Suggested treatment for sexual difficulties and research into asexuality

Norman Swan:  Hello and welcome to this week’s Health Report with me Norman Swan.

Today, research into addiction, plus people who are asexual, have few sexual feelings and are happy about it, and using Buddhist style meditation, or what’s called mindfulness meditation, to treat sexual difficulties including pain, lack of interest or as a result of cancer treatment.

The person doing this work is Dr Lori Brotto who’s Associate Professor of Gynaecology at the University of British Columbia in Vancouver.

Lori Brotto:  Well mindfulness techniques have been in existence for millennia now, at least 3,000 to 4,000 years in the eastern world. Since about the 1970s mindfulness based techniques have made their way into western medical health care primarily through the area of chronic pain treatments. Since that time they have been applied and tested in a variety of different medical conditions and psychiatric conditions. Mindfulness can be described as present moment non-judgmental awareness and it’s the embodying of the present moment in a non-judgmental compassionate stance.

Norman Swan:  So give me an example.

Lori Brotto:  So an example would be taking part in a twenty-minute body scan that invites the individual to pay attention and notice different parts of their body progressing from say the big toe all the way up through the tip of their head, noticing the sensations in those parts of the body, attempting to distance yourself from any distracting thoughts or judgments about those parts of the body and really tuning in to the breath as you’re moving through different parts of the body.

Norman Swan:  So accepting the world as it is?

Lori Brotto:  In a nutshell, yeah, you could say that, it is accepting whatever it is as difficult, or as painful, or as emotionally vulnerable you might feel. 

Norman Swan:  Let’s talk then about those two different areas, in particular you’ve been working on in using this technique applied to sexual problems. What’s this vulvodynia that you’ve been treating, or vestibulodynia as some people call it?

Lori Brotto: Provoked vestibulodynia or PVD for short can be described as a sharp, shooting burning pain around the opening of the vagina or the vulvar vestibule. It affects probably between 15% to 20% of women across ages.

Norman Swan: That’s a huge percentage.

Lori Brotto:  It is an enormous percentage of women when you compare it to say the prevalence of depression or diabetes, which have rather similar prevalence rates, yet public awareness about PVD or vulvodynia more generally is really quite poor.

Norman Swan:  How disabling is it?

Lori Brotto:  Well women will say that it becomes increasingly more disabling with time, so with the first few attempts at intercourse there’s a kind of normal acceptance that it might be awkward, it might be uncomfortable. But when this persists for many months—or many years as the data suggests that the average woman experiences this pain for about four years before she receives a diagnosis—it begins to extend into many different parts of her life and her relationship. Interference can range from difficulties riding a bike, wearing certain types of clothing to significant impairments in a relationship. So not only is sexual intercourse or sexual penetration completely avoided, women will say that they avoid all kinds of sexual intimacy including touching and kissing, or holding hands for the fear that it might lead to this painful experience.

Norman Swan:  Give me a typical story.

Lori Brotto:  A typical story would be the 21-year-old woman who says, ‘I have never been able to use tampons, I’ve had numerous yeast infections and have tried a variety of treatments for this condition and my earliest experiences of intercourse have always really been quite painful for me. I attributed the pain to the yeast infections, or I attributed the pain to my sexual naivety, yet it was only when the pain persisted for many years that I said to myself there must be something more going on. I went to my family doctor, my family doctor did a physical exam, couldn’t find any signs of inflammation or infection or redness and said to me "it must be all in your head, go home and have a glass of wine".'

Norman Swan:  And is there a cause?

Lori Brotto:  This is an area of intense scientific research, the more that we learn about the patho-physiology of pain in general, the more we're understanding about provoked vestibulodynia. Our best guess is that it’s characterised by central sensitisation, so in other words there seems to be a dysfunction in the pain centres in the brain. It’s probably not a local inflammation or local infection response, although that’s what the earliest research tended to focus on, something in the local periphery and now with the advent of imaging research and intense research in this area it seems to be characterised as a central sensitisation phenomenon.

Norman Swan:  And it always starts young?

Lori Brotto:  From what we know, about half the women will describe a lifelong picture where penetration of any kind, tampon use, gynaecologic exam, sexual intercourse has always been painful. But for about 50% of women they’ll describe more of a secondary picture where they’ve had no discomfort at all with penetration and then an event in their life, or some sort of physical assault or trauma has led to the onset of these symptoms. The latter group we tend to see more often in peri- and post-menopausal women.

Norman Swan:  How are you treating it?

Lori Brotto:  Currently our centre has moved almost exclusively now to mindfulness-based cognitive behavioural groups and this is stemming from really a large body of research finding that mindfulness based therapies can be very effective for a variety of chronic pains.  So our typical format involves having a group of say six to ten women with the condition taking part in weekly two-hour sessions over the course of eight weeks. The in-session component involves a combination of education, some elements of psychotherapy and a fair bit of mindfulness practice and in between the sessions we give women a number of homework exercises as well as guided audio CDs to listen to.

Norman Swan:  So tell me about the mindfulness part – what do you do with them?

Lori Brotto:  So the in-session practice will involve either one of the facilitators leading a guided mindfulness session or listening to an audio recording. We can use different facets of the woman’s experience, whether it be taste, so you might ingest a raisin, and focus on all of the different qualities of the smell and the taste as one is taking in this small piece of fruit in their mouth. We also might do a listening meditation where we may play a particular piece of music and have women in a non-judgmental present oriented way focus on the listening piece, or we may do something that’s a bit more focussed on her body, that might be focussing on the breath, focussing on different parts of her body and see a body scan.

Norman Swan:  But it’s not focussing on her genitalia?

Lori Brotto:  There is an at home exercise where the woman is asked to actually provoke the pain through her hands and that then becomes the focus during the mindfulness based exercise. So as she is provoking the pain herself, can she experience the pain sensation itself without all of the additional layers of suffering emotional turmoil, distress, devastation that the pain tends to evoke when she’s being sexual with a partner.

Norman Swan:  So you’re trying to remove all the collateral damage?

Lori Brotto:  Exactly.

Norman Swan:  So what happens?

Lori Brotto:  We’ve been running similar groups of this kind, albeit in a more abbreviated format, for about five years now, and the feedback has been really very positive. From not only the pain sensation decreased—and how we measure pain sensation is we will actually have women take part in a controlled Q-tip test where a physician will touch around the vulvar vestibule with a cotton swab and the woman will report how painful the experience is.  So we see a decrease in those pain ratings. I think also more importantly than that women will self report that they’re focussing on the pain less, the pain is less catastrophic, they are not as hyper vigilant to the pain, they are avoiding sex less, overall their sexual response has improved as well.

Norman Swan:  And they’re enjoying sex?

Lori Brotto:  They are starting to enjoy sex as well.

Norman Swan:  How long is the treatment?

Lori Brotto:  Our current protocol is an eight-session treatment, and we strongly encourage women to continue practice following the eight weeks. In other mindfulness based protocols that have looked at this for pain and other conditions again they find that those patients who do the ongoing continued practice tend to show sustained benefits even five years after treatment.

Norman Swan:    And the homework?

Lori Brotto:  The homework involves daily mindfulness exercises of various forms. It amounts to approximately 30 minutes every day of structured practice.

Norman Swan:  Doing what?

Lori Brotto:  The practice at home will involve some of the segments that we’re doing in session together as well as additional exercises that we’ve discussed in session but have not actually practised in session. So for example having the woman provoke her own pain and be very mindful of the pain in a sort of non-judgmental, present-moment kind of way.

Norman Swan:  So it’s fairly intimate and not something you could do in a group?

Lori Brotto:  That’s right and that’s why we reserve some of those more intimate exercises for at home. There are also homework exercises of a more traditional sex therapy kind of variant, so sexual communication exercises, sexual touching exercises, sensate focus exercises with those women who are partnered.

Norman Swan:  And you’ve been using this technique, in fact you’re applying what you’ve learnt from looking after people who have had cancer.

Lori Brotto:  That’s right. So in the last seven years we’ve carried out at least three studies now adapting the mindfulness based intervention to gynaecologic cancer survivors who we know have a high incidence of sexual side-effects following treatment. And most recently we’ve looked at either three-session or four-session mindfulness intervention versus a wait-list control group, or an education only control group. And women will report improvements in their level of sexual desire, their level of sexual arousal; we also measure the physiological sexual arousal response. We have women come into our lab, we expose them to some short video clips, neutral and erotic video clips and we measure their sexual arousal response  before and after treatment. And not only do we see an increase in the genital arousal response but we also see more agreement between the genital response and women’s self-report of being sexually aroused. So it seems that their mind and their body is more in unison following the intervention.

Norman Swan:  So if you like there’s a non-disjunction here that if you show an erotic video to somebody they get a genital response but their brain might not register that fact. So their body is responding despite their mind.

Lori Brotto:  That’s right, that’s a well recognised, well replicated finding in women’s sexuality that the genital arousal response tends to be quite automatic, yet the subjective response—women may say that they are not aroused at all by the film, or they may even say that they’re completely turned off.  This really characterises the lot of sexual difficulties that we see where women will say my body is responding but my mind is simply elsewhere and focussing on other distractions. For the gynaecologic cancer survivors many of them will say that they’re worried about pain, they’re worried about what their partners might be thinking during sexual activity. They have a whole host of myths and mal-adaptive beliefs about—will sexual activity cause the cancer to recur, can I transmit my cancer to my partner? And all these kinds of beliefs tend to surface during sexual activity.

Norman Swan:  And you’re working with men now.

Lori  Brotto:Increasingly we’re working with men.

Norman Swan:  This is post-prostatectomy?

Lori Brotto:  That’s right so post-prostatectomy and also men following treatment for colon cancer who will report a very high incidence of erectile difficulties. But also some of the very similar concerns that women are reporting—not feeling interested, feeling distracted, being preoccupied about how the sexual encounter will progress given a period of relative sexual abstinence during treatment. We have adapted many of the same exercises and materials for women and now to men.

Norman Swan:  With good results?

Lori Brotto:  It’s too early to say because we haven’t looked at any systematic data so far, we have anecdotal feedback from the men and it’s been very overwhelmingly positive.

Norman Swan:  And this is your observation. How much randomised controlled trial evidence have you got that’s of gold standard for evidence?

Lori Brotto:  Most of our research has begun in the pilot data sense that we’re trying to see what the elements of the treatment look like so they’ve not been controlled. We have recently randomised women to the mindfulness group versus an education only group, and so we are finding that the benefits that women are showing with the mindfulness based intervention cannot be accounted for by simply the passage of time, nor the expectation that they might get out of participating in a research trial.

Norman Swan: Dr Lori Brotto is also studying a fascinating group of people who are basically asexual and her starting point was that this was a problem.

Lori Brotto:  Yes, this is a fascinating area of study because these individuals, which by our best estimates represent probably 1% to 2% of the population, will say ‘I’m not interested in sexual activity, nothing provokes sexual desire for me, yet it doesn’t bother me in any way’.  And the only kind of semblance of bother or distress is that it bothers people around them, so society, or partners or friends might say to the asexual individual ‘but don’t you ever get sexually excited, isn’t there anything that ever turns you on’?

Norman Swan:  Or you’re really gay.

Lori Brotto:  Or you’re gay, or you’re repressing something, or perhaps you were the victim of trauma as a child. Our group has explored many of those different possible explanations for asexuality and we find that this is a very psychologically healthy, well adjusted group of individuals.  And this is likely not a sexual dysfunction. 

Norman Swan:  So you’ve been just trying to find out more about them?

Lori Brotto:  Yes, so until now our research has largely been descriptive, so through a combination of large internet-based surveys as well as inviting asexuals into the lab where we can measure the sexual arousal response, we’ve been able to learn some really interesting findings.

Norman Swan:  So when you show them erotic videos what happens?

Lori Brotto:  They show the same genital arousal response that those individuals who say that they have sexual interest show. So the conclusion there is that it’s not a dysfunction in the plumbing so to speak, it’s not a dysfunction of sexual arousal.

Norman Swan:  You see something erotic, your body responds but they’re not interested.

Lori Brotto:  They’re not interested; they say they would rather be watching a boring documentary.

Norman Swan:  Really?

Lori Brotto: Yes.

Norman Swan:  So what is it about them, what have you found?

Lori Brotto:  So we found that this condition is probably not a sexual dysfunction because there is no distress associated with their lack of desire. And it’s caused our group to increasingly look at, well, could there be some sort of neural developmental or congenital reasons that could account for the asexual orientation in the same way that there’s very strong and conclusive evidence for those factors in homosexuality. So we’ve looked as some biomarkers such as looking at the ratio between the second and the fourth digit, we’ve looked at handedness, in other words we know that gay individuals have a much higher prevalence of left-handedness compared to right-handedness. And we’ve looked at something interesting called the fraternal birth order effect, which is the finding that gay men have a much higher rate of having older brothers than age matched straight men. And we’re finding some of those same kinds of correlates among asexuals, starting to point probably more to a neural developmental aetiology to counteract.

Norman Swan:  So tell me about this second finger, fourth finger ratio, because it’s thought to be influenced by something in the womb, by exposure to male hormones in the womb.

Lori Brotto:  Yes, so the finding is that the ratio between the second and the fourth digit significantly differs in gay men versus straight men. There was a similar finding among lesbian women versus straight women although the differences don’t tend to be as strong as you see in men.

Norman Swan:  And this is where the fourth finger is bigger than the second finger?

Lori Brotto:  That’s exactly right.

Norman Swan:  We’ve got a whole audience now looking at their hand.

Lori Brotto:  Well here is where we need to pay attention to measurement issues because there really is a science behind how you’re measuring the distance between the base of the finger and the tip of the finger. So for those viewers who are watching this, you know put the ruler away you really need to see someone who is actually skilled in doing these kinds of measurements. So what we found among asexuals is that the ratio between the second and the fourth digit on their dominant hand resembled the ratio among the homosexual samples that have been widely published on in the past and significantly differed from heterosexual samples.

Norman Swan:  And so they show a similar pattern to homosexuality?

Lori Brotto:  Exactly yes.

Norman Swan:  But they’re not gay?

Lori Brotto: But they’re not gay, they’re not attracted to men or women.

Norman Swan:  What’s going on?

Lori Brotto:  We really don’t know. Our research and the very preliminary research of others has been purely at a descriptive level, trying to characterise these individuals. And I think what we need to see more of is kind of basic science research, perhaps doing some imaging data on these individuals, actually looking at the brains of these individuals while they’re exposed to erotic films to see if the brains are actually registering the erotic content of the stimuli.

Norman Swan:  And do you show them heterosexual erotic content or homosexual erotic content?

Lori Brotto: Until now we’ve only shown heterosexual erotic content although we know that for women the kind of erotic stimuli that you show, be it heterosexual, homosexual or even primates having sexual activity really is irrelevant. Women will show the same level of genital arousal response.

Norman Swan:  That’s profoundly disturbing.

Lori Brotto: Disturbing or very, very interesting that the genital arousal response is so automatic and so robust.

Norman Swan:  What about the lives of these people, what’s happening in their lives, are they single, are they partnered, what’s going on there?

Lori Brotto:  Well I think you see the same kind of variability among asexuals as you see among sexual individuals. You see some that will describe themselves as asexual romantic, which means that they desire the same kind of closeness and compatibility and long term stability in a partnership that a sexual individual will. Yet they have no desire for the sexual elements of that relationship. Yet you also find other subgroups of asexuals who will describe themselves as a-romantic so no desire for the sexual and similarly no desire for any romantic attachment at all as well.

Norman Swan:  Do they marry each other?

Lori Brotto:  There is a very large online asexuality community and part of that website is devoted to matching, so it’s a bit of an online dating website for asexuals, that’s an ideal situation because it allows one to overcome all of the difficulties in having one asexual partnered with a sexual person. How do you negotiate sexual activity in those partnerships? But it does happen, it does happen that some asexuals do partner with sexual individuals.

Norman Swan:  That would be nice if they could find each other because they could have an intimate companionship that might actually be undermined a little bit if there was an incompatibility between the two partners.

Lori Brotto:  Yes, that is ideal although the typical story of the asexual individual is not one in which they wake up one day, you know early in their sexual development and say, ‘Oh, I am an asexual’. The more typical story is one in which the individual doesn’t have any sexual feelings yet they engage in many years of experimentation, testing out whether they might be attracted to men or women or other variants, etc. And so their observation that they are indeed asexual tends to happen much later on in life. Many of them will say that it is only upon finding this online asexual community, that that is the first time that they’ve identified with that label.

Norman Swan:  Never let it be said that I don’t take you to interesting places. Lori Brotto is Associate Professor of Gynaecology at the University of British Columbia.

References:

Sadownik LA et al. Provoked Vestibulodynia: An explorative study of women’s experiences. BC Medical Journal 2012;54:22-28

Brotto LA et al. Predictors of sexual desire disorders in women. Journal of Sexual Medicine, 2011;8:742-753

Brotto LA  & Yule M Psychological and subjective sexual arousal in asexual women: A pilot study of sexual orientation groups. Archives of Sexual Behavior, 2012;40:699-712