Management of Sexual Problems: The Approach of Mindfulness

Sandra Vilarinho

Disclosures

Curr Opin Psychiatry. 2017;30(6):402-408. 

In This Article

Abstract and Introduction

Abstract

Purpose of review: During the last 10 years mindfulness has been progressively integrated into protocols for the management of sexual problems. The purpose of this study is to systematize potential benefits of mindfulness in sexual well-being (considering mind, emotion, and body), and to shortly review current applications and effectiveness of mindfulness-based interventions to the treatment of sexual problems.

Recent findings: The majority of evidence available focuses on women's sexual desire and arousal problems, although there are also preliminary findings for the effectiveness of mindfulness-based interventions in enhancing other components of the sexual response. Relationship issues, sexual pain, sexual abuse, and sexual distress have also revealed to benefit from mindfulness-based interventions.

Summary: The practice of mindfulness is a promising clinical approach with encouraging results for women's sexual problems. Further empirical research with different populations and greater methodological rigour is still needed to clarify the effectiveness of mindfulness as a specific component and the mechanisms contributing to therapeutic change.

Introduction

Mindfulness has a long history in Eastern tradition. This practice has been adopted in contemporary psychology as an approach for increasing awareness and responding skilfully to mental processes that contribute to emotional distress and maladaptive behaviour.

Although there is growing support for an association between mindfulness and various aspects of well-being, only recently researchers have investigated mindfulness in relation to sexual well-being. Interesting to note that this happens more than three decades after Masters and Johnson (1970) addressed the importance of being focused on the present moment during sexual experiences.

Origins and Definition of Mindfulness

Mindfulness is an ancient eastern meditation practice rooted in the Buddhist teachings of over 2500 years ago. Mindfulness occupies a central role in a tradition that was developed as a path leading to the cessation of personal suffering.[1] It refers to a process of becoming more aware and accepting toward all experiences – including the unpleasant ones. This may seem counterintuitive at first, because it involves the idea of allowing and turning toward unpleasant experience, rather than trying to get rid of it or control it. Mindfulness is not a set of techniques to be learned to escape from unpleasant feelings, a relaxation exercise, or a concrete goal to be reached, but rather a way of being that takes ongoing practice and commitment.

Kabat-Zinn,[2] the pioneer in the therapeutic application of mindfulness in Western culture, defines mindfulness as the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment to moment. The practice involves bringing attention to one's own thoughts, feelings, and actions as they occur, with curiosity, openness, and acceptance.

Mindfulness Applications and How it Works

Developed and implemented by Kabat-Zinn[3,4] in the seventies, mindfulness-based stress reduction, the pioneer 8-week mindfulness-based treatment for chronic pain has helped to establish mindfulness as an empirical research topic.[5] After this manualized treatment program, mindfulness has been widely used and integrated in several psychological and medical approaches. Evidence of psychological effectiveness has been found across a wide variety of problems, ranging from chronic pain, fibromyalgia, cancer, psoriasis, irritable bowel syndrome, immunological deficits or stroke, and brain injury, to psychological problems such as generalized anxiety disorder, eating disorders, posttraumatic stress disorder, substance use, ruminative thoughts, negative affect, or recurrent depression.[6]

Although a huge body of research has convincingly proven the effectiveness of mindfulness training in a variety of contexts to promote health and well-being, the question 'why is mindfulness so effective?' is still an ongoing question.

Discussions in a consensus meeting of mindfulness teachers, practitioners, and experts about how mindfulness works have resulted in the definition of a two-component process involving (a) the self-regulation of attention so that it is maintained on immediate experience, and (b) orienting to the present experience with curiosity, openness, and acceptance[6–13]

Regarding the mechanisms of mindfulness, Shapiro et al.[14] proposed a model composed of three core elements: intention, attention, and attitude. According to this conceptualization, through intentionally attending to experience in an open, discerning way, it is possible to develop the capacity to perceive and to change our relationship with the experience, becoming less identified with it, and better able to see it with clarity and objectivity. The proposal is that mindfulness training develops the ability to disidentify, or reperceive one's experience, and this mediates change, both directly and indirectly.

In a recent study, Lindsay and Creswel[15*] proposed a testable theoretical framework – monitor and acceptance theory – to help explain mindfulness effects on cognition, negative affectivity, and stress-related health outcomes. According to this proposal mindfulness can be beneficial by enhancing awareness of one's experiences – attention monitoring improves cognitive functioning outcomes, and it may also increase affective reactivity – and by modifying one's relation to monitored experience – acceptance reduces affective reactivity. Others suggest that positive effects of mindfulness could be explained by mechanisms such as observing, describing, acting with awareness, nonjudging of inner experiences, and nonreactivity to inner experiences.[16]

In a review of how mindfulness meditation might lead to improvements in psychiatric and stress-related symptoms, it was proposed that mindfulness may be of benefit by increasing attention regulation, emotion regulation, body awareness, and changes in perspectives of the self.[17] Concordantly, neuroimaging studies have evidenced functional and structural changes in a myriad of brain regions mainly involved in attention systems, emotion regulation, and self-referential processing.[18]

Mindfulness and Sexual Well-being: Clinical and Theoretical Possibilities

Only more recently the pioneering research of Brotto and Heiman[19] has opened the field of investigation to explore the potential and promising effects of mindfulness in sexual well-being. Some possible explanations have been presented, both from what has been observed in the clinical practice, and expected from a theoretical point of view. Contributes are integrated according to main themes common to both, mindfulness and sexuality, as following: mind, emotion, and body.

Mind

Internal distractions, judgments, self-criticism, and inner dialogues can easily interfere with focusing on sexual pleasure, sensation, or intimacy. It is frequent for individuals with sexual problems to become preoccupied with nonerotic thoughts or behaviours that generate performance anxiety, and negative expectancies about sexual performance, body image concerns, and critical assessments of themselves or their partner.[20–23]

On the opposite side, the practice of mindfulness helps to quiet the busy and judgmental mind. It also helps to observe negative cognitions in an open and curious way, and then to gently refocus attention on the present moment. People higher on mindfulness practice report less frequent negative cognitions and a greater ability to let go of negative thoughts when they arise[24] and people who undergo mindfulness treatment report significant decreases in rumination.[25]

If we think about the sexual scenario, by cultivating the ability to be present – attention to the here and now of sensation, pleasure, and eroticism – it may become easier to observe and participate in the sexual experience without getting caught up in inner dialogues or being distracted by automatic intrusive thoughts. Sommers[26] suggest that mindfulness enables people to be more present centred (as opposed to past or future centred) during sex, and more process absorbed (instead of goal directed), both processes contributing to improve sexual experience. People are encouraged to reframe sex as something to be experienced with meaning, rather than an achievement (goal-oriented language – 'succeed', 'fail', try" – is pointed out and discouraged).[27] If we consider orgasmic problems, for example, people often become very goal focused, and the awareness of the body without a particular goal could be very helpful.

Body image concerns may also change with mindfulness, considering the practices invitation (e.g. body scan) to dedicate a particular kind of attention to the body, curious and without a judging attitude. Is has been also proposed that mindfulness may help to change the response to negative thoughts about the appearance of one's body. Research on mindfulness and body image, although scarce, has been showing that higher levels of mindfulness are associated with higher levels of body satisfaction and sexual body esteem, as well as lower levels of social comparison.[28,29]

Emotion

Sexual problems are directly influenced by and impact upon emotion. Emotions of sadness, disillusion, fear, and less pleasure or satisfaction have been associated with sexual dysfunction in men; women with sexual dysfunction, compared with women without sexual problems reveal less pleasure and satisfaction, and more sadness, disillusion, guilt, and anger.[30] The role of anxiety and depression has been also emphasized in many sexual problems. When confronted with emotions such as anxiety, many people attempt to avoid the thoughts, feelings, and physical sensations associated with it. Unfortunately, these strategies to avoid often exacerbate what is avoided.[31]

More than changing the content of emotional states (self-narratives and cognitions), mindfulness-based interventions focus on changing the perspective from which emotions are experienced, encouraging acceptance and curiosity about the experience itself (self-experiential focus), that is, the focus is on changing the relationship (and not the content) with the emotional (painful) states.[32]

One of the explanations for the benefits of mindfulness on sexual functioning has been related with the possibility of emotion regulation. The meditative practice may contribute to enhance the participants' ability to regulate emotional distress through a variety of means, including reappraisal, exposure, extinction, or reconsolidation.[33] For example, mindfulness may be effective by changing one's response to anxiety-related affect and thoughts, allowing a receptive approach, rather than avoidance.[34]

It has been also suggested that mindfulness may exert indirect effects on sexuality via its effects on anxiety or depression. Brotto and Basson[35*] found that reduced depressive symptoms predicted improvements in sexual desire following mindfulness intervention.

Body

The ability to be aware of the bodily sensations and to see that thoughts are just thoughts about sensations, that they are useless and can make things worse, can be a difficult task nowadays in the Western culture that enhances the mind–body split. The mindfulness practice of approaching the body and physical sensations with an interested and friendly awareness (re)places us in the bodily experience, that is, the experience of being the body, thus restoring the body–mind integration.[5]

In the sexual scenario, the focus on the sensorial experience proposed by the mindfulness practice (e.g. body scan) may result in a higher awareness of the sexual arousal and greater attunement to pleasurable sensations. Just as the breath is an anchor in traditional meditation, sensual and sexual feelings, and sensations may become an anchor for the mind to be present and connected during the sexual encounter. Additionally, it has been also proposed that by facilitating the experience of genital response, mindfulness can contribute to increasing the consonance of genital and subjective response. For example, one study with university students revealed that women participating in the meditation group (a 12-week course involving a meditation component), when compared with an active control group, demonstrated greater awareness of the physiologic changes accompanying sexual arousal, in response to sexual stimuli.[36]

In the context of sexual pain, the practice of the nonidentification with thoughts together with acceptance and nonjudgmental attitude, favours decentring from the fear of pain, resulting in relaxation. If women can observe such thoughts as 'just thoughts', their emotional valence is lessened, and the sensation of pain may be experienced purely as a physical sensation, without the multitude of layers of affective and cognitive suffering.

Mindfulness and Sexuality: Evidence

Although the mechanisms underlying the impact of mindfulness on sexual well-being – probably multifactorial – have yet to be empirically demonstrated, the evidence for the mindfulness practice benefits in the management of sexual problems has been growing since 2007, with promising results.

Brotto and Heiman[19] conducted the first group treatment, including a component of mindfulness into the development of a psychoeducational program for women with sexual complaints secondary to gynecologic cancer.[19,37] The program was developed to specifically target sexual arousal complaints in women with radical hysterectomy because of cervical or endometrial cancer (n = 22). Mindfulness was included as a very specific application, being just one of the five components of the psychoeducational program. At the end of treatment, women mentioned mindfulness as being particularly helpful as it encouraged them to tune into remaining genital arousal that they otherwise believed was gone after their cancer treatment. By being mindful of existing arousal, women believed that they were able to enjoy and therefore augment their sexual arousal to an even higher level. Some women commented that through the self-observation exercises in a mindfulness way, they were able to view their bodies in a more positive light.[19,37]

Following the previous study, Brotto et al.[38] adapted the existing mindfulness-based psychoeducation to a group format for women with sexual desire/interest disorder and/or sexual arousal disorders (n = 26). The psychoeducational program occurred in three group sessions, each with 90 min, spaced 2 weeks apart. At the end of treatment, a significant beneficial effect of the program was found on sexual desire, sexual distress, and self-assessed genital wetness (despite little or no change in actual physiological arousal). From the total sample, women with a sexual abuse history improved significantly more when compared with the others on genital tingling/throbbing, arousal, overall sexual function, sexual distress, and on negative affect while viewing the erotic film. Moreover, there was a trend for greater improvement in depression scores among those with a sexual abuse history.

In a more controlled setting, and taking into account the limitations of the previous studies, the benefits of mindfulness were also explored in women with sexual distress and a history of childhood sexual abuse, by comparing a brief cognitive behavioural intervention versus a mindfulness-based intervention.[39] Twenty partnered women were randomized to two sessions of either a cognitive behavioural or mindfulness-based group treatment. Results revealed a significant decrease in sexual distress in both groups. Furthermore, women in the mindfulness-based treatment group experienced a significantly greater subjective sexual arousal response to the same level of genital arousal (higher concordance between subjective and genital response) compared with the cognitive behavioural group and to pretreatment.

In a controlled study with women who had a history of hysterectomy because of cervical or endometrial cancer, and were experiencing distressing sexual desire and/or arousal difficulties that they attribute to their cancer treatment, mindfulness-based intervention revealed important improvements in almost all domains of sexual response, overall sexual functioning, and sexual distress. These improvements were maintained at a 6-month follow-up. Women's perception of sexual arousal during an erotic film increased after the treatment, despite the fact that physiological sexual arousal did not increase.[40]

In an online mindfulness-based intervention with chat room support group for women with sexual difficulties (desire, arousal, orgasm, and/or sexual pain) and their partners, results revealed that women who received the intervention, compared with the control group, showed improvement in all dimensions of sexual functioning, and decreased sexual distress. Only sexual pain revealed no impact of the treatment. Results were maintained at a 3-month follow-up.[41,42]

Recently, a four-session mindfulness-based cognitive-behavioural sex therapy program for women with low sexual desire (n = 117) significantly improved sexual desire, arousal, lubrication, satisfaction, and overall sexual functioning. No control condition was used. At the end of treatment scores on all sexuality measures remained in the clinical range, this being interpreted by the authors as revealing the need for a longer treatment.[35*]

Following this, and even more recently,[43**] an eight-session group that included a more extensive practice of mindfulness skills, was designed and pilot tested in a sample of 26 women with sexual interest/arousal disorder. This program provided women with more opportunities for mindfulness practice, both within and between sessions (almost half of each session was devoted to an extended guided practice and inquiry). Again, there was no control group. The majority of women remained on average in the clinical range, although at the end of treatment, they all reported significant improvements in sexual desire, overall sexual function, and sex-related distress, regardless of treatment expectations, relationship duration, or low desire duration compared to baseline. Mindfulness and depressed mood also improved, and revealed to be significant mediators of sexual function. Interoceptive awareness was a significant moderator of changes in sexual desire, suggesting that this variable should be included in futures studies.

Research into combined cognitive behavioural therapy and mindfulness for sexual pain disorders is also at the beginning. A qualitative study tailored to women with provoked vestibulodynia (chronic pain condition involving sharp pain to the vulvar vestibule) with a four-session mindfulness and cognitive behavioural therapy confirmed also the benefits of a mindfulness-based approach for improving quality of life and reducing genital pain. The treatment revealed positive changes in important areas of women's lives, including positive psychological outcomes and self-efficacy related to a feeling that pain management was much more under women's own control than they previously believed.[44]

Beyond the clinical scenarios, some interesting findings additionally highlight and suggest the mindfulness potential for improving sexual responses. This may be important if we think that enhancing the sexual lives may serve as a shield against the development of sexual dysfunctions.

In a qualitative study with 10 sexually healthy women, Mayland[45] found that the practice of mindfulness without any sexual purpose, positively impacted sexual experiences. In this study, extended mindfulness meditation practice (mean practice around 19 years and a minimum of 5 years) was found to be associated with an increase in sexual awareness and self-acceptance, and higher levels of sexual satisfaction. In their interviews, women described integrating mindfulness into their sexual activity such that it allowed them to be highly aware and present during sexual encounters, free of sexual expectations, such as orgasm, and so more sexually satisfied. Furthermore, several women mentioned a heightened awareness of genital arousal and feeling like they had a greater understanding of their sexuality since beginning meditation practice. Some also reported being less critical in their everyday lives, more at peace and experiencing life more deeply.[19,45]

In another qualitative study with relatively happy, nondistressed couples, a mindfulness-based intervention significantly enhanced relationship satisfaction, autonomy, relatedness, closeness, acceptance of one another, and reduced distress.[46] Results suggested that couples who practiced more had better outcomes and greater mindfulness practice on a given day was associated with several consecutive days with improved levels of relationship happiness, relationship stress, stress coping efficacy, and overall stress. The benefits revealed to be maintained at 3-month follow-up.[46]

A phenomenological study explored women's experiences with meditative practices with regard to their romantic relationships and physical intimacy.[47] Interviews were conducted with 10 married and unmarried women practicing meditation, including a mindfulness component, for 6 months or more. In general, results revealed increased empathy for others and compassion for themselves and subsequent enrichment of relationships, improvement in couples' communication, and a greater sense of emotional intimacy and connection associated with meditation practice. However, the authors warn that the effects the participants reported cannot only be credited to the practice of meditation as other factors may have contributed to the outcomes the participants described, including maturation, counselling and in some cases a different partner.

A cross-sectional study with people that practiced meditation and yoga (n = 51), revealed a significant positive correlation between mindfulness and sexual motivation and sexual consciousness.[48]

In another study with a nonclinical sample, orgasmic and nonorgasmic women were divided and compared on dimensions of mindfulness and sexual functioning. Orgasmic women revealed higher on mindfulness in their everyday lives and within the dyadic sexual context. Moreover, mindfulness (every day and sexual context specific) accounted for 51% of the variability in measures of sexual distress.[49]

More recently, in an online sample (n = 355), adult women who reported higher levels of mindfulness reported also significantly less frequent cognitive distraction during partnered sexual activity and significantly higher levels of sexual satisfaction. Moreover, it was found that cognitive distraction (because of appearance concerns, performance concerns, and everyday distractors) mediated the association between mindfulness and sexual satisfaction.[50]

Limitations

In the recent years mindfulness has made its way into sexual health care, with very encouraging results, both in clinical and nonclinical scenarios. More and more practitioners in sexual health are teaching their patients the practice of awareness to the here and now. However, the ever-growing clinical experience of integrating mindfulness in the treatment of a variety of sexual problems contrasts with the shortage of controlled trial studies. Although suggestive and promising, most of the existing studies lack adequate methodological rigour.

Moreover, except in two recent studies, mindfulness was integrated as part of the treatment program and not alone as a single treatment, making it more difficult to understand the outcomes, and to attribute the effect only to the practice of meditation. Evidence has been found mainly in women's sexual difficulties. No studies so far examined the possibility of using mindfulness with other groups such as men, the aging, or people of diverse sexual orientation or sex identity.

More research with controlled trials is needed so as to determine the benefits and effectiveness of mindfulness on sexual problems and the precise means through which it is effective.

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