Yoga as Adjunct Treatment in Sex Counseling
Yoga in the West
Yoga, as many other mind-body practices, is an ancient tradition rooted in Eastern practices and philosophies. Such practices have increasingly attracted researchers in multiple fields of study. This growing body of research offers support for its potential benefits.
In the West, yoga is mainly composed of asana (physical postures), pranayama (breathing), and dhyana (meditation). Although plenty of research suggests practicing yoga reduces stress, chronic and acute pain, as well as symptoms related to mental health disorders such as PTSD (Gangadhar, 2023; Kumar et a., 2019; Stephens, 2017), there are some limitations. In these studies, practices are heterogenous, studies tend to have small, convenient, and non-diverse samples, and many lack control groups.
Some researchers have explored the applications of mindfulness-based practices to address sexual and relational concerns. For example, Yekta et al. (2022) showed a relationship between mindfulness-based stress reduction techniques and increased marital satisfaction. They proposed this was mediated through reducing psychological distress and improving emotion regulation and empathy. There is enough evidence to support yoga as an adjunct treatment in medical and mental health settings.
Mindfulness-Based Practices
Mindfulness is linked to enhanced self-esteem, positively influencing body image, and reducing sexual shame and anxiety (Valderrama Rodríguez et al., 2023). These benefits extend to men with physical disabilities. In sex counseling, embracing eroticism may involve mindfulness of bodily elements, acceptance of erotic power, and exploration of genital sensations.
Polyvagal principles align with applying yoga in this context (Schwartz, 2021; Porges, 2022). Creating a context of safety facilitates autonomic regulation and the activation of the social engagement system becomes more accessible. Relationally, through mindful movement and awareness practices individuals and partners can explore concepts such as interdependence, co-regulation, creating a culture of appreciation, acceptance versus shame or judgement, etcetera.
Meanwhile, other aspect of the practices such as expanding the sense of interconnectedness can give an opportunity for expression of positive emotions, such as happiness or gratitude, which has been shown to promote treatment adherence (Olem et al., 2022). Positive affect is believed to boost coping efforts, especially in the face of chronic stress. It has been suggested that this is due to changes linked to the activation of the dopamine reward system, and having a positive emotional disposition is connected to increased activity in brain regions tied to emotional processing and executive functioning.
Positive affect is tied to higher resting metabolism in specific brain regions. Experiencing positive emotions is associated with activation in key brain areas like the orbitofrontal and cingulate regions, as well as the left prefrontal cortex, which are crucial for emotional processing and executive functioning. It may contribute to a greater capacity for self-regulation.
Olem et al. (2022) noted that interventions promoting positive affect, often including mindfulness training, have been effective in increasing positive feelings and reducing negative ones. Mindfulness training in these interventions improve recognition, awareness, and tolerance of strong emotions. Additionally, positive affect interventions offer training in coping skills and sensitize individuals to natural sources of reward, potentially leading to improvements in psychological processes related to regulating emotions, including increased mindfulness (Carrico et al., 2018).
The benefits of mind-body practices might increase well-being, but their components have differential effects. The ReSource Project- a 9-month mental training program- examined the impact of four meditation practices on mid-life adults. The study involved 229 participants and focused on breathing meditation, body scan, loving-kindness meditation, and observing-thought meditation (Kok & Singer, 2017).
The results showed that body scans increased interoceptive awareness and reduced thought content, loving-kindness meditation enhanced positive feelings toward others, and observing-thought meditation increased meta-cognitive awareness. All practices, including breathing meditation, improved positive affect, energy, and present focus while reducing thought distraction. Each practice had distinct psychological changes, such as attentional stabilization, enhanced interoceptive sensitivity, cultivation of benevolence, and promotion of decentering.
Numerous studies, including Galante et al. (2016), have corroborated the positive effects of mindfulness and various meditation practices on well-being. In a randomized controlled trial with 809 participants, they investigated an internet-based Loving-Kindness Meditation (LKM) intervention, comparing it to a light physical exercise course (LE). Both courses, delivered through video-based instructions, aimed to enhance well-being by eliciting positive emotions, bolstering psychological resources, and fostering altruism. The findings suggest that a one-month internet-based LKM training could potentially decrease anxiety and promote altruistic behavior.
Other studies have studied the impact of meditation on cardiovascular activity. For example, Lumma, Kok, and Singer (2015) evaluated heart rate (HR), high-frequency heart rate variability (HF-HRV), and subjective assessments of effort and likability across three meditation types: breathing meditation, loving-kindness meditation, and observing-thoughts meditation, each varying in cognitive demands. Over three months of daily practice, loving-kindness and observing-thoughts meditations resulted in higher heart rate (HR) and perceived effort compared to breathing meditation.
Throughout the training, HR and likability increased, while high-frequency heart rate variability (HF-HRV) and perceived effort decreased. The changes in HR and HF-HRV were more pronounced for loving-kindness and observing-thoughts meditations. Despite study limitations, such as the absence of baseline measurements and a control group, the research suggests that these meditation practices may enhance autonomic flexibility, potentially improving resilience and cognitive effort management. This adds valuable insights to the literature on meditation interventions, emphasizing that not all practices lead to relaxation, but participants may still derive benefits from them.
Engert et al. (2017) investigated the impact of contemplative mental training on psychosocial stress reduction, emphasizing the physiological measures used in a 9-month longitudinal study involving 313 participants. Three types of contemplative mental training, focusing on attentional, socio-affective (compassion), or socio-cognitive (perspective-taking) abilities, were compared. Results indicated a reduction in self-reported stress across all three types of training, with socio-affective and socio-cognitive training demonstrating a significant attenuation in physiological stress response, particularly in cortisol secretion (up to 51%).
The study suggests that daily intersubjective skills practice represents a cost-effective and accessible approach to building psychosocial stress resilience. Notably, the compassion-based affect module significantly reduced both self-reported and cortisol stress reactivity. The Perspective module, focusing on metacognition and perspective-taking, was also effective in reducing psychosocial stress, highlighting the overall effectiveness of intersubjective practices in improving social relations and stress reduction. Importantly, the study found an increased correlation between subjectively experienced stress and cortisol stress reactivity after mental training, suggesting a healthier stress response.
The benefits of mindfulness-based practices have been supported by neurobiological measures as well. A study by Singleton et al. (2014) found a positive correlation between increases in self-reported psychological well-being (PWB) scores and gray matter concentration in bilateral brainstem clusters. Notably, these changes were observed in areas associated with neurotransmitter synthesis and release, particularly norepinephrine and serotonin, which play crucial roles in mood and arousal modulation.
The serotonergic system is linked to functions such as sleep, mood, appetite, and conditioned fear, while the norepinephrine system modulates arousal and attention. It is important to acknowledge that these studies are preliminary, with small sample sizes and often lacking control groups, limiting their generalizability to diverse populations. Despite these limitations, the findings hold promising potential for understanding the neurobiological mechanisms behind mindfulness interventions, suggesting potential applications in supporting sexual and relational health to enhance experiences of desire, pleasure, and satisfaction.
Valk et al.’s (2017) study examined the effects of daily mindfulness-based practices in the brain. Results showed such practices can induce structural plasticity in socio-affective and socio-cognitive brain networks in healthy adults. These structural brain changes were correlated with behavioral improvements in attention, compassion, and cognitive perspective-taking. The exercises included breathing meditation, body scans, open awareness, Loving-Kindness Meditation, communication exercises, thought observation, and perspective-taking.
In a randomized trial, Petzold et. al. (2023) showed efficacy in contemplative practices conducted as dyads to increase positive and other-related thoughts and an increase in self- and past-related thoughts. Solitary practices also showed an increased positive affect by reducing future-, other-related, and negative thoughts, while increasing self-related thoughts.
Moreover, yoga’s benefits go beyond the benefits related to physical activity. So et al. (2020) compared the effectiveness of mindful and non-mindful exercises in reducing anxiety in non-clinical populations. Using a meta-analysis of 24 relevant studies, it was found that mindful exercises, particularly yoga, were more effective than non-mindful exercises in alleviating anxiety symptoms. The results suggest that yoga could be recommended as a primary healthcare strategy for anxiety reduction.
A randomized study (Alleva, 2020) with 114 young adult women (mean age = 22.19), a 10-week Hatha yoga program showed a positive impact on body image, compared to a waitlist control group. Results showed a decrease in self-objectification and increased in embodiment over time. These changes contributed to enhanced body appreciation, body compassion, and appearance evaluation.
Yoga and Trauma Recovery
According to the Polyvagal theory, trauma is a complex interconnection of emotional, physiological, psychological, and social dimensions. Porges suggests designing therapeutic interventions that induce calm states and activate neural regulation of the social engagement system. Yoga, with its holistic approach involving physical postures, breathwork, and meditation, appears effective in reducing psychological, physiological, and emotional distress, improving quality of life.
Research indicates that combining mindfulness-based interventions and yoga is effective in reducing trauma-related symptoms. Mindful movement and interoceptive awareness in yoga help regulate affective arousal, enhance the experience of emotions in the present moment, and foster a sense of safety within the body. Utilizing yoga as a therapeutic tool involves a comprehensive strategy that combines neurobiology and physiology to address the impact of trauma. This approach aims to release ingrained patterns and emotional dysregulation resulting from compromised feelings of safety. Through a secure embodiment practice, it facilitates the restoration of authenticity via physical movement and the development of trust within the body.
Clinical evidence supports the effectiveness of mindfulness-based stress reduction (MBSR) in treating post-traumatic stress disorder (PTSD). MBSR, characterized by slow breathing and extended exhalation, enhances parasympathetic tone. Additionally, studies highlight yoga as a therapeutic approach for PTSD and dissociation, as it downregulates the stress response and alleviates symptoms after natural disasters (Boyd, Lanius, & McKinnon, 2018).
Anxiety disorders, including PTSD, are associated with low heart rate variability (HRV) and low gamma-aminobutyric acid (GABA) activity, both of which are responsive to yoga. The interplay between the prefrontal cortex (PFC), hippocampus, amygdala, and the autonomic nervous system, combined with GABA system inputs, forms a network through which yoga practices may alleviate symptoms. In particular, yoga-induced PFC activation and increased parasympathetic activity could enhance inhibitory control over the amygdala, reducing PTSD symptoms by mitigating amygdala overactivity (Breit, et al., 2018).
Trauma-informed yoga, rooted in the yogic tradition's emphasis on mindful movement and proprioceptive feedback, aids individuals in tolerating somatic sensations and regulating emotional states (Kearney & Lanius, 2022). Trauma-Sensitive Yoga (TSY) is a therapeutic application within group settings. Two randomized controlled trials involving women with treatment-resistant PTSD showed significant symptom and dissociation reductions.
Nicotera and Connolly (2020) tailored a Trauma-Informed Yoga (TIY) intervention to sexual assault survivors in a community-based group setting. Employing a one-sample, pre- and posttest design, the research utilized survey items from established measures, including the Five Facet Mindfulness Questionnaire and the Difficulties in Emotion Regulation Scale. The participant cohort, primarily comprising White individuals (67.6%), followed by Latina (13.5%), African American (8.1%), multiracial (5.4%), and other (2.7%), with an average age of 29 years, consisted entirely of females. The results exhibited statistically significant improvements in emotion regulation and skilled awareness, suggesting potential reductions in PTSD symptoms. These findings are supported by previous studies conducted in different settings- such as a Veteran’s Medical Center (Pence et al., 2014) and with survivors of childhood sexual abuse (Lily & Hedlun, 2010).
Studies on Trauma-Sensitive Yoga (TSY) demonstrate its efficacy in reducing PTSD, depression, and anxiety symptoms, particularly among interpersonal trauma survivors. The concept of peaceful embodiment, characterized by control and connection with one's body, is emphasized. However, despite evidence of yoga's effectiveness, research does not fully address relational traumas.
To address this gap, a qualitative meta-analysis of six studies with 105 participants was conducted to identify the healing agents of yoga in interpersonal trauma recovery (Ong Gaffney et al., 2023). Six meta-categories emerged, including stabilization (coping strategies), authenticity and self-acceptance, equanimity (calming the mind), and community (reduced isolation). The findings offer a comprehensive understanding of how yoga may facilitate recovery from interpersonal trauma.
The brain is extended throughout the body through the nervous system. Memory, for example, is not stored only in the brain but -in a sense- it is in the body’s tissues as well. Somatosensory integration at different brain levels, generates the emergence of the mind. A sense of being alive, in a body, comprising three distinct subcomponents: (i) the sense of body ownership, denoting the self-attribution or self-identification with one's body; (ii) the sense of agency, reflecting the perception of causing the body's actions; and (iii) the sense of self-location, encompassing the feeling of being positioned in space and perceiving the world from that particular perspective (Ventura, 2022).
Research has shown a link between childhood abuse and cortical thinning in specific brain regions (Heim et al., 2013). Childhood sexual abuse was associated with cortical thinning in the genital representation field of the primary somatosensory cortex, while emotional abuse correlates with thinning in areas related to self-awareness. These neuroplastic changes may have served a protective role during childhood development but might contribute to psychological difficulties, relational struggles, and/or sexual dysfunction later in life.
Previous research has demonstrated that yoga's focus on mindful movement and interoceptive awareness plays a pivotal role in regulating emotional arousal. Practicing yoga can improve body awareness (Hartnol & Punt, 2017) while contributing to creating a secure emotional experience and a heightened sense of bodily safety.
Polyvagal Theory provides a foundation for developing therapeutic interventions aimed at fostering calm states and promoting neural regulation of the social engagement system (Ong Gaffney et al., 2023). As discussed in previous chapters, emotions play a significant role in shaping human cognition and behavior (Stevens, 2022). Arousal, characterized by physiological changes during activities such as sexual stimulation and exercise, modulates responses to various situations. D'Hondt et al. (2010) discovered an increase in skin conductance response (SCR), an index of sympathetic autonomic arousal associated with emotion and attention, following exposure to affective stimuli (Grasser, 2022).
The Autonomic System, consisting of the Sympathetic and Parasympathetic Systems, collaborates for optimal arousal regulation, serving as the organism's energy management systems, coordinating responses to maintain or restore homeostasis. Dr. Stevens has developed a six-step psychotherapeutic guide utilizing emotions as a foundation, which include mindfulness-based practices to improve awareness (associated with the activation of the rostral anterior cingulate cortex, RAS), differentiating the knowing (sense of self) from the known (for example, differentiating fear from the awareness of being afraid), practicing self-compassion, psychoeducation, learning coping skills, and affect reconsolidation (reconstructing the emotional response to a memory and modifying its association, creating a new possible response).
There has been growing interest in exploring Vagus Nerve Stimulation to treat various conditions (Breit, et al., 2018). Preliminary research suggests that Vagus Nerve Stimulation affects the activity of various cortical and subcortical regions, with structural connections between the vagus nerve and mood-regulating brain areas, influencing serotonin, norepinephrine, and dopamine concentrations. Additionally, VNS may exert monoamine-independent effects, impacting monoamine metabolites and promoting hippocampal neurogenesis.
Positive emotions generated through practices like loving-kindness meditation increase vagal tone, providing benefits for individuals with depression, anxiety, and chronic pain. Yoga-based interventions have been found effective in treating depression by stimulating the vagus nerve, improving autonomic regulation, cognitive functions, mood, and stress coping (Breit, et al., 2018). Mindfulness’ cultivation of non-judgmental and compassionate awareness, which involves accepting thoughts and emotions as they are, can foster an acceptance-based approach and facilitate the alignment of one's actions with personal values, even in the face of difficulties (Bossio, Higano, & Brotto, 2021; Fisher et al., 2022). This approach can lead to greater psychological flexibility and emotional well-being.
Wang et al. (2022) demonstrated the effectiveness of utilizing experiential awareness, also known as 'experiential self-focus', as a foundational method for emotional regulation. This approach involves recognizing affective experiences as adaptive phenomena and employs mindfulness techniques such as non-judgmental, open awareness, acceptance, curiosity, and compassion. The process entails being attuned to bodily sensations, followed by verbalizing or expressing these feelings.
In their investigation on sleep, participants were directed to focus on and acknowledge their emotional experiences, understanding the context before expressing it in an open and non-evaluative manner. In comparison to strategies like attention reallocation and cognitive reappraisal, this experiential focus demonstrated superior long-term positive effects. The experiential approach enhances the ability to identify stressors originating from bottom-up processes and integrates them with personal meaning, potentially improving future arousal regulation capabilities.
Mathersul et al. (2022) investigated the effectiveness of breathing-based yoga (SKY) in improving both intentional and physiological aspects of Emotional Regulation (ER). Using Heart Rate Variability (HRV) as a biomarker, lower resting HRV indicates vulnerability to maladaptive responses. SKY was found comparable to Cognitive Processing Therapy (CPT) for PTSD symptoms in US Veterans, with improved self-reported ER. The study suggested that cultivating non-judgmental awareness enhances ER and uniquely demonstrated SKY's positive impact on both intentional and physiological ER in individuals with PTSD symptoms. While HRV is a validated ER biomarker, it's noted for its non-specific associations, serving as a potential general wellness marker.
A pilot study conducted by Rodríguez Jiménez et al. (2022) explored the impact of body awareness training on 31 university teachers using a controlled, randomized pre-post experimental design with two experimental groups (Hatha Yoga and Dance Movement Therapy/Body Mind Centering) and a control group (n = 10). The interventions were assessed for their effects on body awareness, mindfulness, wellbeing, life satisfaction, and stress through self-perception tests. Qualitative analysis included cortisol levels, heart rate variability, sleep quality, and participant reflections.
Results revealed significant differences between the control group and the Hatha Yoga group in terms of stress reduction and wellbeing. The Body Movement Awareness group showed contributions to self-knowledge, communication, and kinesthetic empathy. Both interventions demonstrated a stress reduction at the end of the study, countering anticipated stress from impending exams, with significant results for the Hatha Yoga group and a trend for the Body Movement Awareness group.
The study highlighted the effectiveness of Hatha Yoga in immediate stress reduction, increased body awareness, and subjective wellbeing. The Body Movement Awareness program sustained cortisol level reduction and outcomes related to self-awareness, self-knowledge, and social interaction. Surprisingly, stress reduction was accompanied by sympathetic nervous system activation in both interventions compared to the control group.
Despite limitations, this research holds significance for university teachers. Future studies should strengthen both physiological and psychometric tools for result robustness, refine the evaluation of body awareness in interventions, and explore a combined approach with Hatha Yoga and Body Movement Awareness programs for comprehensive teacher wellbeing enhancement.
Furthermore, increased engagement in yoga has been correlated with enhanced mental health and favorable changes in salivary stress biomarkers (decreased cortisol, increased 1,5-AG) (Balasubramanian et al., 2023). In their cross-sectional online survey, Galloway, Foulstone, and Lurie (2022) revealed a positive and statistically significant relationship between time spent practicing yoga and relationship satisfaction (b = 0.005, 95% CI 0.001 to 0.009). Yoga serves to acquire coping skills through mindfulness, breathwork, and physical movement, fostering stabilization and enhanced self-connection.
Yoga and Mindfulness-Based Practices in Sex Counseling
Existing research consistently highlights the positive impact of mindfulness practices on various facets of sexuality, encompassing satisfaction, sexual functioning, and genital self-image (Valderrama Rodríguez, 2023). When integrated into sex counseling, mindfulness not only addresses specific concerns but also enriches overall quality of life by enhancing attention, concentration, sensory awareness, enjoyment, and the capacity to experience the present free from judgment or expectations (Thouin-Savard, 2019). Mindfulness-based practices can be flexibly adapted to address diverse concerns and relationship dynamics.
The current body of research on mindfulness and its impact on women's sexuality is more extensive, yet there is an opportunity to explore its potential benefits in addressing specific sexual challenges experienced by men, without the potential side effects associated with certain medications (Valderrama Rodríguez, 2023). Integrating mindfulness into interventions for sexual health could signify a shift toward a comprehensive biopsychosocial approach to treating male sexual dysfunction.
Studies examining the relationship between mindfulness and male sexuality reveal positive outcomes across various aspects, including sexual desire, performance anxiety, sexual satisfaction, fantasies, and pornography use. Mindfulness-based interventions, especially those targeting male sexual dysfunction issues such as erectile dysfunction, concentrate on reducing performance anxiety and enhancing sexual desire (Bossio et al., 2018). Bossio et al. (2018) demonstrated promising results, with effect sizes indicating a moderate to large impact on erectile functioning (Cohen's d = 0.63), substantial improvement in overall sexual satisfaction (Cohen's d = 1.02), and a noteworthy enhancement in non-judgmental observation of one's experience (Cohen's d = 0.52).
In summary, practicing mindfulness involves being present in the moment without judgment, and research suggests its effectiveness in improving sexual health and addressing dysfunction. Mindfulness-based interventions, as studied by Krieger et al. (2023) and Brotto (2018), can enhance awareness of one's body and emotions, fostering a better connection with sexuality and potentially reducing anxiety related to sex. Sensate Focus is highlighted as a key element in modern Sex Therapy interventions, as discussed by Tajik, Shahali, and Padmehr (2023).
Sensate Focus
For social beings like humans, touch plays a crucial role. Positive forms of touch, such as hugging, cuddling, or holding hands, provide emotional benefits by reducing stress and promoting stronger social bonds. Moreover, pleasant touch has been shown to trigger the release of hormones in the brain, enhancing social interactions and contributing to improved mental well-being (Liu et al., 2022). During early mother-infant interactions, nonverbal communication, particularly through touch, plays a pivotal role in expressing affection. This tactile communication in the initial year contributes significantly to lifelong socioemotional well-being. Research underscores the significance of early physical contact in fostering positive neurodevelopmental outcomes, such as stabilized heart rate, regulated arousal, reduced infection risk, and enhanced regulatory and social learning abilities (Wigley et al., 2022).
Sensate Focus, a therapeutic technique centered around tactile exploration, proves to be an effective intervention for individuals grappling with sexual issues (Avery-Clark & Weiner, 2017). Research indicates that sensate focus is an effective strategy in addressing sexual dysfunctions (Vowels, 2023). Additionally, it can significantly enhance sexual intimacy and overall satisfaction in relationships. Sensate focus helps bridge different types of touch, facilitates the creation of pleasure maps, and potentially strengthens body maps.
Sensate focus combines exposure therapy, associating positive experiences with touch and intimacy, and mindfulness to divert attention from disruptive thoughts. Counselors instruct clients to touch for their own pleasure while focusing on texture, temperature, and pressure. Couples are encouraged to release judgment and be present during these exercises. However, for optimal results, explicit communication exercises, a psychoeducational component, and a collaborative approach may be necessary (Vowels, 2023).
Yoga as an Adjunct Treatment for Sex Counseling
Yoga as an Adjunct Treatment for Sex Counseling integrates mindfulness-based practices, such as the Wheel of Awareness, body scans, and mindful breathing, with touch explorations based on the sensate focus intervention, informed by Avery-Clark and Weiner’s (2017) illustrated manual. The Wheel of Awareness is a practice for integrating consciousness. The integration of consciousness refers to the process of differentiating and linking the "knowns" and "knowing". This involves both the ability to differentiate between various aspects of experience and the capacity to link them together cohesively while separating our awareness (‘knowing’) from what we are aware of (‘knowns’) (Siegel, 2021). This process contributes to a more unified and comprehensive understanding of the self and the surrounding world as well as a higher flexibility in potential choices.
This practice is built on the Three Pillars of Mind Training: focused attention, open awareness, and kind intention (Siegel, 2010; Siegel, 2018). In Interpersonal Neurobiology, the mind is defined as an embodied and relational emergent, self-organizing process that regulates the flow of energy and information (Siegel, 2020). The practice of monitoring and modifying energy and information flow generates the capacity for regulation. The research identified in their publications, some of which has been discussed elsewhere in this work, has found consilient findings support that such practices lead to higher degrees of integration across different brain regions (interconnected connectome) and lead to increased well-being (Goleman & Davidson, 2017).
Yoga as adjunct treatment in Clinical Sexology integrates the Wheel of Awareness practice, somatic exercises, and Sensate Focus. Through these methods, it promotes autonomic regulation, learning how to create cues of safety, and stimulate several systems that contribute to optimal function. Placing sexuality within the Triangle of Well-Being (energy and information flowing within brain, mind, and relationships) offers a comprehensive framework to understand its dynamics. This intervention develops skills needed to cultivate healthy and thriving relational and sexual well-being.
I am a PhD in Clinical Sexology candidate at Modern Sex Therapy Institutes and have a Master of Science in Educational Psychology. I work with individuals, couples, non-monogamous relationships, and groups in topics related to sexuality, emotional regulation, communication dynamics, and changing behaviors.
