Episode 401: A New Way of Treating Arousal and Libido Problems
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You're listening to the Sex and Psychology Podcast, the sex ed you never got at school and won't get anywhere else. I am your host, Dr. Justin Lee Miller. I am a social psychologist and research fellow at the Kinsey Institute and author of the book, Tell Me What You Want, The Science of Sexual Desire and How It Can Help You Improve Your Sex Life. In the last episode, we talked all about female sexual interest arousal disorder, which is the single most common sexual dysfunction that women experience.

In today's show, we're going to talk about a new way of treating it. Women who have issues with low desire and arousal face a lot of hurdles to seeking treatment. For one thing, there can be shame and embarrassment about bringing up a sexual problem with your doctor. And even if you do, your doctor might not be equipped to treat it because most doctors don't receive much in the way of sexual medicine training. Also, while there are a lot of psychological therapies that work for desire and arousal problems, that kind of therapy can be really expensive.

And there's no guarantee that there will be therapists in your local area who are trained in it because there are a surprisingly small number of certified sex therapists who are out there. My guest today has developed an online sexual health platform called eSense that's designed to bring evidence-based treatment for low sexual desire and arousal to the masses. This platform is built on the principles of cognitive behavioral therapy and mindfulness-based therapy, and it could very well be a game changer in the way we treat some of the most common sexual problems.

So we're going to talk about how the platform works, why psychological therapies are often more effective than pharmaceuticals, and how technology, including artificial intelligence, is set to change the future of sex therapy. I am joined once again by Dr. Lori Brado, an internationally recognized leader in sexual health research. She is a professor in the University of British Columbia Department of Obstetrics and Gynecology. Lori is a registered psychologist and holds a Canada Research Chair in Women's Sexual Health.

She is author of the fantastic book, Better Sex Through Mindfulness, How Women Can Cultivate Desire. This is going to be another fascinating conversation. Stick around and we're going to jump in right after the break. Have you ever felt like you and your partner have gotten out of sync? You're not alone. It happens from time to time in almost every relationship. But getting that connection back is easier than ever with Paired, an app for couples who want to strengthen their relationships.

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Okay, Laurie, let's talk about how to treat problems with low desire and arousal in women. So in the last episode, we did a deep dive into what's called female sexual interest arousal disorder, which is kind of a mouthful. I've had to say it many times now. So you recently developed an online sexual health platform called eSense that can help women who are struggling with this. And it's based on two of the most highly effective treatment options for it.

But before we get into eSense and how it works, let's talk about how this disorder is often treated in general. So first, one of the most common and effective treatments is cognitive behavioral therapy, or CBT for short. So what is CBT anyway, and how can it help in treating a problem with low desire or arousal?

Yeah, great. So your listeners might be familiar with CBT, cognitive behavioral therapy, because it's been a very long standing and effective treatment for things like depression, anxiety, chronic pain, stress, many, many different conditions lend themselves quite well to a cognitive behavioral approach.

And it's built upon the theory that there are strong connections between our thoughts, our emotions and our behaviors. So, for example, if you're a person who has beliefs like I'm not good enough, that's going to lead you to feel sad. It's going to lead your behavior to withdraw and isolate, which is then going to reinforce the beliefs like I'm not good enough and perhaps lead to many other negative beliefs. So there's this really tight system between thoughts, feelings and behaviors that

And CBT mostly targets thoughts as a way of dismantling that system. So we use things like thought records and thought challenging to replace those really deeply embedded dysfunctional thoughts with thoughts that are more realistic.

That's the C part of CBT. And then we can also target behaviors. So we can target avoidance behavior. So for this depressed person who is isolating, you know, we can use approaches like scheduled outings and small doses of doing the things that fear them, again, as a way of dismantling that system. Works really, really well. It's fairly structured. There's lots of homework exercises and people who like a fairly structured approach and using evidence to inform beliefs

they really like a cognitive behavioral approach. So in the case of treating something like low sexual interest or arousal, you would, in this case, be targeting maladaptive beliefs around sex, like maybe beliefs that they're not, for example, a sexual person of worth. And then you'd also be targeting behaviors that might be contributing, like let's say they are going to bed much later than their partner or much earlier because they're trying to avoid sex with them. So is that kind of like how it would be applied here?

You got it. That's exactly, yeah. And, you know, other researchers like Pedro Nobre and others around the world have spent their career focusing on what are the kinds of dysfunctional beliefs that people with low desire have. And we know there's, you know, there's some common ones that come up, like, you know, I'm not good enough sexually, I'm not capable of sex, I don't know how to engage in sex, etc.

And that people tend to ruminate over these. So they think about them and they tend to come up over and over and over again. So that's exactly how a CBT approach would work.

Yeah, makes sense. Changing the cognitions and the behaviors that are interfering with their desired goal, in this case being to increase arousal and desire. Now, the other big treatment for this issue that we see a lot, and you've done a ton of work in this area, is mindfulness-based therapy. So in a nutshell, what is mindfulness-based therapy and how can it help in treating something like an issue with low desire or arousal?

Yeah. So like CBT, mindfulness has been around for a while too. Meditation dates back 4,000 plus years. So mindfulness is kind of the secular adaptation of traditional meditation practices. And it involves paying attention on purpose, non-judgmentally. So the person would be guided to

to focus on, let's say, the breath. And there's many different things that we can focus on, but let's use the breath as an example. And so over the course of many minutes, the person would focus on where the breath sensations appear, deep in the belly, maybe in the chest, maybe the nostrils. And what they're doing is they're continually focusing their attention on the sensations that are emerging, right?

Right. So the coolness of the air, the movement of the diaphragm, whether that creates relaxation, whether that creates tingling sensations. And that's half of mindfulness. The other half is that we do that non-judgmentally. And in my opinion, this is where the rubber hits the road with it being effective for sexual concerns because we're so judgmental of ourselves and others when it comes to sex.

We do that kind of paying attention with a lot of kindness, right? We don't beat ourselves up if we're having a hard time focusing. We don't say, oh, that's it. I can't do this if our mind takes off. And so it's that combination of paying attention on purpose with compassion and kindness that makes up mindfulness.

Yeah. And so in the case of low sexual interest or arousal, I guess what you're doing here is you're kind of getting yourself out of your head and into the moment and focused on your bodily sensations. And through that, that can create opportunities for

desire and arousal to set in and also for you to even notice those things in the first place. Because I think for many of us, our mind is just always constantly running and is distracted and focused on other things. And sometimes we kind of need to really just get out of our head in order to put ourselves in the right headspace to even feel desire for sex. That's exactly it. Yeah. And that's why mindfulness, as we and others have found, that it is so effective, not just for low desire, but for a whole range of different sexual concerns.

Yeah, and I think that's one of the fascinating things in your research is that it seems to work for almost everything in terms of sexual problems that people might have. And it also works across genders. You know, I know you wrote a book on mindfulness-based practices for women and how that can help in terms of dealing with women's common sexual problems, but also works pretty well in men and people of any gender or sexuality. That's right. You got that. Mm-hmm.

All right. So let's talk about the eSense platform that you created. So what's the story behind why you wanted to develop it in the first place? You know, where did this originate?

So this dates back to 2016. Kyle Stevenson, who is a professor at Xavier University, and I were having a conversation about, you know, could we come together? Could we collaborate really to address the well-known gaps in women getting access to sexual treatments, which we talked about in the previous episode?

And so those very early conversations was a lot of brainstorming. What might this look like? Is this a website where there we list how CBT and mindfulness works? And it sort of started from there. And it was, you know, a very kind of rudimentary website at first, mostly us designing it and us using our own clinical experience combined with research and

to really put together the elements of this treatment. And so over time, that has really evolved into what we now call eSense, which is a digital therapeutic

that delivers separately cognitive behavioral therapy and mindfulness-based therapy targeting specifically low desire in women. And we've done the early feasibility and usability studies where we looked at, you know, if we build it, will they come? And certainly we found high rates of engagement. We found high rates of satisfaction. And we integrated a lot of the, you know, the patient's feedback into subsequent versions of e-media

So it was very much co-developed with patient input. And then we got some funding along the way where we tested it in a much larger randomized clinical trial against a control group and found not only that eSense worked, but that the effect size of improvements was really high. So like much higher than we see in studies of sexual pharmaceuticals of low desire and

and that the benefits were retained when women were assessed several months later. So very high rates of improvements in desire and distress and also improvements in things like relationship satisfaction and overall sexual function itself. And then we went on to say, okay, it works in the lab. How does it work in the wild? So we did one implementation science study where we partnered with several sex therapy clinics across North America and

And we asked them to offer it to women who were waiting on their wait list to see a clinician. And we wanted to see, could clinics offer it? And would those patients on the wait list accept it? So we've done some separate work showing that it's highly implementable and

And then some of the more recent fun stuff we've been doing is adapting it to different populations. So we're well into a randomized clinical trial with an adapted version for cancer survivors. We've got another version that's done in partnership with Amelia Stanton from Boston University for trans women. Again, all done in partnership with community groups of trans women. And then we've got some other adaptations in the work for neurodiverse women, for women with severe obstetric tears, etc. So yeah,

It's been a labor of love. It's been an amazing partnership with Kyle and our much larger team. And we're just excited to get it out to the world now. Yeah, that sounds like almost 10 year labor of love. Pretty much. Yeah, and still going. Yeah.

You know, I think you mentioned a lot of important things there. One is that, you know, the effects persist once people are done with the program, right? And I think this is a really important point. You know, in the previous episode, we were talking about pharmaceutical treatments for women with low sexual desire and, you know, the benefits of that.

drug treatment are only going to last as long as you're taking the drug itself, right? So if you discontinue the drug, benefits will go away. But something like this, where you're actually changing their cognitions, their behaviors, and their practices in the bedroom, you can have this change that persists over time, even though the treatment itself has stopped. And so I think that's really the key value and benefit of programs like this is that it creates this long lasting change because you're not just like,

getting a temporary fix by changing something in your body's brain chemistry.

Yeah, that's exactly it. And that's, you know, people are learning skills that they're quite motivated to keep practicing in their life. And in some of my work that's focused mostly on mindfulness, what we found there is like even when we reassess them a year later, they haven't just maintained their improvements, they've continued to improve. And they're seeing other benefits on things like mood and anxiety and quality of life.

And I think this is what really makes, you know, a psychological approach different from a pharmaceutical approach. But it does take work, right? It's so much easier to take a medication effortlessly, thoughtlessly. And the kinds of skills that we're talking about cultivating really take effort. It's kind of like going to the gym. You know, you're going to see those fitness markers improve when you put the time in and you lift the iron. And we kind of talk about these skills in the same sort of way.

But again, people, you know, we found pretty high rates of engagement. People were very motivated and overall they liked the exercises and they found them, you know, they could relate to them. They could relate to the patient journeys because we've got journeys of different women presented throughout eSense. And overall, it's about bringing these evidence-based skills out to people so they can really use them in their lives.

Yeah. And I think, you know, I'm not in any way anti-medication, including, you know, taking medications in the case of sexual dysfunctions or disorders. But I think all too often we're seduced by this idea of the quick fix, right? Because we can get this immediate effect. But in the process, we don't really deal with the underlying psychological issues. And if we don't deal with those, you know, just changing something physiologically might not actually do a lot to change the

quality of the sex that we're having. You know, if you were having very mediocre or middling sex to begin with, and then you take a drug that increases your desire for it, now you just have desire for mediocre sex more often. You know, so I think, you know, that's really one of the other benefits of these kinds of therapies and treatments is that they attend to the psychology of it. And I think they also help people to have better quality sex in the process.

That's absolutely right. And I'll make a note about, you know, Kyle, my partner in this work has a real interest in trauma and methods of improving trauma. And although eSense is not a treatment for trauma, and we talk about, you know, history of sexual abuse and post-traumatic stress disorder, PTSD, minimally throughout eSense.

Kyle led some analyses that showed us that actually eSense reduced PTSD symptoms. So that's really promising for the very high proportion of women who have both a history of trauma and they have low desire. And I know clinically, a lot of healthcare providers say, well, maybe you should go to the trauma work first before we address the sexual issue. And obviously this is very individual taken on a case-by-case basis. But

But at least our research and with eSense shows that maybe this is an approach for women who kind of have both and they can kind of work through it at their own. And that might then position them to decide what's next for them. So how long does the program take to complete? You know, is the timeline similar to what you'd be doing if you were going through face-to-face therapy? Do you go through it at your own pace? So it might be different for different people. What does the timeline look like?

Yeah. So each of those arms, CBT and mindfulness, is comprised of eight modules. And that was intended to really map on to eight sessions of CBT or eight sessions of mindfulness.

In our randomized clinical trial, we found that it took people on average about 11 weeks to do it. So again, very much in the range of about three months of going to treatment if you're doing so on a fairly regular basis. Of course, some people don't go to therapy on a regular basis. They may go once every two months, and then it takes a lot longer to

And so one of the things we're really curious to see when we launch our commercial pilot, which we're going to do in a few months, is when we remove all of the kind of research-related restrictions and recommendations, how do people use it in real life? And there, it'll be really curious to see, do they need the full eSense 8 modules? Or do they benefit enough after a few modules? Or do they prefer to use it kind of spread out over the course of a year?

That'll be some of the data that we're going to be really interested in tracking. And I think it sounds like one of the benefits of a program like this is that, you know, it goes back to what we were saying in the previous episode about how many women don't get help for something like sexual interest arousal disorder, in part because they're too afraid or embarrassed to bring it up with their doctor, or they bring it up with their doctor and their doctor has no idea how to treat it.

and they just tell them to have a glass of wine instead. And so here you've got a platform where you can go with discretion, you know, in the privacy of your own home. You don't have to go talk to your doctor about it first, right? And so it kind of removes that one hurdle, but it also, you know, provides another treatment tool in case your doctor doesn't know or isn't aware of current treatment methods or practices. So, you know, having that benefit of widespread access

and being able to do it in the comfort of your own home. And then also, you know, I imagine it's going to cost a lot less than going into therapy for three months. So you can see a lot of potential here.

Yeah. And we brought a CEO onto eSense Health, which is the company that we've spun out and, you know, very much aligned with our values of making things accessible. We're pricing it less than the cost of two therapy sessions. And that's really important because we want to make sure that regardless of your own personal socioeconomic situation, that this is something accessible for you. And I think for a lot of people, this will be the first time that

they've ever kind of had any kind of professional guidance to address their bothersome low desire. Yeah. So given all of the current discussions around artificial intelligence that we've been hearing, I'm curious as to whether there's an AI component to your platform and also the extent to which in general you think AI and chatbots have the potential to help in online sex therapy.

Yeah, awesome question, Justin. The answer is yes to both. So, you know, if we look at some of the work by Laura Vowles and Nicola Doering showing that actually online chatbots in the therapy context when it comes to sex therapy are

are quite good. And, you know, obviously they need to be programmed and the algorithms are influenced by what you feed into them, but they can validate, they understand therapeutic, you know, understanding quotation marks, the different therapeutic modalities, people enjoy using them. In fact, Laura has done some research that has found that people themselves can't tell the difference between whether it's a human therapist or an AI therapist on the other end of

So one of the things with eSense in our clinical trials to date is that every user has been paired with a navigator. And basically the navigator is someone that we've trained as an undergrad student, typically in psychology that we've trained on things like active listening and empathy and validation and support. And they check in with person who's working through eSense once a week for, you know, 15 or so minutes and,

And we have a trial underway right now where we're comparing the human navigator to an AI chatbot navigator. So again, we've programmed Amanda, who's the chatbot navigator, based on our training materials for the navigators in eSense, combined with what's commercially available in terms of mindfulness-based therapy, like my book and cognitive behavioral therapy.

And we're predicting that we're going to see high levels of engagement in the AI chatbot group, perhaps even similar to the human navigator group. Time will tell. We're well into the trial right now. But I think this is the wave of the future. And I think, of course, the quality of these AI chatbots depends on what we're feeding into them. So

So here's where we need to make sure that the kind of data that we're using to program these chatbots is based on good evidence-based data. But this is going to be a part of our future. And I think it's a wonderful thing because it means that for people who are not getting access whatsoever, they are now for the first time.

Yeah, you know, and I was going to ask, like, are online sexual health programs like this going to be the future of sex therapy? And, you know, I was thinking about this from the standpoint that in the United States alone, you know, we're a country of 330 million plus people, and there are only a few thousand certified sex therapists. You know, there just aren't enough of them to go around. And so having other tools and ways for people to access evidence-based

based sex therapy resources is vital, you know, especially tools that can do this work for a fraction of the cost. And also, you know, a lot of people just live in areas where they don't even have any sex therapists, you know, which is part of the reason why we've seen a big growth in therapists who are administering their services online so that they can reach

rural populations or people who otherwise just live in areas where you just don't happen to have any or many sex therapists around. So would you expect we're going to see a lot more programs like eSense in the future that cover a lot of different kinds of sexual problems and issues for people across genders? That's my hope, actually. And I had the chance to present eSense for the first time to the Society for Sex Therapy and Research.

And was somewhat inundated afterwards from different folks saying, oh, can you do an adapted version for premature ejaculation? Can you do an adapted version for Southeast Asian with orgasm problems? Can you do an adapted version for XYZ ejaculation?

And my hope is that, yes, that, you know, there's nothing quite like eSense out there. There definitely are other apps, sexual health apps. A lot of them mostly deliver education, which is fantastic and great, but really none that are delivering, you know, therapy skills in the way that we are. So our hope is that this opens the door for other groups of researchers with a bit of an entrepreneurial spirit to say, you know, it's not enough to just be doing research on these topics.

We need to close the gap in people accessing good care because as you pointed out, Justin, you know, the kind of mismatch between the number of people needing concerns and the availability of providers is enormous. So could digital therapeutics be a way to close that gap? I think so. So when will the platform be available and where will people be able to go to access it? Is there a place people can find out in the meantime?

Yeah, so our website is just eSense.health. So www.eSense.health. From there, it can sort of take you to one of our current clinical trials, like the clinical trial for cancer patients, clinical trial for neurodiverse women, etc. And then our hope is that in a few months, so sort of late summer 2025, we'll be launching a commercial pilot.

And so at that time, we're going to be looking for large numbers of women with low desire who want to try it. They'll be able to access it free of charge. And then we'll really use that feedback to kind of finalize our business plan and make it available. We've also been talking to many different menopause clinics, cancer clinics and pelvic floor physiotherapy clinics.

And the response has been overwhelmingly positive where people are saying, tell us when this is ready. We want to make this available to patients. So our hope is, you know, 2025 is going to be a year of kind of refining what it's going to look like when it's commercially available and maybe early 2026, people can actually get access to it.

Yeah, well, we're very excited for it to come out and I'm sure you'll have no shortage of people who sign up who are interested to learn more. Now, I have one other question for you, which is about technology and how it's increasingly being applied in the world of sex therapy. And I know, Laurie, that you've done some work on virtual reality applications in sex therapy. So tell us a little bit about how you think other emerging technologies are going to shape the therapy landscape going forward.

Yeah. So in the same way that tools like eSense, you know, are delivering psychological treatments, we're seeing many different kinds of technological tools that I think are going to really boost our ability to support people. So you and I on a previous podcast talked about our work in virtual reality, specifically for women and others with vaginismus, which is that tightening of the pelvic floor that prevents penetration, wanted penetration, right?

And these women have so much anxiety and phobia and fear that they just don't do the exercises, even though we have evidence-based tools. And what we've shown in our proof of concept study, and now we're moving on to a much larger trial, is that if we can bring them in a controlled lab setting in a hospital context, put on a VR headset on them where we're exposing them to these sexual scenes, they can manage their anxiety and they feel motivated to go home and practice penetration on their own.

Some of them leave in tears because this is the first time where they feel like they've been able to overcome their fear. So again, you can think about virtual reality for other kinds of sexual concerns where there's avoidance at play or where there's high levels of anxiety at play. We're going to see a lot more research in this area and we should welcome it. The world is ready to embrace these technologies. So let's use them to our advantage and in a way that can really help people live better sex lives. Yeah. Yeah.

I totally agree. There's so many applications or potential applications here of all of these technologies, artificial intelligence, virtual reality. Unfortunately, I think in some ways it's harder to apply them in the world of sex therapy because sex in general is taboo. And so that can sometimes create issues with

fundraising and venture capital to try and invest in these things and develop the technologies out. But I think the appetite, the demand is there and it's going to be so overwhelming. And there are so many opportunities here that at some point investors will get off the sidelines and get over their fears and concerns about sex and say, hey, you know, there's a lot of opportunity to make money here.

Yeah. And especially if they're personally impacted in some way, they're more likely to put their money where their mouth is. So yeah, that's certainly our hope because until now, eSense has been exclusively funded by research grants. But as we move into this more commercial realm, we're going to be relying on fundraising and angel investors and venture capitalists and that sort of thing. So yeah.

So I think part of our narrative is about highlighting that sexual health is health. It's a part of your overall health and quality of life. And so that's, I think, a narrative anyone can buy into and invest in. Totally agree. Sexual health is health. So thank you so much for this amazing conversation, Laurie. It was a pleasure to have you here. Can you please tell my listeners where they can go to learn more about you and your work?

Yeah, for sure. So you can find me on Instagram at Dr. Lori Brado. I mentioned our eSense URL is just eSense.health. And anyone who's interested in participating in research studies in my lab, again, our Instagram handle is UBCSHR, which stands for University of British Columbia Sexual Health Lab. Well, great. I'll be sure to include thanks to all of that in the show notes. Thank you again so much for your time. I really appreciate having you here. Thanks, Justin. Thank you.

Thank you for listening. To keep up with new episodes of this podcast, visit my website, sexandpsychology at sexandpsychology.com or subscribe on your favorite platform where I hope you'll take a moment to rate and review the show. If you listen on Apple Podcasts, please consider becoming a Sex and Psychology Premium subscriber to enjoy ad-free listening for just $3.99 a month.

You can also follow me on social media for daily sex research updates. I'm on Blue Sky and X at Justin Laymiller and Instagram at Justin J. Laymiller. Also, be sure to check out my book, Tell Me What You Want. Thanks again for listening. Until next time.