The Role of Attention in Sexual Arousal: Implications for Treatmentof Sexual Dysfunction

David C. de Jong

Department of Psychology, University of TorontoThe literature on the role of attention in sexual arousal is reviewed, especially that which hasimplications for noninvasive treatment of sexual dysfunction. Findings suggest that voluntarycontrol of sexual arousal can be achieved through attentional focus on nonsexual cognitionsor sexual fantasy. Cognitive biases may direct attention and thus facilitate or impede sexual arousal. Sexual arousal may be influenced by directed attentional focus, and preliminary evi-dence 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 findings are discussed. This research establishes thecentral role of attentional processes in facilitating physiological and, especially, subjectivesexual arousal. Implementing approaches that capitalize on attentional processes could advance noninvasive treatment of sexual dysfunction. Future avenues of research might inves-tigate how play, mammalian play circuits, and flow states are relevant to sexual response and satisfaction.

Sexual arousal has been defined as an emotional andmotivational state arising from an interaction betweengenital response, central arousal, information processingof sexual stimuli, and behavior (e.g., Bancroft, 2003).Sexual arousal comprises both subjective and genitalarousal. Subjective arousal is the emotional experienceof sexual arousal including the awareness of autonomicarousal, expectation of reward, and motivated desire(Everaerd, 1988). Genital arousal results from vasodila-tion of genital tissues: In females, this response leads tovasocongestion of the genital tissues and lubrication,and in males, erection.In the current understanding of the processes of sex-ual arousal, a large divide exists between knowledgeabout the physiology of sexual response and knowledgeabout the subjective experience of sexual arousal(Morin, 1995). Research into the role of attention in sex-ual arousal, which integrates experimental cognitivemethodologies and cognitive neuroscientific findingswith knowledge of sexual response, is beginning tobridge that gap. As will become evident over the courseof this review, this work has profound implications forunderstanding both human sexual response and sexualdysfunction.Subjective experience is a fundamental aspect of human sexual response as a phenomenon in its ownright. However, as a phenomenon, it is among themost understudied aspects of sexuality. In the subjec-tive dimension of sexual arousal, a person experiencesa private world of eroticism in which perceptions andphysiological responses are infused with meaning, sex-ual memories are revisited, and fantasies are explored.The literature addressed in this review providesempirical support for the relevance of subjectiveexperience to sexual response. At least two ramifica-tions follow from these findings. First, this work hasimplications for treatment of sexual dysfunction. Per-ceptions of stimuli and physiological responses tothem can be invested with multiple layers of meanings,some of which may be either positive or negative, andeither sexual or not. As the following research hasestablished, the allocation of attention brings differentaspects of these meanings more clearly and vividlyinto awareness, and that awareness of those meaningsimpacts physiological and subjective arousal. As willbe discussed, treatment strategies that take advantageof such processes (e.g., Brotto, Basson, & Luria,2008) are being developed and may enhance sexualarousal and experience.Second, by highlighting subjective experience, thiswork raises questions about the very definitions of

I thank Gillian Einstein for her invaluable guidance and contribu-tions to the development of this article, Geoff MacDonald and ananonymous reviewer for suggestions and comments, and Jordan B.Peterson for bringing the relevance of mammalian play circuits tohuman sexual behavior to my attention.Correspondence should be addressed to David C. de Jong,Department of Psychology, University of Toronto, 100 Saint GeorgeStreet, Toronto, Ontario, Canada M5S 3G3. E-mail: davidcdejong@gmail.comJOURNAL OF SEX RESEARCH,

(2-3), 237–248, 2009Copyright

The Society for the Scientiﬁc Study of SexualityISSN: 0022-4499 print

1559-8519 onlineDOI: 10.1080/00224490902747230

sexual dysfunction. The models of sexual response (e.g.,Masters & Johnson, 1966) upon which the clinical litera-ture is largely based do not account for the nonlinearunfolding of sexual experience in terms of factors suchas 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 multipledesires, meanings, and contextual factors that may beassociated with or may inﬂuence sexual activity forboth women and men (Basson, 2001; Janssen, McBride,Yarber, Hill, & Butler, 2008). The work reviewed in thisarticle underscores the inﬂuence that such factors haveon sexual response.After a brief discussion of attention, research thatinvestigates the role of attention in sexual arousal isreviewed, especially that which has clear implicationsfor the development of noninvasive treatment of sexual dysfunction. Three themes emerge from thesestudies, and the review is organized accordingly:voluntary control, cognitive biases, and directed atten-tion. Information-processing models of sexual arousalare addressed, followed by discussion of furtheravenues for research. It is crucial to note that theresearch presented provides converging evidence sug-gesting that a person may have a certain amount of cognitive control over the degree of sexual arousalwith which she or he responds to stimuli found tobe attractive. None of the research suggests that a per-son has cognitive control over the types of features,individuals, or genders to which he or she mightsexually respond.

Attention

Over 1 century ago William James (1890) wrote,‘‘Everyone knows what attention is. It is the takingpossession by the mind, in clear and vivid form, of one out of what seem several simultaneous possibleobjects or trains of thought’’ (pp. 403–404). Althoughthis deﬁnition still stands, later researchers haveexpanded on it. As discussed by Spiering and Everaerd(2007), attention comprises three subsystems: orienta-tion to sensory stimuli, activation of ideas from mem-ory, and maintenance of an alert state (Posner, 1994).As described by Gopher and Iani (2003), attention isthe spotlight (metaphorically speaking) that brings sti-muli in the environment into conscious awareness andthat can be governed by both

bottom-up

and

top-down

processes. Bottom-up processes involve orienting atten-tion elicited by stimuli in the environment (e.g., a ring-ing telephone). Top-down processes include constraintsimposed by a person in service of goal-orientedbehavior (e.g., attending to the text on a page one isreading). Another example of top-down guidanceof attention is the influence of implicitly-learnedcontextual cues that have predictive value for eventsin one’s environment (Jiang & Chun, 2003).Attention, as it relates to sexual arousal, is also gov-erned by both bottom-up and top-down processes. Asdiscussed later, attention can be oriented toward sexualstimuli by unconscious processes through the activationof implicit memory by stimuli in the environment(Spiering & Everaerd, 2007). Attention can also beintentionally directed through controlled processestoward sexual stimuli, either internal or external.Although attention is studied as a phenomenon in itsown right, it is also clearly linked to perceptual, cogni-tive, and behavioral processes. In light of the concep-tualization of sexual arousal as an emotional state(e.g., Everaerd, Both, & Laan, 2006), a brief mentionof the literature addressing emotion and attention iswarranted. In a review of this literature, Compton(2003) described findings relevant to this discussion.Individuals have attentional biases related to their con-cerns. This bias is directed by both top-down processes,mediated by frontal lobe regions, and bottom-up pro-cesses, mediated by amygdalar responses. The role of the amygdala in bottom-up processing of emotionally-relevant information is supported by imaging studies,which also indicate that such processing can be inter-rupted by increased cognitive load (e.g., mathematicaltasks). Frontal regions may modulate amygdalarresponses through reciprocal (i.e., bidirectional influ-ence) connections in accordance with current goalsand task demands. Thus, insofar as the subjectivecomponent of sexual arousal is an emotional state,attentional processes play a vital role in processes of sexual arousal as well.

The Role of Attention in Sexual Arousal

Several reviews addressing the role of attention insexual arousal have already been written (e.g., Barlow,1986; Dekker & Everaerd, 1989). This review overlapswith these and other literature surveys on the keystonestudies that best portray the advances made in this area.Of work conducted since the past surveys, the studiesselected for review are those that have clear implicationsfor the development of noninvasive treatment of sexualdysfunction. As mentioned earlier, the review is orga-nized by three themes: voluntary control, cognitivebiases, and directed attention. Mention should also bemade of research addressing sexual arousal in terms of category speciﬁcity (e.g., Chivers, Seto, & Blanchard,2007) and sex differences in the concordance betweensubjective and physiological arousal (Laan & Everaerd,1995; but see also Rellini, McCall, Randall, & Meston,2005). This work raises interesting questions regardinggender and sexual orientation differences in arousalpatterns; however, in light of the focus of this review,it is not discussed here.

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Voluntary Control of Sexual Arousal

Therelevance of attentional processestosexualarousalwas perhaps first established by the early studies onvoluntary control of sexual arousal. Pivotal to thesestudies was the use of distraction, that is, diversion of attention. Laws and Rubin (1969) instructed men whowatched an erotic film either to achieve erection or toavoid getting an erection, using any means necessaryexcept masturbation or not viewing the film. In eachcase, the men were successful in either increasing or inhi-biting their erections and reported using strategies suchas fantasizing or concentrating on distracting thoughts.Cerny (1978) extended these findings to females, estab-lishing that females have the ability to increase orsuppress both subjective and genital sexual arousal,although the author did not report on the cognitive stra-tegies employed by the participants. Laan, Everaerd,Van Aanhold, and Rebel (1993) instructed a group of sexually functional women to achieve maximum arousalwhile either watching erotic film excerpts or fantasizing.Women in both groups elicited measurable subjectiveand physical sexual arousal, although the effect wasgreater in the fantasy condition. The authors suggestedthat the participants’ increased attention to erotic cuesallowed the women to achieve this effect. In a similarstudy by Beck and Baldwin (1994), women who wereshown erotic film segments reported using cognitive stra-tegies such as nonsexual and negative thoughts (e.g.,about pain) to inhibit arousal, or positive thoughts andfantasy to elicit genital arousal.The two studies just discussed established that inter-nal distraction could be used to inhibit sexual arousal;other researchers have demonstrated that externaldistraction can have a similar effect. Geer and Fuhr(1976) used a dichotic listening paradigm to establishthat distraction has such an effect: As cognitive tasksbecame increasingly complex, they found diminishedsexual arousal as measured by penile tumescence.Similar findings in women occurred during a study inwhich engagement in mathematical tasks diminishedboth subjective and physiological indexes of sexual arou-sal (Adams, Haynes, & Brayer, 1985). It should be noted,however, that findings regardingtheeffects ofdistraction,especially in terms of differential effects on participantswith and without sexual dysfunction, are inconsistent(e.g., Abrahamson, Barlow, & Abrahamson, 1989; vanLankveld & van den Hout, 2004).

Cognitive Biases and Sexual Arousal

The evidence reviewed thus far establishes that atten-tion paid to sexual cues facilitates sexual arousal, andthat distraction interferes with that effect. The evidencereviewed next indicates that individuals may have cogni-tive biases that orient attention to information that mayfacilitate or inhibit sexual arousal. In a study aimed atdelineating the inhibitory effect of anxiety on sexualarousal, Beck, Barlow, Sakheim, and Abrahamson(1984) informed sexually functional and dysfunctionalmen that they might receive an electric shock either con-tingent or not contingent on their ability to achieve anerection. The conditions were intended to elicit eitherperformance anxiety or generalized anxiety, respec-tively. In sexually functional men, noncontingent shockthreat resulted in greater genital arousal than did a no-shock condition; in contrast, sexually dysfunctionalmen showed less arousal during both shock threat con-ditions. As Barlow (1986) suggested, a distinctionbetween the components of anxiety is necessary tounderstand these ﬁndings. Although the autonomiccomponents of anxiety (e.g., increased heart rate, bloodpressure) 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 ﬁndings, Barlow (1986) posited amodel of erectile dysfunction, central to which is theidea that increased autonomic arousal results in anarrowing of attentional focus (Wiegel, Scepkowski, &Barlow, 2007). The model outlines a process wherebya male focuses his attention on either erotic cues ornonerotic, self-evaluative cues (e.g., fears over perfor-mance). In both cases, autonomic arousal (due to sexualarousal in functional men and anxiety in dysfunctionalmen) creates a feedback loop, further narrowing theman’s attentional focus on the information to whichhe is already attending. In sexually functional men,attention becomes increasingly focused on erotic infor-mation, creating a positive feedback loop. This feedbackloop facilitates sexual response and erection, which inturn leads to approach behavior. In the case of sexuallydysfunctional men, attention becomes more focused onnonsexual, task-irrelevant material, creating a negativefeedback loop. The resultant interference preventsprocessing of sexual cues and impedes sexual arousal,leading to avoidance behavior. An important aspect of this model is that it is the distraction created byperformance-related cognitions that impedes sexualarousal rather than the autonomic arousal associatedwith anxiety.Findings from a study by Elliot and O’Donohue(1997) suggest that Barlow’s (1986) model can beapplied to female arousal. They used a dichotic listeningparadigm and an experimental design that crossed threelevels of distraction (high, low, and none) with anxietyand no-anxiety conditions. Women experienced higherlevels of genital arousal in the no-distraction conditionthan in the high-distraction condition. Contrary to theauthors’ expectations, although women indicated higherlevels of anxiety in the anxiety condition as opposed tothe no-anxiety condition, there was no overall effectfor anxiety on levels of genital or subjective sexual arou-sal. The authors offered several possible explanations

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