By Justin Lehmiller
What is a day in the life of a sex researcher like? In this interview series, I talk to some of the world’s foremost authorities on sex in order to answer this question, but also to provide a glimpse into what they’re currently working on, what the media tends to get wrong about sex, and what they think about some of the most pressing issues facing the field of sex research today.
For this interview, I spoke with Dr. Lori Brotto, a clinical psychologist and Professor at the University of British Columbia. Brotto is also the Canada Research Chair in Women’s Sexual Health and she has an extensive body of work that addresses topics including sexual desire, sexual dysfunction and its treatment, and asexuality. Below is a transcript of our conversation.
Lehmiller: Please tell us the story behind how you became a sex researcher. What is it that initially inspired you or drew you to this field of study?
Brotto: The simple answer is serendipity. It’s somewhat ironic because I grew up in an ultraconservative, Italian, Catholic household and was bombarded with all of the various stereotypes that we—as sex researchers, sex therapists, sex educators—fear the worst of. These include beliefs such as if you have premarital sex that no one will want to settle down with you, that masturbation is the devil’s work, that girls don’t solicit sexual activity, and so on. Growing up, I never questioned it because I didn’t have any sort of medium to compare those beliefs to. That was my entire education around sexuality—I didn’t receive sex education at school.
I should back up and say that I always had an interest in behavioral disorders, the struggle of humanity, disorders of the human mind, etc. It was in my second year of my undergraduate work that I started volunteering and I had difficulty finding a lab to volunteer in because I hadn’t had any background experience. The lab that accepted me was a rodent lab doing behavioral studies on the impact of antidepressants and other pharmaceuticals on the sexual behavior of rodents.
So I basically spent the remaining time of my undergrad as well as the two years of my Master’s degree looking at the impact of both psychosocial stressors as well as antidepressants and cortisol injections on sexual behavior. That was how I fell into doing sex research completely unintentionally. Really, it was serendipity.
In 1999, I completed my Master’s degree—but that was also the year that, in Canada, Viagra was approved and a landmark population prevalence study came out looking at how common sexual concerns are. That all kind of converged at the same time. So we had this blockbuster medication that was discreet, cheap, and effective and very readily taken up by men who were suffering from erectile problems—and at the same time, there was this large study that found 43% of women had sexual concerns. It led me to look into the literature—surely there was something comparable for women’s sexual concerns, given that they’re even more common than men’s.
My literature search was very, very brief. There was no FDA or Health Canada approved medications for women. The literature on psychosocial treatments for women’s sexual problems was very sparse and it led to me looking to women’s sexual health for my PhD, which I started and fully immersed myself in. Being in a clinical training program and hearing from both men and women about the degree of suffering around their sexual concerns, that really solidified that this was the career path for me.
It wasn’t until the day of my PhD defense that my dad found out that I had been doing sex research for the last 10 years. Happy ending to that story: my parents are quite proud of their sex researcher daughter. I’ve certainly changed their views around sexuality and it’s something we talk about openly and really recognize the importance of.
Lehmiller: What is your primary area of research and what methods do you typically use to answer your research questions?
Brotto: My primary interest is in understanding the causes of sexual concerns, primarily in women, and then evaluating psychosocial treatments. Within the psychosocial treatments, we’ve evaluated sex education, cognitive-behavioral interventions, and mostly mindfulness-based interventions, which has been my main area of interest for the last 18 or so years.
What we’ve done is taken existing evidence-based psychological treatments and adapted them to individuals with sexual health concerns. There are various adaptations we’ve made, such as when we’re doing mindfulness skills, we will emphasize a focus on feelings in the body, feelings of arousal. We’ll often pair the skills with arousal-inducing activities and then invite our participants to pay attention to those parts of the body and what that feels like.
The main methods are applied mixed methods that involve a combination of both quantitative measures, self-report measures, as well as psychophysiological measures. We use a vaginal photoplethysmograph to look at what the body does: how does the body respond before and after treatment and what’s the extent of concordance or agreement between the body’s arousal and the mind’s arousal. That degree of concordance is something we’re very interested in before and after mindfulness treatments because what we’re doing during mindfulness is enhancing the connection between the body’s sensations and the mind’s awareness of it.
We’ve also been incorporating eye tracking, mostly as a measure of attention, because part of the thinking is that problems in attention likely contribute to some of the difficulties that people face when they’re being sexual—either they’re inattentive or they’re focusing their attention on catastrophic beliefs, or even on benign distractions. We’re very interested in the extent to which our treatments can actually improve attention.
In addition to those quantitative metrics, we always include qualitative measures. So in every treatment outcome study, our participants take part in exit interviews with someone who wasn’t involved in the treatment at all. It’s an opportunity for us to really capture the ways that they experienced the treatment that are not captured by our traditional quantitative measures. Often, I would argue, that’s where the rich nuance lives. So what are the different ways in a person’s life that participating in this intervention has really impacted them?
Lehmiller: Can you tell us a little bit about one specific study you’re working on right now, perhaps the study you’re most excited about at the moment?
Brotto: Over the years, we’ve done many adaptations of our mindfulness interventions and delivered it face-to-face with individuals, couples, and groups. It’s very apparent that the people who are able to attend our face-to-face sessions represent a very small and highly specific segment of the much larger population, so there are lots of barriers that exist. For anyone who lives outside of our geographic area, anyone who doesn’t have the means to come to our sessions, or anyone who’s living in more rural and remote areas, these interventions are simply not available to them.
Over the last three years or so, we’ve been innovating a new online delivery platform that we call eSense, which has within it a mindfulness arm that really mirrors the face-to-face intervention, and it also has a cognitive-behavioral arm. We’ve now done three feasibility studies to look at how we can repackage the information in a somewhat interactive, although asynchronous way.
The findings have been so, so promising. We’ve now applied for two much larger grants to do a fuller scale, randomized trial comparing these two arms—the cognitive-behavioral therapy and the mindfulness arm—done entirely online. The reason it excites me so much is because it helps overcome the huge problem with access that we face. Access is, in part, gendered. It’s impacted by race and ethnicity, by socioeconomic factors, and by other intersections such as self-identity and sexual orientation. So this, I think, will allow us to take a look at how well our interventions work for a much broader population.
Lehmiller: One of the things I really love about your work, and especially your work on mindfulness, is that it’s very applied, very focused on practical implications and solving problems. For people who might be kind of new to the concept of mindfulness, can you tell us a little bit about what exactly that means and how people might benefit from incorporating some mindfulness practices in their everyday life?
Brotto: Mindfulness is an aspect of meditation, which has been around for millennia. It’s really been over the last 40 or so years that scientists, as well as practitioners, have simplified the practice of meditation so that it is secular. It’s accessible. You can use it anywhere, anytime. You don’t need to be in lotus pose on a mat. And it’s really simply defined as present moment, non-judgmental awareness.
So it’s a combination of two things: concentrated attention training, whereby you focus on a target of interest. That target can be a body sensation, it can be breathing, it can be sounds. Then the second component is the non-judgment or compassion work. This means that as you’re paying attention, you’re not judging yourself. You’re not berating yourself for doing this wrong. You’re not sifting through types of observations as being good or bad. Whatever arises is allowed to be there and, in fact, is supposed to be there.
As for the question of how to get started and how to incorporate that, there’s a plethora of available apps. I certainly have some of my favorites, like Headspace, Happify, and Calm. Also, many community centers offer meditation and mindfulness groups. Dharma centers do as well. You can even hop on YouTube—there’s a myriad of free and available guided meditations of varying lengths, from three minutes all the way up to an hour.
The work in bringing mindfulness into sexuality is about first starting with a basic grounded daily practice of mindfulness and then gradually incorporating it into your sex life.
Lehmiller: You’ve done research on a lot of different topics and have made several important contributions to our understanding of human sexuality. One that I wanted to briefly touch on is asexuality, which is a topic that is widely misunderstood in the general public and also by many sex therapists. Can you tell us a little bit about what your work has taught us about asexuality? For example, how is it different from low libido? Also, do you think it should be characterized as a unique sexual orientation?
Brotto: My interest in asexuality started shortly after the publication of a paper using prevalence data from a large British sample, published by Tony Bogaert. One of the questions that was asked was, “Are you attracted to men, women, both, or neither?” Of course, we know today that the categories are much broader than those four, but at that time, those were the four categories that were asked. About 1% of that sample of 18,000 respondents endorsed the neither response. In other words, not being attracted to anyone.
The media took this up like a firestorm and their interpretation was, “People are lying. How can this be possible? Maybe this is an extreme expression of lack of interest in sex?” Even some of the clinicians that I had been working with at the time (in 2005) shared concerns that these people were no different from the folks they’re seeing in their clinic who are reporting low desire.
So we launched our first study and it was a mixed methods study that involved administering some of the commonly used, validated measures of sexual response. Then we followed it up with interviews with asexual persons that were recruited through AVEN, the Asexuality Visibility and Education Network. What we found was that their experience of lack of attraction was qualitatively different from what we know about low desire.
We’ve now replicated this in a number of studies since, and what we know is that individuals who identify as asexual are not inherently distressed or bothered by their lack of attraction in the way that individuals with low sexual desire are. So when asked, “If there was a pill or a treatment that could restore your attraction or desire, would you take it?”, the asexual participants told us, “No.”
One of the other things that we looked at over the years was the extent to which their lack of attraction was due to or associated with mental health issues. So could this be a depression or an alexithymia, where a person is just incapable of experiencing and expressing emotions? Is this a social personality disorder? We’ve asked that question now over a number of studies, and we find that the rates of mental health struggles in asexuals are really not that different from the general population. Yes, there’s more perceived stigma that they face because of their asexuality, but they’re not more likely to have mental health issues.
So when we look at some of the other findings in our research, our working hypothesis is that asexuality is probably best conceptualized as a unique sexual orientation. Just like we can have folks who are interested in one gender or many genders, you can also have a person who’s not attracted to anyone or anything.
Lehmiller: My last question for you is this: in your experience as a sex researcher, what are some of the biggest misconceptions you’ve encountered about sex? This could be things you might also encounter in your clinical work as well. What are some of the things that seem to be widely believed by the public that aren’t really supported by the science?
Brotto: There are so many pertaining to sexual desire and sexual behavior that the research completely refutes. A really common one is that if you don’t feel spontaneous desire—you know, that feeling of desire that just hits you—then there’s something wrong with you and you might have a sexual problem. The data actually tell us that it’s quite common, it’s quite normative, to not have that experience of out-of-the-blue sexual desire.
Another one is that sexual desire fades with age and, in particular, that menopause sort of marks the end of sexual desire for women. Again, when we look at all the different population-based studies, there’s actually no association between a sexual desire disorder diagnosis and age. So older, as well as younger and mid-age women, are just as likely to be distressed by low desire.
The third one that I hear really commonly is that if you have to plan sex, there’s something very clinical and problematic about that. I often say to people, “What else do you do in your life that’s of interest and value and important that’s not planned?” That really speaks to this belief—maybe media fueled—that sex is always spontaneous and never planned.
In the media, you never see people put condoms on or take socks off or put kids to bed, and yet those are the realities of our lives. For desire to be something that is pleasurable and rewarding, we absolutely need to plan it. I like to turn that myth on its side and say, “We actually should be embracing the planning of sex because it allows us to prioritize, plan, and maybe even fantasize about it in the lead up.”
Lehmiller: I love that answer, especially the way you framed planning for sex. We plan for everything else that’s fun in life. For example, we plan to go to an amusement park. We plan our vacations. We plan so much of our fun—and sex is largely about fun, so why don’t we plan that as well?
Dr. Justin Lehmiller is an award winning educator and a prolific researcher and scholar. He has published articles in some of the leading journals on sex and relationships, written two textbooks, and produces the popular blog, Sex & Psychology. Dr. Lehmiller’s research topics include casual sex, sexual fantasy, sexual health, and friends with benefits. His latest book is Tell Me What You Want: The Science of Sexual Desire and How It Can Help You Improve Your Sex Life. Follow him on Twitter @JustinLehmiller.