Yoga and Sexual Functioning: A Review

Abstract

Yoga is an ancient practice with Eastern roots that involves both physical postures (asanas) and breathing techniques (pranayamas). There is also a cognitive component focusing on meditation and concentration, which aids in achieving the goal of union between the self and the spiritual. Although numerous empirical studies have found a beneficial effect of yoga on different aspects of physical and psychological functioning, claims of yoga's beneficial effects on sexuality derive from a rich but nonempirical literature. The goal of this article is to review the philosophy and forms of yoga, to review the nonempirical and (limited) empirical literatures linking yoga with enhanced sexuality, and to propose some future research avenues focusinging on yoga as a treatment for sexual complaints.

Full text

Journal of Sex & Marital Therapy, 35:378–390, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 0092-623X print / 1521-0715 online
DOI: 10.1080/00926230903065955
Yoga and Sexual Functioning: A Review
LORI A. BROTTO, LISA MEHAK, AND CASSANDRA KIT
Department of Obstetrics and Gynaecology, University of British Columbia
Yoga is an ancient practice with Eastern roots that involves both
physical postures (asanas) and breathing techniques (pranaya-
mas). There is also a cognitive component focusing on meditation
and concentration, which aids in achieving the goal of union
between the self and the spiritual. Although numerous empirical
studies have found a beneficial effect of yoga on different aspects of
physical and psychological functioning, claims of yoga’s beneficial
effects on sexuality derive from a rich but nonempirical literature.
The goal of this article is to review the philosophy and forms of
yoga, to review the nonempirical and (limited) empirical literatures
linking yoga with enhanced sexuality, and to propose some future
research avenues focusinging on yoga as a treatment for sexual
complaints.
The psycho-medical approach to treating sexual difficulties has a
relatively short history, but one that is characterized by sharp turns. In the
1980s, a paradigm shift began whereby humanistic and behavioral treatments
of sexual problems fell out of favor, and treatment of sexual difficulties
began to fall into the domain of medicine. This occurred largely because
urologists were interested in the biological basis of sexual difficulties, and
because of the observed benefits of medical interventions in curing erectile
dysfunction (Tiefer, 2006). Despite the enormous popularity and success of
the oral pharmaceutical agents for men’s sexual difficulties, at least one-third
of men do not refill their prescriptions (Klotz, Mathers, Klotz, & Sommer,
2005; Son, Park, Kim, & Paick, 2004), the success of oral pharmaceuticals
can trigger dissatisfaction in a female partner who may have habituated
to a new sexual repertoire that does not focus on intercourse (Askew
& Davey, 2004; Loe, 2004), and these sexual pharmaceuticals have been
largely ineffective for women (e.g., Basson, McInnis, Smith, Hodgson, &
Address correspondence to Lori A. Brotto, Department of Gynaecology, 2775 Laurel Street,
6th Street, Vancouver BC, V5Z 1M9, Canada. E-mail: lori.brotto@vch.ca
378
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Yoga and Sexual Functioning 379
Koppiker, 2002). In contrast to this very short sexual pharmaceutical history,
Eastern approaches have many millennia of history for conceptualizing
and addressing sexual complaints. Eastern approaches such as tantra, Tao,
mindfulness, acupuncture, and yoga have all been implicated in sexual
fulfillment and pleasure (as reviewed in Brotto, Krychman, & Jacobson,
2008), and the efficacy of some of these approaches has been established
in empirical studies (Brotto, Basson, & Luria, 2008; Brotto & Heiman,
2007; Danielsson, Sj¨
oberg, & ¨
Ostman, 2001; Powell & Wojnarowska, 1999).
More recently, yoga has been found effective for improving ejaculatory
control among men with premature ejaculation (Dhikav, Karmarker, Gupta,
& Anand, 2007). The goal of this review is to explore the historical and
empirical literature on the role of yoga in sexual health and discuss future
research worth exploring on yoga for specific sexual complaints. Moreover,
we provide a limited background on yoga theory from an authentic Eastern
perspective, which is essential for linking yoga to enhanced sexuality
theoretically.
WHAT IS YOGA?
A historical note on the origins and philosophies of yoga is essential in
order to place yoga within a theoretical framework for being used for
sexual enhancement. The word yoga is derived from the Sanskrit root yuj
meaning “to yoke, to bind, to attach, to join, to direct and concentrate one’s
attention on, or to use and apply” (Iyengar, 2001, p.1). Yoga is one of
the six systems of Indian philosophy that was systemized by Pata˜
njali with
his text, The Yoga S¯
utras. Here, yoga is described as a sacred science that
involves evolution through eight components, known as the eight limbs
of yoga. The first step is Yama (attitudes towards the environment), and
evolving through to Sam¯
adhi (complete integration with the object to be
understood). The other limbs include: Niyama (attitudes towards the self),
¯
Asana (the practice of body exercises), Pr¯
an¯
ay¯
ama (the practice of breathing
exercises), Praty¯
ah¯
ara (restraint of the senses), Dh¯
aran¯
a(the ability to direct
the mind), and Dhy¯
ana (the ability to develop interactions with what one
seeks to understand (Desikachar, 2003). Through these limbs one is given
the tools to connect with the higher being (which can be translated to
whichever belief system one chooses) and therefore be liberated—free of
suffering mentally, physically, emotionally, and spiritually.
In the Western world, the most discussed of these components are
¯
Asana and Pr¯
an¯
ay¯
ama.¯
Asanas are postures used to exercise the entire
body, whereas pr¯
an¯
ay¯
ama exercises the breath through different patterns
of inhales, exhales, and holds. ¯
Asana and pr¯
an¯
ay¯
ama aid the practitioner in
improving health and controlling the mind; as one gains the ability to control
the body and breath, one develops the capacity to control the mind (Iyengar,
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380 L. A. Brotto et al.
2001). The ¯
asanas and pr¯
an¯
ay¯
amas prepare the individual for meditation;
they give one the ability to focus and concentrate on the present moment,
with the least amount of resistance, in order to reach the goal of liberation
(Satchidananda, 1977, p. 166).
In order to achieve a meditative state, some forms of yoga have mantras,
mudr¯
as, and kriy¯
as, which act to assist one in connecting to the spiritual
to evoke focus, strength, and healing. Mantras are sanskrit words, taught
as sound syllables, which act as sound currents to focus the mind. Through
repetition of these words, silently or aloud, one reconditions the patterns of
the mind, directing the mind’s attention to whichever quality one chooses
to manifest (Kaur Khalsa, 1996, p. 35, p. 308). According to Yogi Bhajan,
mantras create a direct connection to the higher being, similar to prayers,
which allow one to evoke the quality of mind and body in which one
seeks (Kaur Khalsa, 1996, pp. 36–37). Mudr¯
as are subtle physical positions
that may involve the whole body or just the hands, which are used to
focus energy (Satyananda, 1996, pp. 423–424). Kriy¯
as can combine mantra,
mudr¯
a, breath, and postures into a “complete action” which gives individuals
exercises to invoke cleansing, healing, or manifesting different qualities of
mind and body (Kaur Khalsa, 1996, pp. 229–275).
YOGA AND HEALTH
Part of yoga’s long-standing and increasing popularity relate to its effects on
mental health. In yoga, psychological suffering is described as duhkha, which
refers to suffering, troubles, or sickness of the mind. Duhkha is a restrictive
state that prevents action and understanding (Desikachar, 1999, p. 83), and
is thought to arise from avidy¯
a, or “incorrect comprehension” derived from
the conditioned patterns of unconscious action. These ingrained habits and
perceptions (sam
.sk¯
ara) obscure an individual’s concept of reality. Yoga
provides a means to become aware of duhkha and therefore overcome
these obstacles and retain “correct understanding” (Desikachar, 1999, pp.
10, 83–84).
In the Yoga S¯
utras, Pata˜
njali reveals yoga as “chitta vrtti nirodhah,”
which translates as “restraint of mental modifications or as suppression of the
fluctuations of consciousness (Iyengar, 2001, p. 2). Pata˜
njali further explains
the five causes of psychological pain as: ignorance (Avidy¯
a), having a sense
of individuality that limits a person from a group (asmit¯
a), attachment of
passion (r¯
aga), aversion (dvesa), and the instinctive clinging to life and
bodily pleasures, which results in the fear of death (abhinive´
sa) (Iyengar,
2001, p. 5). In other words, much of psychological suffering results from
these conditioned patterns of perceptions, thoughts, attitudes, and behaviors,
and yoga can be used as a vehicle to alleviate such pains.
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Yoga and Sexual Functioning 381
There is compelling empirical data showing the benefits of yoga on
psychological well-being and mood (Elavsky & McAuley, 2007; Hadi &
Hadi, 2007; Oken et al., 2004). Meditation plus yoga significantly improved
remission rates in long-term depressed patients compared to hypnosis and
psycho-education control (Butler et al., 2008; Lavey et al., 2005). Moreover,
there is both an acute effect of yoga (from the start to the end of a session)
as well as a chronic benefit (over long-term practice; Shapiro et al., 2007).
The beneficial effects of yoga on mood have been shown both in seniors
(Oken et al., 2006) as well as in young adults (Woolery, Myers, Sternlieb, &
Zeltzer, 2004). Neuroendocrine data show that the improvements in mood
and affect are associated with a decline in cortisol levels (West, Otte, Geher,
Johnson, & Mohr, 2004).
Yoga has also been shown to benefit physical health (Hadi & Hadi, 2007;
Smith, Hancock, Blake-Mortimer, & Eckert, 2007), including improvements
in blood pressure, body mass index, and heart rate (McCaffrey, Ruknui,
Hatthakit, & Kasetsomboon, 2005), improved performance on motor skill
tasks in children (Telles, Hanumanthaiah, Nagarathna, & Nagendra, 1993),
and improved lung capacity similar to athletes (Prakash, Meshram, &
Ramtekkar, 2007).
Yoga theory suggests that physical and psychological illness result
from an inbalanced or blocked chakra system (Bhushan, 1997). Many have
attempted to correlate the chakra system to Western physiology in order to
gain an understanding of the underlying mechanisms of the mind-body-spirit
connection (Roney-Dougal, 2000). It is believed that the chakra system
directly and indirectly affects the endocrine system and nervous system
through energy, known as life force (pr¯
ana; Kaur Khalsa, 1996, p. 53).
Iyengar (2001) explains that, “Yoga is the method by which the restless mind
is calmed and the energy is directed into constructive channels” (p. 2). Thus,
pr¯
anic energy is directed through the body via yogic breath and posture,
to either maintain or rebalance the chakra system, and therefore heal and
sustain the health of the body and mind.
YOGA INTERVENTION PROGRAMS
Given the well-documented health benefits of yoga, it follows that yoga has
been used as a popular nonpharmacological alternative to treat a plethora of
physical and psychosocial anomalies. In a systematic review by Smith and
Pukall (2009), yoga interventions specifically for cancer patients were noted
for eliciting significant improvements on measures of sleep, quality of life,
levels of stress, and mood. As an alternative to Western medicine, yoga has
been shown empirically to treat depression among inpatients (Krishnamurthy
& Telles, 2007; Shapiro et al, 2007), to improve chronic pain, pancreatitis,
and low back pain (Chou, Huffman, American Pain Society, & American
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382 L. A. Brotto et al.
College of Physicians, 2007; Fleming, Rabago, Mundt, & Fleming, 2007;
Sareen, Kumari, Gajebasia, & Gajebasia, 2007; Williams et al., 2005), to
treat cardiovascular disease (Bijlani et al., 2005), diabetes (Sahay, 2007),
irritable bowel syndrome (Kuttner et al., 2006), osteoarthritis (Kolasinski
et al., 2005), migraine (John, Sharma, Sharma, & Kankane, 2007), multiple
sclerosis-associated fatigue (Oken et al., 2004), and menopausal hot flashes
(Cohen et al., 2007).
YOGA AND SEXUAL HEALTH
Given the inextricable link between sexual health, well-being, and physical
health (Laumann et al., 2005; Lindau et al., 2007), it is reasonable that yoga
might also be associated with improvements in sexual health. For example,
yoga moderates attention and breathing (Gupta, Khera, Vempati, Sharma, &
Bijlani, 2006; Telles, Raghurai, Arankalle, & Naveen, 2008), decreases anxiety
and stress (McCaffrey et al., 2005; Michalsen et al., 2005; Smith et al., 2007),
induces a state of relaxation (Krishnamurthy & Telles, 2007; McCaffrey et
al., 2005), and modulates cardiac parasympathetic nervous activity (Khattab,
Khattab, Ortak, Richardt, & Bonnemeier, 2007). All of these effects are
associated with improvements in sexual response. Female practitioners of
yoga have been found to be less likely to objectify their bodies and to be
more aware of their physical selves (Impett, Daubenmier, & Hirschman,
2006). This tendency, in turn, may be associated with increased sexual
responsibility and assertiveness, and perhaps sexual desires. Perhaps more
importantly, however, is the effect of yoga on mindfulness, or the ability
to remain focused and in the present in a nonjudgmental manner. Given
the tendency for distractions to impede on women’s sexual functioning
(Barlow, 1986; Dove & Wiederman, 2000), the increased ability to minimize
distraction and enhance awareness of the body to allow sensorial cues to
be detected and integrated into conscious awareness is a major facet of
why yoga might be helpful for enhancing sexuality. Notwithstanding this
potentially important role of yoga in improving sexual health, most of the
literature on the topic derives from nonempirical sources.
YOGA AND SEXUAL HEALTH: NONEMPIRICAL SOURCES
Among the extensive body of nonempirical literature focused on yoga, there
is a vast amount of data linking yoga with improved sexual health, as well
as touting yoga as an effective treatment for nearly every sexual ailment.
Yoga theory proposes that certain diseases pertaining to sexuality
suggest blocked or stagnant energy in the root chakra (mooladhara chakra)
or the second chakra (swadhisthana chakra). One way to release this
energy is to raise or move one’s kundalin¯
ithrough the spine and up to
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Yoga and Sexual Functioning 383
the brain through the n¯
ad¯
is (channels through which energy passes through
the chakras [Iyengar, 2001, p. 100, p. 368; Kaur Khalsa, 1996, pp. 47–48]).
The term kundalin¯
iliterally means, “the curl of the lock of hair of the
beloved.” This metaphor depicts the flow of energy and consciousness that
exists within all individuals (Kaur Khalsa, 1996, p. 43). In Tantric practices
and Kundalini yoga, yoga is used as a tool to prepare for the movement
of kundalin¯
ienergy. In doing so, one may gain awareness of oneself
and release the energy that may be sustaining the source of blockage or
stagnation. Kundalin¯
ienergy has been said to increase sexual pleasure and
extend the longevity of sex by facilitating male orgasms without ejaculation
(Francoeur, 1992).
Moola bandha is another yogic concept that has tremendous utility
in women’s sexual response by assisting women to learn sexual control
and alleviate sexual problems. Bandhas are a means “to lock” or “to
bind or tie together, to close” certain areas in the torso in order to
intensify the cleansing processes of yoga (Desikachar, 1999, p. 71). The
bandhas are explained to facilitate proper functioning of the endocrine
system. All bandhas indirectly influence the pituitary gland and brain. Moola
bandha is a perineal contraction that stimulates the sensory motor and
the autonomic nervous system in the pelvic region, and therefore enforces
parasympathetic activity in the body. Specifically, moola bandha is thought
to directly innervate the gonads and perineal body/cervix. To a lesser extent,
the sympathetic nervous system is also stimulated (Buddhananda, 2007,
p. 3). In men, practicing moola bandha has been associated with relieving
spermatthorrea, preventing inguinal hernia, and controlling testosterone
secretion. In women, exercising moola bandha has been shown to relieve
dysmenorrhea, ease childbirth pain, lessen symptoms of menopause, and
improve sexual difficulties (Buddhananda, 2007, pp. 33–35). Kraftsow (1999)
clarifies that exercising moola bandha is similar to the kegel exercises
prescribed for women before childbirth and throughout life to reduce urinary
incontinence. He describes how moola bandha stretches the muscles of
the pelvic floor, increases circulation in that area, balances, stimulates,
and rejuvenates the area through techniques that increase awareness and
circulation. As a result, exercises that utilize moola bandha may be helpful
in aiding people who lack sexual vitality and have poor sexual functioning
(p. 288). In numerous sex therapy centers, the practice of moola bandha is
used to enhance women’s awareness of their own genital arousal sensations,
and in this way, may be a helpful adjunct for improving sexual desire and
arousal.
O’Brien (1994) recommends a yoga pose known as the ‘frog pose’
(bhek¯
asana) to strengthen women’s pelvic floor muscles. The author
suggests this exercise for pregnant women preparing for childbirth, but
pelvic floor muscles play an important role in sexual health as well. In
our experience, such poses may be helpful for women with provoked
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384 L. A. Brotto et al.
vestibulodynia and/or vaginismus given the often weakened nature of these
muscles.
In part of their yogic teaching, Swami Satyananda Saraswati (1996),
founder of the Bihar School of Yoga in Rishikesh, India, and B.K.S. Iyengar
(2001), founder of the Ramamani Iyengar Memorial Yoga Institute (RIMYI)
in Pune, India, suggest combinations of yogic tools to prevent sexual
problems and maintain overall sexual health. They suggest such techniques
may assist in lessening symptoms of HIV or herpes, aiding/preventing
erectile dysfunction, dealing with spermatorrhea, reducing symptoms of
menstruation and menopause, recovery from miscarriage, and general toning
of reproductive organs. For erectile dysfunction, Satyananda prescribes
¯
asanas, pr¯
an¯
ay¯
ama, Bandha, and Mudr¯
a(pp. 534–535). In his book,
Satyananda warns that individuals suffering from specific sexual ailments
should seek advice from a competent yoga therapist to get a proper yogic
prescription.
An instructional yoga video by Chheda and Khan (2004) claims that
yoga results in increased blood flow to the genitals, aids menstrual problems,
and increases male and female sexual function overall. The video provides
educational information and also demonstrates a complete yoga routine
designed to facilitate these sexuality-specific effects of yoga. One might
therefore use these techniques in sexual difficulties arising from deficient
genital blood flow (e.g., as in irradiated vaginal tissue of gynecologic cancer
survivors).
Among introductory yoga books, many mention sexual disorders
and advertise yoga as a means of treatment. Claire (2003) claims that
yoga increases strength, keeps practitioners centered and present through
meditation and breathing, creates relaxation, lowers stress and performance
anxiety, and helps the practitioner to maintain attention in sex. The author
states that it can resolve premature ejaculation, erectile dysfunction, and
orgasm difficulties (Claire, 2003, p. 185). Thomas writes that yoga strengthens
and tones the urogenital area, strengthens pelvic floor muscles, massages
the prostate gland, strengthens genital muscles, increases blood flow in
the genitals, and builds stamina and control, and specific yoga poses are
recommended. Unfortunately, no empirical studies are provided to support
these impressive claims.
For Indian men who practice brahmacharya, or celibacy, certain yoga
poses are thought to control (i.e., reduce) erection and desire (Alter, 1997).
For instance, there is a central pose known as siddh¯
asana in which the
practitioner’s legs are crossed while seated during which a celibate man can
pinch his penis and scrotum with his heels to control his desire. This type of
control is considered a highly desirable state to attain for these men choosing
celibacy.
Popular websites also make claims of yoga’s effects on sexual dysfunc-
tion. For instance, a website called “Health and Yoga Infoplace” contains
an entire section on yoga as a treatment for erectile dysfunction, where a
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Yoga and Sexual Functioning 385
series of yoga poses are described to be an effective treatment for erectile
dysfunction (Nagarathana, 2007). Again, unfortunately, no empirical data are
provided to substantiate these claims. It should also be noted that while
this type of informational website exemplifies how accessible information
on yoga has become, not all experienced practitioners of yoga would agree
that yoga exercises should be recommended to general populations without
the guidance of a yoga therapist.
For women, Ripoll and Mahowald (2002) argue that hatha yoga can
effectively ease the symptoms of chronic pain syndromes such as vulvodynia
because of the positive effect of yoga in strengthening pelvic floor muscles.
Unfortunately, no empirical data are provided.
YOGA AND SEXUAL HEALTH: EMPIRICAL STUDIES
Despite the abundance of nonempirical data suggesting that yoga and sex
are not only linked but potentially mutually beneficial, very little research
has been conducted to substantiate these claims. Our careful review of the
literature revealed only one controlled study of yoga as a treatment for sexual
dysfunction.
Dhikav, Karmarker, Gupta, and Anand (2007) successfully treated
Indian men with premature ejaculation with yoga. Premature ejaculation
traditionally falls into the medical domain and is most often treated
with serotonergic anti-depressants (Waldinger, 2008). The 68 men who
participated in the study were offered a choice between the yoga-based,
nonpharmacological treatment and the more traditional pharmacological
intervention fluoxetine (Prozac). In the yoga group, men were given a
prescribed set of ¯
asanas and pr¯
an¯
ay¯
amas to practice for 1 hour each day.
Differential relaxation techniques, as well as perineal and pubococcygeal
exercises, were included in the program. Notably, there was no component
of sex therapy or sex education to men receiving the yoga intervention.
Remarkably, all 38 men participating in the yoga group had both subjective
and statistically significant improvements in their intraejaculatory latencies.
There were no side effects or dropouts in this treatment arm. These data
provide an excellent example of the potential usefulness of yoga as a
nonpharmacological treatment for sexual disorders, and in a compelling
way, suggest that yoga can be as effective as traditional western medical
approaches.
THE FUTURE: INTEGRATING YOGA INTO CONTEMPORARY
SEX THERAPY
Yoga has a rich history with roots in India but branches in all cultures
and parts of the world. The literature demonstrating beneficial effects
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386 L. A. Brotto et al.
of yoga in numerous physical and psychological ailments is compelling
and growing and yoga interventions are increasingly incorporated into
existing treatment programs because of their demonstrated benefit. In the
domain of sexual response, yoga has also been touted as a method for
improving genital awareness, stimulating genital blood flow, enhancing
relaxation of the pelvic floor, reducing vulvodynia, reducing symptoms of
premature ejaculation, enhancing erectile capacity, extending the longevity
of intercourse, and fundamentally, of enhancing sexual pleasure. However,
the empirical research is limited to one controlled study of yoga for the
treatment of premature ejaculation in men. Moreover, there is no empirical
research on specific ¯
asana for specific sexual problems, despite this practice
and teaching for many hundreds of years. Clearly, this is an area of research
worthy of future efforts.
One specific practice in yoga, the moola bandha, bears particular
promise in the treatment of sexual problems, especially in women, where
it has been used for centuries. Again, however, there are no empirical data
demonstrating its tremendous anecdotal benefits. As a treatment for women
with pelvic pain disorders, the moola bandha may complement pelvic floor
physiotherapy by relaxing and enhancing awareness of pelvic floor tension
for women with vestibulodynia and vaginismus. Future research may be
aimed at comparing standard care with and without the practice of moola
bandha instruction for the treatment of dyspareunia.
Kundalini yoga also bears great promise in the treatment of sexual
problems with its focus on sexual energy and deserves to be studied
empirically. The advantage of kundalini yoga is that it does not require
being a yoga expert or following instructions from a yoga teacher in the
long term (although initial instruction by a teacher is required). Practitioners
can do so in the privacy of their own homes. Also, because of its holistic
nature of integrating yoga with breath work, results are often noted much
sooner than other forms of yoga.
With the advent of the age of “evidence-based treatment,” professionals
and the lay public want proof that our interventions are effective. Because
yoga has been practiced and taught for many centuries, and because of
the power of the personal attestation that yoga is effective, it has not been
subjected to the scrutiny of empirical testing that many other interventions
in medicine have. Those who practice yoga experience the benefits. It is our
hope that this experience will ignite an interest in testing and demonstrating
the beneficial effects of yoga for many different facets of human sexuality.
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