JOURNAL OF SEX RESEARCH, 46(2-3), 237248, 2009 Copyright # The Society for the Scientic Study of Sexuality ISSN:

0022-4499 print=1559-8519 online DOI: 10.1080/00224490902747230

The Role of Attention in Sexual Arousal: Implications for Treatment of Sexual Dysfunction
David C. de Jong
Department of Psychology, University of Toronto The literature on the role of attention in sexual arousal is reviewed, especially that which has implications for noninvasive treatment of sexual dysfunction. Findings suggest that voluntary control of sexual arousal can be achieved through attentional focus on nonsexual cognitions or sexual fantasy. Cognitive biases may direct attention and thus facilitate or impede sexual arousal. Sexual arousal may be inuenced by directed attentional focus, and preliminary evidence suggests that mindfulness techniques may result in longer-term changes in attentional focus; these changes, in turn, may improve sexual response. Information-processing models of sexual arousal developed in light of such ndings are discussed. This research establishes the central role of attentional processes in facilitating physiological and, especially, subjective sexual arousal. Implementing approaches that capitalize on attentional processes could advance noninvasive treatment of sexual dysfunction. Future avenues of research might investigate how play, mammalian play circuits, and ow states are relevant to sexual response and satisfaction.

Sexual arousal has been dened as an emotional and motivational state arising from an interaction between genital response, central arousal, information processing of sexual stimuli, and behavior (e.g., Bancroft, 2003). Sexual arousal comprises both subjective and genital arousal. Subjective arousal is the emotional experience of sexual arousal including the awareness of autonomic arousal, expectation of reward, and motivated desire (Everaerd, 1988). Genital arousal results from vasodilation of genital tissues: In females, this response leads to vasocongestion of the genital tissues and lubrication, and in males, erection. In the current understanding of the processes of sexual arousal, a large divide exists between knowledge about the physiology of sexual response and knowledge about the subjective experience of sexual arousal (Morin, 1995). Research into the role of attention in sexual arousal, which integrates experimental cognitive methodologies and cognitive neuroscientic ndings with knowledge of sexual response, is beginning to bridge that gap. As will become evident over the course
I thank Gillian Einstein for her invaluable guidance and contributions to the development of this article, Geoff MacDonald and an anonymous reviewer for suggestions and comments, and Jordan B. Peterson for bringing the relevance of mammalian play circuits to human sexual behavior to my attention. Correspondence should be addressed to David C. de Jong, Department of Psychology, University of Toronto, 100 Saint George Street, Toronto, Ontario, Canada M5S 3G3. E-mail: davidcdejong@ gmail.com

of this review, this work has profound implications for understanding both human sexual response and sexual dysfunction. Subjective experience is a fundamental aspect of human sexual response as a phenomenon in its own right. However, as a phenomenon, it is among the most understudied aspects of sexuality. In the subjective dimension of sexual arousal, a person experiences a private world of eroticism in which perceptions and physiological responses are infused with meaning, sexual memories are revisited, and fantasies are explored. The literature addressed in this review provides empirical support for the relevance of subjective experience to sexual response. At least two ramications follow from these ndings. First, this work has implications for treatment of sexual dysfunction. Perceptions of stimuli and physiological responses to them can be invested with multiple layers of meanings, some of which may be either positive or negative, and either sexual or not. As the following research has established, the allocation of attention brings different aspects of these meanings more clearly and vividly into awareness, and that awareness of those meanings impacts physiological and subjective arousal. As will be discussed, treatment strategies that take advantage of such processes (e.g., Brotto, Basson, & Luria, 2008) are being developed and may enhance sexual arousal and experience. Second, by highlighting subjective experience, this work raises questions about the very denitions of

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sexual dysfunction. The models of sexual response (e.g., Masters & Johnson, 1966) upon which the clinical literature is largely based do not account for the nonlinear unfolding of sexual experience in terms of factors such as motivation for sexual intimacy, genital arousal, subjective sexual arousal, and desire for intercourse, especially in the case of women (Basson et al., 2004). Further, these models do not acknowledge the multiple desires, meanings, and contextual factors that may be associated with or may inuence sexual activity for both women and men (Basson, 2001; Janssen, McBride, Yarber, Hill, & Butler, 2008). The work reviewed in this article underscores the inuence that such factors have on sexual response. After a brief discussion of attention, research that investigates the role of attention in sexual arousal is reviewed, especially that which has clear implications for the development of noninvasive treatment of sexual dysfunction. Three themes emerge from these studies, and the review is organized accordingly: voluntary control, cognitive biases, and directed attention. Information-processing models of sexual arousal are addressed, followed by discussion of further avenues for research. It is crucial to note that the research presented provides converging evidence suggesting that a person may have a certain amount of cognitive control over the degree of sexual arousal with which she or he responds to stimuli found to be attractive. None of the research suggests that a person has cognitive control over the types of features, individuals, or genders to which he or she might sexually respond.

contextual cues that have predictive value for events in ones environment (Jiang & Chun, 2003). Attention, as it relates to sexual arousal, is also governed by both bottom-up and top-down processes. As discussed later, attention can be oriented toward sexual stimuli by unconscious processes through the activation of implicit memory by stimuli in the environment (Spiering & Everaerd, 2007). Attention can also be intentionally directed through controlled processes toward sexual stimuli, either internal or external. Although attention is studied as a phenomenon in its own right, it is also clearly linked to perceptual, cognitive, and behavioral processes. In light of the conceptualization of sexual arousal as an emotional state (e.g., Everaerd, Both, & Laan, 2006), a brief mention of the literature addressing emotion and attention is warranted. In a review of this literature, Compton (2003) described ndings relevant to this discussion. Individuals have attentional biases related to their concerns. This bias is directed by both top-down processes, mediated by frontal lobe regions, and bottom-up processes, mediated by amygdalar responses. The role of the amygdala in bottom-up processing of emotionallyrelevant information is supported by imaging studies, which also indicate that such processing can be interrupted by increased cognitive load (e.g., mathematical tasks). Frontal regions may modulate amygdalar responses through reciprocal (i.e., bidirectional inuence) connections in accordance with current goals and task demands. Thus, insofar as the subjective component of sexual arousal is an emotional state, attentional processes play a vital role in processes of sexual arousal as well.

Attention The Role of Attention in Sexual Arousal Over 1 century ago William James (1890) wrote, Everyone knows what attention is. It is the taking possession by the mind, in clear and vivid form, of one out of what seem several simultaneous possible objects or trains of thought (pp. 403404). Although this denition still stands, later researchers have expanded on it. As discussed by Spiering and Everaerd (2007), attention comprises three subsystems: orientation to sensory stimuli, activation of ideas from memory, and maintenance of an alert state (Posner, 1994). As described by Gopher and Iani (2003), attention is the spotlight (metaphorically speaking) that brings stimuli in the environment into conscious awareness and that can be governed by both bottom-up and top-down processes. Bottom-up processes involve orienting attention elicited by stimuli in the environment (e.g., a ringing telephone). Top-down processes include constraints imposed by a person in service of goal-oriented behavior (e.g., attending to the text on a page one is reading). Another example of top-down guidance of attention is the inuence of implicitly-learned 238 Several reviews addressing the role of attention in sexual arousal have already been written (e.g., Barlow, 1986; Dekker & Everaerd, 1989). This review overlaps with these and other literature surveys on the keystone studies that best portray the advances made in this area. Of work conducted since the past surveys, the studies selected for review are those that have clear implications for the development of noninvasive treatment of sexual dysfunction. As mentioned earlier, the review is organized by three themes: voluntary control, cognitive biases, and directed attention. Mention should also be made of research addressing sexual arousal in terms of category specicity (e.g., Chivers, Seto, & Blanchard, 2007) and sex differences in the concordance between subjective and physiological arousal (Laan & Everaerd, 1995; but see also Rellini, McCall, Randall, & Meston, 2005). This work raises interesting questions regarding gender and sexual orientation differences in arousal patterns; however, in light of the focus of this review, it is not discussed here.

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Voluntary Control of Sexual Arousal The relevance of attentional processes to sexual arousal was perhaps rst established by the early studies on voluntary control of sexual arousal. Pivotal to these studies was the use of distraction, that is, diversion of attention. Laws and Rubin (1969) instructed men who watched an erotic lm either to achieve erection or to avoid getting an erection, using any means necessary except masturbation or not viewing the lm. In each case, the men were successful in either increasing or inhibiting their erections and reported using strategies such as fantasizing or concentrating on distracting thoughts. Cerny (1978) extended these ndings to females, establishing that females have the ability to increase or suppress both subjective and genital sexual arousal, although the author did not report on the cognitive strategies employed by the participants. Laan, Everaerd, Van Aanhold, and Rebel (1993) instructed a group of sexually functional women to achieve maximum arousal while either watching erotic lm excerpts or fantasizing. Women in both groups elicited measurable subjective and physical sexual arousal, although the effect was greater in the fantasy condition. The authors suggested that the participants increased attention to erotic cues allowed the women to achieve this effect. In a similar study by Beck and Baldwin (1994), women who were shown erotic lm segments reported using cognitive strategies such as nonsexual and negative thoughts (e.g., about pain) to inhibit arousal, or positive thoughts and fantasy to elicit genital arousal. The two studies just discussed established that internal distraction could be used to inhibit sexual arousal; other researchers have demonstrated that external distraction can have a similar effect. Geer and Fuhr (1976) used a dichotic listening paradigm to establish that distraction has such an effect: As cognitive tasks became increasingly complex, they found diminished sexual arousal as measured by penile tumescence. Similar ndings in women occurred during a study in which engagement in mathematical tasks diminished both subjective and physiological indexes of sexual arousal (Adams, Haynes, & Brayer, 1985). It should be noted, however, that ndings regarding the effects of distraction, especially in terms of differential effects on participants with and without sexual dysfunction, are inconsistent (e.g., Abrahamson, Barlow, & Abrahamson, 1989; van Lankveld & van den Hout, 2004).

Cognitive Biases and Sexual Arousal The evidence reviewed thus far establishes that attention paid to sexual cues facilitates sexual arousal, and that distraction interferes with that effect. The evidence reviewed next indicates that individuals may have cognitive biases that orient attention to information that may facilitate or inhibit sexual arousal. In a study aimed at

delineating the inhibitory effect of anxiety on sexual arousal, Beck, Barlow, Sakheim, and Abrahamson (1984) informed sexually functional and dysfunctional men that they might receive an electric shock either contingent or not contingent on their ability to achieve an erection. The conditions were intended to elicit either performance anxiety or generalized anxiety, respectively. In sexually functional men, noncontingent shock threat resulted in greater genital arousal than did a noshock condition; in contrast, sexually dysfunctional men showed less arousal during both shock threat conditions. As Barlow (1986) suggested, a distinction between the components of anxiety is necessary to understand these ndings. Although the autonomic components of anxiety (e.g., increased heart rate, blood pressure) might facilitate sexual arousal (see Meston & Gorzalka, 1996), the cognitive component of anxiety, such as a bias toward performance-related cognitions, impedes sexual arousal. Based on such ndings, Barlow (1986) posited a model of erectile dysfunction, central to which is the idea that increased autonomic arousal results in a narrowing of attentional focus (Wiegel, Scepkowski, & Barlow, 2007). The model outlines a process whereby a male focuses his attention on either erotic cues or nonerotic, self-evaluative cues (e.g., fears over performance). In both cases, autonomic arousal (due to sexual arousal in functional men and anxiety in dysfunctional men) creates a feedback loop, further narrowing the mans attentional focus on the information to which he is already attending. In sexually functional men, attention becomes increasingly focused on erotic information, creating a positive feedback loop. This feedback loop facilitates sexual response and erection, which in turn leads to approach behavior. In the case of sexually dysfunctional men, attention becomes more focused on nonsexual, task-irrelevant material, creating a negative feedback loop. The resultant interference prevents processing of sexual cues and impedes sexual arousal, leading to avoidance behavior. An important aspect of this model is that it is the distraction created by performance-related cognitions that impedes sexual arousal rather than the autonomic arousal associated with anxiety. Findings from a study by Elliot and ODonohue (1997) suggest that Barlows (1986) model can be applied to female arousal. They used a dichotic listening paradigm and an experimental design that crossed three levels of distraction (high, low, and none) with anxiety and no-anxiety conditions. Women experienced higher levels of genital arousal in the no-distraction condition than in the high-distraction condition. Contrary to the authors expectations, although women indicated higher levels of anxiety in the anxiety condition as opposed to the no-anxiety condition, there was no overall effect for anxiety on levels of genital or subjective sexual arousal. The authors offered several possible explanations 239

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for this lack of effect. First, they suggested that it might have been because the laboratory conditions did not evoke real-life situations. Second, it could be the case, as others have found in samples of men (e.g., Beck et al., 1984), that anxiety alone does not interfere with sexual arousal. The authors noted that this nding supports Barlows suggestion that it may be the distraction of negative cognitions rather than anxiety itself that impedes sexual arousal. Elliot and ODonohue did nd, however, an interaction between anxiety and distraction such that in the no-distraction condition, anxiety served to increase subjective sexual arousal. The authors suggested that this effect might actually have resulted from increased autonomic arousal misattributed by the participant as sexual arousal. Barlows (1986) model has since been updated to integrate recent advances in the conceptualization of anxious apprehension (Wiegel et al., 2007). The negative and positive feedback loops continue to play key roles in the updated model, but now, incorporated into each feedback loop are nested loops in which cognitive biases orient attention toward certain types of information and thus facilitate either positive or negative attributions. In the positive loop, attention is oriented toward threat-related information and self-evaluation; in the negative loop, cognitive biases are resistant to the development of cognitions characteristic of those with sexual dysfunction. Findings from studies by Payne, Binik, Amsel, and Khalife (2005) and Meston (2006), to be described shortly, support both the existence of such biases and their impact on sexual arousal. Meston (2006) explored the relation between state and trait self-focused attention (self-consciousness) on sexual arousal in a group of women with and without sexual dysfunction (including both pain and arousal disorders). Findings indicated that, while watching erotic lm segments, state self-focused attention (induced by a reective screen in front of the video monitor) decreased vaginal pulse amplitude (VPA) in sexually functional women. In sexually dysfunctional women, this effect was not found, possibly because the participants were already focusing attention on distracting selfand performance-related information. Further, state self-focus lowered the correlations between VPA and self-reported measures of sexual arousal; it did not impact levels of subjective sexual arousal in either groups. Trait private self-consciousness (the extent to which a person attends inwardly to the self and internal states) was positively correlated with sexual satisfaction, sexual desire, and orgasm. In terms of effects on sexual arousal and function, these ndings point to a benecial role for dispositional private self-focus and a detrimental effect for induced public self-focus. Meston (2006) suggested that public self-consciousness, in a real-world setting, likely interacts with a womans appraisal of how she is viewed by 240

her sex partner: If she feels valued, there will be a faciliatory effect on arousal; if she does not, the trait may have a detrimental effect on sexual arousal. This conrmed the ndings of Korff and Geer (1983, described later) demonstrating that, in women, attention to bodily sensations (i.e., private self-focus), especially those of the genitals, increases concordance between genital and subjective sexual arousal. Payne and colleagues (2005) investigated attentional biases for pain-related stimuli in women with and without vulvar vestibulitis syndrome (VVS). On an emotional Stroop task, women with VVS revealed greater interference for pain words than did controls, indicating a selective attentional bias toward pain stimuli. This effect was predicted by anxiety. On a memory recall task, women with VVS were higher in hypervigilance for coital pain, which was predicted by fear of pain. Thus, the authors suggested that anxiety might orient preattentive processing of threat-related stimuli, whereas fear subsequently directs allocation of attentional resources toward the threat-related stimuli. They noted the relevance of Barlows (1986) model in which anxiety exacerbates focus on task-irrelevant cues, which in turn impedes sexual arousal. In conclusion, the authors noted that treatment of VVS must address not only sensory systems but also cognitive factors including anxiety and fear. Directed Attention and Sexual Arousal The studies described next demonstrate that sexual arousal is inuenced by the cues toward which ones attention is directed. In a study investigating concordance of subjective and physiological arousal, Korff and Geer (1983) found that in a group of healthy women who were shown erotic lm segments, highest concordance between genital and subjective arousal occurred when participants, as instructed, directed their attention to bodily cues (e.g., heart rate), and especially genital cues (e.g., vaginal lubrication), as compared to women who received no instructions at all. Heiman and Rowland (1983) found that sexually functional men, while listening to an erotic audiotape, showed greater genital sexual arousal when instructed to get an erection as quickly as possible (performancedemand condition) in contrast to being instructed to focus on pleasurable internal sensations (sensate-focus condition). Sexually dysfunctional men showed the opposite effect, responding with greater genital arousal in the sensate-focus condition than in the performance-demand condition. Barlow (1986) suggested that the diminished arousal in functional men in the sensatefocus condition may have been due to the effect of distraction of nonperformance related self-focus; in contrast, the sexually dysfunctional men were likely distracted by performance-related self-focus, but not by sensate focus.

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Dekker, Everaerd, and Verhelst (1985) investigated the effects of directed attentional focus on subjective sexual arousal in male and female participants who listened to an erotic audiotape. Imagining the sexual feelings they themselves might have in the recorded scenario resulted in greater subjective sexual arousal than focusing on the situation and events described in the story. In addition, those participants who experienced greater arousal in the sexual feelings condition had reported higher levels (near signicance) of sexual daydreaming and more frequent use of fantasy during masturbation. Dekker and colleagues surmised that, based on the association between the found effect and the use of sexual imagery in daydreaming and during masturbation, voluntary control of sexual response may depend on analogous processes of control; they further speculate that these processes might be learned. Brauer, ter Kuile, and Laan (2008) asked women with and without supercial dyspareunia to focus on either the genital pain or the pleasure that the actress in an erotic lm might be experiencing. In contrast to those in the enjoyment-focus condition, women who focused on genital pain responded with lower genital arousal (marginally signicant) and greater negative affect. Women with dyspareunia who focused on genital pain reported less positive affect. Women in the enjoyment-focus condition reported the lowest levels of negative affect. As the authors suggested, in light of information-processing models of sexual arousal (e.g., Janssen, Everaerd, Spiering, & Janssen, 2000, discussed later), the ndings indicate that appraisal has a modulatory effect on sexual arousal and on evaluation of negative affect. The authors suggested that in terms of these participants, focusing on the enjoyment of the actress might have led the women to make a positive appraisal of the sexual stimuli, thus enhancing genital response through attentional focus; those in the negative focus group were led to make negative appraisals, thus inhibiting genital response. That the women who focused on pain still responded with genital arousal further supports information-processing models (e.g., Janssen et al., 2000) in that genital response can be elicited, even under adverse conditions, through unconscious appraisal. Whereas paradigms such as those used by Geer and Fuhr (1976) manipulated levels of available attentional resources through distraction, in a series of studies by Koukounas and Over (1999, 2001), levels of sexual arousal were manipulated, and effects on attentional resources were assessed. In their rst study (1999), the authors manipulated levels of sexual arousal by eliciting habituation and novelty effects in a group of healthy male participants. Habituation was achieved by presenting the same erotic lm segment 18 times, and novelty, by presenting a segment only twice. Reaction time in response to a signal was considered to be an index of the attentional resources being allocated to the erotic lm. The effect of habituation was evident, in that

physiological and subjective indexes of sexual arousal steadily decreased. The effect of novelty was indicated by an increase in physiological and subjective indexes of sexual arousal. In nal trials rehabituation was evident, as levels of sexual arousal and absorption once again decreased. More importantly, reaction times in response to the signals uctuated in directions opposite to the changes in sexual arousal. The authors noted that these ndings are correlational, not causal: Rather than the decrease in attention causing the decrease in arousal, as one might be tempted to surmise, it may have been the decrease in sexual arousal that caused the decrease in attention. They noted that a critical assessment of causality between these two variables would involve manipulation of attentional resources and assessing effects on sexual arousal, as implemented in the study described next. Koukounas and Over (2001), using the same habituationnovelty paradigm they had used in the 1999 work, investigated the effects of spectator-oriented focus and participant-oriented focus on sexual arousal in healthy men. Men were instructed either to engage their senses and emotions while imagining participating in the depicted sexual activities (emotion-focus condition) or to watch as an impartial, emotionally-distant observer (stimulus-focus condition). Degree of attentional engagement was assessed via self-report. As in the earlier 1999 study, the mens genital arousal closely tracked reports of subjective sexual arousal and absorption; all three measures showed effects of habituation, novelty, and rehabituation. Subjective arousal, genital arousal, and absorption were signicantly greater in the emotion-focus than in the stimulus-focus condition. Further, the difference in response levels between the nal habituation trials and the novel trials was greater for the emotion-focus condition. The authors suggested that, to the extent that disorders of low sexual desire may result from habituation of sexual response to sexual cues, the methods used in this study might aid in the psychophysiological assessment of such conditions. Of the studies considered in this review, those described next are perhaps most relevant to the development of noninvasive treatment of sexual dysfunction. Kuffel and Heiman (2006) investigated the effects of experimentally-adopted sexual schemas on the sexual and affective response of women with and without depressive mood symptoms. Pretest measures indicated that in contrast to women with normal mood, those with depressive symptoms reported lower levels of sexual desire, but they were similar in indexes of arousal, orgasm, and satisfaction. The identities that the women were asked to try on as a means of enacting positive or negative schemas entailed that the participant either view sex as important, enjoyable, and her own body as sexually responsive or that she view sex as unimportant, unarousing, unpleasant, and her own body as unresponsive. Adopting a positive sexual schema resulted in 241

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greater subjective and genital sexual response and positive affect while viewing erotic stimuli, even for the women with depressive symptoms or negative pre-existing sexual self-schemas. The authors suggested that, in light of information-processing models of sexual arousal (e.g., Janssen et al., 2000), adoption of a positive sexual schema might guide attentional processes, facilitating association of a stimulus with positive sexual meaning and thus activating sexual response. The authors noted that the effect of the sexual schemas might have been confounded by the manipulation of affect because both elements were embedded in each schema. Future researchers might inquire whether interventions aimed at modication of an individuals normal schema may have a longer-term impact on sexual response. Investigations into the impact of adopted schemas on the processing of sex-related information would also be valuable. Middleton, Kuffel, and Heiman (2008) extended the ndings of Kuffel and Heiman (2006) to a group of women with and without female sexual arousal disorder (FSAD). Pretest measures indicated that those with FSAD showed lower arousal, desire, orgasm, and satisfaction than the healthy women, along with more negative sexual self-schemas. Using the same paradigm, they similarly found that adoption of a positive sexual schema resulted in greater subjective sexual arousal, genital sexual arousal, and positive affect, even for the women with depressive symptoms and negative preexisting sexual self-schemas. The authors noted that it may be the case that the primary feature of FSAD is decreased subjective, but not genital, response (citing Brotto, Basson, & Gorzalka, 2004) and that, although their subjective sexual arousal was still lower than that of sexually healthy women, those with FSAD showed signicant increases on this measure during posttesting. Brotto, Heiman, et al. (2008) investigated the effects of mindfulness meditation on sexual function and wellbeing in women with FSAD following hysterectomy for cervical or endometrial cancer. Mindfulness, the attentional stance underlying Buddhist meditation, involves the cultivation of nonjudgmental attention and awareness of the unfolding of experience moment by moment (Kabat-Zinn, 2003). Investigators have established the clinical effectiveness of mindfulnessbased interventions on conditions ranging from psoriasis to chronic pain, including psychological disorders such as generalized anxiety and depression (for a review, see Baer, 2003). A growing body of neuroelectric and imaging studies establishes that meditation can result in increases in indexes of attentional resources both during meditation and as a result of long-term practice (for a review, see Cahn & Polich, 2006). In the study by Brotto, Heiman, et al. (2008), women participated in a psychoeducational intervention that unfolded over three 1-hr sessions and consisted of elements of cognitive and behavioral therapy with education and mindfulness training. Homework materials included readings 242

addressing behavioral approaches to orgasmic disorder, marriage success, mindfulness, and relaxation. The component that taught mindfulness strategies included exercises in which the woman was to use sustained attentional focus to bring sensory information, both sexual and not, into her awareness. In one exercise, for example, the woman was to use a vibrator to become sexually aroused, and to attend mindfully to the accompanying sensations and experience in the present (Brotto & Heiman, 2007). Findings indicated that, compared to pretests, the intervention positively affected sexual desire, orgasm, satisfaction, sexual distress, depression, and overall well-being. In response to viewing erotic lm, there was a nonsignicant trend toward increased genital arousal and perceived genital arousal. Brotto, Basson, and Luria (2008) replicated the Brotto and Heiman (2007) ndings, using an adaptation of the same intervention with a group of women with either sexual desire and interest or sexual arousal disorders. After completing three 90-min sessions and homework exercises, it was found that, compared to pretreatment tests, the intervention improved sexual desire and reduced sexual distress. In response to the erotic lm there were increases in self-reported sexual arousal (e.g., genital tingling, wetness) and marginally signicant increases in subjective and genital arousal. Further, women with a sexual abuse history showed a greater improvement than those without such history on self-reported genital arousal, overall sexual function, sexual distress, negative affect in response to the erotic lm, and depression. As was found in the earlier study, women reported that the mindfulness component was the most effective aspect of the intervention. The authors of both of the mindfulness-based intervention studies noted that their studies are unique, as they appear to be the rst to indicate that psychological interventions may increase genital and perceived sexual arousal in women. They also noted, however, that the absence of a control condition makes it difcult to draw rm conclusions about the effectiveness of the intervention. In light of this discussion, it is impossible to know to what extent cultivation of attention may have had on sexual response. Qualitative data suggest that the women found the mindfulness-meditation component of the intervention the most helpful; however, mindfulness meditation was only one of several components of the intervention, and attention only one aspect of that component (relaxation being another). Further research, especially that in which the effect of nonmeditative relaxation training is compared to mindfulness meditation, would help to delineate the role of attention in such interventions. Summary Research to date clearly establishes the relevance of attentional processes to sexual response. Through

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differential focus of attention on either sexual cues (e.g., fantasy) or distracting nonsexual cues (e.g., pain), sexual arousal can be elicited or suppressed. External distractions that divert attention from sexual cues can inhibit sexual arousal. Cognitive biases can orient an individuals attention, which in turn may have an impact on sexual arousal. In men, biases toward nonerotic selfevaluative cues may inhibit sexual arousal. In women, induced self-consciousness may inhibit genital sexual arousal, and a disposition toward attending to internal states may facilitate sexual response and satisfaction. Women with VVS may have an attentional bias toward pain-related information. The types of cues to which a person attends also inuence sexual response. For women, focusing attention on bodily and especially genital cues may increase concordance between subjective and genital arousal. Sensate focus may facilitate arousal in sexually dysfunctional men but may distract and hence inhibit arousal in sexually functional men. In women and men, imagining sexual feelings may facilitate subjective sexual arousal. This effect may be mediated by regular engagement in sexual daydreaming and fantasy, suggesting that the ability to engage in such imagination may be learned. In women with and without supercial dyspareunia, focusing on pain as opposed to pleasure may inhibit genital arousal and elicit negative affect or decrease positive affect. In males, as sexual arousal diminishes due to habituation and increases due to novelty, allocation of attentional resources decreases and increases in parallel. Further, in response to sexual stimuli, sexual arousal may be increased by imagining emotional engagement with the material but inhibited by remaining an impartial observer. In women, including those with depressive symptoms, FSAD, and negative pre-existing sexual schemas, the adoption of a positive sexual schema can increase subjective and genital sexual arousal. A psychoeducational intervention including elements of mindfulness training may lead to improvement in sexual function and satisfaction in women with and without FSAD, including those with FSAD following hysterectomy due to cervical or endometrial cancer. Information-Processing Models of Sexual Arousal Taking into account prior research on the cognitive aspects of sexual arousal, Janssen and colleagues (2000) offered the following model of sexual arousal. They noted the body of research showing that genital arousal and subjective sexual arousal are distinct: In both men and, especially, in women these two components can be discordant (e.g., Laan & Everaerd, 1995). They also noted ndings indicating that genital responses are easily elicited in sexually functional women and men, even under unfavorable laboratory conditions in which anxiety is induced or performance demands are made (e.g., Beck et al., 1984; Laws &

Rubin, 1969). Further, they noted the nding that subjective arousal is facilitated by attention allocated to sexual cues, either internal or external. In light of these ndings, they suggested that these components of sexual arousal are mediated by different mechanisms. The model offered by Janssen and colleagues (2000) incorporates two pathways, one dependent on unconscious (automatic and preattentive) processing and the other dependent on conscious (controlled) processing. The pathway operating unconsciously comprises an appraisal stage and a response generation stage. Appraisal involves the mechanisms that give stimuli emotional and sexual meaning by encoding and matching the stimuli to implicit memories. The response generation stage is integrative, connecting these sexual meanings with response and motor plans, and automatically triggers genital arousal. The perception of this genital arousal also becomes a stimulus to be appraised and associated with sexual meaning. The appraisal and response generation stages activate the controlled pathway by orienting attention toward the sexual meanings that are associated with the stimuli, facilitating the subjective experience of sexual arousal. This model takes into account the multiple meanings that can be attributed to sexual stimuli (cf. Barlow, 1986; Basson, 2001; Janssen, McBridge, Yarber, Hill, & Butler, 2008) due to ones history and situational factors (Spiering & Everaerd, 2007), resulting in positive or negative emotions. If the meanings (both explicit and implicit) attributed to the stimuli are primarily sexual and positive, then attention and the two stages of appraisal and response generation create a positive feedback loop, thus heightening the effect of the stimuli and increasing the probability of concordance between genital and subjective arousal. In such a case, a person also becomes aware of, and might attend to, his or her increasing genital arousal, which also contributes to the feedback loop. If the meaning associated with the sexual stimulus is either nonsexual or negative, then the chance of subjective arousal is decreased, resulting in discordance between subjective and genital arousal. For example, one might associate anxiety or fear of performance with sexual stimuli, thus drawing attention away from any positive sexual meanings and impeding sexual arousal. Spiering and Everaerd (2007) described the neural correlates of the two pathways in the model offered by Janssen et al. (2000). They suggested that the neural pathway mediating the automatic connection between the perception of a stimulus and the appraisal process is the direct thalamo-amygdala projection, which facilitates quick, instinctive responses that operate outside of conscious awareness (LeDoux, 1993). That the amygdala responds preattentively to stimuli in an unconscious manner is supported by functional MRI and PET scan studies indicating that subliminally presented angry faces elicit amygdalar and heightened skin 243

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conductance responses (e.g., Morris, Ohman, & Dolan, 1998). Further, Spiering, Everaerd, Karsdorp, Both, and Brauer (2006) found that subliminally presented sexual pictures sped up identication of subsequently presented sexual pictures without affecting reports of subjective sexual arousal. As Spiering and Everaerd suggested (2007), this nding indicates that initial appraisal of a stimulus as sexual may operate preattentively, activating implicit memories such as innate sexual reexes, learned sexual scripts, and classically conditioned responses. Also as described by Spiering and Everaerd (2007), events outlined by the second pathway bring sexual arousal into conscious awareness. Explicit memories (including recollections of sexual encounters, sexual attitudes, fantasies, and memories related to sexual costs and rewards) are localized in the neocortex, mediated by the hippocampus. The insula is believed to be responsible for integrating bodily sensory information with conscious awareness (e.g., Damasio, 2003). The activation of implicit memories, represented in the amygdala, orients attentional processes, which are mediated by the prefrontal cortex and anterior cingulate cortex (Posner, 1994). Through top-down attentional amplication of bodily sensory information and explicit memories, sexual arousal enters conscious awareness. Basson (2002; see also Basson, 2001) offered a model of female sexual arousal in which she proposed an explanation for the nding that the concordance of genital arousal with both subjective arousal and awareness of genital sensations is lower in women than in men (e.g., Laan & Everaerd, 1995; but see also Rellini et al., 2005). The element of Bassons (2002) model most relevant to this discussion is a stage in which a woman assesses the contextual cues and her subjective arousal associated with the stimulus. Initially, the sexual nature of the stimuli is processed by the limbic system and causes rapid genital congestion outside of conscious awareness. This automatic genital response has been found in both sexually functional and dysfunctional women, including women with sexual arousal disorders (Laan & Janssen, 2007). Next, conscious appraisal of contextual cues surrounding the sexual stimuli may lead to subjective arousal. Subjective arousal may be further increased by awareness of genital arousal. Further, the state of subjective sexual arousal is also appraised (e.g., Should I be sexual now? Is it safe to be sexual now?). The cognitive appraisal also entails making affective judgments and results in either positive (e.g., enjoyment, interest) or negative (e.g., guilt, fear) judgments. To support the addition of this stage, Basson (2002) cited evidence indicating that, when describing sexual arousal, men tend to focus on their sexual excitement, white women may tend to focus on other emotions, both positive and negative (e.g., enjoyment, shame; Dekker & Everaerd, 1988). Feedback from these cognitions and emotions modulate limbic processing and, therefore, also the experience of subjective arousal. 244

This process of appraisal determines her decision whether to remain focused on the sexual stimuli.

Discussion The research discussed in this review integrates methodologies and ndings from diverse literatures and clearly establishes that attentional processes play an important role in human sexual response. Stimuli, including that which is either in an individuals environment or due to genital response, may be invested with sexual or nonsexual meaning, and these meanings can be positive or negative. Attentional focus on these meanings facilitates the conscious and subjective experience of sexual arousal. Research such as that by Kuffel and Heiman (2006) and Brotto, Heiman, et al. (2008) suggests that interventions capitalizing on these processes may be effective in treating sexual dysfunction. Further avenues for research exist, however, especially avenues that may integrate ndings and theory from other literatures. The following discussion offers speculations and suggestions for future research. One line of inquiry that may prove fruitful is to address the impact of contextual factors on attentional processing of sex-related information. Recent work suggests that pre-existing contextual factors may impact sexual response and desire for sexual activity (Basson, 2001; Janssen et al., 2008). It is possible, however, that an individual or couple could intentionally structure contextual factors in such a way that the processing of sex-related information, and thus sexual response and enjoyment, may be facilitated. As discussed by Jiang and Chun (2003), investigations into the effects of contextual cueing suggest that humans use contextual information to guide allocation of attention. Contextual refers to the impact of cooccurring predictive information on the processing of target information. Cueing refers to top-down attentional processes. Thus, contextual cueing refers to the top-down orienting of attention by contextual information that has predictive value. Moreover, contextual information may be implicitly learned, outside of conscious awareness. In the studies discussed by Jiang and Chun (2003), target processing (e.g., identication of location or shape of an object) was facilitated when the target was consistently accompanied by repeated information (e.g., spatial congurations, distractor shapes). In these studies, participants exhibited chance-level recognition performance for the repeated contextual information, indicating that the learning of contextual information occurred without awareness. In light of these ndings, questions are raised regarding the impact that contextual cues may have on the processing of information in a sexual setting.

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Play An individual or couple could arrange contextual information in many ways such that attentional processing of sex-related information is facilitated. The use of candlelight, preferred music, certain types of clothing, or verbalizations (e.g., dirty talk) all may serve as contextual cues. Engagement in sex play may be an example of advanced use of contextual cues. The term play dees conclusive denition; however, in one attempt, Garvey (1977) described it as pleasurable and intrinsically motivated activity, which is actively and voluntarily engaged in and that may or may not include structure. The ambiguity of play lies in the fact that play both is and is not what it appears to be: A playful nip is not only not a bite, but it is also not not a bite (Schechner, 1988). The role of play as it relates to adult sexuality is largely neglected as a research topic. Exceptions exist (e.g., Betcher, 1987), although such work tends to address sex-play such as bondage and discipline, dominancesubmission, sadism and masochism (e.g., Langdridge & Barker, 2007). Neuroscientic evidence suggests that the mammalian brain contains neural systems devoted to play behavior. It could be the case that engagement of these circuits may facilitate heightened attention and thus enhance sexual response and satisfaction.

Mammalian Play Circuits In his thorough discussion of mammalian play, Panksepp (1998) described its function in mammalian development: facilitation of learning and physical skill acquisition, assimilation of the young into social structures and hierarchies, learning of social skills such as the management of aggression and defeat, and development of courting and parenting skills. In rats, play manifests as rough-and-tumble play involving chasing, rapid pivots, high-frequency vocalizations, wrestling, and pinning. The play of chimpanzees includes tickling, nuzzling, laughter, and play-ghting. Panksepp noted that the play impulse seems to be innate: If young rats are denied social contact following birth, they begin to play at their rst given opportunity. The neural systems that specically mediate play behavior include nonspecic reticular nuclei such as the parafascicular complex and posterior thalamic nuclei. Panksepp described ndings indicating that damage to those areas abolishes play behavior in rats, leaving other complex behaviors (e.g., foraging) intact. In humans, Panksepp suggested, play behavior emerges from these same systems and operates in tandem with higher cognitive functions that mediate social constructions. Thus, in humans play behaviors take on many different forms, ranging from the games and

make-believe of children to sports, drama, dancing, and word-play in adults. Perhaps incorporating elements of play into sex therapy can capitalize on these evolved mechanisms. In humans, the relevance of play to sexual activity seems intuitive: Both activities can be pleasurable, intrinsically motivated, and actively engaged in. They can involve high levels of physical contact and, at times, laughter. The overlap between the modulatory effects of serotonergic and dopaminergic systems on both play and sexual behavior suggests that this may be the case. Activation of serotonergic systems reduces play behaviors in nonhuman animals (e.g., Normansell & Panksepp, 1985). In humans, activation of serotonergic systems has an inhibitory effect on sexual arousal (e.g., Demyttenaere & Jaspers, 2008), as it does in rats (Bitran & Hull, 1987). In rats, play behavior was found to lead to an increase in dopamine use in the brain (Panksepp, 1993), and dopamine-blocking agents were found to reduce playfulness (Beatty, Dodge, Dodge, White, & Panksepp, 1982). Analogously, dopamine facilitates sexual arousal, orgasm, and ejaculation in humans and other animals (e.g., Melis, Succu, Mascia, & Argiolas, 2005; Zion et al., 2006). These ndings indicating similar modulatory effects of serotonin and dopamine on both play and sexual behavior support the speculation that mammalian play circuits may be relevant to human sex play. It is not hard to make a case for the relevance of attentional processes to play, although Panksepp (1998) made no mention of such a connection in his discussion. Garvey (1977) stated that active engagement is one of the dening features of play, and this element is evident in the absorption of an individual in her or his play or play partners. By approaching sex as play, individuals or couples may establish contextual cues that increase attentional focus on sexrelated information. Further, such an approach may be facilitated by circuitry of ancient origin that allows play behavior in all mammals. The number of ways in which elements of play can be integrated into sex is limited only by ones imagination. For example, role-play may enable the exploration of identities, motivations, interpersonal dynamics, and scenarios that an individual or couple may not be inclined to enact in non-play situations. As Schechner (1988) pointed out, perhaps such enactments both are and are not what they appear to be. This ambiguity that is inherent in play may allow a couple to explore sexuality, sexual responses, and intimacy. Although the evidence indicates that the adoption of an alternate identity can inuence sexual response and can facilitate sexual arousal (e.g., Middleton et al., 2008), whether role-play can be applied to sex therapy seems to be a neglected research question, although rare exceptions exist (e.g., Henkin, 2007). 245

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Flow States Cskszentmihlyi (1990) described ow as a mental a state during which a person is immersed in an activity and experiences a feeling of energized focus. In a ow state, a person is focused on a task toward which he or she has clear goals, which is intrinsically rewarding and which provides immediate feedback about performance. Flow states are characterized by feelings of absorption, loss of feeling of self-consciousness, and distortion of sense of time. Rock-climbing and musical performance are often offered as examples of activities that may elicit ow states. Marr (2001) proposed a biobehavioral model of ow, which incorporates a dynamic feedback loop comprised of a series of nested insights and rapid set shifting that triggers dopamine release. This release in turn increases the saliency of the task and thus heightens attentional focus. As Marr noted, dopamine has been found to protect goal-related neural activity against interfering stimuli, hence stabilizing active neural presentations in the prefrontal cortex (Durstewitz, Kelc, & Guntu n, 1999). Marr further rku noted that, as mediated by midbrain structures, dopamine labels stimuli with appetitive value and provides signaling of reward contingencies (Schultz, 1998); thus, absorption in the task at hand is rewarded and reinforced. Although a signicant body of research addresses ow as it relates to activities such as sports, the possibility that ow experiences may have relevance to sex seems to be largely unexplored, as noted by Kleinplatz and Menard (2007). Kleinplatz and Menard asked a pool of female and male practitioners of consensual sadomasochism to describe their experiences of great sex. Among the themes that emerged, the most prominent was a state of being fully present and totally absorbed in the moment. Participants described heightened awareness of bodily sensations, of sexual tension, and of their partner. Certain methodological issues may be raised regarding this study. First, the term great sex is highly subjective: Great sex might entail highly pleasurable sex to one person or highly procreative sex to another. Second, for the population sampled, ndings may have been confounded by factors such as high sex drive or erotophilia. In future studies, investigators might inquire as to whether similar themes would emerge from different populations. However, the fact remains that some people experience a higher proportion of satisfying, or great, sex than others, and to the group studied the importance of attentional focus is clear. It is interesting to note that Kleinplatz and Menard reported that some of their participants men tioned the relevance of Cskszentmihlyis (1990) work a on ow states to their sexual experiences. As suggested by Kleinplatz and Menard, to understand how sexual satisfaction may be achieved, research must include populations that not only experience sexual problems, 246

but also those that report high levels of sexual satisfaction. Further inquiry into the relevance of play and ow states to sex would be invaluable, especially investigations that both assess the ability of such individuals to maintain attentional focus on sexual cues and control for sex drive and traits such as erotophilia.

Conclusion In this review, research is discussed that clearly establishes the relevance of attentional processes to sexual arousal. This research not only grounds the theory that through attention, voluntary control of sexual arousal is possible, it also shows that an individuals attention can be directed by cognitive biases or situational factors such that sexual response is facilitated or diminished. Integrating this work with neuroscientic ndings has allowed the development of information-processing models of sexual arousal. This work also establishes that attentional processes facilitate subjective sexual experience and, further, makes it clear that multiple meanings and desires play an important role in how sexual experience unfolds. This work has clear implications for the development of noninvasive treatment of sexual dysfunction. To date, the cutting edge of this research suggests that sexual function may be facilitated by interventions enabling an individual to cultivate mindful attention or modify sexual schemas. Further research may clarify the role of attention in these interventions. The integration of such research with that from other literatures generates many interesting questions. Research into the role of ow states in sex may point to ways that attentional focus during sexual activity may be enhanced. The incorporation of play into sex may serve to heighten attention and thus intensify sexual response and satisfaction. Advancing such research, although recognizing the importance of the subjective dimension of sexual arousal, will certainly allow a deeper understanding of human sexuality to emerge.

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