Arch Sex Behav (2016) 45:1907–1921

DOI 10.1007/s10508-015-0689-8

ORIGINAL PAPER

Mindfulness-Based Sex Therapy Improves Genital-Subjective

Arousal Concordance in Women With Sexual Desire/Arousal
Difficulties
Lori A. Brotto1 • Meredith L. Chivers2 • Roanne D. Millman3 • Arianne Albert4

Received: 3 February 2015 / Revised: 3 November 2015 / Accepted: 30 December 2015 / Published online: 26 February 2016
 Springer Science+Business Media New York 2016

Abstract There is emerging evidence for the efficacy of mind- Keywords Sexual desire
Sexual arousal

fulness-based interventions for improving women’s sexual func- Vaginal photoplethysmography
Mindfulness
DSM-5

tioning. To date, this literature has been limited to self-reports of Sexual dysfunction
sexual response and distress. Sexual arousal concordance—the
degree of agreement between self-reported sexual arousal and
psychophysiological sexual response—has been of interest due
to the speculation that it may be a key component to healthy sex- Introduction
ual functioning in women. We examined the effects of mindful-
ness-based sex therapy on sexual arousal concordance in a sample Lack of motivation for sex affects up to 40 % of women aged
of women with sexual desire/arousal difficulties (n = 79, M age 16–44 (Mercer et al., 2003; Mitchell et al., 2013) and is the
40.8 years) who participated in an in-laboratory assessment of most common reason prompting women to seek sex therapy.
sexual arousalusing a vaginal photoplethysmograph before and When clinically significant distress accompanies the loss of sex-
after foursessionsof groupmindfulness-based sextherapy. Genital- ual desire, estimates reveal that up to 12 % of women are affected
subjective sexual arousal concordance significantly increased from (Shifren, Monz, Russo, Segreti, & Johannes, 2008). The 5th edi-
pre-treatment levels, with changes in subjective sexual arousal tion of the Diagnostic and Statistical Manual of Mental Disor-
predicting contemporaneous genital sexual arousal (but not the ders (DSM-5) defines this syndrome as‘‘Female Sexual Interest/
reverse). These findings have implications for our understand- Arousal Disorder’’(SIAD; American Psychiatric Association,
ing of the mechanisms by which mindfulness-based sex therapy 2013) and a diagnosis is made when any three of six criteria are
improvessexual functioning in women, and suggest that such treat- met for a minimum duration of 6 months and accompany clin-
ment may lead to an integration of physical and subjective arousal ically significant distress. The criteria include: (1) lack of desire
processes. Moreover, our findings suggest that future research for sex, (2) lack of sexual thoughts/fantasies, (3) lack of initia-
might consider the adoption of sexual arousal concordance as a tion and receptivity of sexual activity, (4) lack of sexual pleasure,
relevant endpoint in treatment outcome research of women with (5) inability for sexual stimuli to trigger desire, and (6) an impaired
sexual desire/arousal concerns. physical sexual arousal response.
Todate,themostwidelystudiedtreatmentforlowsexualdesire
in women has been testosterone. A large number of randomized
& Lori A. Brotto
Lori.Brotto@vch.ca
controlled studies have demonstrated the efficacy of topical testos-
terone in surgically menopausal women (reviewed by Davis,
1
Department of Gynaecology, University of British Columbia, 2013). Moreover, estimates suggest that 4.1 million prescrip-
2775 Laurel Street, 6th Floor, Vancouver, BC V5Z 1M9, Canada tions for off-label testosterone are made annually in the U.S.
2
Department of Psychology, Queen’s University, Kingston, ON, alone (Davis & Braunstein, 2012). Nonetheless, testosterone remains
Canada unregulated, and although it was approved for use in patch form
3
Department of Psychology, Simon Fraser University, Burnaby, in Europe (for surgically menopausal women with low sexual
BC, Canada desire), it is currently unavailable in North America. Various
4
Women’s Health Research Institute, Vancouver, BC, Canada other pharmaceutical agents have been the subject of clinical

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1908 Arch Sex Behav (2016) 45:1907–1921

trials for treatment of low sexual desire, but as of October 2015, Basson, & Luria, 2008a; Brotto et al., 2008c, 2012a; Brotto, Seal,
flibanserin is the only medication approved in the U.S. for this & Rellini, 2012b).
condition. The mechanisms by which mindfulness led to these improve-
Despite considerable interest in testing pharmacological options ments in women with sexual dysfunction are not entirely clear
for women’s low sexual desire, psychological treatment has been and may relate to a decrease in spectatoring—defined by Masters
themainstay of therapy for women with sexual desire difficulties. and Johnson (1970) as the process of watching oneself during sex-
Because cognitive distraction during sexual activity is prevalent ual activity from a third person perspective—a decrease in anx-
among women with sexual dysfunction, and negatively impacts iety, encouraging an attitude of acceptance and non-judgment,
their sexual satisfaction and desire (Nobre & Pinto-Gouveia, 2006), and/or an increase in perception of physical sexual response. In
this provides justification for the application of cognitive chal- support of the latter, one laboratory-based study in which female
lenging strategies (i.e., identifying, challenging, and replacing students without sexual difficulties were randomized to either an
irrationalthoughts)inherenttocognitivebehavioraltherapy(CBT). 8-week mindfulness meditation group or to an active control rated
Trudel et al.(2001)compared theeffectsofCBT (which included the intensity of their physiological responses after viewing emo-
both cognitive challenging as well as behavioral strategies) to a tional photos (Silverstein, Brown, Roth, & Britton, 2011). The pri-
wait-list control in 74 couples in which women met criteria for mary analysis focused on interoceptive awareness, the capacity to
HypoactiveSexualDesireDisorder(HSDD).After12 weeks,74 % accurately detect physical sensations, after the mindfulness inter-
of women no longer met diagnostic criteria for HSDD, and this vention. Interoception has long been of interest to emotion research-
stabilized to 64 % after 1-year follow-up. In addition to signifi- ers, and is known to correspond to an afferent pathway from parts
cantly improved sexual desire, women also reported improved of the body to the spinal cord, brain stem, and ultimately to the
quality of marital life and perception of sexual arousal, but the rightanteriorinsularcortex(Craig,2002).Studyparticipantswere
group couple therapy formatmay not be feasible in typical clini- shown a series of 31 pictures containing sexual and non-sexual
cal settings. Another treatment outcome study of 10 sessions of imagesandwereaskedtoindicatetheirlevelofphysiologicalarousal
CBT,2–3ofwhichincludedthepartner,foundonlya26 % reduc- (calm, excited, and aroused). Reaction time, or how quickly an indi-
tion in the proportion of women who had significant concerns vidualratedtheintensityofarousalintheirbody,wasusedasanindex
with low sexual desire (McCabe, 2001). Taken together, these stud- ofgreaterinteroceptiveawareness.Womeninthemeditationgroup
ies suggest that CBT is effective for a proportion of women with hadsignificantly faster reaction times thanwomenin thecontrol
low sexual desire, but such an approach may also have limitations. group, and the quickerreactiontimesignificantlycorrelatedwith
Specifically, because of the often-noted distractibility, anxiety- increasesin mindfulness, attention, non-judgment,self-acceptance,
proneness, judgmental intrusions, and inattention described by andwell-being,andwithdecreasesinself-judgmentandanxiety.Sil-
women with low sexual desire (Meston, 2006), and also because versteinetal.inferredthistomeanincreasedinteroceptiveawareness
of the varied ways in which desire is experienced (Meana, 2010; following mindfulness training that may correspond with activity in
Sand & Fisher, 2007), other skill-based approaches may be nec- the insula cortex.
essaryforwomenwhodonot benefit from cognitivechallenging. Thereismarkedindividual variabilityin the abilityto detect inter-
To address thesegaps, third-generation CBTapproaches, suchas nal physical sensations, with some individuals being highly intero-
mindfulness-based cognitive therapy, have been gaining traction ceptively aware, and others being relatively naı̈ve to changes in
in many domains of physical and psychological health. bodily reactions. Furthermore, there is marked variation in sex-
Mindfulnessmeditationhasa3500 yearhistoryandfornearly ual concordance among women. In their meta-analysis of the sex-
the past four decades has made its way into Western medicine. ual psychophysiology literature, Chivers et al. (2010) found, using
Defined as present-moment, non-judgmental awareness with a pooled sample of n = 2345 women, that variation in women’s
curiosity, openness, and acceptance (Bishop et al., 2004), mind- sexualconcordancewasnotaccountedforbyavarietyofmethod-
fulness meditation has been a major addition to the psycholog- ological factors such as the number of stimulus trials in a given
ical treatmentarsenal forthetreatment ofanxiety,depression,sub- experiment, the use of female-centered versus male-centered erotic
stance use, childhood behavior problems, and a host of medical stimuli, or stimulus length; however, higher sexual concordance
concerns, including pain, irritable bowel syndrome, fibromyal- was associated with using stimuli that varied in content, inten-
gia, and high blood pressure (Grossman, Niemann, Schmidt, & sity, or modality (r = .49) and method of calculating correlations
Walach, 2004; Merkes, 2010). Although the precise mechanisms (between-subjects [r = .29] versus within-subjects [r = .43]).
by which mindfulness is associated with symptom relief is not Chivers et al. also found that concordance among women was
fully understood, its benefits may be associated with an increase related to method of assessing genital response, with genital tem-
in metacognitive awareness, or the ability to experience thoughts perature (e.g., labial thermistors and thermographic imaging)
merely as mental events (Teasdale et al., 2002). Over the past yieldinghigherestimatesofsexual concordancethanvaginal pho-
10 years, mindfulness has been applied to and found effective toplethysmography (.55 vs. .26, respectively), although thermo-
for the treatment of sexual dysfunction in women (Brotto, graphic methods of assessing genital response also produce wide

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inter-individual variation in sexual concordance, similar to vagi- did not significantly differ from the control group (Cohen’s d
nal photoplethysmography (Kukkonen, Binik, Amsel, & Carrier, full sample = -0.56).
2010). Regardless of measurement method, broad variation in In this article, we focused on changes in concordance between
sexual concordance suggests the presence of moderators, of which genital sexual response (vaginal pulse amplitude; as measured by
sexual functioning may be one (Boyer, Pukall, & Chamberlain, vaginalphotoplethysmography)(Sintchak&Geer,1975)andcon-
2013). tinuously reported subjective sexual arousal (Rellini, McCall,
Low sexual concordance can manifest in one of two ways: Randall, & Meston, 2005) following treatment. Given that the
increases in genital sexual response in the absence of genital aware- MBST encouraged the daily practice of focusing on and experi-
nessorsexualaffect,ortheconverse.Consistently,itistheformer encing general and genital arousal responses non-judgmentally,
that is the case for sexually functional women; genital response to we expected treatment to be associated with significant increases
sexual stimuli is rapidly and automatically evoked by processing ingenital-subjectiveconcordance.Sinceparticipantswereencour-
of sexual stimuli (Chivers & Bailey, 2005), but genital awareness aged to practice mindfulnessexercises daily between groupses-
or sexual affect may not be simultaneously reported (Chivers sions,wepredicteddegreeofhomeworkcompliancewouldmod-
et al., 2010). This pattern is also common among women with eratetheincreasedconcordanceaftertreatment.Asanexploratory
Female Sexual Arousal Disorder (FSAD)—which the former analysis, we also included age, diagnosis of FSAD, and arousal
DSM-IV-TR characterized as self-reported impairments in scores from a validated measure (both subjective arousalas well
genital vasocongestion (American Psychiatric Association, as lubrication) to moderate improvements in concordance. Fur-
2000)—such that they self-reported lower sexual affect to sexual thermore, we hypothesized an increase in self-reported sexual
stimuli in the laboratory but showed a robust genital response, arousal with treatment, consistent with previous findings. We did
similar to women without sexual arousal problems (Laan, van not expect to find an effect of treatment on genital sexual response
Driel, & van Lunsen, 2008; Meston, Rellini, & McCall, 2010). per se, given evidence that vaginal pulse amplitude may not dif-
In their meta-analysis, Chivers et al. reported the average cor- fer between women with and without sexual dysfunction (Laan
relation for women with various sexual difficulties (n = 235) as et al., 2008). Finally, we predicted changes in concordance to be
.04 (-.10 to .17), whereas for women without sexual difficulties associated with improvements in sexual desire and with decreases
(n = 1144), the correlation was .26 (.21 to .37). in sex-related distress.
Sexualconcordancemayberelatedtosexualfunctioningamong
healthy women, such that greater concordance is associated with
more frequent experience of orgasm (Adams, Haynes, & Brayer, Method
1985; Brody, 2007; Brody, Laan, & van Lunsen, 2003). Coupled
withdatashowinghighersexualconcordanceamongwomenwith- Participants
outasopposedtowithasexualdysfunction,thesedatasuggestthat
sexual concordance may be a key component to healthy sexual Participants were part of a larger study evaluating outcomes of
functioning in women. Current treatments for sexual dysfunction, group mindfulness-based sex therapy on various indices of sex-
however, do not focus on skills that may enhance women’s sexual ual desire, sexual response, and affect (Brotto & Basson, 2014).
concordance nor have treatment efficacy studies used sexual con- Women seeking treatment for sexual desire and/or arousal con-
cordance as a primary outcome. cerns from the British Columbia Centre for Sexual Medicine,
In light of mounting evidence that mindfulness improves whether the difficulties were lifelong or acquired, were eligible
women’s self-report of sexual function and awareness of bodily to participate. Inclusion criteria included: age between 19 and
sensations, and that concordance between genital and self-re- 65 years, fluent in English, and willing to complete all four group
ported arousal may be relevant to women’s sexual interoceptive sessions, regular homework, as well as assessment measures (con-
awareness, the current study was designed with these themes in sistingof both self-report questionnaires and a laboratory-based
mind. Specifically, the goals were to: (1) examine the effects of a psychophysiological sexual arousal assessment) at three time
group mindfulness-based sex therapy (MBST) on concordance points. Women with difficulties in achieving orgasm were also
between genital and subjective sexual arousal; (2) examine the includedaslongasthosewerenotexperiencedasmoredistressing
effects of treatment on self-reported sexual arousal and, sepa- than the desire and/or arousal concerns. We excluded any woman
rately, on genital arousal; and (3) test the relationship between with dyspareunia (chronic genital pain not resolved with a per-
changesin concordance and improvements in clinical symptoms sonal lubricant).
(i.e., sexual desire and sex-related distress) with treatment. A Theoriginal studydescribing treatment efficacy included117
separate publication documents the significant beneficial effect women who provided pre-treatment assessment data. The data
of this MBST compared to a delayed treatment control group here focus on 79 women who had complete data from their psy-
on the primary endpoint of self-reported sexual desire (Cohen’s chophysiological assessments (both genital and subjective arousal)
dtreatment = 0.97; dcontrol = 0.12) (Brotto & Basson, 2014). Sex- atallthreetimepoints—immediatepre-treatment,post-treatment,
related distress also significantly improved with treatment, and and 6-month follow-up. The sample included 41 (51.9 %) women

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who were assigned to the immediate treatment group and 38 viewing stimuli. Women were instructed to move the mouse
(48.1 %) women who received treatment after an initial 3-month up and down the track over the course of the film to indicate
wait-list period. Only pre- to post-treatment data for women in their level of subjective sexual arousal, from 7 to -2, with 7 =
thecontrol groupwereincluded(i.e.,theirwait-listdatawerenot). Highest Level of Sexual Arousal, 0 = No Sexual Arousal, and
Also, in this article, we did not include data from the control group -2 = Sexually Turned Off. We have previously used this device
for their two pre-treatment assessments, so the present analyses in treatment outcome studies on women with sexual dysfunction
did not compare the effects of treatment versus wait-list control (Brotto et al., 2012b). Like VPA data, the mean contemporaneous
on concordance. The mean age of the sample was 40.8 years (SD sexual arousal response was obtained every 30-s, producing six
11.5, range 20–65). A total of 84.6 % were in a committed rela- data points during the neutral film and 13 data points during the
tionship, 6.4 % were casually dating, and 9.0 % were single. The erotic film, corresponding with the 30-s epochs of VPA data.
mean relationship length was 13.2 years (SD 10.7). Most partic-
ipants were of Euro-Canadian descent (81.0 %) followed by East
Discrete Measure of Sexual Response and Affect
Asian (7.6 %) and South Asian (2.5 %). This was a highly edu-
cated group in that 67.1 % had some post-secondary education,
The Film Scale, a 33-item self-report questionnaire, was used
and 22.8 % had an advanced graduate degree.
to assess subjective arousal and affective reactions to the erotic
Although all participants self-reported difficulties with sexual
films. This scale was adapted from Heiman and Rowland (1983)
desire and/or arousal and met criteria for the DSM-5 diagnosis of
and assessed six domains: subjective sexual arousal (1 item),
SIAD, 33 (41.8 %) women met DSM-IV-TR (American Psychi-
perception of genital sexual arousal (4 items), autonomic arousal
atric Association, 2000) diagnostic criteria for HSDD and 24
(5items),anxiety(1item),andpositiveandnegativeaffect(11items
(30.4 %) women met criteria for FSAD. The remaining 22
each). The scale has been found to be a valid and sensitive mea-
(27.8 %) women met criteria for both HSDD and FSAD.
sureof emotional reactions to erotic stimuli. Items wereratedon
a 7-point Likert scale from Not at All (1) to Intensely (7). Pre-
Measures
treatment reliability for the Film Scale during the neutral phase
was very good (Cronbach’s alpha = 0.82) and excellent following
Assessment of Psychophysiological Sexual Arousal
the erotic phase (Cronbach’s alpha = 0.94).
Genital response was measured with a vaginal photoplethys-
mograph(Sintchak& Geer, 1975)consistingofatampon-shaped Homework Compliance
acrylic vaginal probe, inserted in private by the participant. The
probe (Behavioral Technology Inc., Salt Lake City, UT) contin- Homework compliance was rated by the group facilitators on a
uously measured vaginal pulse amplitude (VPA) during the neu- Likert scale from 0 (did not complete homework/did not attend
tral and erotic film segments. VPA was recorded using a personal sessions) to 2 (notable efforts at completing homework/attend-
computer(HPPentiumMLaptop)thatcollected,converted(from ing sessions). A rating was given for each participant at each of
analog to digital, using a Model MP150WSW data acquisition the four group sessions, and then a mean score across the sessions
unit [BIOPAC Systems, Inc.]), and transformed psychophysi- was derived.
ological data, using the software program AcqKnowledge III, Ver-
sion3.8.1(BIOPACSystems,Inc.,SantaBarbara,CA).Thesignal Female Sexual Arousal Disorder symptoms
wassampledat200 Hzandbandpassfiltered(0.5–30 Hz).Atrained
research assistant performed artifact smoothing of the signal fol- Subscales of‘‘Arousal’’and‘‘Lubrication’’on the Female Sex-
lowingvisual inspectionofthedataandbeforedatawereanalyzed. ual Function Index (FSFI) (Rosen et al., 2000) were used in mod-
VPA data were subsequently divided into 30-s epochs, producing eration analyses. The FSFI is a 19-item self-report questionnaire
six data points for the neutral film and 13 data points for the erotic considered to be the gold standard measure of sexual function in
film for each sexual arousal assessment. women. There were 4 items in the Arousal domain and 4 items in
the Lubrication domain; responses were coded on a 5-point Likert
Contemporaneous Assessment of Subjective Sexual Arousal scale. A respondent who had not engaged in sexual activity for the
past 4 weeks was excluded from those items. Cronbach’s alpha for
Subjective sexual response was measured continuously during these two domains was excellent (a = 0.89 and a = 0.93, respec-
the neutral and erotic films with an arousometer that was con- tively) for the current sample.
structed by a local engineer modeled after the one described by Sexual Desire was measured with the 14-item Sexual Inter-
Rellini et al. (2005). This device consisted of a computer optic est/Desire Inventory (SIDI) (Claytonet al.,2006). Possible total
mouse mounted on a plastic track with 10 intervals, and was scores range from 0 to 51, with higher scores indicating higher
affixed to the arm rest of the recliner so that the participant could levels of sexual interest and desire. The SIDI has excellent inter-
easily move the mouse, while simultaneously reclining and nal consistency (Cronbach’s a = 0.90). Item-total correlations

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were high for‘‘Receptivity,’’‘‘Initiation,’’‘‘Desire-frequency,’’ environment, participants were encouraged to relax on a com-

‘‘Desire-satisfaction,’’‘‘Desire-distress,’’and‘‘Thoughts-positive’’ fortable reclining chair for a 10-min period after the probe was
(r[.70), good for‘‘Relationship-sexual,’’‘‘Affection,’’‘‘Arousal- inserted. Subjective sexual arousal and affect were assessed at
ease,’’and‘‘Arousal-continuation’’(r[.50), but poor for the orgasm the end of the adaptation period using the Film Scale, which
item(r = .10)(Claytonetal.2006).Cronbach’salphaforthecurrent served as the discrete assessment of arousal and affect before the
sample was a = 0.76. erotic film sequence.
Sexual Distress was measured with the 12-item Female Sex- Before the film sequence began, women were reminded to
ual Distress Scale (FSDS) (DeRogatis, Rosen, Leiblum, Burnett, use the arousometer to capture their subjective sexual arousal
& Heiman, 2002). Scores can range from 0 to 48, where higher throughout the film sequence. The researcher instructed partic-
scores represent higher levels of distress. The FSDS has been ipants to:‘‘Monitor your subjective feelings of sexual arousal to
shown to have good discriminant validity in differentiating the film by using this device. By ‘subjective feelings of sexual
between sexually dysfunctional and sexually functional women, arousal,’ we mean how mentally sexually aroused you are in
with 88 % correct classification rate, and found to have satis- your mind while you’re watching the film.’’Further instructions
factory internal consistency (ranging from 0.86 to 0.90) (DeRo- were given on the numerical demarcations on the device and
gatis et al., 2002). Reliability for the current sample was excel- what the upper (most sexual arousal you have experienced orcan
lent at a = 0.92. imagine) and lower (sexually turned off) anchors reflect. Partic-
ipants practiced moving the arousometer in the presence of the
Procedure researcher and any questions on its operation were addressed
before the film sequence began.
Following a comprehensive assessment by an experienced sexual The researcher then initiated the video sequence from the
medicine clinician, eligible women were informed about the adjoining room. The audio component was delivered via wire-
study. If interested, they were provided with a one-page brochure less headphones to the participant. Women watched a 3-min
outlining information about the study and contact information for neutral documentary about Hawaii followed by a 7-min erotic
the study’s coordinator. Next, they took part in a telephone screen film that depicted a heterosexual couple engaging in foreplay,
that further explained the study procedures, provided some infor- oral sex, and penile–vaginal intercourse. There were three dif-
mation about the treatment content, and informed women about ferent film sequences counterbalanced across women and ses-
upcoming schedules for the MBST groups. They were then mailed sions so that participants viewed the same film only once over
a consent form. The return of a signed consent form indicated the three testing sessions. Immediately after the video sequence,
informed consent, at which time women were assigned to par- participants completed the Film Scale a second time, which asked
ticipate in either the immediate treatment group or the delayed them to evaluate their subjective sexual arousal and affect to
treatment group. Whenever possible, we utilized random assign- the erotic film. They were then instructed to remove the probe and
ment to group; however, in cases where participants’ schedules meet the researcher in a separate room. After a debriefing period,
werenotflexible,weassignedwomentothegroupthataccommo- the researcher disinfected the probe in a solution of Cidex OPA
dated their schedules. Participants were then scheduled for a base- (ortho-phthalaldehyde 0.55 %), a high level disinfectant (Advanced
line sexual arousal assessment to take place in a sexual psy- Sterilization Products, Irvine, CA, USA), promptly following
chophysiology laboratory. Women were also mailed a package of each session.
questionnaires and asked to return them completed at the time of All procedures were approved by the Clinical Research
their sexual arousal assessment. These same questionnaires and Ethics Board at the University of British Columbia and the Van-
sexual arousal assessment were repeated 2–4 weeks after the couver Coastal Health Research Institute. All procedures were
completion of their MBST group as well as 6 months later. The carried out in accordance with the provisions of the World Med-
duration between baseline and the two subsequent assessments ical Association Declaration of Helsinki.
was relatively equal across all participants, with no more than
2-week variation, typically at the follow-up assessment. Mindfulness-Based Sex Therapy
The sexual arousal assessment took place in a sexual psy-
chophysiology laboratory, located in the university hospital, and The MBST (Brotto, Basson, & Luria, 2008b) was based on an
housed a comfortable reclining chair, a large screen TV, and an integration of psychoeducation, sex therapy, and mindfulness-
intercom. A thin blanket was placed over the seating area of the based skills, the latter of which have received extensive empir-
chair. Following written consent, participants were tested by a ical support in other populations (Grossman et al., 2004). Stem-
female researcher. Women were first shown the vaginal photo- ming from evidence that women with sexual desire/arousal dif-
plethysmograph and encouraged to ask any questions about how ficulties are often distracted during sexual activity and/or judg-
to insert it. The female researcher then left the room, while mental (of themselves or their partners), mindfulness skills were
participants inserted the probe and informed the researcher via primarily aimed at orienting the woman to the present experi-
intercom of their readiness. In order to habituate to the testing ence, while simultaneously noting negative thoughts as‘‘mental

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events’’—something to be noticed but not focused on. Consis- In-session mindfulness practice centered on‘‘Breath and body’’
tent with mindfulness-based cognitive therapy for prevention of as the focus of attention. Like the Body Scan, participants were
depression relapse (Teasdale et al., 2000), MBST aims to help guided to notice and attend to various parts of the body, includ-
women develop awareness in all areas of their life, including real ing sensations associated with breathing and the breath itself. In
andanticipatedsexualsituations.Atleast4weekswerespentencour- mindfulness-based therapy for depression (Basson, 2001), this
aging women to practice mindful self-awareness in non-sexual sit- practice also typically follows a foundation of practice using the
uations as a means of developing the skill of moment-by-moment Body Scan. For homework, participants were encouraged to do a
awareness. In-session‘‘inquiries’’following mindfulness practice ‘‘seeing meditation’’with their genitals as the focus of the prac-
were intended to allow participants to view their practice as a depar- tice. They were asked to observe their genitals with a hand-held
ture from their typical mode of being, which may have been char- mirror, and in addition to noticing moment-by-moment visual
acterizedasfuture-oriented,multi-tasking,and/orruminativeabout and bodily sensations, they were also asked to take note of any
pastevents.Atlaterstagesofthegroup,womenwerethenencour- follow-on thoughts, emotions, or beliefs as a result of the seeing
aged to apply their new skills in progressively more sexual situa- practice.
tions—first on their own(followingexposure to an erotic stimulus Session 3 began with an in-depth review of the home body-
such as a vibrator or erotic film), and next together with a partner oriented mindfulness practice, and participants were encour-
(if applicable, during actual sexual activity). The aim of the home aged to start to think about the relevance of this practice to their
practice was to encourage participants to develop a regular mind- sexuality more broadly. Next, there was in-session psychoedu-
fulness practice and acquire experience observing thoughts,espe- cation on Gottman’s principles for lasting relationships (Gott-
cially negative ones, as mental events, before introducing practice man & Silver, 1999). The guided in-session practice utilized
together with a partner, or applying mindfulness during at-home mindfulness of thoughts, and the practice was followed by a dis-
sexual activities. Although sensate focus shares with mindfulness cussion on the high prevalence of automatic thoughts/logical
thegoalofpresent-momentawareness,theformerrequiresapartner errors of thinking, and using the cognitive behavioral model to
to be present and does not have the advantage of portability that illustrate the association between thoughts, emotions, and beh-
mindfulness has (i.e., in homework activities women were enco- aviors. The discussion also highlighted how mindfulness skills
uraged to use informal mindfulness practice throughout their days are aimed at simply bringing awareness to negative/judgmental
tocomplement theformal practices).Concurrent with theprinciples thoughts and were contrasted with CBT skills, which are aimed
ofmindfulness, women wereencouraged at thestart of Session 1 to at identifying and challenging problematic thoughts. For home
‘‘letbe’’strongwishesforchange,andforthedurationofthesessions practice, women were encouraged to repeat the mindfulness of
to focus instead on being fully in the present. Goals for the group genitals exercise from the previous 2 weeks in which they obs-
were not elicited. erved their genitals moment-by-moment and non-judgmentally,
In the current study, treatment was delivered by two group but this time were also encouraged to incorporate the sensation
facilitators (selected from a trained pool of six sexual medicine of touch. This was framed as a non-masturbatory exercise
physicians, psychologists, and upper-level residents/graduate designed to enhance mindful awareness of genital sensations.
students)to groupsconsisting of 4–7 women. Sessions took place Session 4 was devoted to home practice review followed by
in a large group room at the BC Centre for Sexual Medicine, and an introduction of sensate focus to be used with a partner (if
each 90 min session was spaced 2 weeks apart. available). The facilitator explained the first (of three) phase of
sensate focus as originally defined by Masters and Johnson
Contents (1970). Specifically, sensate focus was described as having the
goals of: tuning into sensations (and in this way, women were
Session 1 provided educational information on the prevalence encouraged to use the mindfulness skills they had been devel-
and known etiology of low desire and arousal. Mindfulness was oping), relaxation, and providing feedback to a partner about the
then introduced through in-session practice of the‘‘Body Scan,’’ received touch. In-session trouble-shootingaround common bar-
which is also the foundational practice in mindfulness-based riers, such as finding the time for the hour-long practice, then fol-
therapies (Teasdale et al., 2000). By orienting attention to var- lowed.Sensate focuswasdescribed specificallyasanon-demand
ious parts of the body, women were encouraged to become exercise (Weiner & Avery-Clark, 2014); if women (or their part-
aware of sensations in that region and any subsequent ‘‘mental ners)experiencedsexualexcitement,theywereencouragedtonotice
events’’(thoughts, beliefs, emotions, other cognitive activity) that the accompanying sensations in the same way they had practiced
follow on the awareness of sensations. After a guided in-session noticing sensations during the Body Scan. The second half of the
practice, participants were encouraged to practice the Body Scan finalsessionprovidedanoverviewontheuseofcognitiveandtactile
daily at home, and were provided an audio-recorded guide. toolstoaugmentsexualresponse(e.g.,fantasy,erotica,andvibrators)
Session 2 provided an opportunity for in-depth homework during mindfulness practice. Specifically, instructions were pro-
review, followed by psychoeducation on sexual anatomy and vided to women to elicit a sexual arousal response using one of
physiology and the circular sexual response cycle (Basson, 2001). these tools, and then use those sensations as the focus during a

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mindfulness practice, and they were encouraged to try this at subscales of the FSFI (Rosen et al., 2000)] changed the degree of
leasttwotimesathome.Byelicitingastrongerbodilyresponsewith concordance between genital and subjective sexual arousal at
these erotic aids, we hypothesized greater facilitation of inte- each of the time points.
roceptive awareness. The group ended following a discussion of To aid in the interpretation of the magnitude of concordance
strategiesformaintainingmindfulnesspracticeat home,andwith between genital and subjective sexual arousal, we also carried out
the encouragement to view these four sessions as potentially the within-subjects and between-subjects Pearson r correlation coef-
beginningofalifelongpracticeusingmindfulnessbothinsexualand ficients on VPA and continuous self-reported arousal during the
non-sexual aspects of their lives. Whenever possible, the facilita- erotic segment of the film only. In this way, concordance estimates
tors referenced published findings on the efficacy of mindful- could be compared to the mean concordance values from a
ness therapy in other populations, and integrated emerging knowl- meta-analysis of several psychophysiological studies (Chivers
edge on the impact of mindfulness practice on neural plasticity and et al., 2010).
brain function. All material was compiled into a facilitator and
participant manual that included space for personal practice Hypothesis 2
notes and observations (Brotto et al., 2008b).
We predicted that treatment would be associated with significant
Data Analyses improvements in self-reported sexual arousal and affect but not
with any significant changes in genital sexual response measured
Hypothesis 1 in-laboratory.Wetookdifferencescoresfromresponsesfollowing
the erotic stimulus minus mean scores during the baseline period,
We predicted a significant effect of MBST on increasing con- asperCliftonetal.(2015).Wenextcarriedoutarepeatedmeasures
cordance between genital and subjective sexual arousal. Mul- analysis of variance (ANOVA) across the three assessment points
tilevel methodology was used to assess this question as it allows on these difference scores. To examine the effects of treatment on
for the examination of changes within an individual (rather than genital sexual response, a similar mixed within-between repeated
averages across individuals) and has specifically been used to measures ANOVA was carried out on VPA percent change score,
examinechangesinsexualconcordance(Clifton,Seehuus,&Rellini, which was calculated as follows: (mean erotic VPA minus mean
2015;Rellinietal.,2005).WeusedtheHierarchicalLinearModeling neutral VPA) divided by mean neutral VPA, as per Clifton et al.
software program (HLM 6.08) (Raudenbush, Bryk, & Cong- (2015).
don, 2004) to test whether concordance significantly increased
from pre-treatment to post-treatment, and again at six-month Hypothesis 3
follow-up.
We used a two-level model with repeated measures modeled We predicted an association between concordance and clinical
at Level 1 to estimate intercepts (mean of the outcome variable at symptoms—namely, sexual desire, and sex-related distress.
the start of the erotic film) and trajectories of change (slopes) in Firstly, Spearman’s rank correlation coefficient (rho) was used as
the outcome. We standardized all Level 1 variables across waves the estimate of concordance between VPA and subjective aro-
prior to analyses, allowing for the interpretation of the coefficients usal for each woman at each time point (pre-, post-treatment, and
as standardized betas. All coefficients were modeled as random follow-up) separately. These concordance estimates were then
(Nezlek, 2001). used as a fixed variable in a mixed-effects model examining the
First, we assessed the effect of the intervention on the con- relationship between either SIDI scores (measuring sexual desire)
temporaneous (e.g., T30s ? T30s, T60s ? T60s, and so on) relation and concordance over time points, or FSDS scores (measuring
between genital and continuous subjective arousal (i.e., whether sex-related distress) and concordance. The models included con-
genital arousal predicted contemporaneous subjective arousal, cordance, time point (pre-, post-treatment, and follow-up), and
and whether subjective arousal predicted contemporaneous genital their interaction, as well as participant ID as a random nesting
arousal).Themodeltestedthesimpleslopesofsexual concordance effect.
ineach timeperiodseparately(i.e.,againstaslopeofzero).Dummy
coded time variables were included to control for any mean dif-
ferences in the outcome of interest at the different assessment Results
points.
Second, we conducted five Level 2 moderation analyses to Concordance Between Genital and Continuous
determine if age, homework compliance, or FSAD status [asse- Subjective Sexual Arousal (Hypothesis 1)
ssed in two ways; firstly, as a dichotomous variable according to
whether the woman had a clinical diagnosis of FSAD or not, and Results of the contemporaneous analyses are shown in Table 1
secondly using continuous scores on the lubrication and arousal and indicated that genital and subjective arousal covaried

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Table 1 Contemporaneous reciprocal associations between genital and subjective arousal

Coefficient SE t ratio p

SA ? VPA
Pre-treatment 5.71 9 10-2 0.005 10.92 \.001
Post-treatment 6.40 9 10-2 0.004 16.68 \.001
-2
Follow-up 5.98 9 10 0.005 12.85 \.001
SAPre-treatment 8.12 9 10-3 0.004 1.99 .05
SAPost-treatment 5.25 9 10-3 0.001 3.50 .001
SAFollow-up 5.01 9 10-3 0.001 3.40 .001
VPA ? SA
Pre-treatment 1.82 0.26 6.87 \.001
Post-treatment 1.88 0.23 8.22 \.001
Follow-up 1.70 0.19 8.97 \.001
VPAPre-treatment 1.79 0.50 3.58 .001
VPAPost-treatment 1.37 0.28 4.96 \.001
VPAFollow-up 1.08 0.26 4.20 \.001
df = 78
VPA Vaginal pulse amplitude (genital arousal), SA subjective arousal

throughouttreatment.Specifically,increasesinsubjectivearousal of all v2 difference tests comparing the unconstrained and con-

predicted contemporaneous increases in genital arousal, and strained models, pre-treatment = post-treatment, v2(1) = 10.40,
increases in genital arousal predicted contemporaneous increases p = .001; pre-treatment = follow-up, v2(1) = 10.34, p = .001;
in subjective arousal. post-treatment = follow-up, v2(1) = 12.30, p\.001, showed that
the unconstrained model fits the data significantly better. In other
Subjective Arousal Predicting Genital Arousal words, the degree of concordance between subjective and genital
arousal at each time point was significantly different from every
When examining the association between subjective arousal other time point. Further, these differences were in the expected
and contemporaneous genital arousal, SAPre-treatment (top half of directionsuchthatbetavaluesdecreasedovertime(i.e.,therewas
Table 1) represents this association during pre-treatment. This less change in genital arousal associated with the same level of
coefficient was significant, indicating that for every one stan- subjective arousal over time).
dardized unit of subjective arousal increase, women showed an
average corresponding increase of 0.008 millivolts in VPA, Genital Arousal Predicting Subjective Arousal
equivalent to a 0.16 standard deviation increase in VPA. SAPost-
treatment and SAFollow-up were also statistically significant, indi- In examining the association between genital arousal and con-
cating that for every one standardized unit of subjective arousal temporaneous subjective arousal, VPAPre-treatment (bottom half of
increase, women showed an average corresponding increase of Table 1) represents this association during pre-treatment. This
0.00525 millivolts in VPA at post-treatment and 0.00501 mil- coefficient was significant, indicating that for every one stan-
livolts in VPA at follow-up, respectively. This corresponds to an dardized unit of genital arousal increase, women showed an
average increase of 0.15 standard deviations in VPA at post- average corresponding increase of 1.79 units of subjective arou-
treatment and 0.12 standard deviations at follow-up. sal, equivalent to a 1.16 standard deviation increase in subjective
To examine whether sexual concordance significantly dif- sexual arousal. VPAPost-treatment and VPAFollow-up were also sta-
fered at pre-treatment, post-treatment, and follow-up, we tistically significant, indicating that for every one standardized
examined the model with no constraints and compared this to unit of physiological arousal increase, women showed an average
models constraining every unique pair of concordance ratios to corresponding increase of 1.37 units of subjective arousal at post-
be equal. The models were compared using standard v2 differ- treatment and 1.08 units of subjective arousal at follow-up, respec-
ence tests in which the goodness-of-fit for two models is differ- tively. This corresponds to an average increase of 0.76 standard
enced (Schermelleh-Engel, Moosbrugger, & Müller, 2003). If deviations in subjective sexual arousal at post-treatment and 0.64
themodel withmore constraintsresultsina significant increasein standard deviations at follow-up.
the overall v2, this is indicative of a poorer fit, and the model with Toexaminewhethersexualconcordancesignificantlydiffered
no constraints is retained. After applying the conservative Bon- at pre-treatment, post-treatment, and follow-up, we again exam-
ferroni correction for multiple tests (a = 0.05/3 = .017), results ined the model with no constraints and compared this to models

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Arch Sex Behav (2016) 45:1907–1921 1915

constraining every unique pair of concordance ratios to be equal. FSAD status (assessed dichotomously according to whether
Results of all v2 difference tests comparing the unconstrained women had a clinician-determined diagnosis of FSAD or not;
model with constrained modelsshowedno statistically significant n = 79), and using mean scores on the lubrication (n = 62) and
difference in fit, pre-treatment = post-treatment, v2(1) = 0.71, arousal (n = 62) domains of the FSFI (measured continuously)
p = .40;pre-treatment = follow-up,v2(1) = -0.56,p = .46; post- changed the degree of concordance between genital and sub-
treatment = follow-up, v2(1) = 1.49, p = .22, indicating that the jective sexual arousal at each of the time points. All time points
degree of concordance between genital and subjective arousal at were included in the moderation analyses for age and FSAD
eachtime point was not significantlydifferent from any othertime status, while only post-treatment and follow-up were included
point. in the moderation analyses involving homework compliance
We calculated both within-subjects correlations and between- (homework had not yet been assigned at pre-treatment).
subjects correlations and these are shown in Table 2. Across Neither age, diagnosis of FSAD, continuous FSFI scores on
time points, the magnitude of the correlation between genital and the lubrication and arousal domains, nor homework compliance
subjective sexual arousal was larger for within-subjects correla- moderated the association between contemporaneous subjective
tions (range .28 to .33) than for between-subjects correlations and genital arousal as an outcome (ps ranged from .21 to .79).
(range .13 to .22). Using a paired samples t test comparing pre- to Similarly, neither age nor FSAD status (assessed dichotomously
post-treatment,andaseparateonefrompost-treatmenttofollow-up and continuously with the FSFI) moderated the contemporaneous
revealednostatisticallysignificant differencesforwithin-subjects (ps ranged from .35 to .92) association between genital and sub-
concordance estimates. The same non-significant results were found jective sexual arousal as an outcome. Degree of homework com-
using Fisher’s r-to-z transformation for the between-subjects con- pliance was, however, found to moderate this association, such
cordance estimates (Table 2). that greater homework compliancewasassociatedwith an increase
Focusing specifically on the within-subjects correlations, the in the number of subjective arousal units associated with a stan-
rangeofconcordanceestimatesatpre-treatmentwas-.90to?.91. dardized unit increase in genital arousal (Table 3). Specifically,
A total of 19.1 % had negative concordance (defined here as foreverystandardizedunitincreaseofgenitalarousal,womenshowed
r B -.25), 10.6 % had no concordance (defined here as -.24\ a marginally significantly greater increase in subjective arousal
r\.24), and 70.2 % had positive concordance (defined here as with more homework compliance at post-treatment (t = 1.67, p =
r C .25). At post-treatment, the range was similarly large: -.80 .10) and a significantly greater increase in subjective arousal with
to .94 with 15 % having negative concordance, 20 % having no greater homework compliance at follow-up (t = 2.13, p = .04).
concordance, and 65 % having a positive concordance.
Effects of Erotic Film and Treatment on Self-Reported
Moderation of the Association Between Genital and Sexual Arousal and Affect (Hypothesis 2)
Continuous Subjective Arousal
To test the ability of the erotic film to significantly increase self-
Five separate Level 2 moderation analyses were conducted to reported sexual arousal and affect, a paired samples t test was used
determine if age (n = 79), homework compliance (n = 78), or to compare mean scores on Film Scale domains before the neutral
film and after the erotic film at post-treatment. There was a sig-
Table 2 Concordance between genital and continuous subjective sexual nificant increase in perception of genital sexual arousal, t(78) =
arousal calculated with within-subjects correlations and between-subjects -10.53, p\.001, d = 1.93; subjective sexual arousal, t(78) =
correlations across three time points
-8.66, p\.001, d = 1.38; positive affect, t(78) = -6.43,
Pre-treatment Post-treatment Follow-up p\.001, d = 1.20; autonomic arousal, t(78) = -7.36, p\.001,
d = 1.23; negativeaffect,t(78) = -3.47,p = .001,d = 0.59,anda
Within-subjects .30 (.54) .33 (.47) .28 (.47)
correlations significant decrease in self-reported anxiety, t(78) = 2.62, p =
n = 47 n = 60 n = 76
.011, d = -0.42, following the erotic film. These findings suggest
Between-subjects .22 .13 .14
correlations that the erotic film was effective at eliciting a subjective sexual
n = 79 n = 79 n = 79
response at post-treatment (Table 4).
Within-subjects correlations used responses during the erotic segment of A repeated measures ANOVA did not find a significant effect
the film only and continuous measures of subjective sexual arousal.
of treatment on subjective sexual arousal difference scores, F(2,
Sample sizes vary due to missing data. Paired samples t test revealed no
significant difference from pre- to post-treatment, t(46) = -0.21, p = 156)\1, p = .861, d = 0.05 from pre- to post-treatment; d = 0.06
.835; or from post-treatment to follow-up, t(58) = 0.76, p = .448. Between- from post-treatment to follow-up. Perception of genital sexual
subjects correlations were calculated with percent change in genital sexual arousal similarly did not significantly change with treatment, F(2,
arousal from neutral to erotic film conditions, and using the difference
156)\1, p = .747, d = 0.07 from pre- to post-treatment; d = 0.05
between neutral to erotic film conditions for discrete self-reported sexual
arousal. Fisher’s r-to-z transformation found no significant difference from from post-treatment to follow-up.
pre- to post-treatment, z = 0.61, p = .542; or from post-treatment to fol- Focusingonaffect,arepeatedmeasuresANOVAdidnotfinda
low-up, z = -0.06, p = .952 significant effect of treatment on the change in positive affect

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1916 Arch Sex Behav (2016) 45:1907–1921

Table 3 Homework compliance as a moderator of the association between increased VPA at pre-treatment, t(78) = -2.00, p = .049; at post-
genital and contemporaneous subjective arousal as an outcome treatment, t(78) = -2.00, p = .049; at post-treatment, t(78) =
Coefficient SE t ratio p -2.78, p = .007; and at follow-up, t(78) = -2.19, p = .032, veri-
fying the sexually arousing properties of our erotic stimuli
VPA(T) ? SA(T)
(Table 4).
Post-treatment To examine the effects of treatment on VPA percent change
Low HC 1.76 0.20 8.94 \.001 scores, a repeated measures ANOVA across all three time points
High HC 2.79 0.36 2.83 .006 was carried out and found not to reach statistical significance, F(2,
Follow-up 156) = 2.58, p = .079; d = 0.28 from pre- to post-treatment;
Low HC 1.45 0.14 10.46 \.001 d = -0.34 from post-treatment to follow-up.
High HC 2.50 0.33 3.22 .002
VPAPost-treatment
Low HC 0.94 0.23 4.16 \.001 Association Between Sexual Concordance and Clinical
High HC 1.57 0.38 1.67 .10 Symptoms Using the Sexual Interest/Desire Inventory
VPAFollow-up and the Female Sexual Distress Scale (Hypothesis 3)
Low HC 0.59 0.12 5.06 \.001
High HC 1.14 0.26 2.13 .04 Significance of the interaction term and the main effects were
df = 76
estimated using likelihood-ratio tests comparing the fit of the
model containing theterm versus the fit ofthe model withthe term
VPA vaginal pulse amplitude (genital arousal), SA subjective arousal, HC
homework compliance removed. p-values\.05 were considered as indicating a signifi-
cant relationship between the term of interest and the outcome
from neutral to erotic film conditions, F(2, 156) = 2.54, p = .082, variable. There was no significant interaction between time and
d = 0.14 from pre- to post-treatment; d = 0.08 from post-treat- concordance for either SIDI or FSDS (Likelihood-ratio test statis-
menttofollow-up.Asimilarpatternwasfoundfornegativeaffect, tic [LRT] = 3.9, p = .15, and LRT = 3.2, p = .21, respectively).
with no significant effect of treatment, F(2, 156)\1, p = .948, This suggests that any relationship between concordance and the
d = 0.00 from pre- to post-treatment; d = 0.04 from post-treat- clinical symptoms of desire (SIDI) and distress (FSDS) did not
ment to follow-up. differ significantly over the time periods. If the interaction terms
were removed, there was still no significant relationship between
Effects of Erotic Film and Treatment on Genital Sexual either SIDI or FSDS and concordance (LRT = 0.2, p = .68, and
Arousal (Hypothesis 2) LRT = 0.0, p = .99, respectively); however, there was a signifi-
cant effect of time period for both outcomes (SIDI: LRT = 17.3,
To test the ability of the erotic film to significantly increase genital p = .0002; FSDS: LRT = 9.0, p = .01), with SIDI scores increasing
sexual responseateachtimepoint,apairedsamples t testwasused significantly post-treatment and remaining high at follow-up,
to compare mean VPA (in mV) from the neutral to the erotic film. and FSDS scores decreasing significantly at post-treatment
A paired samples t test revealed that the erotic film significantly and remaining low at follow-up.

Table 4 Effects of erotic film on discrete measures of subjective sexual arousal, perception of genital arousal, positive affect, negative affect, autonomic
arousal, anxiety, and vaginal pulse amplitude (VPA) from neutral to erotic films at pre-treatment, post-treatment, and follow-up
Pre-treatment Post-treatment Follow-up
Neutral Erotic Neutral Erotic Neutral Erotic

Subjective arousal 2.91 1.14*** 4.27 1.41 3.04 1.19*** 4.47 1.30 2.97 1.10*** 4.32 1.34
Perception of genital arousal 1.45 0.58*** 2.80 1.31 1.51 0.66*** 2.93 1.36 1.46 0.59*** 2.83 1.29
Positive affect 1.71 0.64*** 2.49 1.41 1.63 0.66*** 2.57 1.46 1.54 0.53*** 2.57 1.38
Negative affect 1.38 0.44*** 1.52 0.57 1.26 0.36*** 1.40 0.50 1.28 0.35*** 1.43 0.53
Autonomic arousal 1.58 0.54*** 2.25 0.92 1.56 0.62*** 2.37 1.00 1.52 0.61*** 2.35 0.96
Anxiety 2.06 1.08** 1.66 1.19 1.68 0.87** 1.39 0.90 1.59 0.81 1.41 0.84
VPA (mV) .044 .063* .058 .037 .043 .063** .063 .029 .044 0.67* .060 .043
Data represent means and SD
* p\.05, ** p\.01, *** p\.0001 paired samples t test from Neutral to Erotic conditions. All variables, except VPA, have a 1–7 range

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Discussion and self-reported clinical symptoms of (low) desire and sexual

distress reflect different, unrelated aspects of the female sexual
We examined the effects of a group mindfulness-based sex response, accounting for their lack of significant association.
therapy on concordance between genital and subjective sexual Conversely, homework compliance did significantly moderate
arousal in women seeking treatment for concerns of sexual desire sexual concordance,such that, for everystandardizedunit increase
and/or arousal using a series of hierarchical linear models, first ofgenital arousal, women showed a significantly greater increase
with subjective arousal predicting genital response and then the in subjective arousal with greater homework compliance at follow-
reverse. We found evidence of significant sexual concordance at up. This suggests that recommended daily at-home mindful-
all time points, with subjective arousal predicting contempora- ness practices, designed to cultivate better integration of awareness
neous genital arousal, and significant increases from pre- to post- and physical sensations, may have contributed to the increase in
treatment, such that there was less change in genital arousal concordance.Ofnote,thismoderationwassignificant at follow-up,
associated with the same level of subjective arousal, suggesting butnotatimmediatepost-treatment,suggestingcumulativeeffects
greater coherence between these two aspects of the sexual res- of mindfulness practice over the 6-month follow-up period. Other
ponse (Brotto et al., 2012b). In contrast, although genital response data showing a dose–response relationship between duration of
predicted significant increases in subjective arousal contempo- mindfulness practice and improvements in symptoms of depression
raneously at all time points, we found no change in this measure of and anxiety supports this interpretation (Krusche, Cyhlarova, &
sexual concordance as a function of treatment. Within-subjects Williams, 2013). Others have also found that amount of at-home
correlations revealed the magnitude of the association (between mindfulness practice is associated with self-report measures of
.28and.33)tobewithintherangefoundamongseveral otherpsy- affect and well-being, but not with indices of medical health
chophysiological studies of women (Chivers et al., 2010). These (Carmody & Baer, 2008). Our homework compliance scores
resultssuggestthat increasesinsexual concordanceassociatedwith were assigned by group facilitators; therefore, future studies
mindfulness-basedsextherapymaybedrivenbychangesinsubjec- could have participants monitor amount of at-home practice to
tive sexual response rather than genital response. correlate mindfulness practice with changes in outcomes.
Interestingly, although the erotic film significantly increased
self-reported sexual arousal, affect, and genital sexual response at Sexual Concordance as a Potential Study Endpoint?
each time point, there was no significant effect of treatment on
either self-reported or genital response compared to baseline, sug- Our findings suggest that skills aimed at enhancing a woman’s
gesting that the change in sexual concordance following treat- concentration training and compassionate self-acceptance may
ment was not a straightforward consequence of increases in self- be associated with greater integration of physical and mental
reported or genital response. Clifton et al. (2015) also found sexual responses to erotic stimuli in a laboratory setting. Con-
similar effects, with women higher in SESII excitation scores and sidered in the context of prior research showing similar effects of
passionate-romantic scores showing higher genital-subjective attention training on sexual arousal (Meston, Rellini, & Telch,
concordance, despite no significant association between individ- 2008), and the specificity of mindfulness interventions (versus
ual predictors and genital or subjective sexual response sepa- cognitive behavioral sex therapy) on changes in sexual concor-
rately; women who rate themselves as more easily arousable may dance (Brotto et al., 2012b), we propose that sexual concordance
be more in tune with their body’s physiological responses to sex- be considered a meaningful study endpoint in sexual psychophys-
ual stimuli, even though the magnitude of their actual physio- iologyresearch.Intreatmentoutcomeresearch,itisnotuncommon
logical or subjective sexual response is no different from women toseethetreatmenteffectsonself-reportedbutnotgenitalresponse
with lower excitation scores. Similarly, we found a significant effect (Diamond et al., 2006). Elsewhere, we have proposed that sexual
of mindfulness treatment on concordance (compared to pre- concordance may reveal treatment effects that might otherwise
treatment levels) but not on genital or subjective sexual response be overlooked when examining only self-reported or psychophysi-
separately, suggesting that treatment may have contributed to ological sexual response alone (Chivers & Rosen, 2010). Others
women’s capacity to detect and integrate their experience of have shown that sexual concordance is meaningfully associated
sexual excitation. withcognitiveandschematicaspectsofwomen’ssexualfunctioning,
FSAD diagnostic status and FSFI lubrication and arousal suchashighersexual excitationandpassion-andromance-related
domain scores did not significantly moderate sexual concordance cognitive schemas, in the absence of direct effects between these
at any of the time points. This was a surprising result, given both variables (Clifton et al.,2015). In thecurrent study, we demonstrated
clinical domains improved after treatment (Brotto & Basson, asimilarpatternwithsexualconcordanceincreasingaftertreatment
2014), and other research has noted relationships between sexual butnodetectablechangeineitheraspectofsexualresponsethrough-
functioning and sexual concordance in healthy women (Brody out treatment. Taken together, these findings provide preliminary
et al., 2003) and in women with sexual difficulties (Chivers et al., support for the possibility of sexual concordance being a more
2010). Our findings suggest, perhaps, that sexual concordance relevant and sensitive study endpoint.

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1918 Arch Sex Behav (2016) 45:1907–1921

Mechanisms of Action Limitations

The direction of concordance effects, with subjective arousal Therewerelimitationsinthisstudythatmust beconsidered.Firstly,

predicting contemporaneous genital arousal (but not the reverse), treatment included a combination of (primarily) mindfulness exer-
suggests that mechanisms underlying change in sexual concor- cises,psychoeducation, and sex therapy. It is unknown whether
dance are predominantly, as expected, top-down, as opposed to benefits were due to one specific component of treatment or to
bottom-up.Aswomendeliberatelyguidedtheirattentionontodif- theirsynergisticeffects.Ofnote,however,previousresearchtesting
ferent foci—whether the breath, body, sounds, or thoughts—this a similar (but not identical) treatment protocol found that partici-
may have translated into an improved ability to detect sensations pants self-reported the mindfulness component to be the most effec-
in thebodyassociated withsexual arousal.Silverstein et al. (2011) tive aspect of treatment (Brotto & Heiman, 2007). Future research
found decreased reaction time to rating bodily reactions to sexual thatdismantlesthesecomponentsandteststhemagainstoneanother
stimuli in women following mindfulness training. Given that the is needed in order to empirically substantiate these observations.
insular cortex mediates interoceptive ability (Critchley, Wiens, Secondly, our measure ofsexual functioning (i.e., the FSFI) was
Rotshtein,Öhman,&Dolan,2004),andisassociatedwithincreased limited because it excluded women who were not sexually active
thicknessfollowingmindfulnesspractice(Hölzel etal.,2010),itis in the preceding 4 weeks, and assessed only the intensity and fre-
possiblethatinsula-mediatedincreasesininteroceptiveabilityfrom quency of sexual arousal, without consideration for the multiple
the various mindfulness exercises contributed to the improved ways in which sexual arousal may be experienced in women. Our
concordance between genital and subjective arousal. ability to detect associations between change in sexual concordance
Because sexual concordance was not significantly different and changein clinical symptomsmaybe relatedtotheselimitations.
with treatment when genital arousal predicted subjective sexual Relatedly, we were also unable to examine correlations between
arousal, this suggests that it was unlikely that genital sensations concordance and the orgasm domain given the large proportion
ledwomentoexperiencemoresubjectivearousal,therebydriving of missingdata in theFSFI. Importantly, thissamplerepresents only
concordance. Furthermore,it hasbeenarguedthat treatments aimed asmall cross-sectionofwomen with sexual desiredifficulties, and
atimprovinggenitalresponsemaybeineffectivewithoutthecapacity we limited the upper age to 65 in recognition of the large hetero-
todetectandpositivelyappraisethosephysiologicalchanges(Chivers geneityinthewayswomenexperience(lossof)sexualdesire(Meana,
& Rosen, 2010). The genital arousal response to erotic cues is rela- 2010). It is possible that such an intervention would have yielded
tively automatic (Chivers & Bailey, 2005; Chivers, Rieger, Latty, different results in a much larger, more representative sample of
& Bailey, 2004; Laan, Everaerd, van Bellen, & Hanewald, 1994), women with sexual desire complaints.
regardless of women’s age or sexual dysfunction status; indeed, Thirdly, our capacity to detect associations between change in
womenwithadiagnosisofFSADhadthesamemagnitudeofVPA sexual concordance and sexual functioning was limited by
assexuallyhealthycontrols(Laanetal.,2008).Inthecurrentstudy, examining these relationships in a clinical sample only, such that
there was no immediate effect of treatment on VPA. Therefore, range restriction in sexual functioning may have hampered the
itisnotlikelythatourtreatmentledtochangesingenitalresponding, detection ofanassociationthat may havebeen observedifwomen
which then drove an increase in concordance. A top-down mecha- without sexual dysfunction were included. To that end, there was
nism in which women deliberately focused attention on emerging, considerable variability in the range of concordance estimates
moment-by-moment sensations over the course of treatment, across participants, both at pre- and at post-treatment, but with the
likely led to their contemporaneous detection of genital arousal majority of participants showing a positive concordance estimate.
in the laboratory setting, thereby increasing sexual concordance. Also, in the absence of a no-treatment control group, the magni-
In addition to mindfulness practice increasing awareness of tude of any change in subjective or genital sexual response with
visceral (and likely genital) cues, current models of the mecha- treatment cannot be established and should be the focus of future
nismsofmindfulness(Teper,Segal,&Inzlicht,2013)suggestthat research.
increases in acceptance and self-compassion may have cultivated To examine whether sexual concordance changed during two
anopennesstoallelementsofourparticipants’experienceofsexual pre-treatment assessments before treatment was administered,
response without attempting to alter them. Teper et al. surmised genital arousal andcontinuous self-reported sexual arousal during
that when one observes and accepts current emotions, this may the erotic film segment were analyzed for 25 women who
facilitate emotion regulation. Given evidence that negative affect received two pre-treatment assessments. Within-subjects correla-
during sexual encounters may significantly predict sexual diffi- tions were calculated, then statistically compared using a depen-
culties (Nobre & Pinto-Gouveia, 2006), it is possible that women dent samples t test. There was no significant difference between
experienced an improved ability to regulate such emotions and the concordance estimates at the two pre-treatment assessment
thereby tune into and accept their visceral sensations. points (data not shown), suggesting that the repeated assessment

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of concordance does not significantly impact the concordance positive response to treatment such that therapies (whether psy-
estimates themselves. Furthermore, this finding strengthens our chological or pharmacological) can be individually tailored to
conclusion that the increases in sexual concordance observed women’s needs.
with treatment are not likely attributable to the passage of time.
Acknowledgments The authors wish to thank Yvonne Erskine for
overall coordination of this study. We also wish to thank group facilitators
Implications Miriam Driscoll, Shea Hocaloski, Gail Knudson, Brooke Seal, and Morag
Yule. Our thanks to Dr.Rosemary Basson and Dr. Mijal Luria for developing
The incentive motivation model (Both, Everaerd, & Laan, 2007) the treatment manual used to deliver the mindfulness intervention. Funding
proposes that sexual desire is triggered by sexual arousal, whereas for this study was provided by a BC Medical Services Grant to Lori Brotto.
previously, sexual desire and arousal were viewed as distinct and
Compliance with Ethical Standards
sequential phases of sexual response (Masters & Johnson, 1966).
According to the incentive motivation model that informs current Conflict of interest None of the authors have any conflicts of interest to
DSM-5definitionsofSIAD,sexualdesireandarousalarereciprocally disclose.
reinforcing,suchthatsexualdesireemergesfromexperiencingsexual
arousal (Toates, 2009). Genital responsesalone may not, however,
be sufficient for generating sexual desire; instead, the integration
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