgreatermind–bodyintegration.

Thesefindingsprovidesupport for treatmentsaimedat increasing

sexual interoceptionandnon-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-

ingdisconnected sexually’’whenpresenting for sex therapy, our

data suggest that mindfulness may improve the integration

betweengenital and self-reported sexual arousal.Although this

study did not identify individual differences predicting treat-

ment-related improvements in sexual concordance, thewide range

inconcordanceestimates across participants suggests that future

research could identify characteristics associatedwith 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), there is anopportunity for

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 overall coordinationof this study.Wealsowish to thankgroup facilitators

MiriamDriscoll, SheaHocaloski,GailKnudson,BrookeSeal, andMorag

Yule.OurthankstoDr.RosemaryBassonandDr.MijalLuriafordeveloping

the treatmentmanualused todeliver themindfulness intervention.Funding

for this studywasprovidedbyaBCMedicalServicesGrant toLoriBrotto.

Compliance with Ethical Standards

Conflict of interest Noneof the authors have any conflicts of interest to disclose.

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