A lot of women notice their desire for sex fading over time and assume something is wrong with them, but there's often a real reason for it, and they're not the only ones going through it.

I sat down with Dr. Lori Brotto, one of the most recognized researchers in women's sexual health, to talk about why desire changes and what actually helps bring it back. We discuss the difference between spontaneous and responsive desire, how to tell low desire apart from asexuality, and how sensate focus works in sex therapy.

Lori also introduces eSense, her mindfulness and CBT based digital platform built to close the access gap for women who can't reach a sex therapist, and shares surprising research on how an AI-powered navigator stacks up against a human one.

What You'll Learn

• How to differentiate low desire (a treatable concern) from asexuality (a sexual orientation).
• What sensate focus actually is and how it's used in sex therapy.
• Why sexless relationships often start with avoiding non-sexual touch, not sex itself.
• What mindfulness and CBT do as treatments for low desire.
• The origin and design of eSense: a self-directed digital program modeled on real sex therapy sessions.
• The risks of unregulated AI (like general chatbots) in mental health contexts, and how eSense was trained differently.
• Access, translation, and the biopsychosocial barriers facing racialized and non-English-speaking women.
• Technoference: how technology disconnects us in daily life, and how it can also be used to rebuild presence.
• A live guided mindfulness exercise listeners can follow along with.

Get in Touch with Lori:

Website

eSense website

Instagram

Get in Touch with Me:

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Preorder my book

hey y'all, it's me, Dr. Smeenerman Gyno Girl. Welcome back to another episode of Gyno Girl Presents Sex, Drugs, and Hormones. I'm Dr. Smead Ramon. Today I'm talking with someone who I'm super excited about.

Her research has fundamentally changed how we understand women's sexual desire. Dr. Lori Barato is a psychologist, a professor, a researcher, an author, and an internationally recognized leader in the field of women's sexual health. For more than two decades, she has studied sexual desire, arousal, distress, mindfulness, and the mind-body connection, and the many reasons our brains and our bodies don't always seem to speak the same language when it comes to sex. And I think her work has

helped challenge one of the biggest mistakes we've made in sexual health and for women, and that's the idea that women's experiencing low desire that when women experience low desire, we simply need to find the one thing that's wrong with her, which we know desire does not happen in a vacuum. It exists in body, brain, relationship, culture, hormonal environment. It is truly biopsychosocial. Lori's research on mindfulness and cognitive behavioral therapy has now culminated into this amazing platform called eSense.

It's a digital intervention designed to bring evidence-based treatment for sexual concerns for women who may never have access to sexual medicine specialists, which we know there's so many sexual medicine deserts around the world. And so this raises, this actually also raises an interesting question, which I want to talk to Lori about, which is: can technology help us become more present when technology itself has made it harder for us to be present? So I can't wait to have that discussion.

But today we're going to talk about desire, brain, mindfulness, HSDD medications and hormones, essence, AI, technoference, all the good things. So thank you so much, Dr. Lori Berater, for being here today. I'm super excited. Well, good pleasure. Awesome. well, I mean, first I like to get a good background story on everybody that I talk to. So, you know, as Guy No Girl, I love a good

me as well. What a pleasure to be here. Thank you.

Background superhero story. So tell me what brought you into the field of sexual medicine and then specifically studying women's desire. Like what was your impetus?

Yeah, great. Thank you so much. So I mean, I'll be honest totally by accident. I never set out to be a sex researcher, sex therapist, sex educator. I started volunteering in a lab that was studying animal models of sexual dysfunction. And so I spent many years stressing rats. So I would put them into crowded cages, I would shine strobe lights on them, I would play white noise, which if you can imagine.

on a chronic basis would significantly elevate anyone's cortisol levels. And it definitely did with these with these rats. And then I would measure the impact on their sexual activity. So looking at things like how many mounts did it take the male rats before they reached ejaculation, how long did it take them before they would start mounting again? And and it really introduced to me as a you know kind of very young scientist, the really serious science around sexuality, that this was something that

huh.

we could quantify, that we could observe, that we could make inferences from when we studied animal models. so after six years of of doing that, Viagra was approved. And Viagra's approval, you know, this blockbuster medication that was effective and accessible and everyone was talking about it, led me to look at the the field of women's sexual health and

Yeah.

I asked the question, well, surely there must be something comparable for women. And that literature search sh turned up pretty quick. So the answer was a resounding no. Not only was there not a comparable blockbuster for women, actually the science that sought to understand female sexual health was was quite a bit smaller than the the field of of men's sexual health. That was in 1998. So I made a switch. I decided to start doing research on female sexuality.

I was at the University of British Columbia in Vancouver, and there was really no one around to kind of provide that mentorship. So I would drive from Vancouver to Seattle and be mentored by Dr. Julia Hyman, who really is a giant in the in the field of sex research. and she helped us set up a sexual psychophysiology lab in Vancouver, where I then spent for my PhD understanding while studying and trying to understand what happens in the woman's body.

as she was exposed to audiovisual erotica. And then really importantly, what was happening in her mind at the same time. so I was looking at kind of the degree of agreement between the body's arousal, the mind's arousal, and when those two processes were not in sync with one another. and then of course I fell in love with the field and have been really, really happy to be a an active member in it ever since.

Awesome. I thought I love that story. I know sometimes we have to I you know, we're recording this on the day I find out that Gloria Stein we find out that Gloria Stein and Pat and you know, she's been such a revolutionary, like just we have to take the bull by the horns and and do it ourselves sometimes, right? So I think that

Yeah, it's pretty remarkable what what she did in the in the sixties and seventies. And, you know, I just referenced Dr. Julia Hyman who shares many stories of being, you know, one of the few female sex researchers in the 70s and having to really advocate for the importance of studying female sexuality as a as a serious area of health. And I feel like in some ways, you know, fast forward now 50 years, we're still trying to make that argument.

Yeah.

Hundred percent. Yeah. Yeah. Yeah. I mean if you think about just the amount of time it takes any medications for women's sexual health to get approval in in government systems, especially I'm talking about the United States specifically, it's it's astounding. So we still have a probably a long way to go, but hopefully slow and steady. Slowstead.

I think we've definitely made a lot of headway, but we still have a long way to go for sure.

Yeah. We'll get there. So it's steady.

well, let's talk a little bit about desire then because I think this is one of the best like one of the things I love to talk to my patients about in long-term relationships, what happens to women's sexual desire. And you know, once they understand responsive versus spontaneous desire, it's like a light bulb, you know, hits them in the because you know, most people want

to want to have sex, you know, the way they used to or, you know, the way that they previously sought to. So can you just walk us through like what's the difference between spontaneous and and and and responsive desire, wh how we've gotten it wrong in the past?

Yeah. So it's a great place to start because I think just sharing this one piece of information can help to not only normalize people's experience, but maybe empower them to take a look at what I can do in my own life to cultivate sexual desire. So, you know, I think it's it's e easier to understand what spontaneous desire is, and it's that sort of feeling that comes somewhat out of the blue where you want to have sex. Maybe it's new in a relationship, maybe it's you see someone.

That you're fantasizing about, and there's sort of that internal urge, wanting, motivation, interest, drive, libido to have sex with them. And that type of desire has been studied a lot. We know actually a lot about it. We know that it's primarily dopamine driven, the reward center of the brain. it's more common early in a relationship, and it's often associated with what we maybe conventionally think about when we think about desire, right? That sort of feeling that just hits you.

Yeah. Yeah. Yeah, exactly. Yeah.

comes out of nowhere and it's very visceral and physical. The electricity, right? You don't see people planning or putting kids to bed or taking socks off. and we contrast Thank you, porn. and we contrast that with a different a different kind of desire. It's not a better or a worse kind of desire. It's just a different kind of desire that also has been studied quite a bit. And it's the desire that emerges

Yeah. It's in porn. So porn shots.

After a person has started to become sexually excited. So if you kind of imagine a scenario where let's say a woman in this case will agree to sex, maybe even initiate sex, but not necessarily because she's in the mood or feeling, you know, desire or horny, but she might say yes to sex because she wants to have an orgasm or she wants connection or she wants to celebrate an anniversary or you know, some other

of of many, many different reasons that that might motivate her to kind of move from neutral towards open and initiating and accepting. And so then over the course of the encounter, if the kinds of stimulation and touch and exchange are right for her, they actually work to elicit arousal for her and she feels arousal.

That then paves the way for wanting. So she sort of gets to a point in the interaction where she says, now I'm in the mood. This feels really good. I want this to continue, not just for the original reason, but now I have desire. And so we call that responsive desire because it it's desire that emerges in response to arousal. And s while some people have associated that responsive desire more with women's desire than with men's.

Yeah, yeah.

and I find it interesting too because you know you have patients that come in all the time very upset. They feel, you know, they feel broken, they feel like they in they're internally dying because they don't have this desire like they used to. And usually it's in midlife. and then s and then and it's happened so that I've I've treated patients, you know, sent them to a sex therapist, given them all the HCSDD medications, and then

you know, they'll come back after some sex therapy and realize, you know what, it turns out I'm asexual. And to me that's been like very profound because, you know, I think a lot of us don't ought and and I tell patients that sometimes 'cause they're like, Well, I don't know. I don't think I've always been that way. I don't where they had experienced this feeling of always wanting it at some point and now don't. And then some patients are like, Well, I've never really been that but

Mm.

It's it's different now. So I know you've done some research on this as well. So can you talk to us a little bit about, you know, how to differentiate and and how as a therapist we might go into that research once?

Yeah.

Yeah, such an important question because asexuality is not a sexual dysfunction or sexual problem. it's a sexual orientation, right? And we our group certainly has done a lot of research trying to not only understand asexuality, but how is it different from low desire and distressing low desire? And one of the ways that we've approached that question is by doing really in depth interviews with people who identify as asexual and people who

Yeah.

Don't identify as asexual, but maybe have have a long history of low desire that's bothersome for them. And there's a couple of key differences. One is that the person who identifies as asexual will say, you know, I never remember a period of my life, and certainly not in my kind of early development, where I was ever attracted to anyone sexually. I can appreciate the aesthetic qualities of people, but it doesn't translate into a kind of sexual.

craving or wanting and I never remember that. and then the other really important difference is the asexual person is not bothered by their asexuality in the same way that, you know, as long as let's say a a gay person is in a welcoming, supportive environment, they're also not distressed by their sexual orientation. Whereas the person with low desire,

is far more likely to say, this bothers me, this gets in the way of my relationship. I want to improve this. If there's a treatment, please give it to me. And and so I I think it really is important that as healthcare providers, when we provide care for people with low desire, that we are careful to differentiate is is could this be asexuality?

Yeah. And what I found interesting is, you know, dealing with the patients that, you know, have come back to me like, you know what, I it's it's turned out I'm asexual. Some of them feel so relieved to find out, and then others feel very stigmatized about it, right? Like like, my God, I'm asexual. Like what? I mean, you know, like and so I think it just comes to any stigmas that that come up with sexual sort of orientation. But have you seen any trends or like what do you what what's your thoughts around that?

Exactly.

Yeah, and and in fact, I've seen a number of couples in my clinical practice that kind of fit exactly what you've just described. So for the longest time there was an assumption that they were both, you know, sexual, what we call allosexual, which is the person which has the capacity for sexual attraction. And then at some point, well into the relationship, one of them realizes that they're asexual. Well, now what do you do? You're in a long-term committed relationships.

Relationship. You don't want to end the relationship, but how do you kind of negotiate this new place where you realize one person does not want sex? Right. So it's quite different from working with a couple who have say discrepant sexual desire where there's actually a lot we can do to reach some middle ground. in the case where one person identifies as asexual, it it can be really tricky because it means either one person having sex that they absolutely don't want to have, or the other person.

foregoing sex altogether when they identify as sexual. So there's not a one size fits all cookie cutter answer. It really depends on the couple, but that's the kind of work I really love to do because there actually are options for couples like that. It's not just, you know, meet in the middle and instead of having sex once a week, it's once every two weeks. It it really is quite nuanced. And again, it's, it's I think a a really great place that a sex therapist can be useful to a couple like that.

And I want to talk about you know this new digital platform, but before we do, can we sort of embark on you know when in sex therapy you're getting different treatments? There's the idea of what sensate focuses and how we talk about that in a therapy setting so that people can kind of understand what happens in sex therapy and and some of the terms that are used.

Yeah. Yeah, a a great question. And I and you know, I think in the same way that we trust our physicians like you to use evidence based tools, right? You're kind of the things that you prescribe and recommend are things that have been studied and there's good support for, and sex therapists do the same thing.

Now we strive to do the same thing because there may be some, and this is a plea to people that, you know, vet the people you work with. Make sure that, you know, they're reputable, they've got a degree, they've they know what they're doing, they're following evidence-based care. And so, as a licensed psychologist and sex therapist, I follow, you know, what does the evidence say has been studied and found to have the most support for? So things like sensate focus.

masturbation of your partner. This is exploratory touching with the goal of the receiver of the touch tuning in, paying attention, feeling what d different touches feel like, helping them overcome anxiety, and really importantly to stay really present. And then the two switch roles, the giver becomes the receiver, the receiver becomes the giver, and the other person gets to experience it. And it's structured in the sense that for the first maybe even several weeks,

There's no touching of erogenous zones. So nipples, breasts, vulvas, you know, testicles, et cetera. It's it's exactly it's prescription, it's off limits. And that's because we really want to help people kind of cultivate that skill, that really difficult but important skill of being able to pay attention when you're receiving touch. And then with practice and then feedback from the therapist you're working with, we can gradually introduce those more erogenous zones.

It's very prescriptive. Yeah.

But again, the goal is not to create arousal or to help the person reach orgasm. It really is about being able to train presence and to do so in a non-judgmental way. So definitely sensate focus is one of the critical tools in our toolbox. There's others as well, like cognitive behavioral therapy and mindfulness that that also have a lot of evidence to support them.

Yeah, and I I love that so many of my patients who ultimately end up in sort of sexless marriages because, you know, I tr as a you know, I treat a lot of midlife women who are struggling to do everything, you know, every caretaking duty, every you know, chores, all the things. And so a lot of times they'll come back to me and say, Well, no, I we're not at kissing yet. You know, so like they'll talk to me about where they are in this prescriptive cycle. But I think it's so helpful because if you've

if your if your partner has become a roommate to you more than anything else. Like you don't I mean, it truly in a sexless marriage, people aren't even touching each other anymore, right?

Yeah.

No, they're not they're not undressing in front of each other. In fact, the the low desire person might intentionally, you know, go to bed at a different time or undress in the bathroom, whereas maybe in the past they'd have no problem undressing in front of the partner. And it's because their mind is sort of forecasting that, if I get undressed in front of my partner, it's gonna arouse them, they're gonna want sex, it's gonna be a disappointment. So it's almost like they avoid all the cues that could possibly lead them in that direction of

sexual activity. And that's often the part that a lot of people and couples say they miss. They miss the touching, the connection, the undressing, the kissing, the, you know, all of the, all of the maybe non-sexual ways that people can be intimate with one another. And they tend to forego all of that altogether when there is low desire.

Yeah, I think that's that's probably one of the most problematic things. And and I think that's then you lose communication skills, right? Because you're like, Who do I bring up, you know, even kissing that person again or whatever, you know? And so it becomes offered.

Yeah. And then just becomes awkward, right? So and then months go on, sometimes years go on, sometimes even decades go on.

Yeah. And that's I think those are the ones that people almost lose hope in the relationship, right? Like I think that that leads to

Yeah, exactly.

well tell me a little bit about I wanna I wanna dive into the Esense, which is an amazing platform. I was, you know, looking at it this week when I was telling a patient about it. and I wanna know like what I mean, I can imagine what your motivation around this is because sex therapy is so sometimes difficult for patients to access in a lot of ways. Because not only because, you know, there might be a monetary reason, but a lot of times it's you're giving me another to do list. Like you're giving me another thing.

Yeah.

Yeah, yeah, yeah.

Another appointment, another, you know, and so tell me what went through your mind when you were thinking about creating this platform.

Yeah, yeah, great. So, I mean, as we just reviewed, we actually have really good evidence, a few decades worth of evidence that things like mindfulness based interventions, as well as cognitive behavioral therapy, which is a different system of psychological treatment, work quite well for for managing low desire, particularly in women.

Thank you, Laura. Before you go into that, can you talk a little bit about how what you're just trying? Yeah.

What those are? Yeah, so mindfulness is it's it's sort of derived from Eastern meditation, but it's very kind of i it's modern day, it's secular, it doesn't depend on anyone's religion. It's basically a set of skills that we practice with the goal of cultivating present moment, non-judgmental awareness.

So there will be exercises that we practice like body scans, mindfulness of thoughts, mindfulness of breath that help us kind of gather our attention, bring it to a particular target in the here and now, and really importantly, do that in a non-judgmental way. So you'll be listening to a guide and you'll be following along, guiding your attention on sensations of the breath, sensations in the body, et cetera.

As a way of changing our emotions and affect. So, as an example, the person with low desire might say, I have, I I can't feel desire. My partner may as well leave me for another person where they can be sexually happy, right? So this sort of very catastrophic black or white, if my desire if my desire and arousal aren't working, the only option is to end the relationship and set my partner free.

Yeah.

you can see the really black and white nature that. And you can imagine if a person is having thoughts like that on a repeated basis, it's going to impact how they feel, right? So they'll become more depressed and anxious, their desire will in turn reduce and it'll start to impact their behavior, where they're avoiding sex, there they might become, you know, it might impact how they communicate with a partner. And so what we're targeting in CBT is we're trying to

Challenge and change and replace those irrational thoughts, as well as targeting some of the behaviors that get in the way in order to improve affect and mood. Okay. So mindfulness is kind of present moment acceptance base, CBT is change-oriented, and both work, and it turns out they work about the same to improve low desire. so

Sina, you mentioned, you know, a lot of the barriers that women have to even seeing a sex therapist. You know, it's there's stigma, there's shame, there's cost, there's geography, there's where do I start? I get onto Google and I type in sex therapist and I have no idea how to vet you know people who are credible versus those who aren't. and so several years ago, Dr. Kyle Stevenson, who's a close colleague of mine at Xavier University in Cincinnati, he and I got together and say, is there something we can do to help overcome this gap? Is

You know, we we have these evidence-based treatments, but how do we kind of get them into the homes so women can use them? And so we sort of mapped out what does it look like when a woman were to if a woman were to see me or Kyle in sex therapy, and can we map that out into a series of modules that they could work through on their own? So that was how we kind of came up with the idea of eSense. We then sat at the table with women.

Mm.

Who have firsthand lived experience of low desire and sort of co-designed the program. And so essense embeds two arms, mindfulness and CBT. And within each of those arms, each are based on eight modules that again is intended to mimic what it would look like if she were to see a sex therapist. So, as an example, if she were in the mindfulness arm, it would be a combination of the actual exercises that we would do.

In this office doing sex therapy. So all the audio guides, all the instructions, all the homework sheets, all of the reflections. there's videos that explain different concepts like the sexual response cycle, there's animated gifts, and then really importantly, there's patient stories. And so the woman who's working through it kind of follows the journey of these three women with low desire, and they differ in terms of their race, their religion.

their age, their sexual orientation, you sort of follow them as they go through the exercises and struggle through them. And then you kind of watch how they overcome that. And that's intended to provide some motivation for them to continue. and so over the last several years, we not just designed it, but we've been testing it. And we have a quite a number of publications that show that it's feasible, it's usable, it works. And then when women in

the improvements that women see in many different facets. Low desires improved, their distress is improved, their quality of life is improved, and they're able to retain those gains when we reassess them six months later. And it actually makes sense because if you learn a new skill, you're more motivated to implement it in your life. So it's not that once they finish, they kind of revert back. They continue to use these skills and they continue to benefit from them many months later.

Yeah.

It's wonderful. do you find that like when you talk to other like sex therapists and colleagues, are they concerned about, you know, this kind of platform? Like, is it gonna replace me in some capacity or or how have you navigated that discussion?

Yeah. Yeah, great great, great question. And the outer answer is a resounding no. And it's because all of us have, like you, very long wait lists, right? So like my own wait list in my clinical practice, which is arguably small, but my wait list is, you know, eighteen months. and that's the case with a lot of my sex therapy colleagues, is you know, they're keen to be able to have another tool. Ultimately, at the end of the day, all of us

Yes.

Right.

have the same goal in mind, and that is to bring the best possible care to women and to have multiple tools in our toolbox. So yeah, the sex therapists, and I've presented on it now at a variety of sex therapy meetings, they're they're excited about this and they're they're also thinking about how can we use a platform for this for maybe other systems of psychological therapy, like more dynamic or systems-oriented therapies. because we know and there's been extensive research published on this, most women with low desire

Right.

are not getting help. They're never reaching out to primary care, to a nurse, you know, to a naturopath, and certainly not to a sex therapist. And so the the women we see that walk through our doors is a is a tiny segment of the much larger population of women.

to agree on that too because as someone that does sexual medicine in my office and patients come to me because of their pain or desire or hormones, it's always something I recommend. I'm like, you know, part of the treatment really is sex therapy. Like, you know, I can give you Addy and Bilecy and all the great things, but you need to kind of work on this aspect, you know. And they're like, Okay, yeah, sure. And then when I see them in follow-up, did ever go see so-and-so? And they're like, you know, I never got around to so that's why I'm so excited about this, because it's like at least half of my

Yeah. Yeah. Yeah.

when I when I referred them because I have a list of local sex therapists and you know at least half of them come back and they're like I I haven't gotten around to that yet, you know? And so there's this element of untreatment that's happened, right? Like they're not getting fully treated. And so I think this is a great gap that you're filling.

Yeah, yeah, yeah, yeah.

Yeah, and and I think it it's a really nice adjunct to sexual medicine care, right? So you absolutely want to make sure, you know, that the woman is kind of optimized in terms of her vaginal estrogen and other aspects of her kind of medical physiological health, t so that she's kind of in the best state to be able to benefit from skills that like Essence provides. So it's a really great tool to be used alongside.

Told.

sexual medicine care.

Hundred percent, hundred percent. okay, so let's talk about this concept that I actually I I learned last year at Ishwish when we had someone talking about sort of

technology and and everything it's technoference that like how much technology has really transformed you know our ability to connect with others in some ways but also become truly disconnected from the people that are in our immediate lives right like and so on the one hand you know you know I know people from all over the world and and this is great but on the other hand how much do I really spend when my I don't spend anyone you know so that's always the question right

Yeah. Yeah.

It's like, well, you know, he's always like, your phone is your best friend. But you know, everyone tries to like, you know, take take that technology and and minimize it. But how you know, how is this clash happening? Where you know, you're using technology which is interfering in in lives to actually like treat one of the issues which is like not being mindful. Yeah.

Yeah.

Yeah. Yeah.

Yeah.

Yeah, that technology contributes to. Yeah. Yeah. Yeah. It's it feels like a vicious circle, doesn't it? I mean, the reality is, the reality is, is we have become more disconnected in society. And we might not feel like that personally, like, you know, I'm an exception, but the data that have captured this are really crystal clear. We become more disconnected, rates of loneliness.

Yeah. Using email.

Yeah, so

are increasing, particularly among midlife women. And we can't assume that just because a woman has people in her life that she's not lonely, right? So you can absolutely feel lonely despite having people in your life. And so connection is really, really important. the other thing that we know is because is that we're becoming a lot more aware of the role of inattention, right? So why are we seen

higher higher diagnoses of ADHD in midlife women. This is it's not like they suddenly got ADHD. It was always there. It's a it's a childhood disorder diagnosis. But during midlife, with some of the cognitive changes that happened during perimenopause, those symptoms that women struggle with, inattention, word finding problems, other cognitive issues, kind of rise b above a threshold and therefore they get labeled and often diagnosed.

And we know that technology can certainly fuel this. So the more that our brains are sort of multitasking and being everywhere at the same time, the more our brains are not in one place. And I would argue that that is nowhere more important than it is during sex, where there is no benefit to you to be planning tomorrow's dinner, to be thinking about.

Yes.

the PTA meeting and you know what what your travel schedule is like when you're having sex. And yet you talk to women and they'll say, my God, you too? Like you're thinking about other things during sex. And it's almost like you've, you know, you've given them permission to disclose this deep dark secret that is so common. And of course they're multitasking during sex because they're so good at multitasking in the rest of their life. So

That's what they did.

We do not want to portray technology as the demon because look at all the advances it's allowed us to do. As you said, you have friends all over the world that you can stay connected with because of technology. But how

And I think actually the menopause movement is from technology, right? Like social media has really been in all these groups that come together and now you have all these conferences all the time of people educating. Yeah. So

It it sure is. It sure is.

Yeah. Yeah.

Yeah. Yeah. So I think it's a it's a question of saying how do we harness technology to be able to kind of cultivate back even places in our life where we really want to be more present, like while we're eating, right? Like think think about mindless eating, how often, you know, we're eating as we're walking or we're eating as we're doing other things. And i exactly you're you're and we're and we're really not kind of

Yeah.

Yeah. Yeah. Taking pictures while we eat.

Well, first of all, we're overeating, but we're also not really enjoying the meal that maybe we spent time preparing or someone else spent time preparing for us. And so, having said that, we also know that technology can help bridge a gap in access to care, right? So telehealth, telemedicine, digital apps that deliver treatments and that sort of thing. But the key is that in using those digital tools, you're not just passively reading about.

You know, what's the theory of mindfulness and the theory of CBT? You're actually doing the treatment. So in that way, technology is sort of replacing your one-on-one sex therapist. It's functioning like a sex therapist for you, holding your hand through it, but doing so in the privacy of your own home.

Yeah. And I think you know, this is where people have this love hate relationship with not only technology, but let's talk a little bit about AI as well, because I think that, you know, this is p here to stay and we have to like sort of reckon with it. I always talk to patients about, you know, in some ways like there are patients who come to me after having chat GPT, like their symptoms and they have language to discuss things that they never were able to, right? Especially I have

Yeah.

a a large number of like, you know, maybe neurodivergent patients who are like, I would never have been able to say this to you, but Chat GPT told me how to do it. And I'm like, yeah, bravo, because like that's amazing. but there's also a lot of so much misinformation in that capacity as well. Have you sort of decided to integrate, you know, AI into your esense portal as well or a digital platform as well.

Yeah. Yeah.

Yeah, yeah, great question. So along with eSense, kind of this self-directed program that women work through, they also have the option to have a navigator. And we've tested what is the sort of added value in having a navigator. so an a navigator is not a professional therapist, it's you know an undergrad in psychology that we train who's available to answer questions, provide support, validation, that sort of thing. And

And so when women sign up for eSense, they have the option of also having a navigator. And what we found is that it increases their adherence to the program. They kind of stick with it a little bit more because there's a, you know, someone on the other side offering encouragement. So over the last exactly, right? You're more likely, you're you're I mean, there's been date on this. You're more you're more likely to lift heavier when you've got a trainer than when you're doing this on your own.

Like a personal trainer. Have an appointment, yeah.

And so one of the things that my my grad student has been testing over the last couple of years is can we train an AI LLM powered chatbot to do exactly what our human navigator does? So we took all the same training materials that we trained our undergrads, and we trained Amanda, who is a chatbot that was developed by Laura and Matthew Vowels in the UK, and they've published a ton of research on.

kind of what is the role of AI-powered chatbots in sex therapy. So they partnered with us on this work and then we embedded it within eSense. And then we looked at, you know, what was the difference in their experiences and in their outcomes, the women with low desire who were randomized to either the human versus the AI chatbot navigator. Here's what we found. What we what we found was

Very interesting and so nuanced is that women engaged more with eSense when they had a human on the other side. So there was more kind of engagement, more reaching out to them. But at the end of the day, both groups had the same improvement in their desire and reduction in their distress, regardless of whether they had the AI helper or the human helper. And then furthermore, what we also learned is that there are some people who

For a variety of reasons, really prefer a human to chat with. And there are other people who much prefer a chat bot. The anonymity, you know, if there's additional stigma there, even though they don't know the human navigator on the other end, having an AI chat bot, being able to give that kind of validation and support was more acceptable to them. So I think at the end of the day, it's going to be a personal preference, but having that bit of extra help helps you kind of work through the program a bit better.

And there's really no difference in how how much you improve in desire. Both groups improved to a s very significant, a clinically meaningful degree.

that's amazing. Now have you ever s have have you ever bl so are patients able to d to determine like or to delineate between like this was a can you can they tell it's a human versus an AI?

Yeah, so in our study they could because it was all audio based, right? So they could hear the voice. And although the I mean the chatbots they sound quite human-like, but there's you know a little bit of a delay, and you have to, yeah. so there was it, so there was a bit of a difference. Yeah. But actually in the work by Laura Vowels that she's published, she's actually published some research using a text-based chatbot versus a text-based therapist, and the patients

gosh, yeah. Okay.

'Cause I didn't know if was Yeah, yeah. I didn't I didn't know it was like a communication just through typing or was it is it actually a person?

huh. Okay, that's what you mean.

Could not tell the difference at all. Could not tell the difference. Isn't that interesting? Yeah.

Okay, okay. That's what I was wondering. Okay. That's very interesting actually. So because so you're saying that the navigator is actually someone speaking to you. I th I was imagining someone just typing it in. Okay. that's right.

Yeah. Yeah. So that's a different way to go is to have it is to have it entirely text based, where they probably won't know the difference at all.

Okay. that's so interesting. Huh. and you know, one of the things with like AI and some other technologies in general that I always think about is, you know, in one of my sort of like on my platform I talk about medical dismissal a lot, right? So like populations of people who are chronically dismissed, you know, conditions that are d dismissed, whether or not it's vowal vaginal pain or, you know, cancer survivors, whatever.

And so as a whole, you know, how the medical system is set up to dismiss populations. And so like I always think about, you know, like it's how are we automating someone to continue to dismiss like women of color, for instance. So like 'cause right, an AI chat box is only as good as the person creating the program. So I mean

Yeah.

And and the algorithms that pr that feed into it to cr to create the responses. There's kind of two limitations there. And we know that there's a gender bias, that most of the data that feeds AI is based on, you know, information based on men. So that is still a problem for sure.

Right.

Yeah. And so how are you navigating that in in knowing that sexual dysfunction is so biopsychosocial and some of that social is culture and religion and you know all the things that we think about that you know are have to be dismissed in in medical settings.

Yeah.

Yeah.

Yeah. Yeah. So within Esense, the chat bot that we kind of co-developed and worked with, we actually trained, right? So we have extensive and long manuals that we actually trained Amanda, the chat bot with that you know, are entirely based on a biopsychosocial model and the, you know, there's a lot of nuance that you can feed into it and there's clinical scenarios. And in fact, when we train our undergrads, we set up

you know, scenarios, we have them kind of practice doing some feedback and then we give them direct feedback about, you know, what did they get right, what did w they want to improve. And so the training is actually very similar in that situation. Now contrast that with if a woman were to go to just Chat GPT where the where ChatGPT is not trained in nuance. And this is where I think a lot of the really alarming cases have come out in the last few years of

That's nice.

Mm.

Right. Right.

Right.

Chat GPT actually agreeing with a person who is in a lot of distress, even suicidal. And in Chat GPT's attempt to validate that very distressed individual, it's actually very sadly backfired. And there's definitely been cases of suicide in that in that situation. So that's deeply worrisome for all of us, and certainly for mental health providers like me, when that.

Right. Yes.

lack of access in care means that people are going to, you know, they're doing the best they can and they aren't going to chat GPT for treatment. It's free. It's right in their home. And the unintended and very dire consequences of that. And so this is something that psychological societies are very aware of. And we're trying to do what whatever we can to not just educate the public, but how do we kind of put systems in place with Meta and elsewhere to be able to flag scenarios like that so that

ch you know, AI is not inadvertently increasing self harm activity.

That's wonderful. Okay. Yeah, no, that's that's what that was one of my curious questions, but I imagined that you had fed it the right information and that would be yeah. well that's great. I mean I love this whole platform that you've created and actually like I can't wait to have patients bring me some feedback on it. and it's available like worldwide pretty much.

So right now, because we've just we've started a soft launch, it's available in the US and in Canada. And our hope is early in twenty twenty seven that it'll be available worldwide. So and so people can sign on and try it for a few weeks totally for free. And then if you like it and you wanna continue, it's less than the cost of two therapy sessions. And in fact, in many states it's less than the cost of one therapy session.

Okay. Okay. Okay. Gotcha.

Yeah, that's true.

and then you have six months of access. And again, our the our published data show that you know, upwards of ninety percent of the women have have quite clinically significant improvements in their desire, and those improvements are retained over time because they they learn new skills and they quite like it. You know, it's like I said, it was co-designed with women with low desire. So the colors and the stories and how we describe different concepts and the videos, they were all designed really with the woman at the center of it.

Yeah.

That's wonderful. Lori, when you were at Ishwish a few years ago, and we you talked about your book Better Sex Through Mindfulness at that time and it was one of the breakout sessions. You actually did like a five minute mindfulness thing with us, I remember. I didn't tell you this.

Which is always risky. It's always risky in a in a big audience of busy people. I'm like, this is gonna f this is gonna flop or I'm gonna have like two people in the front, you know, with their eyes closed.

It really went well. It really went well.

Yeah, no, it was it was really nice. Do you think that like for the people listening you can give them a sense of what you do when you try to do some mindfulness in those settings or even one on one? Like can we do a little exercise? Okay, okay, all right, okay.

my gosh. Yeah, I would love to. Okay. So we're going to start by just coming into the present moment. And so for anyone who's listening right now or maybe watching this, close your eyes. Just take a moment to set aside, imagine putting on the shelf all of the different things you've been thinking about. If you're doing something, just for a brief moment put it on the shelf and just bring your awareness.

Do I do this? I'm doing it.

To the points of contact between your body and the chair if you're sitting, or your feet in the floor if you're standing. And all you're doing is bringing awareness there. So, what sensations do you feel there? Is there a tension, a tightness, a warmth, a vibration, a tingling, a smoothness? That's all you're doing is bringing awareness to those points of contact in your body. And as we're settling in.

Of course, there's distractions, there's other thoughts and sounds. You just notice those are there. And maybe you say to them, I see you. I'll get to you in a few minutes. And so then take a moment and just bring your awareness to your sensations of breathing. Where do you feel the breath in your body? Do you feel the breath going down into your body, deep down into your belly? Can you sense the movement of your belly right now?

And this isn't about changing how you're breathing. It's just about bringing awareness in a really kind and compassionate way. there you are, breath. Hello. I haven't seen you for a while. Thank you for always being there automatically, even when I'm busy. I sense you. And again, as we're continuing on, distractions are there, sounds, thoughts, other things, maybe pains in the body.

You just give them a nod and say, I see you. I will get to you. And for now, I'm just going to honor these sensations of the breath.

Continuing on just for a few more moments now.

Really imagining kind of embodying that kindness to yourself, that taking a few moments to just be fully aware really a is an act of bravery and an act of kindness.

And slowly opening your eyes when you're ready and bringing that same present moment awareness with you as you continue the conversation, as you move on.

That was just a minute. it's just a

That was really good. You have the best voice for that by the way. I'm just so relaxed listening to you. I'm just like, my God, I need to I'm just gonna play it back and forth.

Well, I I actually have a bunch of my I have a bunch of my recordings on my website, lauriebrottel.com. You can go on there, you can download them, you can save them on your phones and devices. They vary in length from three minutes all the way to 30 minutes. And really, there's two things we did there. One was we paid attention on purpose, right? The second thing we did was we were kind to ourselves as we were paying attention. Right. So the non judgmental, the

Yeah.

The it's okay if there's distractions because so often we're like, I can't do this. I hate yoga, right? My brain is is all over. I have an ADHD brain, which I hear sometimes. we actually know that mindfulness skills are especially helpful for people who who are neurodiverse, have ADHD and other things. So it's a but it's a skill that needs that needs practicing, just like other new skills that we might want to adopt in our life.

Yeah, yeah.

I love that. I feel good actually, even after one minute.

I needed that. Okay. all right. Well, thank you so much, Lori. This has been great. I I'm actually gonna log on to eSense and try it myself. I'll let you know. I'll give you some feedback. but yeah, yeah, I I'm super excited about it and and to have another tool to give our patients for I have a lot of clinicians that listen to this and sometimes they're just like, I don't know a good sex therapist or it's so hard to find, you know, like someone that's specific to

Awesome. Please do, please do.

that religion or that that's gonna understand that culture, whoever, and to so have something that's really taught to to embody every everybody. So yeah. So that's it.

Yeah. Yeah.

Everybody. Yeah. Yeah. Actually on that note we have a Spanish tran a Spanish translation complete of eSENS. We're just kind of working on the last details. We're working on a French translation next because French is Canada's second language. but we're we're we're looking at translations in in other languages as well because

No.

well. yeah.

you know, as as you know about and you talk so often about also on your platform, is the kind of additional barriers that racialized women or non English speaking women also face. And so having things that are translated in other languages is really important too.

Hundred percent. I love that. That's great. Well, thank you. You're amazing. I can't wait to see you in Vancouver. And you know, I look forward to trying it eastends. I'm gonna email you after I do it. So but thank you so much. This is great. I I love that you have such an amazing tool out there for for the patients that need it and and I appreciate everything you're doing.

Likewise

thank you. Likewise. Loved this conversation and and thanks for the opportunity to work alongside you as well.

A hundred percent. thanks everyone for listening to Gano Girl Presents Sex, Drugs and Hormones. I'm Dr. Samina Rahman. Remember, I'm here to educate so you can advocate for yourself. See you next week.