Sex therapy: doctor of desire

The Canadian psychologist Lori Brotto is a distinguished academic; she also knows more than anyone what's really going on in the bedroom. She talks to Helena De Bertodano.

Psychologist Lori Brotto; sex therapist
Doctor Lori Brotto Credit: Photo: BIRTHE PIONTEK

When people ask Lori Brotto what she does for a living, she used to answer honestly: 'I'm a sex researcher.' These days she is more oblique. 'I got tired of dealing with the shock or potential embarrassment,' she says, laughing, when we meet at her office in the medical department of the University of British Columbia. 'Women were often fascinated, but with men there was usually an embarrassed laugh and then an inappropriate comment. So these days I usually say I'm a women's health researcher.'

Brotto treats women who have little or no desire for sex – a condition that affects almost one third of the female population. These are women who are usually otherwise healthy, not suffering from depression, illness or any sort of trauma. They say they simply feel no desire for sex. Brotto believes that many women – unlike men – suffer a loss of connection between their brains and bodies, and her job is to teach them to want, and enjoy, sex again. Over a series of sessions Brotto helps them become more aware of what their bodies are doing, even when they claim to feel unresponsive. One of her methods is to encourage them to undergo an experiment that proves that their bodies do respond to sexual stimuli, even if their brains do not.

To illustrate this, she knocks on the door of a room near her office – where she screens porn films for her patients. 'There may be a subject in here,' she says, listening carefully then opening the door a crack. 'No, you can come on in.' The room is tastefully decorated with plants, mood lighting and a maroon carpet. A black armchair faces a flat-screen television. On the wall there is a diagram showing the patient how to insert a photoplethysmograph (a vaginal gizmo to measure surges of vaginal blood flow), which is connected by wires running through a wall to a computer in the next room. The patient is left alone to watch the film while Brotto goes next door to measure her physiological response. 'Almost every woman genitally responds,' she says, which proves that their bodies are out of sync with their heads.

Brotto, 34, says that several of the women who seek her help used to enjoy sex but now find the very suggestion offensive. 'They are juggling work and family, doing everything in the house and they say to me, "My husband has the nerve at the end of the day when I've been going full tilt for 40 hours to want sex, and I have no interest whatsoever. In fact, I'm frustrated at him for even asking me. How dare he?"' She sees women of all ages, some very young, some post-menopausal. 'Several of them say, "Things have always been great in my relationship, but with the transition of menopause something has changed."' Then I have a lot of perfectionists who'll only have sex with the lights off, wearing a T-shirt. So of course their brain is not communicating with their body. Everyone is different, but they can all identify with this one problem, which is not feeling interested.'

Her research has made Brotto one of the world's leading specialists in what is known as hypoactive sexual desire disorder in women, or HSDD (hypoactive meaning less than normally active, not to be confused with hyperactive). For some women, feeling uninterested in sex is not a problem, but others find it very distressing. 'It's only a disorder if you think it's a disorder,' says Brotto, who is defining the condition for the next edition of the Diagnostic and Statistical Manual of Mental Disorders, a bible of every psychiatric disease imaginable, updated only once every 20 years. 'Currently, if you open the manual, low desire is defined as "absent or deficient sexual thoughts and fantasies".

'I'm arguing that that's far too low a bar,' continues Brotto, now sitting back in her office, a bright orderly space packed with medical journals and photos of her family, a poster of Gustav Klimt's The Kiss dominating one wall. 'You are pathologising many women who never spontaneously have fantasies or think about sex but who are quite normal. We need a more elaborate description of what low desire is – it's not only that she doesn't think about sex and doesn't want sex, but also that she can't become excited despite all the good stimuli in her environment. She is not receptive to her partner's advances and she doesn't initiate on her own.'

Perhaps surprisingly, Brotto comes from a staunchly traditional Italian Catholic family. 'It was not the perfect breeding environment for a future sex researcher, to say the least,' says Brotto, who is nearly nine months pregnant and wearing a tight bright-pink T-shirt with grey trousers and comfortable shoes. 'My family told me nothing about the facts of life or even the basics of reproductive health. Nor was I ever told that somewhere between the ages of 11 and 13 you should expect a period. None of that. Zero. Nothing, nothing.' As a result, Brotto had to find her information elsewhere. 'I engaged in risky things as a teenager.
I experimented and did all the naughty stuff that I hope my children never do.'

Brotto, a pretty petite woman with a sharply angled haircut, fell into her job by chance. She had not considered studying sex, but as a first-year biopsychology undergraduate at the University of British Columbia she was determined to get a research placement in any discipline. 'I knocked on a lot of doors, but I was only 18 and no one was interested in taking me on. Except for one professor who at the very end of our conversation said, "You'll be watching rats have sex." I thought, "OK, I'm up for a challenge."'

For six years she studied rats, investigating the effects of stress factors and antidepressants on their libidos. She found herself enjoying her job more than she expected. 'I fell in love with the research. I thought we were asking fascinating questions on
the role of stress in sexual functioning. I had to keep changing the rats' living situation, which was very stressful for them.
My dad helped me make a big box, which I put in a dark room and packed with rats. For 23 hours of the day the room would be pitch black, then for one hour I would turn on a strobe light. It was very stressful for the rats – they had no sex at all.' Eventually, though, she had had enough. 'I just couldn't see myself studying rats for the rest of my life. And, unlike humans, you could never get the affective [emotional] component.'

First she studied sexual functioning in menopausal women, then in women recovering from cancer. 'Very little was known about women's sexual functioning, as the researchers are usually male. If you look at anatomy texts, there are long descriptions of men resulting from very careful cadaver dissections, and then a tiny little section on women that said, basically, the female anatomy is an inside-out version of the male and that's it. End of story.'

During her postdoctoral training she was introduced to a technique called mindfulness, rooted in the Buddhist practice of an intense awareness of every element of immediate experience. 'It's like the warm-up or cool-down exercise in a yoga class, when you are very present and very still, using your breath as an anchor.'

It is this element of her training that Brotto has brought to her present work: 'It was like a lightbulb. I realised that nothing like it
had ever been tried with sexuality, and the women I was seeing were the perfect population for it. Many will complain that their minds are elsewhere when they're having sex. They're thinking about the kids. Or the kids. Or the kids!'

In her group therapy lessons she gets each woman to hold a raisin. 'I'd like you to start by examining your raisin,' she tells the group. 'Study its shape, its contours, its folds.' She finds that, if she can get the women to train their minds to concentrate on the present moment, they will start to enjoy sex more.

'I encourage them to practise mindfulness in general – to take 10 minutes every day where they practise being very present. So, for example, while you're washing the dishes, you notice the colour of the soap, feel the temperature of the water, smell the soap suds. It makes washing the dishes a very exciting activity because of all the sensory input it's sending to your brain.'

She says women have more of a disconnect between brain and body than men. 'Women historically have been multitaskers. The investment of the man in parenting is about a minute: the time it takes to ejaculate. The minimum investment for women is the full nine months of pregnancy, plus breastfeeding, plus the caring, plus plus plus. So women have lists going on in their heads much more than men do. When a woman comes in and says to me, "I just can't turn my mind off. I'm thinking about the grocery list when we're having sex," I say, "Of course you are. You do that the rest of the day; why would you expect it to stop just because you're having sex?"'

Brotto also believes that many women feel under pressure to be like women they see in the media. 'The media shows women as ever-ready, multi-orgasmic, catering to their partners' needs. You don't see women on television putting the kids to bed and then washing their face and going to bed. You see them in an elevator ripping their clothes off, not worrying about socks. So
it is no wonder that many women feel completely inadequate.'

Brotto eventually gets the woman to use mindfulness during sex. 'Given that brain and body were disconnected in these women with sexual problems, I saw mindfulness as a way of fusing that broken link. So I teach her to focus on the sensation, tune into what her body is doing, look into the eyes of her partner, feel her own skin, feel her partner's skin and use the sensory input in every way to keep her very present.'

She is well aware that the women she sees are only the tip of the iceberg. 'We know that there is a big group out there that will continue to have sexual problems for ever because they're too embarrassed to say anything to the doctor.' Even the women who do make it through her door are often very self-conscious. 'They describe their problems in very vague ways, so vague you don't even know what they're talking about. You have to interject and say, "I do this every day. Nothing you say will embarrass me. We've got to get concrete."'

She has such a gentle, unpatronising manner one can imagine people open up easily to her. Once they feel comfortable with her, she can usually solve their problems in a matter of weeks. Even her parents have relaxed about the subject of sex. 'Now my family has fun with it. They love it. They ask me lots of questions, even my father – sometimes very inappropriate questions. We'll be at the dinner table and we talk very openly about gynaecological issues. And my husband, who works in telecommunications, is very laid-back and easy-going – I talk to him a lot about my work.'

Recently, she has been approached to write a book on the subject, which she would love to do as she feels her methods will then reach a much wider audience. 'Sex is still a very taboo subject – which is ridiculous. In fact, I saw a married woman yesterday who said she didn't want to get pregnant because it meant people would know she was having sex!'

Brotto shakes her head in bewilderment. 'Why should we be able to talk about knee pain and back pain and not about sexual distress? Sex is not only intrinsic to human happiness, it is also essential for the advance of the species.'