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The Dose Transcript for November 7, 2024

Host: Dr. Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. It is hard to get good advice from health-care providers on healthy sex and how to make it more satisfying. Recently, White Coat, Black Art did a show on physicians who are helping women boost pleasure, in part by helping them to get to know their sexual anatomy. So this week on The Dose, we are asking: How can women have better sex? Hi, Lori. Welcome to The Dose.

DR. LORI BROTTO: Hi. Thanks so much for having me.

BRIAN GOLDMAN: So when was the moment you knew you wanted to be a sexual health researcher?

DR. LORI BROTTO: It was probably six years into doing sex research with animals. And I was studying the male rat, and I was looking at the impact of stressful environments and antidepressants on male rat sexual behaviour, not knowing at the time that I was destined to be a sex researcher. So it was really a retrospective decision after being deeply engaged in this research for a number of years.

BRIAN GOLDMAN: That's a very interesting segue that I wasn't prepared for. But now, even more than before, I'm dying to hear what you have to say. But before we begin, can you give us a hi, my name is? Tell us what you do and where you do it.

DR. LORI BROTTO: Hi, my name is Dr. Lori Brotto. I'm a professor in obstetrics and gynecology at the University of British Columbia. My field of research is in sexual health, mostly women's sexual health. And I also teach in the medical school, helping future doctors to understand and appreciate the ways in which we inquire people and patients about their sexual health as well.

BRIAN GOLDMAN: I'm really looking forward to this conversation. What are the biggest misconceptions that women might have that get in the way of having a more fulfilling sex life?

DR. LORI BROTTO: There are many, many misconceptions that women have. I'll start with a few very common ones. One very common one is that sexual desire is something that you have or you don't have. And it leads people into difficulty because if there's a period of their life where their desire goes down or is gone altogether, say after a surgery or after having a baby or maybe after a period of a very stressful life encounter, they might feel like their desire is gone and there is no way to get it back. And it can lead people to suffer quite a bit, be quite upset, and obviously take a toll on their relationships or future relationships. So, it's a myth, though. Because desire is something that we equate to emotion. So you can have different degrees of desire, you can certainly have periods of time where the desire might be very, very intense. And it's not dependent on a person's age. And even among those people that have felt like they have lost their desire, we have evidence-based ways of bringing the desire back. So I start with that one because I think it's one of the more common ones that, thanks to a lot of excellent science, we have ways of debunking that myth.

BRIAN GOLDMAN: Any other misconceptions that come to mind?

DR. LORI BROTTO: Yeah, another common one that I hear about as a clinician, I'm also a psychologist delivering sex therapy, and I often will encourage the people that I work with to plan sex. It's often met with, What do you mean plan sex? Doesn't that make it clinical and boring? To which I often reply, Well, what else do you do in your life that is important and of value that is unplanned? So we know, again, based on scientific studies, that planned sexual activity gives a person an opportunity to arrange the context, to maybe fantasize about it, to be very intentional about what barriers can be removed, what facilitators can be put in place. And it's quite the opposite of being clinical and boring.

BRIAN GOLDMAN: Now, Lori, I'm suspecting that one of those misconceptions that you help debunk is the notion that arousal and desire are the same things or somehow interchangeable. And I think you're going to tell us that they're different. So what are some of the distinctions between arousal and desire?

DR. LORI BROTTO: You know, first of all, when we talk about sex and sexual health in everyday life, people might mean very different things, even when they say the words sexual desire. And so, of course, when we talk about desire versus arousal, it is really important that we differentiate them. As scientists, we do differentiate them. We tend to more often describe arousal as what is happening in the body. So in a female-bodied person this might be signs of blood flow to the genitals, what we call vasocongestion. There may be erection of the clitoris or the nipples, again as a result of increased physiological arousal and blood flow. And it's the body somewhat preparing itself for potential sexual activity. And we differentiate that from desire because it's not the case that just because a body is primed and aroused that it necessarily corresponds to the woman, in this circumstance, saying that she is turned on in her mind. In fact, there's been countless now research studies showing that there can be a discordance or a separation between the body's arousal and the mind's level of sexual desire. So by desire, this is, what are the thoughts and feelings in your mind, in your brain? Are you looking forward to sex? Are you planning to have sex? Do you feel motivated to have sex? And it's really important that we ask about both of those because they can be in misalignment. Or sometimes they do align, and when they do, that's great. It means that a person is interested in sex and their body is excited and preparing for it. But that is not always the case.

BRIAN GOLDMAN: So arousal is physiological, desire is psychological. What comes first?

DR. LORI BROTTO: Yeah. And I'm going to backtrack and say desire is mostly psychological and arousal is mostly physiological. But of course, there's physiological and psychological aspects to both. So now to directly answer your question about which comes first. If we focus the conversation on females, so people who are birth-assigned females, where this question has been explored quite a bit in the scientific literature. And specifically, if we look at those females who are in longer term relationships. So again, not the folks who are in a brand new, exciting romance where everything is novel, everything is mystery, there's so much unknown. That is much more the case that maybe desire comes first and then it's followed by arousal. But if we focus instead on those women who are in longer term relationships, there's quite a bit of scientific support for the 'arousal first, desire second' cycle. And we talk about that kind of desire, the desire that emerges after she's been sexually aroused, after she's able to use her mind to tune in to the sensations of arousal. And then responsive desire follows. And we label it as responsive desire because it's desire that responds to arousal. So that's a very common, very normal pattern of 'arousal, then desire' that we want to talk about and normalize for people, especially for those women who feel like they've lost their desire. And as you ask them questions about their sexual encounters and you might ask the question, is it ever the case where maybe you don't have desire at the outset of an encounter, but as the encounter unfolds and you become excited and you tune in, that the desire for the sexual encounter actually emerges and grows from that point? And very often women will say, Oh, yeah, of course. You know, I'm not necessarily motivated at the beginning by desire, but at some point it emerges during, and by the end of the encounter I'm often-- often say to myself or my partner or partners, Wow, that was great. You know, why doesn't this happen more often? So that's what we call responsive desires. An 'arousal first, desire second' cycle.

BRIAN GOLDMAN: So what advice do you have for inspiring desire?

DR. LORI BROTTO: First of all, we want to make sure this is a topic of conversation. So if this is a person who's in a relationship, first and foremost, make sure that they prioritize having conversations about sexual desire, about wants, about maybe things that the couple would like to try. The research tells us that those couples who have sexual communication, it is a strong predictor of long-term sexual satisfaction. Secondly, we need to think about, well, what are those motivations that would move you from being totally neutral towards being motivated or open to engaging in sex, or maybe respond positively to a partner's initiation? The whole field of research that has looked at approach motivations and avoidance motivations has taught us that having approach motivations, in other words, having a list of reasons that are about getting something good out of the encounter, and maybe that includes to obtain closeness; to celebrate a birthday; because one wants to feel pleasure and arousal; because one wants to connect with the partner, etc. So really identifying for yourself what are those approach motivations and ensuring that you're not motivated to avoid something bad. So those people who say, I'm only motivated to have sex in order to avoid conflict in my relationship, to avoid having a belligerent partner, etc., that would be a couple that I would strongly recommend couples therapy to or couples sex therapy to. And that's not a pathway to desire for sure.

BRIAN GOLDMAN: What are some things women can do to explore what turns them on?

DR. LORI BROTTO: So first we need to recognize that a lot of people might have barriers to exploring their own body. Whether those barriers are cultural, religious; messages they grew up with about the inappropriateness of touching your body or masturbating. I mean, even still to this day, there is a cultural and societal taboo around masturbation in women that men don't face. And so there's kind of a gender bias there as well. And I like to frame this as body exploration, especially for those people who might have a hard time with the word masturbation. It's an opportunity to know and understand your body in the same way that it's important to know your body for health-related reasons. So that if something goes awry or you're having a problem, that you're able to describe what that is to a health-care provider. And so I might recommend to a person to incorporate this into, you know, having a bath or a shower. Look at your body. Use a handheld mirror to look at your genitals. And then maybe set some time aside to engage in a body exploration exercise where you simply touch the body, touch all different parts of the body, solely with the purpose of understanding what does that feel like. So not in a goal-oriented way. It's not about producing pleasure or orgasm. It really is about trying to understand how do these particular touches lead to certain kinds of sensations. And that's normal and it's healthy and it's something we definitely want to promote.

BRIAN GOLDMAN: Lori, how important is it to teach mindfulness in the work that you do?

DR. LORI BROTTO: I mean, your listeners might be more familiar with the term meditation, which has many thousand-year history, rooted mostly in Buddhist tradition. Mindfulness is the secular or modern-day adaptation of that. It's been widely studied and written about since about the early 1980s. And mindfulness, as a practice, involves paying attention on purpose, non-judgmentally. So if you imagine an exercise in which the person is guided to pay attention to different sensations in their body, maybe they start with the toes, notice sensations in the toes, notice places of tension, notice temperature, texture, the feeling of the toes against the sock or the floor. And all the while they are also doing it non-judgmentally. So they're not saying to themselves, Ugh, I have a hard time, I can't do this. I'm terrible at paying attention. They're just observing the sensations as they are without judgment. So that's the basic premise of it. And the person can be guided to pay attention to breaths or other body sensations, sounds or even thoughts themselves. And then the flip side of that is we have considerable research evidence that practicing mindfulness can close that gap, can help mitigate the negative impacts on desire and arousal so that people feel desire and arousal again. And they'll often say that when they integrate mindfulness into their sexual encounters, that the encounters are more pleasurable for them.

BRIAN GOLDMAN: Let's get a bit more anatomical. What's the difference between vaginal stimulation and clitoral stimulation?

DR. LORI BROTTO: Vaginal stimulation arises when something is inserted into the vagina. So if we think of typical heterosexual sex or intercourse, that would usually be the penis in the vagina. Clitoral stimulation, on the other hand, is any kind of direct stimulation to the clitoral tissue itself, which is observable on the outside of the anatomy. But the entire clitoral complex itself, the anatomy of it, extends deep below the surface of the skin. It can be stimulated from the outside, but the actual tissue itself falls far below. That's kind of a very anatomical answer, but I think maybe a more important answer that I'll layer on top is that the clitoris has far many more nerve endings than the vagina itself. And also the clitoris, as far as we know, from all of the studies that have been done, the anatomical studies, it's the only part of anatomy that exists solely for sexual arousal and pleasure. Whereas the vagina has other functions, namely the birth canal and other functions as well. And so when we talk about pleasure in female-bodied individuals, that person is far more likely to experience pleasure and orgasm through clitoral stimulation than they are through vaginal stimulation.

BRIAN GOLDMAN: Are you finding that women come to you and say that their partners are too focused on the clitoris and not focused enough on the rest of their bodies?

DR. LORI BROTTO: Sometimes. And especially if a partner has, you know, read something or heard something, heard a conversation that really emphasizes the importance of the clitoris as the, quote, "gateway" to a woman's pleasure. There may be an overfocus on that that could backfire. So stimulation of an un-aroused clitoris can actually be painful to a lot of females. And so, again, this takes us back to the importance of sexual communication and being able to have a conversation around what needs to be in place in order to arouse the clitoris first. That might sound silly, but it literally is about bringing blood flow into the clitoris where the sensation and the pleasure can change quite a bit after the clitoris has been filled with blood, versus when it's un-aroused. You can have too much of a good thing, [laughs] and the same would apply to clitoral stimulation as well.

BRIAN GOLDMAN: Let's talk about sex devices. How can they improve sex?

DR. LORI BROTTO: Vibrators might fall into this category, and I really like to talk about vibrators as sexual tools. They can be used to augment the natural sexual arousal response. And for people who might have a difficult time with that or maybe grew up with or being exposed to messages that vibrators, you can become addicted to them. First of all, there's absolutely no scientific data to support that one can become addicted to vibrators or that it replaces a partner or that it can induce nerve damage or anything like that. So let's debunk those myths. And we want to normalize the use of vibrators as being a tool, something that can really help a person experience maybe a deeper level of arousal or a more efficient level of arousal. I often recommend vibrators when I work with cancer survivors or other people who maybe have had surgery or radiation therapy that can directly impact the nerves and the passageways that give rise to arousal. So having a stronger signal, a stronger boost from something like a vibrator can be really, really important, if not essential.

BRIAN GOLDMAN: Let's move on to talk about medications. Men, of course, have had Viagra for a quarter of a century. What medications are available for women?

DR. LORI BROTTO: So in Canada, there are two Health Canada approved medications to address distressing low desire in pre-menopausal women. One of them is an oral medication called Flibanserin. And the clinical trials show that it needs to be taken orally, daily, for at least eight weeks before the women in those clinical trials showed any significant improvement to their sexual desire. So that was the medication that was approved first. Medications certainly have their place, and for people who maybe have tried therapy or other behavioural methods to improve their sexual desire, they might be a candidate for Flibanserin. At the same time, a significant proportion of users do have side effects, and it can't be mixed with alcohol. So that's one of the medications. The other one is called Bremelanotide, and this is an injection. So the person would give themselves a subcutaneous injection before planned sexual activity. And this medication works on the melanocortin agonist centres of the brain. And like Viagra, it can be used right before planned sexual activity, unlike Flibanserin, which needs to be taken daily. Again, the efficacy or how well that medication works is about the same as Flibanserin. So in the big clinical trials, what it showed is that among people who were already sexually active, that it increased the number of sexually satisfying events by one per month. So probably not going to help the person who has not been engaging in any sexual activity for years, which is actually fairly common when we look at the big population-based studies. So there is a small market for those medications. I'm glad we have at least two products on the market in Canada, but I also feel like the research really needs to do much, much deeper investigation into other safer and more effective products for women.

BRIAN GOLDMAN: What's your take on how drugs and alcohol affect libido?

DR. LORI BROTTO: This has been an area of quite intensive research. And with alcohol, we know that at very low doses, that alcohol can be a facilitator, especially if a person has maybe anxiety about sex, maybe they have what we would call a lot of inhibition. So the part of the brain that kind of puts the brakes on, that very low levels of alcohol can disinhibit some of that and allow a person to more easily move into planned sexual encounters. But at higher doses of alcohol, the research has shown us that both in females and in males, that it can directly interfere with the sexual arousal pathway. So, it can make it more difficult to reach arousal, certainly interfere with orgasm, and chronic alcohol use can be very, very damaging for sexual health and sexual response. So as a clinician, this is definitely one of the questions that we ask about, is we ask about alcohol and other substance use, and try and understand how the person might be using it to engage in sex, and at the same time, is it interfering?

BRIAN GOLDMAN: What are some of the differences you notice with women in straight relationships and women in queer relationships?

DR. LORI BROTTO: So first of all, no differences in anatomy or physiology between straight women, heterosexual women and more sexually fluid women. So the bodies work the same, the anatomy is wired the same way. One of the places that we see a very significant difference is among same-sex relationships, is sexual communication. So, much more comfort with talking about pleasure, with instructing a partner what parts of the body give rise to pleasure. And also, because both of those individuals have the same anatomy, a much greater appreciation for the parts of the body that might be more likely to produce pleasure than, say, penis-in-vagina sexual intercourse. So that's really the main area that we see a difference. But we do see sexual problems among lesbian and other sexual orientation women as well. And in the same way that stress or life events or depression or anxiety can impact desire of straight people, it can impact it among lesbian women as well.

BRIAN GOLDMAN: How can women start a conversation with their partners about wanting a better sexual experience?

DR. LORI BROTTO: Well, this is why I think conversations like the one we're having today are so important. So a woman might say, you know, I was listening to the CBC and I heard this great conversation about sexual health and how it's an important part of quality of life. I learned that sexual desire is not a light switch. I learned that there are a variety of evidence-based ways to cultivate desire. Can we have a conversation about it? And I often recommend don't have the conversation in the bedroom. Don't have that conversation during or right after sexual activity. Prioritize it. Talk to a partner about, you know, can we schedule a time where we talk about sexual health? So, often referencing conversations like the one we're having today can be a nice entry way, especially if a person feels embarrassed or, like many of the couples that I work with, this is a topic that they've never had with their partner before. Let me also say that you're never too old. You're never in a relationship that is too long to begin having conversations about how we can promote better sexual satisfaction.

BRIAN GOLDMAN: Lori, that was marvelous. And I will tell you that if people listening to this episode of The Dose go on to have a conversation with their partner about having better sex, we will have done our work.

DR. LORI BROTTO: I couldn't agree more. That's usually a goal of mine, is that we can stimulate at least one conversation about this really important topic.

BRIAN GOLDMAN: Lori Brotto, thank you so much for speaking with us on The Dose.

DR. LORI BROTTO: My absolute pleasure. Thank you.

BRIAN GOLDMAN: Lori Brotto is a psychologist, professor, and Canada Research Chair in women's sexual health at the University of British Columbia.

BRIAN GOLDMAN: Well, Lori, at the end of each episode of The Dose, I usually give smart advice. But this week, I'm going to give you the last word.

DR. LORI BROTTO: Here's my dose of smart advice: I would encourage women to really think about all of the different parts of their well-being, their relationship, maybe their environment that promotes sexual desire for them. Maybe pay attention to, are there particular times of the month or the year that they reflect back on when they really were motivated for sexual activity, when sex felt especially enjoyable for them. And try and isolate what was it about that instance or that period of time that really promoted that, and how can we infuse that into future sexual encounters. Another piece of advice I would have is that if sex hurts, to get it investigated. Sex should not be painful. If there is pain with sex, no matter if it's a small pain or a very deep and intense pain, to seek out the help of a health-care provider. There can be a variety of different reasons for why sex hurts. And painful sex is never normal, and you should always feel like you can talk to a trusted health-care provider about investigating why it hurts and what you can do to address that. And frame sexual health within the larger context of living well in general. So what are the kinds of things that you're doing in your life to live well? Exercise, minimize alcohol, drink your water, have good social relationships, have an outlet for managing stress. All of those things that directly contribute to living better, also directly contribute to greater sexual wellness.

BRIAN GOLDMAN: Thank you, Lori, for your smart advice. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you liked this episode, please give us a rating and review wherever you get your podcasts. This edition of The Dose was produced by Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health-care provider. I'm Dr. Brian Goldman. Until your next dose.

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How can women have better sex? - Transcript

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