October 2, 2007
A clinic across from Vancouver General Hospital is a strange place to watch porn, but that's what the doctor-in knee-high black stiletto boots, no less-orders. I'm here to put my genitals to the test with Dr. Lori Brotto, psychologist and head of the UBC Sexual Health Lab, which is tucked away on the sixth floor of the new Gordon and Leslie Diamond Health Care Centre. "Our erotic videos are by porn star Candida Royale," says Dr. Brotto, a trim, no-nonsense woman. "She's the standard for sex researchers. We all use the same films to test female sexual arousal because they're female-directed and have more of a story-building plot."
Plot development isn't a key concern at Brotto's sex lab; the story here is that at least a third of women are unhappy with their sex lives. This news is a turn-on to pharmaceutical companies chasing the next magic "cure" and romancing scientists with big grants. But Brotto has developed a treatment model that eschews the chemical approach and has the burgeoning field of sex research abuzz.
Brotto currently has 23 sexual health studies underway at her small lab. Its hub is a surprisingly cozy spot called the "arousal room," complete with white tealight candles. Brotto's videos have been edited down to an 11-minute clip of the sort of scenes that you'd see in a typical hard-core film; this clip is used to assess a patient's physiological response to sexual stimulation.
"Almost every woman we see, whether she has a sexual disorder or not, will genitally respond to this material," says Brotto. "Even if she says she didn't respond physically in post-test assessments. Our research shows that women can be clueless about what their own genitals are doing."
Proof comes from a gizmo the size of a crayon that measures vaginal blood flow and pulse-it's called a vaginal photoplethysmograph. Patients insert the device themselves in private, then sit back on a female-friendly recliner to watch the video. It starts with non-sexual material to establish baseline responses. In my case it's a pineapple-farming documentary. The camera pans across a lush Hawaiian landscape, then segues to a close-up of a pineapple. I wonder not just whether my genitals will react to such an image, but also whether I want strangers to know the answer.
I haven't got much time to fret before a naked man appears on the screen, wedging himself up against a woman's butt cheeks. Sex of various sorts follows, all of it taking place on a bearskin rug with a crackling fireplace in the background. The set triggers my brain's cheese-o-metre, while an IBM computer in the adjacent, florescent-lit room tracks my "vaginal pulse amplitude." These data amount to a kind of genital lie detector test for women who say porn doesn't turn them on. For those diagnosed with a sexual disorder, or convinced that their equipment is faulty (perhaps due to nerve-damaging cancer surgeries), or generally unhappy with their sex lives, passing this test, so to speak, can be a relief. But the fact that even women who say they rarely get turned on have significant physiological responses to porn raises the fascinating question of what's going on in their heads.
"A woman might not report sexual stimulation, but her genitals almost always react automatically to sexual stimuli," says Brotto when, 20 minutes later, having filled out a post-test questionnaire, I return to her office. "It shows there's a desynchrony between the mind and the body."
A growing number of scholars, armed with such tools as photoplethysmographs and brain scanners (which map brain activity while people watch porn or masturbate), are, like Brotto, intrigued by this mind-body disconnect. "It's a hot topic now. We know that at least 30 percent of women are reporting lack of desire and interest in sex, problems with orgasms, and general dissatisfaction with their sex lives." Yet brain scans show that male and female have many similarities in the throes of passion, says Brotto, which means some women may be misdiagnosed as having clinical psychiatric disorders that focus on lack of pre-sex desire.
The authors of the Diagnostic Statistical Manual (the so-called Bible of psychiatry) use definitions like "inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement." Written by mostly male shrinks, and taken from Masters and Johnson models from the 1960s, these dry clinical descriptions pathologize sexuality and encourage women to take hormones or drugs like Cialis and Viagra, which-according to a number of studies, including one by Brotto-don't actually work for women.
Brotto sees many patients plagued by the belief that something's wrong with their wiring and plumbing. "We have these expectations about spontaneous desire," she explains. "If we don't have that fluttery feeling and we're not craving sexual activity, there must be something wrong with us. In the movies, you see people ripping each other's clothes off in an elevator. You don't see them put the kids to bed, go to the bedroom and clumsily take their socks off Yet when you talk to people in relationships of more than a few years, most don't have that spontaneous desire.Why do they have sex, then? Because they think eventually it will feel good. Or, ‘I love my partner, I want that intimacy.' Even, ‘He took the trash out.' Women, especially, start with reasoning, not horniness."
Brotto's all for horniness, but in its absence she's developed a psychological education program that focusses on simple "mindfulness" practices that fill the gaps between pharmaceutically funded biological approaches. "Mindfulness is a really fascinating new topic in sex research," she says, "borrowed in part from eastern meditation. It's being used more and more in the medical field, in everything from depression to cancer therapy."
Brotto was the first researcher to publish a study of its efficacy in the sexual health field. The therapy involves cognitive behaviour therapy (a staple intervention with mental illnesses like depression and obsessive-compulsive disorder), and mindfulness homework that helps women focus on immediate sensory details and tune out the cerebral chatter-whether they're drinking a cup of tea, working in the garden or, as ordered in the homework syllabus, masturbating or having sex with their partner. Think of it as a sort of zen and the art of sexual maintenance.
"Men's testosterone levels are about 10 times higher than women's," Brotto points out, "so that ability to get in the mood quickly is typically easier for them. But they also tend to do better at focussing on sex, and going after what they want. We teach women, ‘Pay attention to the sensory details-they'll excite you.'
"The other problem is that women multi-task more than men do. We've evolved over time to be mothers, workers, caretakers, providers. It's hard to shut that off, be in the moment and be sexually selfish. Women have to work at turning off their brains: stop thinking about the laundry, do your shopping list another time. For some women, it can be a challenge to stay present and focussed enough to get turned on by sex."
Brotto got turned on to sex research "serendipitously." Growing up in Surrey, the rebellious daughter of conservative Italian-Catholic parents, she got her first taste of sex education courtesy of the church. "In catechism classes we learned that sex is something only married couples do," she recalls. The high school version wasn't much better: "The instructor was the phys-ed teacher and the students made a big joke of the whole thing."
When Brotto finished her undergrad degree in biological psychology at UBC in 1993, she was interested in researching depression. "I was looking for any kind of experience in lab work, and the only person taking in young students was Dr. Boris Gorzalka," she says of the UBC psychology professor who heads the Sexual Psychophysiology and Psychoneuroendocrinology Laboratory, which then focussed exclusively on animal models. "He said, ‘I'll take you on, but on condition that you're okay watching rats have sex.' I said, ‘OK,' very reluctantly because I wanted to study humans."
As she pursued her master's degree and then her clinical psychology PhD on sexual arousal disorders, Brotto researched biochemical markers in rats. "In terms of rats' physiological processes, like arousal-the interaction between hormones and neurotransmitters and sex drive-you can see implications for humans." For example, male and female rats, like humans, get bored with monogamous sex: if you introduce a new rat to the cage, even if the rats are physically exhausted, they'll want sex with the new rat.
Which helps explain why the cable guy might look hot, why people cheat, and why couples book rooms with mirrored ceilings for anniversary celebrations. "It's called the Coolidge effect," says Brotto, "after President Calvin Coolidge, who was completely bored sexually with his wife but had great flings on the side." This widespread cultural phenomenon is at least partly neurological: hormones and neurotransmitters kick in when you have a novel partner. But dedicated monogamists can avoid the allure of adultery by cheating their brains; Brotto mentions the efficacy of putting yourself in "a novel environment, or role-playing. After many years with the same partner, sex can be great again."
Brotto switched from rats to humans in the late 1990s. "Viagra had just hit the market, so there was huge interest in sexuality, but mostly men's sexuality. People were saying, ‘Hey, what about women?' We didn't even know if menopausal women differed physiologically from younger women. Same with cancer research. So many women have been through invasive procedures, but we had no clue what was going on in their sex lives as a result. It was uncharted territory. It became clear that this is where I was destined to be. At the time, I was the only one in Canada doing sexual psychophysiology with women."
Brotto spent three years in Seattle working with Julia Heiman, who now runs the famous Kinsey Institute at Indiana University. Alfred Kinsey, a biologist, put sexuality on the map in the 1950s when he switched his focus from the gall wasp to human beings, interviewing thousands of people about their sex lives. Brotto carved out her own niche in cancer and sexuality. But the political climate in the U.S. was heated with religious groups attempting to block funding and sending researchers hate mail.
"Canada has a much healthier, open-minded approach to funding and education around sexuality," notes Brotto, who passed up six job offers in the U.S. for a lab of her own at UBC. Two full-time study coordinators and a dozen grad students, research assistants and volunteers now assist her research, which is funded primarily by the Canadian Institute of Health Research and UBC. She's been making a name for herself by recontextualizing the research around sexuality, like the supposed gender age gap for sexual peak. "That's a myth," she says of research Kinsey did in the early 1950s. "He asked, ‘How many orgasms per week do you have?' and found that 18-year-old boys and 36-year-old women have the most. But boys are masturbating a lot and women-well, sex and orgasms get better over time. There's a longer learning process. Young women have the most orgasm problems. As they get older, there's not a lot of partner turnover and hopefully they know their bodies and are more comfortable."
Those peaks certainly exist, but people misinterpret the numbers as biological imperatives. Brotto's new mindfulness programs, which blend psychotherapy and sex education, are proving effective at bridging the mind-body gap. She whips out data from one patient whose post-therapy photoplethysmograph scores spike much higher, and are more densely packed, than her initial readings. Such results, she says, are typical of women who've graduated from her sex therapy program; all report that mindfulness was the key factor.
And what about men? Roughly the same percentage-almost a third-report being unhappy with their sex lives; 12 percent have erectile dysfunction and 34 percent experience premature ejaculation, the number one male sexual disorder.
"We're learning that men are more similar to women than society gives them credit for," says Brotto. "Men absolutely have that psychological component." Take, for example, empirical evidence that laughter causes erectile shrinking. "It shows how sensitive and self-conscious men can be sexually," she says, of the ‘Is she laughing with me or at me' syndrome some men experience when anything funny happens between the sheets.
"We always interview partners," says Brotto, "and they get involved with the homework assignments. We've also done research with Asian male immigrants, showing that cultural conventions come into play."
For men in long-term relationships, as for women, desire goes down over time. Men, like women, have elevated prolactin after sex-that's the hormone involved in breast-feeding, and it's one of the reasons we want to cuddle; it keeps us bonded long-term. "Ultimately, men have the same hopes and desires as women," says Brotto. "They want to love and be loved."
Underlying these biological and cultural factors, for both men and women, is the fear of loss of control. "To share yourself sexually is the most vulnerable place you can put yourself in," says Brotto. "It's almost impossible to do that and not feel an emotional connection, even in a one-night stand that's just about the sex. Emotional bonding happens. You can't just switch off those feelings."
Turning off the white noise of cultural conventions and media-designer vaginas, the fetishizing of young anorexic pop stars, the "damned if you're too horny, damned if you're not" extremes of psychiatric labelling-isn't easy. But new studies are turning up some unexpected and reassuring news.
"A longitudinal study followed 450 Australian women over the past 15 years," Brotto says. "It found the number one variable that predicted sexual satisfaction was whether a person liked their partner. Period. Even in women with low levels of estrogen, it was the key determinant of how orgasmic or sexually satisfied they were. "How do we get that information out to people and translate it into something that empowers them? Otherwise, all they see is the glossy advertising fantasy."
Of course, uninterrupted liking of your partner isn't always easy. All sorts of factors get in the way, from serious disputes about things like money and religion to arguments over toilet rolls, toenail clippings and dishwasher stacking techniques. This is where sexuality meets power, and it takes us back to the need to drop our facades.
"We've heard stories about powerful men who pay to play the submissive role," says Brotto. "Well, I've met powerful businesswomen who do the same thing." On the flip-side are control freaks who find it incredibly difficult to let loose. Hang-ups about sexuality, combined with our drive to be super-humans with perfect careers, bodies, homes, kids and sex lives (even so-called "super-orgasmic" pills and gizmos are in the pipeline) can gang up against the simple desire to bond with someone we love or lust, batteries sometimes included.
"We think good sex should fall into our laps, but we're not robots," says Brotto, who knows the pressures of juggling a career and a young family (she's married to a telecommunications engineer and is on maternity leave with her second child). "We're all about the quick fix. That's why there's such an appeal to medications. And there's a lot more funding from the drug companies than from federal health agencies, particularly in the U.S. That steers the direction of research."
Brotto believes we need more federal funds devoted to sexual health research, and we need to promote psychological, not pharmaceutical, interventions. "A good sex life can take a lot of work and communication, sometimes about things that are intimate and uncomfortable. A lot of people give up because they're afraid of change, or they don't know how much happier they'll be if they're sexually satisfied. You have to be willing to put in a lot of work."
Brotto produces my test scores. The chart, with its pronounced spikes, looks like the polygraph of a compulsive liar. It's bizarre to see evidence that while my frontal lobes were caught up in critiquing the cheesy décor, my vagina was engaged in its own split-second reactions, some subtle, others extreme.
"Is this normal?" I ask. "Whatever that means."
"It's not like a ruler where zero and 10 means the same to everybody," Brotto explains. "It's a relative scale. We compare your score from the neutral to the erotic film. You showed strong, reliable increases."
A passing grade, in other words, but-since sexual health is a constantly evolving process-she's not about to write me a get-out-of-school note. The prospect of homework has never seemed so appealing.