kim_vopni (00:02.314)
Hi Dr. Brotto, thank you so much for joining me today. I am really excited to chat with you about all things mindfulness and sex.
lori_brotto (00:10.542)
Hi Kim, great to be here.
kim_vopni (00:12.623)
Can you start out by giving us a bit of an introduction in terms of who you are and what led you to becoming really a world-renowned researcher as it pertains to sexual health?
lori_brotto (00:25.294)
Sure. So I'm a registered psychologist by training, a professor in the Department of Obstetrics and Gynecology at the University of British Columbia in Vancouver, and I hold a Canada Research Chair in Women's Sexual Health, which really allows me to spend a good portion of my time doing research into sexual health, mostly women's sexual health and treatments for that. So my journey to getting here was not a linear one.
thinking that I would become a sex researcher, sex therapist, and in fact grew up in a home that was quite sex negative. Not a lot of discussions around sexuality. And in fact, the discussions that we did have were about the dangers of sex, the fact that people would, that everyone would know if you were engaging in or even thinking about sex. So it was definitely not something I signed up for on career day. But through a series of volunteers,
experiences I had as an undergraduate student where I was volunteering in a research lab that was studying animal models of sexual dysfunction and so what that meant is that I was creating stressful environments for rats and then I would study the impact on their sexual activity. Did it make them more likely to engage in sex, less likely to engage in sex? That really cultivated a passion for
that was just so palpable and it was amazing to do this research in animals where you could control things like what they ate and their social environment and things like that. So that continued for about six years and then the year that Viagra was approved in Canada which was 1999.
was the year I made the switch to doing human sexuality research. And the Viagra trigger for me was the fact that we had this, you know, safe, effective, easily to obtain, discrete pharmacological treatment for people with erectile dysfunction. And there was nothing comparable for female sexual problems. And yet at the same time, there was a very large international study which found that
lori_brotto (02:45.872)
sexual problems in women were very high and far higher than in men. So it was this kind of juxtaposition of very high rates of sexual problems in women, no Viagra-like product for women, and I was getting tired of the rat lab. So I made the switch over to studying female sexuality and that was I guess over 20 years ago.
kim_vopni (03:09.802)
Wow, amazing. And your book is called Better Sex Through Mindfulness. Can you explain what mindfulness is to start out with and then how that can lead to better sex?
lori_brotto (03:25.39)
Mm-hmm. Yeah, so mindfulness is an ancient concept.
It's been around for at least 4,000 years rooted in Buddhist meditation and since about the late 1970s it's been secularized, incorporated into Western medicine and essentially it's a practice of non-judgmental present moment awareness. So it's a set of exercises designed to cultivate the skill of paying attention on purpose,
without judgment, non-judgmentally. And it has so many applications to so many facets of sexual response and sexual activity because the kinds of things that get in the way of sexual functioning might relate to inattention, distractions, negative expectations, worries, fear of pain, worry about performance,
partner's reaction, all these sorts of things can definitely get in the way and impede healthy sexual response. So mindfulness is a great antidote to many of those factors. And it's been a big part of my own scientific research is developing, adapting, and then testing how mindfulness might work for things like low desire, pain with sex, fear of vaginal penetration.
women and then also in men performance concerns, etc.
kim_vopni (05:06.602)
So in the population that I work with, there's pelvic organ prolapse is a really big one. That's, I would say, one of the things when you're talking about worry and fear of penetration, wondering what the partner feels, you know, sees all that kind of stuff, that is very high on the list of people dealing with pelvic organ prolapse. I would say also for urinary incontinence, anal
there's any smell wondering if anything's gonna leak out that type of thing. So how would you recommend somebody dealing with when we'll talk about those two conditions first, how would they get started with a mindfulness practice?
lori_brotto (05:47.534)
Mm-hmm. Yeah. So, you know, as you point out, Kim, the worries, the fears, the concerns, worrying about a partner's response, embarrassment, fear, shame, all of those kinds of things. We know that emotions in the moment can actually contribute to further difficulties happening, including pain. So we know that separate from the experience of pain, the
worry about pain can actually intensify the pain itself. So mindfulness which is a strategy about staying very present, staying rooted in your sensations and guiding the mind back from the future, right, the future which is a place of worry and concern back to the here and now can help with distress in the moment, help kind of curtail that fear and that
and might even reduce the likelihood of some of those symptoms from happening. Now that's a bit of a stretch that the science hasn't really looked at that but certainly in the domain of pain we know that there's been now several larger studies including some of our own that have found that mindfulness for women with with all the vaginal pain that yes it can help manage the distress and the future-oriented worrying and also reduce pain intensity.
So it's just a really powerful technique for staying in the present moment and really highlights the notion that tuning in trumps tuning out in terms of being able to cope in the present.
kim_vopni (07:32.65)
So when, like if somebody wanted to get started with a mindfulness practice, you mentioned a series of exercises. Is this something that people can do? So you have a book, you also have a workbook that goes along with it. So is that to guide people that may not have access to a practitioner? Should they work with a practitioner or what's the best approach for them to get started?
lori_brotto (07:44.398)
Mm-hmm
lori_brotto (07:50.414)
Yeah.
Yeah.
Yeah, great question. So, you know, in our research over the years, we've, we've evaluated three sessions, four sessions, eight sessions, one-on-one couple group online, face to face. And what we've discovered is that eight sessions can be terrific for introducing a person to mindfulness, having them establish a baseline mindfulness practice and then giving them time to incorporate their,
more sexual kinds of contacts first on their own, maybe through looking at their body with a handheld mirror or doing some self touch and then eventually engaging in sexual activity with a partner. So the workbook that I published in 2022 was the same treatment manual that we had tested for many, many years and published and found to be quite effective. And it does walk readers through how to start from kind of ground zero.
never had any kind of mindfulness practice and then progresses all the way through those more sexual kinds of mindfulness practices. There are definitely some excellent mindfulness practitioners in North America, in the world. Very few have simultaneous training in sexual health and managing sexual dysfunction. So I really wrote the workbook as a guide to hold
lori_brotto (09:24.272)
so that they could do the exercises entirely on their own.
kim_vopni (09:27.974)
Right. And your practice, so you have a background with psych psychology. And when you're talking about sessions, is that working with a practitioner like yourself?
lori_brotto (09:38.862)
Yeah, so when we've evaluated this in our research, our therapists or our facilitators were either a registered psychologist like myself who had dual training in sexual medicine and mindfulness or a counselor. In some cases, we had actually a mindfulness expert who had very little training in sexuality, but we always ensured that the two facilitators kind of covered the bases in terms of good,
sexuality and expertise in mindfulness.
kim_vopni (10:13.11)
Another thing with regards to people dealing specifically with prolapse, oftentimes activity and I don't just mean sexual activity, but doing things earlier in the day is often more accessible. They may have less symptoms. They may feel stronger, less tired, you know, host of reasons. And when I was reading through doing research on your background and the work that you've done, there was one article that stood out where it said that
having sex in the morning can turn you on more basically. And then so I'm thinking back to this population that it's often recommended, you know, exercise earlier in the day, get all of the more important stuff done earlier. So sex as well could be more accessible to these people during the morning, but why would it turn you on more if you have sex in the morning?
lori_brotto (10:46.894)
Mm.
lori_brotto (11:01.518)
Yeah.
So in part for all of the same reasons that you've described. So more energy, less fatigue, maybe more mobility, but also a whole host of more psychological reasons. So, you know, one of the myths that we often encounter is that there's a separate gas tank that fuels sexual desire and sexual response. And the number of people that I talk to who will only engage in sex,
11 o'clock news after a you know 18 hour day juggling multiple demands and then they experience great difficulty just showing up just being present and you know oftentimes I'll hear people say yeah I fell asleep during sex so if we can kind of debunk that myth that
sex is only sexy late at night and sexy sex is planned sex and that means planning at a time when you're most awake when you're least likely to be distracted when you haven't yet kind of gone through the to-do list and been inundated with all of the things that you need to do in your day that that can facilitate the really important brain body connection that's critical
lori_brotto (12:21.328)
very much about enhancing the connection between the brain's messages that tell the body to become aroused and then the body's messages back up to the brain which say yes we're responding, yes we're showing signs of excitement so the brain can pick that up. So that feedback loop between brain and body is critical and it's far more likely to happen when the person is awake, vitalized, not distracted.
kim_vopni (12:48.594)
Yeah, oftentimes people think that, you know, if you're planning sex or if you're writing it in your calendar to happen at this time that that's not sexy, we did, it's not spontaneous, but that ended up that practice in and of itself could in some ways, maybe even be considered mindfulness where you're, you're making a conscious decision to set aside time when you're feeling fresh when before you have your whole to do list. Is that accurate?
lori_brotto (13:03.566)
Yeah.
Yep.
lori_brotto (13:11.918)
Yeah, completely. So again, the myth that planned sex is bad sex or it's clinical in some way. And then to that I often respond, you know, think about all the things that you do in your life that you really enjoy, that you really anticipate and crave and look forward to and they're all planned. So planning sex can also afford an opportunity to fantasize about it, get the mind in the body and
prepared so that you're most likely to show up and be in the moment when the moment comes.
kim_vopni (13:48.726)
Mm-hmm. You mentioned a term earlier that, and I've heard you talk about it a lot, which is low sexual desire. And when you think of what we've just talked about where there could be symptoms associated with some sort of pelvic floor challenges, the to-do list, there's lots of things that can get in the way, but that doesn't, just because you have those things, doesn't necessarily mean you have low sexual desire. Yet some people associate the fact that they don't feel like having sex at a certain time as low sexual desire.
lori_brotto (14:11.118)
Mm-hmm.
kim_vopni (14:17.802)
So what is true low sexual desire and how do we approach healing that?
lori_brotto (14:24.142)
Yeah, so, oh goodness, there's, I mean, so many myths wrapped up in low desire, including, you know, I should be able to get turned on like a light switch, I should feel the same intensity of desire if I love my partner, etc. So I mean, it just goes on and on. And then the flip side of that is if I'm not feeling in the mood, if I don't have desire, then there's something wrong with me, there's something wrong with my relationship, etc, etc. So we need to think
differently about sexual desire and we need to think about desire as being very similar to other emotions that we have. So if we take happiness as an example, you know, we feel happy in the moment when good things happen.
when happy things occur and it elicits the response the emotional response of happiness sadness works the same most emotions work the same way and sexual desire works the same way as well so if when a person says i have no desire one of the one of the first things i would think about is what is not happening in that person's context either they're more distant context or more
lori_brotto (15:39.696)
in sex for them. So if sex hurts, desire is going to go down. If they're in conflict with a partner and don't feel safe, their desire is going to go down.
if there is so much familiarity in a relationship because it's been a very long-term relationship and you do everything with a partner and there's no room for kind of mystery and discovery, sexual desire is going to go down. So we don't want to assume that just because desire has gone down that the person has a quote sexual dysfunction. We'd want to look at what a lot of these
lori_brotto (16:23.856)
them, desire will emerge from that. So again, we want to normalize the fact that desire is something that emerges, it can be cultivated, it's responsive. And sometimes that's where the work is, is discovering what is inhibiting desire, and what are the enhancers that are, you know, not at play to be able to pull desire out of the person.
kim_vopni (16:47.79)
And you had mentioned one time you were speaking at my Kegels and cocktails event several years ago and I remember one point you had mentioned that I've heard you say a few times is that there may be kind of initially maybe low desire and lack of interest but once activity begins. Then that can sort of stimulate more interest I don't quite know how to describe that in more in technical terms I guess but is that is that true.
lori_brotto (17:09.646)
Mm-hmm.
lori_brotto (17:16.205)
Oh, it's so true. Yeah, I'm glad you brought that up. So this is responsive desire. And I mean, for years and years, the field or the field of sexuality experts and therapists did believe that you would start out an encounter, a sexual encounter because you had desire, right? So you have desire, then you seek out a partner, then you get aroused, and then maybe there's satisfaction, maybe there's an orgasm. And yet over the past several decades, that notion has been
totally refuted and turned on its side in favour of a model which shows that oftentimes for women more so than men and for people in longer-term relationships compared to shorter-term relationships that they might start out a sexual encounter with no desire.
but they started an encounter for good reasons. So maybe it's to have desire, to have pleasure, to have an orgasm, to have emotional connection with a partner, to celebrate a birthday, to celebrate a anniversary, what have you. And so starting a sexual encounter with no desire, but with good, compelling reasons that are consensual for you is very normal, very common.
and allows the person to then enter a sexual encounter where they can receive and respond to the right kinds of triggers for them, whether the triggers are a particular touch on the body or sounds or smells or what have you, and then that would pave the way for the body to start to show some response, some sexual arousal, both physiological arousal as well as more
lori_brotto (19:02.096)
in and if that continues and the person is present and tuning into this that then paves the way for desire so now the person says oh okay at the beginning I just started sex because I wanted to be emotionally close to my partner now I actually have desire for sex
I have, you know, I'm feeling desire and feeling in the mood. So it emerges afterwards and after arousal happens. And that cycle is really normal. And it's, it's one that we want to normalize and, and celebrate and sing from the rooftops because it challenges the kind of dysfunction based model that perpetuates a lot of society and beliefs that, you know, if you don't feel desire at the outset, there's something wrong with you.
kim_vopni (19:53.166)
And when we transition through perimenopause, we reach our menopause and move beyond that, there's also influence hormonally typically, but lots of other factors that are going on that can influence our desire, our sensations, everything. So what exactly is happening during that time to make those changes with regards to our desire and all of the other things?
lori_brotto (20:13.614)
Mm-hmm.
lori_brotto (20:19.566)
Yeah, it's a complex.
time that up to 10 year period of perimenopause where there's fluctuating estrogen levels that can contribute to vaginal dryness, vaginal atrophy which makes vaginal penetration uncomfortable or downright painful, very painful for a lot of perimenopausal women. And again as we talked about earlier, if sex hurts your desire for it is most definitely
going to go down and it's an evolutionary mechanism where our brains have evolved to you know if you touch the stove once and you get burned guess what you're not going to touch the stove anymore and the same thing happens with sex that if you engage in sex and it's very very painful for you your interest in it is going to go way down so making sure that the person is having
lori_brotto (21:23.248)
to restore vaginal moisture through a moisturizer as well as we want to make sure that everyone is using a vulvar lubricant in every sexual encounter well before the perimenopause. That combination can be really really important. So that's a big thing that happens with the perimenopausal
lori_brotto (21:53.168)
might be a new onset of a vulvar pain condition. So the research tells us that there's kind of two spikes in a woman's age where she might be more vulnerable to developing a chronic pain condition like vulvodynia and around the perimenopause is one of those times. So making sure that you've had an examination by a qualified healthcare provider to rule out vulvodynia, to rule out other vulvar skin conditions
could be contributing to pain and discomfort. And then separate from the kind of physical medical contributors there's a all sorts of other changes there's changes in body image and skin and identity maybe the person is mourning their younger self maybe there's physical mobility issues that make sex just more difficult higher proneness for fatigue there can be lots of cognitive
during the perimenopause that makes staying present during sex really difficult. And then of course a partner's responses to all of these changes, whether those are overt responses by a partner or more covert ones that kind of come out and play themselves out in the sexual scenario. So yes we really want to make sure that
women are supported during the perimenopausal transition and that they have access to good information and their healthcare provider team to give them the help that they need.
kim_vopni (23:28.978)
Can you talk a little bit about testosterone because that's often indicated if somebody, so again you've listed off a bunch of reasons why there could be challenges from a sexual health or sexual activity perspective during perimenopause and transitioning over to menopause, but testosterone is often indicated for low libido. So is low libido the same as low sexual desire?
sexual desire the same as libido i guess and it what role would testosterone or could testosterone play
lori_brotto (24:02.67)
Yeah, I think to most people they use those terms desire, libido, sexual interest interchangeably. To someone like me who does a lot of research in this area, I do differentiate those and often libido might be that kind of feeling of spontaneous desire that happens out of the blue, whereas sexual desire and sexual interest is more what we talked about that responsive desire that
lori_brotto (24:32.624)
to most people, again, they might use those terms interchangeably. Yeah, so the question of whether testosterone is indicated, I mean, let's be really clear. It's not approved for the treatment of low desire in Canada. It's used off-label, it's used totally experimentally. Yes, there have been many scientific studies, randomized clinical trials that have compared
lori_brotto (25:02.544)
placebo and certainly those studies do find improvements in the participant's self-reported level of desire. But there are also concerns and side effects. So because it's often because it's not regulated, there can be a significant concern with viralized intermasculinizing side effects. So deepening of the voice, hair growth that is unwanted, metabolic syndrome, which can
the functioning of the organs in the body. And there's been very, very little research on the use of testosterone cancer survivors who are a separate group that experience a lot of sexual side effects. So.
Yes, it is sometimes prescribed by physicians or naturopaths, which can be problematic sometimes because it can be really difficult to measure and know exactly what is in the testosterone that's given. So, yeah, so I often advocate just, you know, talk to a healthcare provider that you trust, be informed, know the science. Yes, there are other products that we might take that are not approved by Health Canada.
but you know, I think knowing the full risks versus benefits to any individual person is the most important thing.
kim_vopni (26:27.795)
There's two medications I know of. Is it Adi and Veilisi? Is that how I pronounced them correctly? Are they approved by Health Canada and the FDA?
lori_brotto (26:32.59)
Mm-hmm. Yep. Yep. Yeah.
Yeah, so they're both approved after many, many years of scientific investigation. So the first one, ADDI, the generic name is flabanserin, is an oral medication that acts kind of like an antidepressant. In fact, it was originally tested as an antidepressant and it failed as an antidepressant, but a subset of the participants in the study had an improvement in their desire. So the clinical trials show that a person needs to be consuming this daily for at least
before they see an improvement in desire. It's only approved for pre-menopausal women and it's contraindicated with alcohol and can impede cognitive function. So if it's taken it needs to be taken at night, the person can't be driving right afterwards and in the the big clinical trials what they found was that it improved the number of sexual encounters that were satisfying by about
compared to placebo. So it is approved, it is available, it's not free, about 30% have side effects, but for some people it offers the solution that they're looking for.
So that's that's Addi or flabanserin. The second one that was approved more recently, Bremelanotide or Vilece is taken on an as needed basis. So it's injectable and it also acts on the brain but you don't need to take it for every day for weeks on end in order to experience benefits. So kind of like Viagra in that way you take it when you need it. Yeah.
kim_vopni (28:16.874)
Yeah, I was just going to say, is it like a, is it kind of like a female Viagra in a sense?
lori_brotto (28:20.206)
Yeah, it's kind of like, but it acts in a totally different part of the brain. It's the melanocortin receptors in the brain, which have been linked to desire. And the benefits beyond placebo are pretty similar to what was found with flabanserin or more Adi. So improving the number of satisfying sexual events by about one per month.
kim_vopni (28:41.598)
really cool to test those against your book and mindfulness practices.
lori_brotto (28:46.222)
Yeah, I've been trying to get that proposal approved for the last five years and I'm just waiting for someone to fund me to do that.
kim_vopni (28:53.486)
Yeah, yeah, I hope it happens. That would be really interesting. And, you know, it's like, it's like a lot, you know, people want the pill, they want the device, they want the something they but oftentimes, when we come back, and we do the work. So in my case, pelvic floor exercise, in your case, the mindfulness, which I would argue mindfulness would be great for pelvic floor exercise as well. That is often where the true success will lie. And sometimes when all of those approaches have been tried, maybe some of these other
lori_brotto (28:56.974)
Mm-hmm.
lori_brotto (29:03.758)
Yeah.
lori_brotto (29:10.19)
Mm-hmm.
lori_brotto (29:15.182)
Yeah.
lori_brotto (29:19.566)
Yeah.
kim_vopni (29:23.53)
we're lucky to have these other options, but it wouldn't be where I would recommend people start. Would you agree with that?
lori_brotto (29:27.822)
Yeah.
I 100% agree and I've been following the prescribing patterns in Canada very closely around these two products and they really weren't the blockbuster drugs that Viagra was for men. So it is an option in the tool belt and definitely I'm a believer of the more options that women and others have, the better to empower them to make decisions that are right for them.
of low desire, concerns are not rooted in an imbalance of neurotransmitters in the brain. So we sort of need to understand the cause before we select the best treatment.
kim_vopni (30:05.174)
Right, right.
kim_vopni (30:10.562)
Yeah, root cause investigation for sure. Before I let you go, I wanna ask one more thing. Again, as I was searching, I saw this, and I feel like I heard you say this, maybe again at Kegels and cocktails, but a raisin can transform your sex life. Can you tell us how a raisin can transform our sex life?
lori_brotto (30:25.006)
Hehehehe
Yeah, so, you know, I mentioned mindfulness kind of making its way into Western medicine since the late 70s. And one of the ways that experts at the time introduced mindfulness to people was through consuming a raisin. And so I've borrowed that exercise and incorporated into the groups that I've run. And what you do is, you know, very first session before any discussion of why
were there and how mindfulness works is you pass around a plate of raisins and then guide the person through mindfully observing the raisins, smelling it, listening to it, putting it against their lip, putting it in their mouth without chewing, taking one chew and what happens over the course of five to ten minutes of observing the raisin in this very detailed way is that the person
lori_brotto (31:29.552)
intensity of sensations, they see colors they never saw before, they feel salivation that they didn't realize happened for raisins, they have all sorts of emotional as well as physiological responses that were previously um unbeknownst to them because we often eat raisins by the handful and we swallow without chewing so it can be such a powerful introduction to what happens when we
lori_brotto (31:59.472)
reason why I use the raise and exercise first when I run mindful mindful sex groups is it's probably the most compelling way of illustrating how mindfulness can then work for sex without me saying here's how mindfulness works for sex we do the raise and exercise they feel the anticipation they they observe what happens when they guide all of their senses on to a
lori_brotto (32:29.392)
from the raisin to the bedroom.
kim_vopni (32:33.238)
So interesting. Thank you, Dr. Brotto, for sharing your wisdom with us, for your amazing book. All the links will be in the show notes for people to be able to access that. I'm grateful for all the work that you do. Thank you so much for being here and for everything that you do to help people.
lori_brotto (32:48.814)
Thank you so much, Kim.
