• Visit Dr. Brotto’s website. Connect with her on Instagram.

Joe Sanok This episode, I just want to do a trigger warning that in it we do talk about some sensitive issues regarding sex and sexuality. Specifically, we talk in the middle of the show about sexual assault a little bit and some treatments around that. Wanted to make sure you are aware of those potentially triggering things going into this episode. Every single phase of private practice has its own unique challenges and its own unique opportunities. Whether you’re starting and growing a solo practice, getting a group practice going, whether you’re already a group practice boss or you want to go big and go national with the skills you have, every phase has its challenges. And you know, doing that in community with people and learning from other folks and having that guidance is so, so important. That’s why we have a membership community for every phase of practice. 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So no matter what your phase is, we have a membership community for you [email protected] memberships. You can read all about them and sign up. Go in there and decide which membership phase is for you and join today again. That’s practiceofthepactice.com memberships. This is the Practice of the Practice podcast with number 1150. I’m Joe Sanak, your host and welcome to the Practice of the Practice Podcast. I am so excited to help you build a thriving practice you absolutely love, but even more so for you to create a year, a life that you enjoy, that you can handle the ups and downs, that you can know what to do for not just your clients, but also for yourself. So this month we are doing the even better year series with the idea that it’s not best year ever, it’s not pass fail, but you know, let’s figure out some areas where we can be even better than maybe we were last year to make our lives a little smoother for ourselves in the areas we have control and let go of the areas that maybe we don’t have as much control. I’m really excited about our guests today. You know, it’s interesting. My mom’s a, she was a school nurse throughout my childhood and then became a nurse practitioner who was in primary care. But as a school nurse she taught sex ed across the entire school district. And so anytime as kids that we would have sex questions, we felt comfortable to ask them. Now my dad was raised in kind of a farmland in southeast Michigan, Polish Catholic family. Family where his parents spoke Polish. And so there was always this funny and now I think amusing dynamic of often asking my mom questions at the dinner table and my dad saying, Mary Ellen, not at the dinner table. So it was this interesting dynamic of just it, me knowing a lot of things from a nurse educator standpoint way before my peers. And so they’d say things, I’d be like, that’s just not true. So I’m excited to talk sex today with Dr. Lori Brado, who is internationally recognized as a leader in sexual health research. She has mentored 149 trainees and evaluated psychological interventions for sexual dysfunction and genital pain, which collectively impact a third of women. Her work influences practices internationally with mindfulness, now implemented in sexual medicine centers and recommended as frontline care in international guidelines. In recognition of her contributions, she holds a Canada Research Chair in Women’s Sexual Health, has received recent awards in mentoring junior faculty, excellent public education through media book awards, and listed among the top 2% cited scientists by Stanford. Lori, welcome to the Practice of Practice podcast. Dr. Lori Brotto Thanks so much, Jo. I’m really happy to be here. Joe Sanok Yeah, well, as I said in the intro, you know, this topic for me, you know, being raised with a school nurse is something that I, you know, it’s funny, my friends, the guys that I tend to be around are emotionally intelligent guys who can have these kind of conversations too. But there’s also a lot of people in the world that are uncomfortable with these conversations. So it’s nice to meet someone that’s doing sexual health and we can talk about how this affects our clients and we can talk about how it affects ourselves. Dr. Lori Brotto Absolutely. Let’s go there. Joe Sanok Yeah, well, let’s, let’s just start with if you this, you know, we’re starting 2025 right now. When you think about how people just in general tend to view sex and sexual health, what are just big picture messages people get and what would you undo from some of those messages? Dr. Lori Brotto Oh, great place to start. Yeah, I mean I, there’s no question that we are bombarded with messages about sex and sexuality and sexual health. You know, you, you can’t walk down the street without confronting a billboard that’s depicting sex as an advertisement for something else. And so on the one hand there is very much this feeling of we live in a sex saturated society. And yet paradoxically, at the same time, when we actually look at what the research tells us, we see that people in long term relationships are engaging in sexual less frequently than we were 20 years ago. On average of about 7 fewer sexual encounters per year than we were 20 years ago. Rates of sexual difficulties are increasing when we look at the big population based surveys and we’re seeing an increasing number of young people, so with sexual problems. So young men with low desire, we see a high proportion of young women with pain during sex or have anxiety about sexual activity. So we should take a step back and I think your opening intro remarks around the fundamental role of sex education from an early young age is so important to allow us to have evidence based information to not only equip us to have good sex, but really importantly to combat myths that we might be exposed to in our kind of day to day life. So I think that would be the off the bat call to action is. So let’s stop and examine what might be some of the myths and stereotypes that we are carrying that are impairing our ability to lead our best sexual life. Joe Sanok Now when you’re so you do research, you train people, there’s so many different directions that we could go and we just have about half an hour together. But when you think about clinicians and they’re working with all Sorts of, of couples, of individuals, what are some things that they should be aware of that maybe, you know, a lot of these people haven’t been in grad school for 10 or 20 years. What’s the research pointing to? What are some of those other trends that you’re seeing that people really need to know in their clinical work? Dr. Lori Brotto Yeah, great, great question. And I also practice as a registered psychologist and sex therapist. Now. I tend to see the folks with really spread specific sexual health difficulties that maybe they’ve, you know, seen a family physician or a counselor with more generalized training. So we can talk about that later. But I think to the, to the vast majority of your audience recognizing that sexual health concerns are often concurrent with mood, so depression, anxiety, chronic stress, other major mental health conditions, we often see sexual health problems secondary to medication. So if a person is using an antidepressant, ssri, snri, very high rates of sexual side effects, and many of those folks have a lot of embarrassment to report those sexual side effects to their care provider. So you might see a person not use their medication or take it in a way that wasn’t originally prescribed. And it’s often because there are sexual side effects. So I think important for your listeners to know that there’s a very high likelihood that at least half, if not more of the clients that they’re currently working with probably currently have or have had some significant sexual difficulty in their life. Joe Sanok Yeah. Now, are there major differences that you’re seeing between the generations, like baby boomers versus like Gen X, Millennials and Gen Z? Like are there major shifts that kind of in either ways people are thinking or ways that they’re experiencing sex? Dr. Lori Brotto Yeah. So the big population based prevalence surveys that ask about different domains of sexual function. So it’ll have a set of questions about your interest in sex and desire, some questions about orgasm, obviously premature and delayed ejaculation in men, pain with sexual activity. And what we are seeing actually is some increasing levels of low desire in young people that we weren’t seeing in surveys that were done, say 20 years ago. And so, you know, that begs the question, well, what is happening? Why are we seeing higher rates of low desire among young people today? And they’re not markedly higher, but they’re creeping up enough to make us, as researchers say, what is going on here? And there’s some speculation that probably with, you know, social media is playing a role in terms of objectification, in terms of negative judgments, where you’re much more apt to compare yourself to other people that you see online perfectionism et cetera, and then just general chronic stress. So I think that has been an interesting finding because for many of those individuals it’s not explained by hormonal or physiological contributors. It really is wrapped up in the person’s sense of self and identity. Joe Sanok So what I’m hearing you say is that social media is making people compare themselves. That there’s this sense of perfection definitely when I think about the stress of people kind of born after probably 1987. So like mid millennials on you look at even just housing costs, how much more expensive it is as a percentage of income now than it was for even, you know, I’m a late Gen Xer or a young Gen Xer. Yeah, I’m right, I’m right on the cusp between the two. There’s things I’m totally Gen X and there’s other things that I’m totally millennial. But it’s like even just thinking about the stress of, you know, 40 to 50% of their income just going into housing and how it’s just hard to prioritize, know things that you want or even have the opportunities if you don’t even have the finances to like go out or you’re working all the time when, when you’re looking at kind of more specific sexual health problems. So I know that’s one area of research and before we started rolling, we were talking about some really innovative things that are helping with some of that. When are, when should therapists be thinking through, like, oh, this definitely needs a referral, or what are some of the. They may be the very first person that someone discloses some of these things to. And a lot of therapists may be like, I don’t know. Back in grad school I took one class that mentioned sexual dysfunctions. I don’t, I mean we may not know what to do. So like, what are some of the things that are kind of popping up now, like when should they be referring, what should they be thinking through in regards to those more nuanced types of things that are going on with people? Dr. Lori Brotto Yeah, great, great question. And so to the listeners, they may, they remember, they may remember back to that one lecture from Grad where they learned about the Plissit model. And PLISSIT basically provides the different stages of intervention and training. So the P is giving permission. And that means even having a book on your shelf that has sexual health or sex therapy in the title conveys to the client in front of you that that client’s sexual health and their well being is important to you. As their provider, even if it’s not the thing that they sought you out for. So giving permission and having an environment that conveys this is a sex positive, sex friendly environment. Should you wish to talk about this, the next level of plicid is li and that’s limited information. And so here’s where you know, having access to some of the evidence based information at your fingertips. So for example, knowing that a third of women over the course of their lifetime will probably struggle with a sexual problem, that’s distressing for them. Slightly lower rates for men, maybe about 20% knowing what are some of the common reasons for sexual problems. So again, having some of that limited information at your fingertips, being able to challenge and debunk myths if you hear them from your clients. So maybe a common myth would be I should experience orgasm during penile vaginal intercourse. Now hopefully that, that is a, that is a myth that we can easily identify and be able to challenge. And then when it gets beyond that of kind of challenging myths and providing good evidence based information, the rest of plisset would be specific suggestions and then therapy. So specific suggestions your listeners may or may not have in their arsenal of different evidence based treatments, but they might be able to use some of their current modalities. So can they use cognitive behavioral therapy to challenge other beliefs and identify avoidance that might. Avoidance that might be coming up during anticipated sexual activity. But once it gets to a point where one feels like, you know, there’s a really, a lot of specialized knowledge about that I’m, I simply don’t have pertaining to this person’s sexual health, such as the specifics of how arousal might trigger orgasm or how delayed ejaculation is impacting their desire. That might be a point where a provider says, this is starting to fall outside of my area of expertise and referral to a sex therapist or a sexual medicine physician might be warranted. And so we do have some directories of how to find those folks in your state or province. Thankfully, we’re a growing body of professionals in that area. But I also would argue that I think a lot of the counselors and psychologists, there’s, there’s a lot that that person can do without having to refer on. So I would empower your listeners to, you know, number one, ask more about sexual health and you can do so in an open ended way. You know, how does your difficulty with X impact aspects of your sexual health or sexual well being and just open the conversation and then sort of go from there and determine if a referral on is is necessary. Joe Sanok Yeah, I found it really interesting before we got rolling, you talking about some of the more innovative treatments that are coming out. We’d love for you to walk through some of those and talk about the research behind them. Dr. Lori Brotto Yeah, I’ll talk a little bit about some of the work we have been doing using virtual reality. And we’ve seen virtual reality in other domains of mental health, in particular as a tool for treating phobia. So you think about the person who has a fear of flying. And leading evidence based treatment would be exposure and response prevention interventions. You have that person get on the airplane, the airplane takes off, and maybe you equip them with some relaxation skills or you provide them with tools to address their problematic thoughts and replace them with more accurate ways of thinking. Hard to do in the kind of real life setting. And so here’s where virtual reality, where if you can bring the person into a simulated environment where they actually feel like they’re sitting on the airplane and taking off, but they’re, you know, in the privacy of a therapist’s office. And we’ve seen some really impressive data showing that people can over can overcome phobias with the use of virtual reality exposure treatment. So we took some of that innovation and we said, well, we have something comparable within the field of sexual health, a condition called vaginismus, which is characterized by an intense fear of vaginal penetration or vaginal insertion to the point where the person actually can even have intense anxiety or even a panic attack. And it’s not just specific to anticipated sexual activity. It can be in anticipation of a gynecologic exam, pap smear, use of a tampon, etc. And gold standard treatment is exposure and response prevention. So you equip the person with a set of vaginal dilators and you ask them to go home and start with the smallest size that they would insert into the vagina. And you encourage them to simultaneously practice relaxation and to challenge some of the concerns that they have that are the beliefs that they have that are coming up at the moment. So beliefs such as this is going to puncture my uterus or you know, this will lead me to bleed for days. These are some of the classic beliefs that people with vaginismus have. The problem is that even though this treatment works very well, avoidance is so high because the anxiety is so high among these folks. So what we’ve done is we’ve created a simulated environment using virtual reality where we bring women with vaginismus into a controlled lab environment. They put on the VR headset, and they can control the environment that they are in. So what they see in this virtual simulated environment is progressively more sexual scenes where they might have a partner approach them and put a hand on them. And then it kind of progresses on to non genital contact through to genital contact and vaginal insertion. All the while the person is, you know, in this safe environment and the experimenter is in the next room encouraging them to relax. So what we found is that we’ve done this with 40 women with vaginismus and 40 women without vaginismus, that it can create very realistic feelings of being immersed in this kind of environment that feels very much like what they might experience at home and that they can overcome their anxiety in this environment, which then empowers them to go home and try the exercises at home. So we just recently got some funding to now try this in a. So we’ve done this in a proof of concept design. Now we’re moving on to actually evaluate this clinically. If it works, then we can take a look at, you know, you can purchase pretty inexpensive headsets to put over your iPhone and you don’t have to get the big, expensive VR headsets, et cetera. So really excited about this as a potential innovation down the road to help a lot of people who really struggle with phobic, like anxiety over sexual. Joe Sanok Something always comes up when you’re running a private practice. 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Is it primarily with the medical side or are there also, like, different things? Like, I’m thinking of, like, victims of any sort of Abuse or traumatic experiences. Is there research around that as well? Dr. Lori Brotto Yeah, great, great point. I mean, what we know is, you know, the, if you have 10 people with vaginismus, there could be 10 different causes of their particular vaginismus. For some of them, yes, it might be due to an overactive pelvic floor that’s preventing, you know, them being able to insert something into the vagina. But there’s a subset of FOL folks that have this phobic like response because of their history of sexual trauma and sexual victimization. And so in our proof of concept study, we didn’t differentiate, we didn’t say, okay, we’re only going to recruit those folks that have, you know, pelvic floor dysfunction. We had a number of people that had, you know, back, they had an etiology that was more psychological and or due to a history of trauma. So going forward, this will be something that we will look more closely into. Is, is, could this be a tool that works for everyone with vaginismus or is it only for folks with a particular presentation of their vaginismus or vaginismus secondary to a certain cause? Joe Sanok Yeah. What other innovative things are happening in the field? Dr. Lori Brotto Yeah, so, you know, we talked a little bit earlier on about some of the barriers that people have and even disclosing to a healthcare provider that they have a sexual problem. And there’s, there’s data that tell us that the majority of women, at least with sexual problems, will never talk to a healthcare provider due to embarrassment, shame, maybe financial barriers that prevent them from seeing a provider. Geographic barriers, although we’re seeing less of that now that people are practicing more online. So we’ve been, my team’s been really interested in can we use digital health technology to deliver evidence based treatments. And there’s definitely apps that exist that deliver sex education. We see lots of fertility apps, apps to track, you know, your ovulation cycle, et cetera. But we don’t really have any digital health tools that are delivering evidence based psychological treatments. So over the last six or so years, our team has developed a digital health tool called E Sense that has two modules to two arms to it. One is cognitive behavioral therapy addressing low desire, and the other one is mindfulness based therapy addressing low desire. And we’ve completed a number of feasibility studies as well as an efficacy study to show that women will engage with it, that they will use it, they will do the exercises, they will download the mindful sex meditations and work through them, and that it is very efficacious. And that the gains in terms of improvements in desire and reductions in distress are sustained six months later. So we’re now moving E Sense along the kind of implementation and commercialization journey to make it available. So we’re working with different health authorities, we’re working with a number of different clinics to test it out and see can this be something that we make available to people and stay tuned. Our hope is that at some point during 2025 that e sense will be available and I think it’ll be great. I don’t think that it’s going to replace the excellent work of the sex therapists that we have existing, but I think it’s really going to fill that gap for those people that never take that step and ask for help. Joe Sanok Oh, such great research and implementation. Yeah, let us know as that rolls out. We’re happy to help get the word out. Dr. Lori Brotto Thank you. Joe Sanok Yeah, I’m wondering, just, you know, obviously all of us therapists are also humans. What are things that as just people seeking better sexual health? You know, most listeners here are self development junkies or like want to improve themselves. What are some ways that we can all implement kind of just better sexual health? Dr. Lori Brotto Oh, love that question. Yes. And thank you for reminding all of us that we, we too are sexual beings. So, you know, I’m, I, I can’t have this conversation and not talk about the importance of sexual communication. So my invitation to everyone listening is, you know, take a look at how you talk about sex in your life, whether you’re in a partnership or not. Do you have some discomfort? You have some ease in talking about sex? I mean, Joe, you, you kicked the segment off talking about growing up in an environment where it was very welcoming of any questions that you had about sexual health. So you probably have a lot of comfort in raising whether it’s talking about how to increase pleasure within your own sexual encounters or how to point out when things are not going well. So think about sexual communication. I would bet that a lot of your listeners are excellent communicators in general, but I would question whether they’re good sexual communicators. Those are not necessarily aligned with one another. I think the other thing to think about is, you know, combat those stereotypes that tell you that sex deteriorates with age and you know that there’s a kind of peak in sexual pleasure that peeks out in your whatever, whatever the age is, 30s, 40s, you name it. We have so much data that tells us that people can continue to have excellent sex lives and in fact continue to thrive sexually in their 70s, 80s and beyond. Now, it doesn’t happen automatically. It comes with effort and intention. And sometimes, yes, the help of a provider can help along, especially if there are physical health conditions that are making it challenging or mental health difficulties that are making it challenging. But really to believe that, you know, you can continue to grow as a, as a sexual being for the rest of your life is something I think is, that can be so, so powerful and that it shouldn’t have to be wrapped up in the frequency of sex or the strength of the orgasms. There’s so many other ways to embody sexual health and sexual wellness that is completely separate from those, those quantitative numbers. Joe Sanok Laurie, the last question I always ask is if every private practitioner in the world were listening right now, what would you want them to know? Dr. Lori Brotto Sexual health is a part of quality of life. So as that pertains to the clients who are seeking your care, as that pertains to you as an individual, it’s not some separate fringe thing that you know, happens only after the 11 o’clock news late at night. It’s a, it’s a part of how we identify ourselves. It’s a part of our overall well being. And so we should celebrate it and talk about it as such in the same way that we talk about health and health promotion in, in general. So sexual health is health. Joe Sanok Laurie, if people want to connect with you, follow your work. Where should we send them? Dr. Lori Brotto You can follow me on social media at Dr. Laurie Brotto. You can also follow our research team for we often post studies that we’re recruiting folks for and that’[email protected] and then I have my own website which is lori brotto.com and have many of the mindful sex meditations that are available to anyone who wishes to download them on that website. Joe Sanok So awesome. Thank you so much for being on the Practice of the Practice podcast. Dr. Lori Brotto Thank you so much for having me today, Jo. Joe Sanok Well, it is a new year and maybe you’re looking at some of your systems, particularly looking at maybe the way that you run Your payroll, your HR, your four 401ks onboarding, commuter benefits, any of those things that are just kind of the behind the scenes. Well, we use Gusto and we recommend Gusto. Gusto helps you with all of the filing of the payroll taxes, calculating all that junk that we don’t need to calculate as owners of a business. If you want to speed up your payroll process, head ON over to Gusto.com Joe again that’s Gusto.com Joe thank you so much for letting me into your ears and into your brain. Have a great day. I’ll talk to you soon. Special thanks to the band Silence Is Sexy for that intro music and this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither the host, the producers, the publishers or guests are rendering legal, accounting, clinical or other professional information. If you want to professional, you should find one.