#250 Rena Malik - Urologist Debunks #1 Sex Myth Every Man Still Believes

25:25So I wanted to give people who felt this sort of like failure or felt this sort of stress or anxiety around it to not feel that, right? Like not feel like they had to do this to achieve some higher being. What, I mean, how did that even, how did that, And what's the myth? What do you supposedly get out of No Nut November? So No Nut November was actually like, came from a meme, right? Like somebody was like, oh, No Nut November, we're going to start No Nut November on November 1st. And like by midnight, oh, I failed already, right? And then, but it took off. And, but semen retention as a practice is actually like a Buddhist Taoist practice that, and there's some religious or spiritual background behind it.

26:07people felt that if they would abstain from ejaculation, that they would be able to focus more on spirituality, on God or a higher power, and they wouldn't be distracted by desire and urges for sex. And so that's sort of where it came from. And from that, they would think they would get all these health benefits, like they would get this brain clarity, they would get testosterone boosting, it would improve fertility, like all these things. But the reality is those things have been looked at scientifically and there has been no true meaningful increase in testosterone or fertility in fact if you abstain for too long you can harm your fertility um and so i think the reality is is there a physiologic benefit not that we see right now based on the evidence that we have and but if you see a psychological benefit by all means please go ahead but just don't make other people feel like they have to do that you know because everyone is different and they're, you know, ejaculating or being intimate with their partner or masturbating may be a really valuable part of their lives that now they feel like they have to give up on because they hear something that they think is like, oh, this is so much better for me to do this.

27:18Man, it just seems like something that would cause a lot of sexual frustration and that would, you know, be amplified during the month as the month goes on. But I mean, the thing is like some people, what happens is when you abstain, you stop, like you may be able to like, particularly for people who are very fixated on sex, they may be able to then like, once they get over that hump, they may then, oh, I'm more focused on other things. I'm more, I don't think about that anymore. Like the desire will naturally go down after some period of time, because you've now like, overcome that constant urge.

27:52And that may lead to more productivity or more happiness or more joy in some people, but it's not everybody. Right. And I think it's like very individual. But I mean, wouldn't, wouldn't the body just take care of itself? I mean, I mean, would a man just store up all of the semen for a month? So what happens is either you're going to have a wet dream. So you're going to have a nocturnal emission. And so then that was the other thing. People would have wet dreams. They'd be like, oh my God, I failed. And it's like, no, you can't even control that. Like you are asleep and it's normal and healthy.

28:23Like your body is just taking care of itself, or they would just absorb it. Like their body absorbs it and your body's constantly making more semen, right? It's just like, it's constantly doing that. So, it's, or sperm specifically, but you know, it's making more all the time. And so like, there is no, it's not like the actual semen itself has some powerful properties. It's really just like dealing with, I think, the mental aspect of it. Interesting. Interesting. Let's move into, actually before we move on are there any other viral trends that you've kind of had to correct yeah so there was one on tiktok for a while there was um a lot of people talking about what's called jelking which is called jelking jelking yeah which is like this practice to increase penile length and so it's like you make an o with okay sign with your finger and you actually like um sort of slowly extend the length of the penis over time this is exercises stretching exercises essentially.

29:21And so people are like, oh, I did this and I increased my penile length and it was great. And so they were talking about this a lot. And actually, that sounds very safe, right? Like, oh, I'm just stretching. Like, what's the big deal? But sometimes, and you can probably relate to most men, when you tell them to do something, they don't just do it. They want to do it the best, right? And so they're like, but you don't just, you tell someone to do something that might improve their life, they're not going to just do it. They're going to go 10x and do it even more, right? And so there's actually some people who would come into the urologist because they've been doing this and, you know, my colleagues have talked to me, it's even in some published data, people would jelk and they would come in and they would develop erectile dysfunction because they've now damaged their penis.

30:01And that's not necessarily reversible. And so it's, you know, it's like, there are ways to safely lengthen potentially, but jelking is not one of them. What are the ways? So the safest way for length is a traction device. So you can buy traction devices online. These are sort of devices that slowly extend your penis with a little bit of pressure over time. And they are meant to be very minimal prep, like minimal tension over time. So there are some that you will use six hours a day and go to sleep with them. There's some that you can get that you can do 30 minutes twice a day, but they are a commitment, right?

30:39You have to be doing it a lot. And then they do work. And they've been shown to increase penile length by about two centimeters. When you've done it for - Two centimeters? Yeah. For prolonged periods of time, for months on end, then you will see an increase. And that's on average, right? So some may see a little more, some may see a little less. But that's generally what they've seen in the studies. And so, yeah, I think there are ways to do it. But it's a commitment, right? You have to be disciplined. You have to keep doing it. Is that what you really want to spend your time doing, right? And that's fine if you do.

31:10No judgment, by all means. But I think that that's probably the safest. Now, there's other things that are available. There's surgical options.

31:23Basically, surgical options are available to lengthen and enhance girth. Girth, probably the safest, is to do fillers. Like women get fillers on their face. There's the same sort of hyaluronic acid fillers that you can get injected into the penis. but they don't last forever. They're like 18 months or so and they'll dissolve. So there are options. Is that safe? You know, we don't have a ton of data, but like I wouldn't inject anything else. So there are like permanent fillers. People have like in jail, have injected all sorts of things in their penis. Like so, you know, like all sorts of things, which please don't inject your penis with anything.

31:59But if, you know, you're going to, if you are very intent on doing it and you've sort of talked to your doctor about it and you know it's not like a psychological issue that needs, you know, attention from a psychologist because there is what we call small penis anxiety, right? People who really feel body dysmorphia, like there's something wrong with them. And that requires, not requires, but should have attention from a psychologist so you can work on your thoughts around it. But, you know, if you don't have a dysmorphia and you just want a bigger penis, like I think that's the safest option in terms of an intervention.

32:31There are some people who will use vacuum erection devices or penis pumps. There's no evidence in the literature that this actually results in enhanced girth, but some people report that they notice that. Again, I think it's all temporary when you're using these traction devices and pumps. Like, I don't know that you're going to have a lasting effect, but I don't know. We haven't looked at it in the long term in terms of scientific data. It's only anecdotes, like what patients tell us and what we see. so I think ultimately like I wish I wish there was a way right like women can enhance their breasts they can get breast augmentations but men still don't have that option right to enhance their genitalia if they really want to in a like a permanent meaningful way yet in a very safe way and I wish we had it because I think men just like women should have that option if they want it right but at this time like you have one penis it is very important and if something happens to it Now you're stuck with that complication.

33:29And so I just think it's really important to think about that before you proceed with anything that's irreversible. Now, I mean, I wanted to cover this later on, but we'll just do it right now since we're on the subject. I mean, size. Does size matter? Yeah. So this comes up all the time, right? Because we are in a society where size is revered, right? Like you will see people joking about it. You will see, I mean, even my children will joke about their penis size and their prepubescent boys, right? Like where did they learn this from? We don't talk about it at home. Like they learned it from their peers.

34:00So this is something that's pervasive, right? People automatically assume bigger is better. The reality is when you look at the data, people overestimate what averages. So they think average is like six inches erect. Average is more like 5.1 to 5.6 inches, depending on the study you look at. That's erect, not flossing. And then, you know, so fine, average is overestimating. We're really bad as human beings at estimating. So when you actually look at people who, you know, you show them, like, this is a five-inch penis, a six-inch penis, this is a seven-inch penis, what are you estimating? So when you have, like, an average-sized penis, they tend to overestimate the size.

34:41They think it's, like, six or seven inches, six inches. And then when you have a slightly smaller than average penis, you tend to underestimate. And when it's bigger, you tend to overestimate. So we're just really bad at one estimating. And a lot of men will measure their phallus. And it's so variable. How warm is it in the room? How aroused are you in that moment? If you're more aroused, you might be a little bit tiny bit longer, tiny bit girthier, right? And so it's so variable that like, it's hard to say like, okay, this is my number. Like this is how big I am. Right. And then it's, so in terms of like pleasure, right.

35:18Cause I think that's what God thinks. Oh, if I have a bigger penis, I will more easily be able to get my partner to orgasm. It will feel better for her in a heterosexual relationship. And the reality is that's not necessarily true. Like, of course there are women who prefer longer penises. They enjoy stimulation, deep stimulation during sex, but that's not the majority. I would say 85 % of women need clitoral stimulation. And the clitoris is above the urethra. It's the area that is very sensitive. It is the homologue of the penis. So it is essentially exactly the same. If you like cut open a cadaver and you look at the anatomy of the clitoris and the penis, the clitoris and the penis look identical.

35:58The clitoris is just smaller and internal, whereas the penis is external. So if you stimulate the clitoris, you will reliably reach orgasm in the majority of women. And that doesn't require a penis necessarily, right? You can do that with your hand, with your mouth, with a toy, with a whole bunch of different things, and not necessarily from penetration. Now, yes, can, will you be stimulating the clitoris when you penetrate? Yes, to some degree, because the clitoris is above the urethra. And so indirectly, you'll be stimulating it. And some women, like I said, the anatomy is variable. So some women may orgasm more easily just through penetration alone.

36:35But the large minority women need either penetration and clitoral stimulation or just clitoral stimulation to climax. And so the reality is that size is not necessary for pleasure. Size is not necessary for a good orgasm. And it is something that we have just made into this big thing. And if you ask women, like when you do surveys of women, 85 % of women are like, I'm happy with my partner's size and I'm totally fine with it. And it's like 45 % of men who feel like they're satisfied with their size. So it's a big dichotomy because we've made it to feel like it's so linked to masculinity or the ability to provide pleasure, but the reality is not so much.

37:16And when you look at even anatomy for women, the vaginal length before it's engorged and aroused is about three to three and a half inches. So if you think about it, Like if you're really large, you can't even really penetrate the entire vaginal length. And so there's actually products that you can wear like buffers so that you don't hurt your partner when you have sex with them if you're a little bit larger than they are. And so it's sort of like a fit, right? Some people have a longer vagina. They may enjoy a longer penis. But again, it's not universal, right? It's not universal. What about girth?

37:51Yeah, so girth, again, I think girth is because the clitoris goes deep into the pelvis and it goes around the vagina. There's like the clitoral bulbs and the legs of the clitoris. So when you have a little more girth, it can stimulate more of the clitoris, right? You're not just focusing on the top, you're also getting the side of it. So it can be helpful, absolutely, to be more girthy. But there's a limit. So in fact, when they, this actually came out from people who do female-to-male surgery, when they were building phalluses, they realized that they were making them too girthy. And it was actually difficult to have sex.

38:26So they actually had to look at what they did was they looked at what kind of sex toys women are buying to decide what was the right size for the majority of women. Because they were like, oh, we were just making them too big. And now this person who wants a penis is not able to use it because it's too big for the partner to accommodate it. And so really, it's like, if you look at what type of sex toys women buy, they buy a little bit longer than average and the same girth as average, which is, you know, about five inches or so. So it's very similar to the average guy. They're not buying those really obscenely large sex toys.

39:02Like, it's just not, I mean, they might for a gag gift or something, but most women are not using those to pleasure themselves. And so that doesn't necessarily, Meaning you don't really need a lot more than average to pleasure a woman. What is average girth? Average girth is about four to five inches around. Okay. Yeah. Okay. Yeah. Wow. Interesting. Interesting stuff. So I wanted to, you know, erectile dysfunction. I mean, you see all the drug ads. We see, I mean, it's everywhere. What are some myths about erectile dysfunction? Oh, there's so many. I would start with like, I think that the first time a man has an issue with an erection, he feels like it's over, right?

39:47And the reality is there is normal fluctuation. There are times where you will struggle to get an erection because we are not static human beings. You are not machines, right? You are people. And so you will feel stressed or anxious or maybe you won't feel well that day, or maybe you had a really stressful day and your testosterone is lower than another day, right? All these things can play a role and you might have trouble getting an erection that day. It doesn't mean you're broken. It doesn't mean that you're doomed for a life of erectile dysfunction. But it often plays out that way because the second a guy has an issue with an erection in the bedroom, the next time he's having sex, he's thinking about that.

40:27He's not enjoying himself. He's not thinking about, wow, this is so hot and I'm having the best time of my life. He's thinking, oh my God, am I going to have an erection? Is it going to last? Is it going to go away? And so you can't be mindful and present and enjoy pleasure because you're obsessing over this. And it becomes this vicious cycle. So I tell all guys, all my patients, like you may have a medical reason that you're having trouble with erections, but every single guy also has problems thinking about erections. Every guy, every guy who has a problem with erections also has a mental issue because they're thinking about it.

41:00Right. And women do too. It's not just men. Like women are like, oh, if I can't climax this one time, am I not going to be able to climax the next time, right? They're thinking about it too. But I think we see it very often, men, because if you can't get an erection, it's very visible. You can see like, it's not happening. Something's wrong, right? And the reaction is often like, oh, the partner might be like, is something wrong with me? So now there's like a little bit of relationship conflict. And so there's all these things compounded and it makes it very difficult to get out of. And so I think that's One of the biggest ones is that.

41:31And then two is that I did mention testosterone, but testosterone is not always the cause. In fact, it's only the cause. Low testosterone causes erectile dysfunction about 3 % to 6 % of the time. That's it? So it may be a part of it, but it's not the only cause. Wow. Only in 3 % to 6 % of the time, it's a testosterone deficiency. Correct. Interesting. More often, it's vascular problems. So high cholesterol, high blood pressure, diabetes, all these things play a role. And I will see very, very healthy looking men whose cholesterol is off the charts. And I will say, look, this is what's likely causing your erectile dysfunction.

42:08And, you know, we can investigate further, but it behooves you to improve your cholesterol. And so I think it's also a really important sign of your health. I think people don't realize this. They think sexual health is like this thing we put in the box and we don't think about. But oftentimes you will see problems with your sexual health long before you see them anywhere else in your body. And the reason is the blood vessels to the penis are significantly smaller, about half the size of the blood vessels to the heart. So before you have a heart attack, you're going to see erectile dysfunction.

42:38And in fact, we've seen that, that when a man has an issue with erections, within seven years, 15 % of those guys will have a heart attack. Wow. And so it's an opportunity for men. If you start having trouble, this is a wake-up call for you to get your whole health evaluated. make sure that you're optimizing your heart health your brain health before you get a stroke right like all these things that in the long term will have you not having the life you want to live right because if we think about sex we want to live well but we also want to have sex throughout our lives right and if you start having issues like you have heart failure and now you get winded just walking a couple blocks right down the street like you're not gonna have sex like you're gonna exhausted.

43:22And so all of these things play a role. And so I find that anytime you think there's a problem with your sex life, that's an opportunity for you to get evaluated, right? To figure out what's going on so that you can fix that part of your life and before it becomes a problem. And with, I'm sorry, within how many years, just 15 %? Seven years. So it's a early warning system. Yeah, we call it the canary in the coal mine. It's like that warning sign. Wow. And then, I mean, what? Trouble either maintaining or getting an erection that's sufficient for intercourse. So either you lose the erection before you penetrate or you can't climax because you're not reaching it soon enough.

44:06And you lose your erection before that. Sometimes people get it confused. They'll think like, oh, I ejaculate very quickly. It's erectile dysfunction. That's actually premature ejaculation. It's treated very differently. And so it's important, like when you go to your doctor, to explain those things. Because what sometimes guys will come in and they'll say, my erection's not working, right? And so I will dig deeper. But sometimes if you go to your primary care doctor, they may not, right? And that may be the only doctor you have access to. And so if you say, I'm not having trouble, I can't, my erections are not working.

44:40They'll give you a prescription and you'll be on your way. But that prescription is not going to fix the issue if it's an ejaculation issue. Interesting. I mean, how do you determine if it is a psychological issue, whether that be reptile dysfunction or premature ejaculation or anything I'm not thinking of? How do you determine whether it's an actual, something's going on with the body versus a psychological issue where you freaked yourself out and now you have performance anxiety? Yeah. So one is talk to the person, right? Like first I'll talk to them, like, okay, what's happening when you're by yourself, right?

45:20Like, do you get erections at night? Do you wake up in the morning with erections? Because that's a sign that things are all working well, right? When you wake up in the morning with an erection, that tells me, hey, your hormones are working, your blood flow is working, all that stuff is pretty good probably, right? Because your body's doing it when there's no stressor around, right? It's just like you're sleeping, your body's functioning normally, you get about three to five erections at night. And so, and you usually wake up with one. And so that's a sign that things are working okay. There are like tests that you can do.

45:48There's even wearables that you can buy to do that. But like you pretty much, there's, there's wearables that are now on the market. You can wear like a ring around your penis that will measure how many erections you get at night, how long they last and how firm they get. And they'll give you data. But at the end of the day, like those, that's, I think some people really like that because they want to like, they want data. They like to know those things. But at the end of the day, like if things are functioning well and you're happy and you're getting morning erections and your partner's happy, like I wouldn't stress about it.

46:14It's when you start feeling like, okay, things are not going well. Okay. Am I getting nighttime erections? That's one, waking up with one. Two, if I masturbate, is it working fine? Right. And sometimes that's like your masturbation is different, but there's no pressure, right? When you masturbate, you're not like worried that like your partner might feel some way or whatever. Like there's no anxiety typically around masturbation unless you feel shame about it, which is a whole different thing. So usually that's another way. Third way is we can do what's called penile doppler ultrasound testing.

46:45So we can actually, we check the blood flow to the penis. So we'll actually give you an artificial erection with a medication and we'll actually then test to see how fast the blood is flowing in and how quickly it's leaving. And we have markers to say what's normal and what's not. And so those are tests that we can do to be definitive, like, yes, the blood flow part is working. Now, the hormone part, we check with blood work. We check if your testosterone is normal, if your free testosterone is normal, all those things. And there's other hormone markers that we'll check as well if they're low to make sure they're not playing a role.

47:18And so those are things we can evaluate pretty well. Beyond that, like I said, I think everyone has a little degree of psychological component to it. Now, how do patients get over their psychological anxieties? Yeah, so it's difficult. I'm not gonna say it's easy. I, you know, I encourage them if they are willing to talk to a sex therapist or even a therapist that has some, you know, openness about talking about sex, because it's really dealing with your thoughts and kind of working with those. And like, especially in the moment, right, when you're with your partner. So it can be like doing mindfulness exercises.

47:55So there's been studies on mindfulness that like, if you do 20 minutes of mindfulness every day, you're more present in the bedroom. So you have more enjoyable sex because you're able to like really pay attention to what's going on rather than getting lost in your own thoughts. And I think just being present in general, like cultivating, I think the other thing about sex in modern day is like, it's rushed. It's like, we're busy with our kids. We're busy with work. We're busy with that. And then we're like, okay, we got five minutes. Like, let's, let's go. And, and there's no, like, you haven't actually made it feel desirable.

48:25There's like another checkbox to do. Right. And so it's like, actually like, Hey, like when you were younger, you used to like, you know, be like, Oh, I can't wait to see you on your date. You'd call each other, you'd text each other, whatever, you know, whatever it was. And, and you'd be excited to like see your partner and like potentially have sex with them. And, and there was like this whole thing, like you just felt so excited about it. But when you're in longer term relationships and the stressors of life come along, we often just are like, we'll, we'll do it when we get to it. We will have sex.

48:51Like it'll happen. You're always there. right? And so it's like, you have to be like intentional about cultivating desire. You have to be like, Hey, does that foreplay starts in the morning? Like with a caress on the back or like a flirty text or whatever, right? Whatever floats your boat and like feeling in the moment, like excited. And I often tell people instead of date night where you go out to eat dinner, like have intimacy night where you like are intimate together. You, you hold each other, you lie together you you explore each other's body depending on what what turns you on right but you actually make that a priority because it is valuable being connected with another human being people who have more sex actually live longer and i think partially it's because of that connection they're getting with another human being um and so you know it's really important that that is so and we're losing connection so much with like ai and and the internet and all these other things We have to be intentional about keeping that.

49:51I mean, we're talking about, you're saying people that have more sex live longer. How much sex should we be having? How many times a week should men be ejaculating? Yeah, so there's science behind this, and I'll give you some data on that. So first of all, when you look at living longer, right? People who have sex 52 times a year, so that's once a week, live longer, have lower heart disease, have better health outcomes, and people who have sex less often than that. So we know that for a fact. And if you have, so a lot of veterans struggle with mental health, so they have depression, anxiety. People who have depression, anxiety, and have sex more often, they actually don't, they do better in terms of their mental health as well as living longer.

50:39so like you might actually be improving your mental health as well as living longer and so there's evidence at least once a week right and then in terms of how often should you ejaculate there's a very famous study where they had looked at ejaculation frequency and the risk of prostate cancer and so they looked at databases where people filled out how often they ejaculated in the last month and they put them into categories so it was like zero to four four to seven seven to 14, 14 to 21, and more than 21. So what they found was that the guys who ejaculated 21 times or more a month, they didn't specify through sex or masturbation, but they did more than 21 times a month, had a lower risk of prostate cancer.

51:18Now, is it the ejaculation? Say those numbers again. More than 21 times a month had a lower risk of prostate cancer. Now, is it the actual act of ejaculation? Is it something else? I mean, there's some theories that like, if you're ejaculating, you're sort of cleaning the pipes, right? Like you're getting any stagnant fluid that might be in your prostate, you're getting that taken out. And so that may be beneficial. Now I can't say for sure, because there's not really a good way to test that. But basically what I tell people is like, have sex, masturbate, enjoy pleasure, enjoy connection with another human being and enjoy pleasure.

51:52Because for some people, masturbation is the only way they're going to get pleasure. They don't have a partner or they don't have someone they can have sex with. So I don't want to take that away from them either. Right. And I think that those things are important for people to feel good. And there's so much value to having orgasms, like physiologically, right? Your heart rate goes down, your blood pressure goes down. Some people sleep better. Some people have post not clarity and they feel like much better after they orgasm. And so I think that, you know, it is something that we need to look at as like a tool potentially to live better, you know, to have a healthier life, to be connected with another human being, to feel good, to feel pleasure.

52:30And I say this often, sex is play. And we don't play as adults. So play, enjoy life, be creative, have fun, and enjoy sex. Why is this something we have to hide behind a corner? It shouldn't be. It should be something that we just openly welcome. And we should be able to talk about sex and be able to express our concerns, our insecurities, and be open with the idea of being vulnerable, right, with another partner, with someone else is really powerful. Because to have great sex, you have to be vulnerable. You are naked in front of another person, literally, physically and mentally, you are naked in front of them.

53:11And so you need to be able to be vulnerable and allow yourself to be vulnerable to truly experience meaningful pleasure. And so many people are so guarded and sex is like just this thing you do, right, for a quick release. But it's actually so much more than that. The cost of everything is still out of control. And many of us are relying on credit cards. If that debt is piling up, you're not alone. Americans collectively owe over$1 trillion in credit card debt. You might have considered reaching out to American Financing, but hesitated because you don't want to give up your low mortgage rate. Well, there's good news.

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56:23Protect more than just your life, protect your future. Go right now to uscca.com.srs. Is there, I mean, are there any studies on whether you're ejaculating with a partner versus masturbation? Is one better than another? Well, in terms of how your brain responds, so there are certain nerve endings on our body that can only be stimulated by another human being. That are caressed in a certain frequency, which is usually like a loving caress. That is what turns those nerve endings on. And so that turns on different areas of your brain. So it will stimulate more of your brain. So you will likely have more pleasure and a higher, you know, sort of response to that.

57:09So in terms of like experiencing pleasure, it will be probably more intense and more enjoyable with another partner compared to two by yourself. But it certainly is, you still can enjoy pleasure by yourself. The challenge, I think, by doing it by yourself is, I'll go back to the example of like when you're a kid and like you're worried like you're in the shower or you're in your bedroom and you're like oh my god someone's gonna walk in or someone's gonna be like why are you in the shower so long and so you learn to rush through masturbation and it becomes this just like quick thing to get a release it's not a time to actually enjoy pleasure right and so I think that's where you know it's okay to explore your body and to feel pleasure by yourself and like allowing that and using it as a tool to like learn about yourself like what turns me on what makes me feel good I think particularly for women can be very useful in learning which sort of stimulation works well for you.

58:02And then you can communicate that with a partner. And also like exploring more than just your genitals, like your whole body can be an erogenous zone, right? You can stimulate anywhere on the body and almost anywhere on the body and someone can get turned on. So it's really like, okay, like we can use this. We can stimulate multiple areas of someone's body and have them feel an amazing pleasure that if you just focus on genitals is not going to not going to be as as robust interesting interesting i mean let's go back to the the implants or or penile wow is that what you call it penile implants yeah implants i mean are there a lot of people doing this yeah i mean so i will say erectile dysfunction is very common 50 of men over 50 will have erectile dysfunction and every decade that increases by about 10%.

58:53So you can imagine there's a lot of guys struggling. Now, because of medications like sildenafil or tadalafil, known as viagrancialis, those medications help a lot of guys get erections without needing surgery. But before these medications were around, we didn't have much. We had vacuum erection devices, which are sort of similar to penis pumps, but they are medical grade. We have injections that you give yourself in the penis that work quite well, but like some guys don't want to inject their penis, which is reasonable. And then we have surgeries. And so typically guys will go through these options.

59:29And then if they still can't get an erection, a penile option is a great option for them. And so what that is, is we actually implant a device into the penis, which they then either pump up with a pump in the scrotum when they want to have an erection and they deflate it when they're done. Wait a minute, they do what? They pump it up? It's got a little pump. I should have brought one with you, but there's a little pump. you pump it up and and then you get an erection and then it's inside your scrotum inside your scrotum yeah and you can't really tell i mean like it looks sort of like there's a little something there right but like it doesn't you can't really tell that someone has a penile implant like in fact in medicine like we'll get consulted like oh this guy has a what we call a priapism erection that won't go away and sometimes it'll be like oh the guy just has an implant like so um so even other doctors sometimes don't notice it is my point.

1:00:18But so you is, you know, it's very hideable, you don't need to know. And then there's other ones where you implant it and you just bend it up and bend it down. So when you want to have an erection, you bend it up and otherwise you bend it down. So there's options. They don't make you larger or girthier, they give you what you have. So if you were to like grab your penis and pull it, that's how long it's going to be. It's not going to be longer, it's not going to make you, you know, it's not going to make you like super human in terms of length or girth, but it's going to give you function so that you can have sex and you can get a rigid erection when you want to.

1:00:50And so I would say that it is a transformative surgery for a lot of guys who have been struggling and can't get an erection and want to be able to get one. And their partner wants to be able to have penetrative sex. Is it mandatory? No, you can obviously pleasure your partner with many different ways. It doesn't need to be an erect phallus, but A lot of people enjoy that, want that, and it's a great option for them. What is the difference between Viagra and Cialis? So they are both what we call PDE5 inhibitors. They work by the same mechanism. Essentially, when you think about an erection, there is an ignition called nitric oxide, which then causes, and that usually comes from stimulation.

1:01:28Like you see something, hear something, feel something, turns you on. Your nerves and your vessels release nitric oxide. then that causes blood to flow into the penis and then it stays there right and that's the erection and then it goes down and blood flow leaves the penis and the erection goes down and so during that process one of the enzymes uh that will break down right the and cause the blood flow to leave these medications prevent that breakdown and so that's how they work and they work similarly but they are slightly different so when you think about sildenafil which is viagra vanafil or nididinifil, which is Levitra and Stendra, those medications, they all work short acting.

1:02:10So meaning you take one about an hour before sex, you need stimulation. Like I said, the nitric oxide has to come from some stimulation for them to work and you get an erection. Works in about 60 to 70 % of guys. It does require that you don't eat with the medication. So sometimes people will eat a big meal and they're like, oh, it didn't work, but I got these side effects. So they get side effects like headaches, flushing, stuffy nose, those sorts of things. But it does work in a lot of guys, it allows them to have erections and have sex. Now, Tadalphal is slightly different because it has a longer half-life.

1:02:43So you can take this medication with food, which is nice for some people who like to have sex in the evening or, you know, they have dinner before, and they can then take this medication and it works, but it lasts longer. So it can last for 36 hours, meaning that If you take it on a Friday and you want to have sex on a Saturday or Sunday, like you're still good to go, which is nice for a lot of people. You can also take a low dose every single day. So five milligrams of Cialis, because it lasts so long, you can take a low dose every single day. And I really like using that because it takes the psychological stress out of it.

1:03:16Like, oh, I have to remember to take this pill. I got to do this. I got to do that. You just sort of take the pill every day and then you're good to go to have sex when you want to. Right. For most people who where it works well. Now, again, these medications are not 100 % effective. Every medication that you take in your life will have some degree of, you know, inefficacy. But they help a lot of guys be able to get good blood flow to their penis and have erections and have sex. Is there any long-term effects if somebody is using that that may necessarily, you know, they don't necessarily need that?

1:03:52Yeah, I mean, I think in terms of law, there's obviously rare things that people will say, like nosebleeds or things like that, that are very rare, right? With Viagra, there are some receptors in the eye that are similar to the receptors that they work on. And so some people get blue-green vision discoloration, and it can cause vision changes. So if you ever notice anything with your vision, you've got to stop those medications. The other risk is if you're taking a medication called nitroglycerin or something you put under your tongue before you have chest pain. If you take both those together, it can lower your blood pressure to dangerous, almost like deadly levels.

1:04:30So those are the two big contraindications. But for most people, these are very safe, very effective. And to DALFIL, there's some actually early data, and it's not like mainstream, but that it might improve heart health. So they looked at like how it's taken in people who have cardiovascular disease, and they've seen actually an improvement in outcomes. And even with muscle health, they're seeing like blood flow to the muscles being better. And it's also great for guys who have an enlarged prostate because it can relax the prostate and allow you to pee better. So there's a lot of benefits. In fact, I just saw a study on women taking to the Allifil to help with overactive bladder.

1:05:05Now, I don't, you know, it's still very early. Again, this is not prime time. This is like early data. But I feel like there's a lot of benefit because ultimately with something like Tadalafil daily, you're increasing blood flow throughout the body. So you're actually not just seeing benefits of the genitals, you may be seeing benefits elsewhere. And that could potentially be beneficial. Now, we don't, you know, these medications have been around for a long time. And we haven't seen any terrible long term sequelae. Now, could there be in the future, potentially? I don't, you know, I can't, I don't future like, but Viagra has been around for a long time.

1:05:36And so it's also been around for a good amount of time as well. And people have taken it for decades without issue. No, Kim. So, I mean, would it be in men's best interest to, I mean, it sounds like there's a lot of other benefits other than sex health. And so, I mean, would it be beneficial for men to be on five milligrams of Cialis every day? You know, I can't say that every guy should be on it, right? I do think there are benefits. And And I do think that if you have any sort of struggle with erections, that I think that being on it is going to benefit you more than, you know, in more ways than just sexual function.

1:06:17And so I do recommend it for almost all my patients to be on it, because I think there's more benefits than just sexual health. Do I think a normal, healthy guy should be on it? It's hard to say yet if I think there's like a long-term longevity life benefit for it. If I had to put money on it, yeah, probably there would be. But, you know, no one's studying that specifically. And so, yeah, I think maybe there might be a long-term benefit for being on it, but we don't really know yet. Okay. What is the average length time-wise in sexual intercourse? Yeah, so this always surprises people. And in fact, even my own friend got surprised by this because he's a urologist.

1:06:56So when you look at the data and they actually look at people having sex, and what they do is they tell people, take a stopwatch. They give it to the female partner. They say, start the stopwatch when you start penetration, turn off the stopwatch when you stop penetration. And they do this around multiple countries. And they find that the average length is about five to six minutes. So a lot shorter than most people think and a lot shorter than you're seeing on erotic films, right? And so that's the reality is that that's average. Now, if you look country to country, some countries are a little bit longer.

1:07:25Some countries are a little bit shorter. For example, UK was longer. Turkey was shorter in the study that was done. but ultimately that's the average length that a man will last during sex now does that mean that there aren't guys of course there's guys who last longer and of course there's guys who are who ejaculate more rapidly now what does that mean right so actually interestingly if you look at mammals who ejaculate right they all ejaculate rapidly there's no like pleasure or enjoyment it's really like for the purposes of having a baby or procreating and so So they quickly, you know, they get done quickly because it prevents like, one, they won't get caught by a predator.

1:08:03Two, there's competition. They're first, right? So the next competition can't come and like get in the way, right? And so there's actually an evolutionary advantage for mammals who ejaculate sooner. In humans, it's different, right? The ejaculation length and pleasure. We actually continue to have sex long after fertility is an issue, right? long after women past fertile ages, people continue to have sex because it's pleasurable. And so this idea of lasting longer, you know, obviously, again, another thing that society is like, oh, it's so great, like you want to have sex forever. But I also see guys who have what we call delayed ejaculation.

1:08:41So they take longer than 30 minutes to ejaculate. And while that's less common, it definitely happens. And those guys are stressed too, because it's like exhausting. it's like there's so much friction it becomes uncomfortable for their partner it becomes uncomfortable for them they're working so hard and and like it's it's no longer fun and so what i tell people is like it's not about fixating on how long you last it's like are you enjoying yourself is your partner satisfied and you know the reality is that women take a lot longer to get aroused and to to get to climax so women on average take about 14 minutes when they're with their partner to reach climax.

1:09:18It's less when they masturbate, it's eight minutes. But again, men take about five to six minutes. So you realize that you have to prioritize female pleasure if you want her to climax, because she's going to take longer. It's also going to take her longer to get aroused. And so really, that's where the difference lies. And so it's really like figuring that out for you and your partner. How do we work together so that everyone achieves pleasure and that we're having a good time because the time that it takes is not the issue. It's like, how much pleasure can you get from having sex and how do we maximize that?

1:09:50Wow. So that's a, that's a pretty big, I don't know if you'd call it a discrepancy from five minutes to 14 minutes. So, I mean, what do you recommend? Yeah. So I recommend that you start by, you know, first of all, make sure your partners arouse. This is the thing. I think women take a lot longer to get aroused. they also take a lot longer to be present in the moment, right? They ruminate about a lot of things. And when they're younger, it's about body image and insecurities. And that can evolve. Women become more confident in their bodies as they age. But then it's like all the other things in their life that they're stressed about, their kids, their parents, whatever, like whatever they're dealing with in their life.

1:10:25And they have a hard time shutting that off. And so one, it's like getting them in the mood, like spending time with them, enjoy, like allowing them to feel desire and to feel arousal. So what happens a lot of times with both men and women, but more often with women is they get what's called responsive desire. So when you're younger, you think you see a partner, you're like, damn, they're so hot. We want to have sex, right? You're turned on immediately. Like there's no need to do anything. You're just like, you see each other and you turn on, you want to have sex. That's it. But as you're with a partner for a long period of time, or, you know, as you evolve in life and you're busier and you're more stressed or whatever, you get what's called responsive desire so you actually like need to be aroused a little bit before you start feeling desire so you're like oh it's like going to the gym you don't really want to go until you're there and then we're like oh thank god i went to the gym i feel great so it's sort of like yeah i didn't really want to have sex but now that i'm like turned on like oh there's the desire oh i remember i like this this is really fun and so it's not an abnormal thing it's actually a completely normal brain response right that you sometimes need to get your head in the right place and allow desire, right?

1:11:33Allow like some arousal to happen. And so that's why I love, like I said, intimacy time, like hold each other, be together, be, be physical, touch each other, whatever. I mean, obviously everyone's not into touch, but like figure out what it is that gets you turned on and allow it to happen, right? Like in a mutually consensual way. And that's why like, sometimes it's like, Hey, let's have this night where we're going to do this, right? Let's actually give each other the time where we're not looking at our phones, where we're not like distracted or thinking about something else. We're just focused on each other.

1:12:03I mean, if you get about it before phones, right? You're like lying in bed, there's like nothing to do. You're like, okay, like, well, it's like I'm bored. Let's have sex, right? Like, like you're right next to me and like your body's right here. I'm like, oh, this feels warm and nice and cozy. And you would like have sex with your partner. And now it's like, well, you don't like you have something else really exciting to look at that has like so much interesting information and whatever you're interested in the moment, you can read about it or watch it or whatever. and so you're like doing that until you're dead and you're like like i'm so tired you fall asleep you put your phone on you go to sleep right and so like there's there's just like there's not as many opportunities right because now there's so much more to distract you than there was before so we have to work a little harder so that's one is like making sure that they are in the moment but two prioritizing foreplay and actually spending time getting them aroused because it's not that they need like penetration like i mentioned earlier penetration is not necessarily how they're going to climax it's going to be clitoral stimulation and sometimes both but you need to sort of focus on foreplay and making sure they feel pleasure and feel feel that desire turning on that the ramp up to i mean everyone can relate to this ramp right you feel like your turn on it goes up and up and up until you climax and so you're trying to get them to get up that ramp a little before you do so that they can get there and then you both can sort of try to climax around the same time or she can climax before you either way um you know it allows you to then to make sure that you both are feeling great pleasure i mean so we're just talking about you know average length of sex you know and how long you know on average men last versus women and And, you know, is there a, I mean, what is too long?

1:13:49Well, again, too long is how long is too long for you and your partner. So like some people, they're fine with however long, right? Even some people who have very short sexual encounters and they love it. And there are people who have long sexual encounters and they love it. It really is bother. That's the key. Like, are you or your partner bothered? Does it cause distress or relationship conflict or issues? If it doesn't, who cares, right? Just be yourself and enjoy each other. As long as you are both having a good time, or if there's more than one person, more than two people in the bedroom, if you're all having a good time, by all means, continue doing that.

1:14:24That's fine. It's when there is a loss of pleasure, distress, that we need to worry, and then we can talk about how to fix it. Even if you don't meet some clinical definition, but you're like, this is too long or too short, let's talk about it, because we can sort of help you figure out what's going on. Maybe there's a psychological issue, maybe there's a medical issue, So regardless, it's all things that we can work with you on. Thank you. Thank you for that. Banna, there's just so many questions that are coming to my mind. But I mean, when we talk about, you know, I saw a video. I didn't watch this one yet, but it was, I believe it was something about, you know, what females find attractive.

1:15:04Yeah. What do females find attractive? Yeah. Interesting. A lot of people think it's like tall men, right? Right. Physically, I'm saying not like emotionally necessarily, but it's all this idea of like, oh, women all want taller. Now, that's true that height matters. But what actually matters is, at least in the data that I found, was that strength. So the display of upper body strength is very attractive to women. And this makes sense evolutionarily, right, where you would need to maybe fight for resources or you need someone to protect yourself. having somebody who is stronger is more likely to one protect you and to also get those resources that you would need right and so evolution it makes sense that when you see someone who's very developed in their upper extremities or their upper body that you would feel like that's the right partner who can protect me and who can also get resources for me and so that's one and the other one is like having sort of a v-shape so your shoulders are broader than your waist and that's not only showing you know obviously upper body strength but it's also showing metabolic health right?

1:16:04So if you have a smaller waist, and you have less visceral fat around your abdomen, you are more metabolically healthy, which means that you probably have better genes that you're then going to pass on to your children that you might have with this person, right? And so there's actually reasons why women find certain things attractive. Now height, if you look at like the data, they'll say like 70 % of when you ask women, like, okay, what's important, 70 % of that attraction quota is is the strength and then if you add another 10 80 it'll go up to 80 if they're tall so they'd rather have a like a average height strong guy than a tall not strong guy does that make sense and so like it's it's really about like how you how you portray this strength and health through the visual eye right like what they're seeing and interestingly that this is obviously more important when you're just trying to hook up with somebody.

1:17:00But when you start looking at long-term partners, that still matters, but then it becomes also like, are they kind? Are they going to stick around and be with you and be the right kind of honest person that you can depend on and they can be reliable? So that becomes also part of the picture when you're looking at like a long-term partner. Anything with the penis? I mean, you can't like, I think you can't, um, you can't see specifically, right? When you're first courting someone, they're not like walking around naked. Um, so you can't utilize that. And I think that, like I said, most people, as long as they're feeling pleasured by their partner, the size of the penis matters less.

1:17:45And, and that's, that's true even in the data. Like I said, there are some women, like maybe 10 to 15 percent and based in the data that are very focused on penile length and that may be because of like they may really develop they may really enjoy like deep penetration because that stimulation may lead to orgasm from cervical stimulation and someone might actually find that painful but some women actually really like that and so they may really enjoy that feeling and that may allow them to feel pleasure and in those cases like that just might not be a right fit for you, right? If that person is like, I need a really, a guy who's really well endowed, well, more power to you, we're not the right fit, right?

1:18:25Because I can't give that to you. I mean, unless you feel comfortable, like wearing a strap on it or something, right? But like, for most people, like that's not going to be the right fit. And look, we don't fit with people because of personalities, because of a variety of things. And so it's okay, if sometimes it doesn't fit because of genitalia, right? But it's like, that doesn't mean that there's something wrong with you just means that that's not a fit right and there's going to be another person where that is a fit and and so that's okay right it's just like anything else there are things that you need in a partner that they may not meet that criteria and they may not be the right person because that's a deal breaker and there's other things where you can compromise on those things and the same goes for sex what about let's move into some some some other sexual activities oral sex i mean I've read, I don't know if any of this is factual, but I mean, I've read that there are supposedly some type of health benefits for females to consume semen.

1:19:22Is there any truth to that? Yeah, there's not a ton. So there's, you know, if you actually look at the nutritional value of semen, it's like very little. So like, it's like very marginal. Yes, there is some protein. Yes, there are some vitamins and minerals and stuff in semen, but like, is it, it's not any, it's not like the equivalent of a multivitamin, right? Like significantly less, but there's no harm either. So like, if you enjoy that and your partner enjoys that, by all means, go ahead, but you don't need to like make semen smoothies or like other, you know, other, come on, you know, you've seen those videos, but like, you don't need to do that, right?

1:19:58Like if you enjoy that, if some people like have kinks and fetishes, they have a cum kink, right? And they enjoy that. That's fine. Great. By all means, like, that's you. Like, I don't want to yuck anyone's yum, but, um, but like, it's not necessary. What about, you know, semen volumizers or people that are trying to, you know, increase the load? Yeah. So again, I think that that comes a lot from erotic films, pornography, right? Like they see these people having very large voluminous loads and the partner and the videos like oh my god right like it's just like this amazing thing and so the reality is that the amount that comes out is really small it's like a tablespoon right if you look at the average amount and we've actually done this right because we do for fertility you actually measure when you get a semen analysis you measure how much comes out so there's an abundance of data on semen volume because of that sort of research and the average is about a tablespoon like five five mls five to five to ten and so it's not a lot and so when you think about what you're seeing on these films oftentimes it's very augmented through like video, right?

1:21:04Video editing, video, other things that are being exploded like around the genitals that look like it's coming from the penis. So that's one. Two is it's variable through age, right? And there's force variability. So when you're younger, you have very robust pelvic floor muscles and pelvic floor muscles are the muscles that sit in the pelvis that are responsible for so many different functions. But one of the functions that they're responsible for is they contract when you have an orgasm and they contract at like a rhythmic like 0.8 seconds and they they give you that pulsing feeling when you have an orgasm they also help you propel semen forward and so when they're strong like when you're young and healthy they will propel up to like 15 to 30 centimeters so pretty far they can propel pretty far and that can look more voluminous right because of going further and when you age when it drops half that.

1:21:57And some guys will come in and they get just a dribble now, or it's like very not forceful. And that's because their, their muscles are just not as strong anymore. And you can, you know, work on strengthening muscular health, including your pelvic floor. But that's sort of the reality for most people. The volume also is variable. It depends on when was the last time you ejaculated. Like if you eject, if you abstain for five days, it's going to be more voluminous. And if you don't abstain, and you just ejaculated the day before, it's going to be less volume is. Also, how much did you drink that day, right?

1:22:27Like how hydrated are you? There's a whole bunch of factors just day to day that play into it. And so, yes, you can, you know, sort of like store it up and like for five days and on the fifth day, you'll say, wow, that was a pretty big, you know, semen volume. And so again, it's not a reflection of your fertility because only 5 % of the entire volume is sperm. Most of it is all these fluids that help nourish sperm, help them move through the female genital tract. They're there for a reason, but the large majority of it is not sperm. And so the only way you can know your sperm health is by actually getting a semen analysis and actually testing that.

1:23:07And when we do those, we actually ask you to abstain for 24 to 48 hours before you give it. So we have a reference, right? Like this is what the average guy has after one day of abstinence or two days of abstinence. And so you should be around this. This is what's average. What, I mean, what are those, you mentioned some exercises. What are those exercises? Yeah. So I'm cautious about saying this because I don't think everyone needs to do them. So there are pelvic floor exercises called Kegel exercise that most people have heard of that can strengthen the pelvic floor. Now you don't have to just do those exercises, but those are the most popular.

1:23:41They have like the best PR of any exercise they've ever seen. But like essentially they are so for guys i tell them it's like you are lifting your penis from the ground without touching it like that's sort of that or if you're peeing and you stop the stream of pee that's you're actually activating those muscles so you don't want to do it when you're in the bathroom but you can use it to learn how what that feels like and then you do those period just like you do crunches or you go to the gym you do reps you do like 10 reps in the morning 10 reps at night you need to make sure you rest and you breathe like just like you would do at the gym you rest, you breathe, you make sure you're not just squeezing, squeezing, squeezing real hard.

1:24:17You squeeze and relax and squeeze and relax because you can get dysfunction, which is why I don't tell a lot of people to just everyone should do them because some people will actually have dysfunctional muscles. And guys, it's very underdiagnosed. No one's really testing their pelvic floor because it requires a rectal exam, a finger in the bottom. And so to test the like, are your muscles tense? Just like people get TMJ, right? They clench up their jaw. their pelvic floor muscles can get tense. And so they can tense up and they won't really know that it's happening, but it will cause these other issues.

1:24:49And so if you strengthen an already tense muscle, you're going to create more problems. So that's why not everyone should do it. But if you have normal function, everything's working great, it's probably reasonable to go ahead and try doing those exercises to strengthen those muscles. It may help you with having a more forceful ejaculate. It may help you with getting stronger erections because there's more blood flow going, you know, It's causing more blood flow to come to the area because you're getting more, just like any exercise. And it may cause you to have more intense orgasms because you have more muscle contracting when it does contract.

1:25:21And so it can be beneficial and it can be a great way to augment your sex life. But again, it's not for everybody. And then how long, is it five days it takes a man to fully reload? Yeah, so when they look at, I mean, actually you're constantly making sperm, right? So on average, it takes about 24 to 48 hours after an ejaculate for you to get the semen back in, I'm sorry, to get the sperm back into the semen. But you will have some potentially in the tract and other things, but you still have some. It's not like it just all goes away and there's nothing left. There's sort of storage mechanisms and things.

1:26:03But in terms of if you're trying to get a partner pregnant, um ideally we say like every other day will allow you to replenish and and have sort of the most amount of sperm getting to the egg if that's what your goal is anal sex yeah any benefits well so like i mentioned um we talked about the skein's glands or the g zone right you know how some women find that really pleasurable that area is the similar to the prostate so some some people, and there's also the clitoris and the legs of the clitoris that are around there. So they're all sort of around the rectum and the anus. Some women will find it very pleasurable to have something inserted in the anus and that will augment their pleasure.

1:26:54And so not everyone does, but just like some people find certain things pleasurable, some people don't. So in terms of like health benefits, not really, but in terms of pleasure benefits, yes, for some people that can be a great way to, um, for them to feel pleasure. Um, it can be augmented with other things like you can, you know, stimulate them clearly at the same time, whatever, right? There's different ways to use it. But what I will tell people is it's not like you can't just have anal sex. If you've never done anything in the, in the anus before you need to sort of prepare. And sometimes that means like using a toy or using a lubricated finger to sort of get the anus ready or prepared to have a phallus inside.

1:27:34You also need to, there's no natural lubrication. So you need lube and go slow, go easy, take your time and sort of like talk. You have to communicate. You have to be like, is this okay? Like there has to be a back and forth dialogue where you feel comfortable and trust each other because it can cause damage if you do it too aggressively or too, you know, too rigorously and not enough lube. You can actually damage the walls of the anus, which are really friable and thin. They're not like as elastic or muscular as a vaginal canal. And so, yeah, absolutely. It can derive a lot of pleasure. It can be a lot of fun for people.

1:28:12You just have to go slow, go easy and talk to each other. What about risks? Like again, the risk, the big risk is, is that you can hurt yourself, but also there is a sexually transmitted infection risk. So oftentimes people will have anal sex and because they can't have, can't get someone pregnant that way, they won't use a condom, but you can still transmit sexually transmitted infections. And it's actually a higher risk because there's more blood vessels. Things can tear more easily in that area. Like I said, it's not lubricated. And so they're at a higher risk of getting STDs. And so it's really important if you're having anal sex with someone where you are not monogamous and tested and clear and you are safe to not use condoms even vaginally, you need to use a condom anally because you want to protect yourself.

1:28:57What about from a bacterial standpoint? Yeah, I mean, from a bacterial standpoint, you know, it's not like you're going to get you as a man, you won't get like a colon infection if they have some sort of infection. That's usually not an issue. It's more the sexually transmitted infections. Okay, okay. G-spot. How do men find it? So the G-zone, it's not a spot actually. A lot of guys think it's like this magical button that you have to find. It's not. There's not necessarily an obvious visual. Like when you look down there like, oh, there's a spot, you know, like bullseye.

1:29:35No, but honestly, I think there's a lot of misconception. Like people are like, wait, what's something wrong with me? I don't see it. like you know it's not it's an area where there's a lot of nerve endings so the skeins glands which we talked about earlier the um the clitoral body the shaft so just like the shaft of the penis the shaft of the clitoris is around that area um and so all those areas are really highly innervated i mean they're really a lot of nerve endings it's about two to three centimeters inside the vagina at the top and so we'll say like it's like a come hither motion is sort of where you'll kind of feel it.

1:30:06But again, you have to talk. I think people feel like that when they have sex, they should just be like magical gods at sex and it should just be perfect. And like, it should be this amazing experience like off the bat. And it doesn't make sense to me because we like you have, it's a skill just like anything else. Like you don't expect to like go, go do a public speech and be amazing at it the first time, right? You, it's a skill that you develop with time, even talking to someone or dating. It's all skills that we learn and we cultivate. And so just like that, sex is a skill. You have to get good at it.

1:30:41And that requires you to get feedback from the person you're having sex with. But we just expect that like, okay, we're just gonna have sex. There's gonna be just moans and groans, but no talking. And it's gonna be great. And everyone's gonna have great orgasms and we're gonna be wonderful at it. It's like, but we have to invest in having better sex. Like what is the point of having sex that's not worth having, right? Nobody wants mediocre sex. Let's have good sex. And so that means, like, let's talk about sex. Let's talk about sex outside the bedroom. Let's, like, find out, like, hey, what turns you on?

1:31:11What is something that you've always been fantasizing about? Or what is, what was good? Like, what did you like about that? And what could be better? You know, and let's not take it so personally. Like, we are trying to be better lovers with each other, right? And so, like, it's important to sort of be like, okay, what's good, what's not good? How can we change this up? The other thing is like monotony is a huge issue. So like people find what works and they do it every time. And that's great. Like it's comforting to have a routine. But if I was to tell you, hey, you're going to like, it doesn't need to be like, let's get out the whips and chains.

1:31:43And like, it can be just as simple as doing it in a different room, doing it at a different time, doing it in a different, like slightly different position, using a pillow, not using a pillow, like just slight variations that make it just different enough where you're like, oh, this is kind of different. Like, this is kind of cool. And keeps you sort of interested, excited, engaged in the process. Are there any positions that men could do that are easier in finding the G zone that women enjoy more? So we know that when women have control, meaning they're on top, or they can sort of angle their bodies in certain ways, that they tend to have more pleasure because they can, again, sort of angle you in a certain way that allows them to achieve more pleasure.

1:32:32So certain things like putting a pillow, so if she's on the bottom, putting a pillow under her pelvis can make it more comfortable and more pleasurable. Having her on top can also allow for more pleasure because she can control sort of the angle that goes in. And there's also certain things, not so the G zone, but there's things that can help you like stimulate the clitoris better while you're having vaginal penetrative sex. So certain positions where you're like sort of aligning your pelvis right on top of her clitoris so that you're kind of like rocking motion, that can also lead to better orgasms.

1:33:09People focus on the G-zone because they hear about it a lot, but it's analogous to the male prostate. Now, not every guy wants prostate play. Like not every guy wants their prostate stimulated for pleasure. And so I don't think we need to focus on the G-zone. We need to focus on clitoral stimulation and also talking to our partner, finding out what they like. Because again, not everybody wants their G-zone stimulator. Like it may not be pleasurable for them or it may not really do anything for them. Whereas some people may be like, yeah, that's it. I love that. And that really turns me on. But you won't know until you ask her.

1:33:41What about, you know, we talked about, you know, how often it would be, what an ideal, what do you call this? ejaculation cycle for a man, what's healthy, 21 times a month, great. What about women? Yeah. So there's so little data on women, but I would venture to say probably having regular orgasms is good for you, right? They don't necessarily always see an ejaculate like men do. And that's different from squirting. Ejaculate is just like this milky white fluid that comes from the skein's glands and it's usually a very small amount so we don't always see it um it's not always very clear some women but yes i see i know exactly what you're talking about and some i've never seen it that's okay um but uh it's more about the orgasm i think because that's what you can sort of reliably say and i think that the orgasm is what we should focus on is getting orgasms for women and really the thing is i think for for women it's probably i mean there's no we don't get we don't get skein's glands cancer is very common right prostate cancer men one in eight men get prostate cancer, right?

1:34:47So it's very common. So it's not, I don't think there's a benefit in that term, but I do think for health benefits, for stress reduction, for pleasure benefits, I think orgasms, regular orgasms are great. Again, I don't, I can't give you an exact number, but I think like if you feel like you are enjoying how often you're having orgasms, do it. And if you feel like you could have more, that's fine. And if you don't like having orgasms, That's okay, too. But you should have something that gives you pleasure in life. Perfect. Brina, let's take a quick break. Sure. And then when we come back, we'll get into some prostate stuff and all that kind of stuff.

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1:37:38Fun surprises like a free six-pack Ketone IQ merch and more. These statements and products have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure, or prevent any disease or condition. all right rena we're back from the break a couple more questions about bedroom stuff yeah and um so one is you know there's this rumor going around that pineapple makes semen taste better pineapple i think i've heard bananas there might be some other stuff i'm not sure is there any truth to that so it's i mean like you can't really design a study tasting semen so i can't tell you like I can't tell you with a degree of like certainty, but if you think about the composition of semen, right, there's fructose and semen and fructose is what makes it sweet.

1:38:31It also has all these minerals in it, which give it that sort of like metallic-y sort of taste. But, you know, at neutral, it's sort of got this little bit of like metallic-y, slightly sweet taste. Now, if you want to make it sweeter, you would think, okay, I want to increase the amount of fructose in the semen. And so, you know, you will see that things that have a lot of fructose can potentially help increase the sweetness of semen. So things like pineapple, other fruits, potentially, yeah, they might increase the sweetness, but it's not going to be, I think what people think is like, oh, I got a date tonight, I'm going to eat some pineapple in the morning, and I'm going to be good to go.

1:39:11It's not that quick, right? So it's sort of like a dietary thing. Like if your diet consists of like healthy fruits and vegetables, you're more likely to have better tasting semen. Now, certain vegetables like asparagus is pretty strong. And so people might notice that their pea stinks after they eat asparagus, that will also affect your semen. Things like coffee, smoking, caffeine, those can make the semen taste a little bit stronger. And so, and certainly, so if you really does, your diet can really alter the taste, at least that's my suspicion based on what we've heard from people anecdotally, what we've taught, you know, the kind of the biology behind it.

1:39:52And so I would suspect that generally speaking, if you eat a healthy diet, drink lots of fluids, you're going to have good tasting semen. If you eat a less healthy diet or you smoke, it's not going to taste as good. And so, you know, I think like obviously um everyone's taste is sort of their own right it's it's based on their biology and and so unless it like your partner's like oh all of a sudden it tastes really different and it tastes unappealing i wouldn't worry about it but like um you know again i think that like it is it's nothing that you should ever like really worry about right your as long as you're a healthy person your semen should be tasting good also the color of the semen can vary i get this question a lot.

1:40:34So like people be like, Oh, it looked, it looks a little yellow now, or it looked a little, um, a little grayish and really the color can vary. Um, it's not dangerous. So the good news is not dangerous. Um, I always say, if you're worried, just drink lots of fluids, it's going to, it's going to dilute everything, right? It's going to make things a little bit clearer. Um, cause I think a lot of times we are drinking a lot of energy drinks or not, not really just water. And so sometimes it's just like increase your water intake and things will clear up. If you get blood in the semen, that's a little bit concerning, but usually 99 % of the time, it's not dangerous.

1:41:09And if it happens once, don't worry about it. If it continues to happen over and over again, that's a time to sort of get a red flag. Okay. And then we may have covered this, forgive me if we did, threw a lot of information at me, but I've heard rumors or maybe read some things wherever it came from. I can't remember, but does ejaculation for men lower the risk of cancer? Yes. So ejaculating, we know there's an association. So when you ejaculate more than 21 times a month, there is a, about a 20 % lower risk of prostate cancer. 20 %? Yeah. And so now is it the ejaculation that's causing that lower risk?

1:41:51I mean, the study that found this data actually tried to control for a lot of different factors, you know, like other health conditions. But you would imagine that someone who is ejaculating that frequently has a partner or is healthy enough to do so. So maybe there are some other factors that we can't really quantify scientifically. But the theory is that perhaps ejaculation is allowing fluid to move through the prostate more readily so that fluid doesn't stick around and cause inflammation or other issues that then may lead to transformations that could lead to cancer. Okay. And what age, how long can people have sex?

1:42:32I mean, as long as they live, but a lot of times people don't. And so we call that sex span, right? Like you think of your lifespan as how long you live, but your sex span is how long you're going to have sex. and so if you remain strong and healthy so you're strong enough that you can still maintain the positions of sex and to be honest there's even like furniture now and like things that can help you have sex if you're a little bit weaker or like can't get certain positions like there's like wedges and slings and different things that can help that so you can continue to have sex but also that you don't get winded right when you're not like exhausted that you can't actually exert enough to have sex.

1:43:13But if you are a healthy person, you've maintained your muscular health through fitness, you've maintained your cardiovascular health through fitness, it is very likely that you continue to have sex well into your old age. I've seen 90-year-old patients who are still having an active sex life. 90 years old? And don't have erectile dysfunction, and they're very healthy. And again, they have prioritized their health, and they have maintained their exercise, they've maintained their health, they've eaten a healthy diet, they've slept, they've dealt with stress, they've created an environment which is healthy around their bodies, and they are still able to have sex with their partners.

1:43:51Now, do you see a lower sex drive in older couples or just older folks in general? Well, so yeah, let's talk about it for each individual. So for men, the most common reason for low sexual desire, especially as they age, one is low testosterone. So testosterone declines at about one to one and a half percent every year after about 40. So if you are very healthy and you started with a normal testosterone, it's unlikely that it should get low enough that it would cause you a problem. But that's not the reality for many people. So about like overall 20 % of people have low testosterone, but that percentage goes up as you age.

1:44:33And that's because add in, you know, like other medical conditions that will affect low testosterone. So we know that as people get more metabolic conditions, like high cholesterol, diabetes, high blood pressure, they tend to get lower testosterone. Add in potentially like lack of sleep and more stress in their life that causes more testosterone, add in sedentary lifestyles, add in even environmental exposures like microplastics and things like that, that we have some control over, but not completely. And now you're in a situation where you're more likely to have a larger decline than is expected.

1:45:12And so we are seeing more and more low testosterone. And testosterone is the hormone of desire. And so when you have low testosterone, oftentimes it will present in men with low sexual desire and loss of morning erections so those late night those morning erections it also testosterone is important for so many things in your body so it increases muscle mass it helps with mood so sometimes people who are depressed men who are depressed will find that their mood gets a little better when they start on testosterone uh brain fog so it helps guys with brain clarity and that's actually one of the very common things i'll see in older guys who have low testosterone is i'll give them testosterone and the first thing they'll notice is that their brain is a little clear.

1:45:53And it helps with like the ability to just do normal functional things like walk upstairs, hand grip strength, like things like that, like functional. And so there's so many facets. It also helps with bone health and bone health is so important as we age. So it's not just a hormone of sexual desire. It's so much more than that. But so that is often a cause in older men of loss of sexual desire. Also, if they're unhealthy, right, they have a health issue and then sex is like off the table because they don't feel well, right? And that happens to a lot of guys where like, like I'll see women like my husband can't have sex because he's unwell, right?

1:46:31Or he his partner is unwell. And so they can't have sex because of that. So that that becomes very common reasons. Now for women, low sexual desire is even more common. So it's actually estimated like 40 % of women have low libido, so low desire. And there's a variety of reasons for that. One is yes, women also have testosterone and their testosterone also declines similarly to men. And so they can't, that can be part of it. There's also changes in menopause that can really affect women as they age. So they can have dryness vaginally, which can make it uncomfortable to have sex and lack of lubrication.

1:47:08They can have their, their tissues actually change. So they get, they get what's called atrophy. So the tissues get thinner, more friable. So it's more painful and it's actually like not as flexible or as stretchy as it used to be. So actually penetration can be painful. Their clitoris can even have changes. Just like men have erectile dysfunction, women can have changes in their clitoris where they may have less pleasure from the same stimulation they were getting before. So it's more difficult to get orgasms. And so when you are having sex, that's not really leading to pleasure. It becomes like less of a priority, right?

1:47:44And so, you know, we have things that can help women too. And I see patients all the time. Sometimes it is off label testosterone, sometimes it's other medications that we can offer. But also it's like dealing with those things or those changes that are happening, because they can really make you not want sex. And then your partner, if you're, if you're, you know, male partner is like, I still want to have sex, but she's like dealing with all these changes hormonally. She doesn't want to, right? She's like, I'm not sleeping well, I'm having hot flashes all the time. You know, everything's dry down there.

1:48:14I might be getting UTIs all the time. All these things are often hormonally mediated and they can be remedied. And same thing for men. If your testosterone is declining, we can improve that either naturally or with replacement. So how can, I mean, what age does menopause usually start? So average is 51, but up to 10 years before that, and that's average, meaning that half of women will be before 51, half will be after, but well before perimenopause, before menopause is perimenopause. That can be four to seven to 10 years before menopause. And again, it can, so that could be as early as your 40s or late 30s, some women are experiencing these symptoms.

1:48:52And that's when the symptoms are really intense because there's like this hormonal chaos, like the, some days your estrogen is really high, some days it's low because your body's like something, Like it's all unregulated, right? And so during that time, they're just like, they're super stressed. They're not sleeping. They're having hot flashes. They don't feel like happy. Sometimes they feel depressed. I mean, there's so many things going on and they honestly feel like they're out of control. Like they don't feel like themselves. I mean, men will say the same thing when their testosterone is low, that they don't feel like themselves.

1:49:22And so, I mean, how do you, I mean, how do men strike up a conversation with their partner who is pretty good at the bottom? So I think you have to really do this cautiously because I think the thing is like, oh, if you say, oh, I think it's hormonal, it almost feels like the partner may feel like affronted, like you're telling me I'm hormonal, you know? So you have to sort of do it in a way like, look, you can try like, hey, look, I saw this video online. I listened to this podcast and they were talking about this. And I'm like wondering if, you know, do you like, are you having any symptoms or do you would you like to see a specialist?

1:49:59Can I help you find one? can I go with you to the appointment? Like, I mean, I love it. Male patients bring me their wives all the time. And I love it. And so supportive, so wonderful. And they have this wonderful, beautiful relationship. And they just want to support each other. And I think it's just being, look, I love you. And I want you to feel well. It's not about wanting sex. It's not about like, wanting, you know, you as a physical being. It's about wanting you to feel like yourself and feel happy and fulfilled and feel like normal in your body. And I think like, showing them that you want that is so valuable.

1:50:31Like the, oh, you love me and you care about me and you want me to feel good. It's not necessarily just about sex. It's, you know, it's much more than that. And so I think that's where it's like, you don't want to start the conversation to be like, oh, we're not having sex. I want you to see a specialist. Or I think you're going crazy and you're hormonal and like, you know, something's wrong here. It's more like, look, I love you. I'm worried about you and I want to help. And like, I really, you know, want to be there for you. What are, I mean, what are some of the initial treatments? I mean, it sounds like lubricant would be an obvious answer if it's dried down there.

1:51:03Lubricant is great. And I think the one thing people don't realize is that lubricant comes in different formulations. Like you can get a water-based lubricant, which is the most common one you see, but those dry up. And so like, if you're going to have sex, it's going to last a few, more than a few minutes. Like you're going to have to reapply. Otherwise it's not really going to work. So you can get water-based, but silicone-based and oil-based are a little longer lasting. and so those are convenient in terms of like allowing you to just apply once and like have sex and not worry about reapplying and so just figuring out like what kinds you guys like and might be experimenting with a few and figuring out what feels good for both of you and what you both like because it's a very individual thing but I think lube is great it's cheap it's available it's accessible and it's like hey let's have fun with it let's make it fun right there's also moisturizers.

1:51:52So for dryness specifically, you can get vaginal moisturizers, just like you have facial moisturizers, there's vaginal moisturizers, and that's just skin. It's just skin. So just like moisturizing the skin, keeping it healthy. And then specifically for what we call the genitourinary syndrome of menopause or the dryness and the other issues, you can use hormonal creams. So like vaginal estrogen, which is very safe. So it's not, when you think about, there's a lot of confusion about hormones. Vaginal hormones don't, very little gets systemically absorbed. So there's never been a risk of breast cancer, ovarian cancer, uterine cancer.

1:52:24In fact, it's probably safe for about anybody unless they have an active breast cancer. So anybody else can get vaginal hormones. And so in those cases, you can do them in a cream, a pill, a ring. There's lots of different options, but they can really, one, keep the tissues healthy so they feel comfortable and they feel good and it feels good when they have sex and can prevent recurrent UTIs. And it can even help like you, if you're looking down there, you may notice that their vulva actually changes, like the lips, the inner lips will actually shrink and resorb because the lack of estrogen. So sometimes if you apply the cream on the outside, it can help keep those tissues healthy too.

1:53:03And so not everyone needs it, like I said, but I think it does benefit people. The majority of women would benefit from it. And I think that it's really very, very safe because, again, it's just topical. Very little bit gets absorbed systemically. Are there, I mean, it sounds like you recommend TRT for men a lot. I recommend TRT for men when they have symptoms of low testosterone, which we sort of talked about, but like low sexual desire, brain fog, fatigue, loss, maybe decreased mood, when they have multiple symptoms that can be related to testosterone and their testosterone is low. And so testosterone is measured through a blood test.

1:53:53The challenge with testosterone is it only gives me a number of what your level is at that time. I don't know what your level was in your 20s. So if you have younger listeners listening, I generally recommend that people get a baseline level when they feel good, right? What is your testosterone when you feel good? So that when you, as you age, you have a reference. And like, if something happened and you're like, oh man, I'm so exhausted. I don't know what's going on. You check your testosterone. If it's the same as it was when you were in your twenties, okay, it's not your testosterone, something else, right?

1:54:19But it gives you a reference because what we don't know and what's difficult to study is your receptors, which is what testosterone attaches to. Some people's receptors are more sensitive. So they need less of it, less testosterone around to get the same results. And some people need more because their testosterone receptors are less sensitive. And so I can't tell that. We don't have like a commercially available test that we can say like, okay, you have a better receptors. You have more, you need more testosterone to saturate those receptors. We don't know. And so it's a very individual thing.

1:54:53Now they can say benchmarks based on like what we know population-based data. And that's usually 300 nanograms per deciliter is like the normal benchmark. But I mean, there are some people who have testosterone that are higher than that, that still have symptoms. And that may be because their free testosterone is low, which is the testosterone that's like around in the bloodstream, that is actually what's actively working on all those receptors. Because most of it is just like with other little molecules that are like little carriers, like little cars they sit in, but they don't let you get off the car so that you can't actually go and work on the organs.

1:55:26They're just there. And so only about like 5%, 5 % or I think it's like actually it's like one or two percent of the testosterone is free and that's what matters and so that's what we want to see because other things that can affect the those carrier molecules the sex hormone binding glibulin so it can cause it to be more so as you age sex hormone binding glibulin goes up so your testosterone may look the same but your SAGPG is going up and now you have less free testosterone and so you're symptomatic and so I think that it It is valuable for men when they're low to improve their testosterone.

1:55:58Now, it doesn't always have to be through replacement. There are things you can do naturally to help improve your testosterone. That includes sleeping more than seven hours a night of high-quality sleep. It can increase your testosterone by 15%. If you have sleep apnea, there's actually been very good studies that when you use a CPAP, which is like a machine that helps people who have sleep apnea, they increase their testosterone quite significantly. So if you snore or you have a really big neck circumference, think about getting a sleep study to find out if you have sleep apnea, because fixing that will fix so many of your issues, including your testosterone.

1:56:32It's actually like a risk. It's actually a mortality risk. People who have sleep apnea die sooner because they're not getting as much oxygen to their brain throughout the night and their organs. If you exercise, resistance training, heavy resistance training of your muscles can help boost testosterone. If you eat healthy, so meaning like what we, again, diet is very challenging to study and it's very difficult to give population-based data, but what we know on a population level is that Mediterranean-style diet, meaning prioritizing healthy fruits and vegetables, not unprocessed foods. I basically tell people unprocessed foods, natural foods, and ideally prioritizing fiber and protein are probably your best bets in terms of overall health for both testosterone and just overall health.

1:57:20And then with testosterone, importantly, you don't want to get on too low fat of a diet. Testosterone is a molecule that's made from cholesterol. And so if your fat goes too low, you won't make enough testosterone. I think that's really valuable for military men is that you guys do a lot of really intense endurance work. When you do really intense endurance work, your testosterone goes down because it's like chronic stress on your body. And so that is something to look out for is if you're doing a lot of intense endurance work during those times, you might be like, man, I'm exhausted. Yeah, you're doing a ton of endurance work, but also your testosterone is low.

1:57:57And so that can come back, obviously, when you stop doing those things. But it is something that you might notice during those stressful periods of time when you're putting your body through these really intense things. I mean, would you, I mean, I've read lots of things, interviewed people about it. I mean, you know, it seems like testosterone Corona is declining in men at a rapid pace as years go on. And they talk about, you know, how kind of like the World War II generation, ever since then, it's just been on a decline. And so, you know, now TRT is, you know, wildly popular. Do you want to have, you know, is an older man, does an older man want the same level of testosterone?

1:58:39Mark, to know what it used to be, right? But at the end of the day, we have to see how you feel. So I think people get very fixated on numbers. And it's important. Numbers help guide us. But what should be guiding us is how you feel, right? So if you're like, I'm full of energy. I feel great. I'm having great sex. And my mood is great. And I'm focused. I'm able to be productive. I don't feel a deficit in any area of my life. Then who cares what your numbers are? You feel good. And that's what matters, right? And I think that's important. Now, I do think that there's some value in keeping track of things because you want to catch things before they become a real, like you don't want to be miserable and can't get out of bed and can't move before you go see the doctor, right?

1:59:23You want to sort of be a little bit proactive. But again, I think it's not necessarily the number always that matters. It's we have to talk about what you feel. Where is the deficit? What's going on, right? Like I said, a lot of people think, oh, my erections aren't working. Testosterone is the answer. And that's not always the case. In fact, it's not very often the case. And so it's like, we have to like, look at you as a person, not as a lab test or as a blood value. We need to look at you and be like, okay, what's going on in your life? What's outside of our clinic room or outside of like, whatever this blood work is showing me, what else is going on?

2:00:00Right? Like, are you having a ton of stress at work? Are you dealing with a financial calamity? Right? Is your partner like super stressed because her mom's in the hospital and like, it's affecting your whole life in homeostasis at home. Like, what is going on? Because you're not just one blood work. You are a whole person. Are there any concerns about going on testosterone replacement? I've heard that it can increase the rate of cancer, enlarge prostate. I've heard all kinds of things about it. So there's a lot of misinformation and some of it was a misunderstanding that now we know better, but let me go through it.

2:00:43So testosterone replacement is, as I mentioned, very helpful in improving all those things that we've talked about. Now, what are the risks, the true risks? So in terms of the things you mentioned, cancer, testosterone replacement does not cause prostate cancer. We know that unequivocally. The issue is that if you develop prostate cancer, which one in eight men will get prostate cancer. and I give you testosterone, I don't know you have prostate cancer because it hasn't, it hasn't shown me yet. Your PSA is still normal. Everything else is fine, but maybe you were destined to get prostate cancer.

2:01:15And then you get prostate cancer. It will cause that prostate cancer once it's there to grow more rapidly. And so that's why it's really important if you go on testosterone replacement to get your PSA, which is a blood test and screening for prostate cancer checked regularly, because we want to make sure that God forbid you are in one was one in eight, that we stop the testosterone, we treat your prostate cancer, right? And we fix that because we don't want an untoward thing to happen. So that's one. In terms of enlarged prostate, they've also looked at that. And there's actually been no evidence that testosterone, again, in and of itself causes an enlarged prostate.

2:01:50Now, if you already have an enlarged prostate, and you have symptoms that are bothersome, when you give testosterone, it will cause a slight increase in both your PSA, and it may cause a slight increase in the size of the prostate. and so if you're already sort of struggling and I give you testosterone it might make you struggle a little bit more whereas the average person it won't bother them at all right the one that it does sort of cause problems with is if you have that sleep apnea we talked about earlier if you have really uncontrolled sleep apnea it can make it worse because it's going to increase muscle mass it also increases the muscle mass in your neck which then makes that sleep apnea worse now usually that gets better with time but if you're really like struggling with sleep apnea already and you're waking up all night and you can't breathe at night, it's going to make it worse, right?

2:02:36And so that's one that we know. The other one that we absolutely know is that it can cause thickness of the blood or it can increase what's caused your hematocrit. And when your blood gets too thick, and it's about like 7 % of people who get this change, depending on which formulation of testosterone you go on, it causes you to be at a higher risk for blood clots and strokes. That we do know. Testosterone replacement will put you at higher risk for those things. So we need to keep a close on it. Absolutely. And so those are the big ones. In terms of like, I think the other big thing people need to know is when you start on it, you need to think of it as you're going to be on it for life.

2:03:13Like you can do a trial, you can do like two or three months, and be like, am I noticing a difference? And if not, go off of it. That's not so difficult. But if you've been on it for years and years and years, if you go off of it, you are no longer, you've shut down your body's process of making testosterone. So you won't make any for a while and you will feel like crap for a while until your body revs it up. Now we can use off-label medications to sort of help jumpstart your body to making testosterone, but it's not something that every doctor does and that every doctor knows how to do. So I just tell people like, think of it like you're going to be on it for life.

2:03:47Is that HCG? Yeah, HCG or Clomid, both those things can be helpful in FSH in some cases to help restart things. The other thing is if you want to have kids, it will make you infertile. and not like your sperm count will go down to zero, but it will go down low enough that fertility becomes challenging. Now, everyone's heard of people who've been on steroids or on testosterone and have had babies. It's because it doesn't go down to zero. It goes down to a very low number. After about 18 months of being on it, you're pretty much at a very low number that would become impossible to, nearly virtually impossible to impregnate another person.

2:04:23So a lot of young guys, as you know, you mentioned like testosterone is declining. A lot of young guys are like, oh, I need testosterone, I don't feel well, and they do indeed have low testosterone, they start it because no one tells them that. Then they get married and they want to have kids, and now they're in a situation where they have little to no sperm, and they have to sort of, again, use HCG, Clomid, and try to get it back. But depending on how long you've been on it and how old you are, it can be more and more difficult. Okay. Okay. So before we move on, And I want to talk about prostate health and that stuff.

2:04:56But are there any, basically what I'm getting at is Gen Z. They're the up and coming generation. Is there substance abuse? Is there certain substances that can affect erectile dysfunction? They can affect hormones, testosterone? So we know smoking unequivocally. I mean, I don't think this generation smokes that much, but they do vape. So smoking can affect erections, absolutely. It will destroy your erections, because it's going to destroy the blood vessel health. And again, those blood vessels of the penis are really, really small. So you're going to see issues with erections before anything else.

2:05:34So if you're smoking, I'm like, this is the best non-smoking ad, is like, don't smoke to help protect your erections. I think everyone would quit, right? I think instead of showing people with lung cancer, they should have shown a penis that doesn't work. I think people would have quit smoking a lot faster. So that's one. But a lot of young people are using marijuana. And marijuana, chronic use of marijuana, can absolutely lower testosterone and cause issues with hormonal health. Really? Yes. So when you're using it chronically, you will see that. And it can cause issues with fertility. So we see a lot of young guys who are trying to have kids and they use marijuana all the time.

2:06:17and for a variety of reasons, recreation, whatever, and now they have really poor semen health, poor sperm health, and they can't get their partner pregnant. So I think marijuana use is legal in some states, and it's okay on occasion recreationally. We don't know if there's a... We know now that alcohol is not healthy in any amount, but we don't have that same granularity about marijuana in terms of is any bad, but definitely chronic use is bad for your sexual health and your hormones. What is chronic use? So chronic use is like every day or multiple times a week. And, you know, if someone is like feeling sort of like they are always mellow because they're on it, they're always sort of like, basically they're feeling the effects of marrow.

2:07:04They need the effects and they're almost like using it because those effects feel so good and they're using it all the time. That's probably a sign they're using it too much. Okay. Yeah. Okay. And so let's get back to prostate cancer. I mean, what age should men be checking their prostates? Yes. So the guidelines would say 55 is the age to start screening for prostate cancer. I would say also if you have a family history of prostate cancer, specifically your dad or your brother, meaning direct first-degree relatives, that puts you at a much higher risk. If you're African-American, that puts you at a higher risk.

2:07:39If you have a BRCA gene, so if your mom had breast cancer and has a BRCA gene, positive, that also puts you at risk of breast cancer. Or if you have multiple cancers in your family, I would still encourage you to get tested earlier. And so like that would be based on at least five years earlier, or if your parent or brother had prostate cancer, let's say at 50, I would start testing you at 45. And so what is the test? So I think it always used to be a prostate exam and a blood test. Nowadays, the prostate exam, which is a finger in the bottom, is sort of decided that it's not always necessary.

2:08:17Because so urologists, we do prostate exams all the time. We know what we're looking for. We know how to do an exam very well. But general practitioners, primary care doctors, family care doctors, what we found is like they don't always really know what they're feeling for because they don't always necessarily like feel abnormal prostates. It's not like their area of focus. And so it was actually creating a lot of false positives where people were like, oh, I feel something. Send you to the urologist. Now the urologist has to like do a biopsy, which is unnecessary. and, you know, it sort of led to this unnecessary, like, further testing and evaluation.

2:08:48So they said, okay, based on that, we don't necessarily recommend that everyone needs a prostate exam. I still think that if you're going to a urologist, it's valuable to get one because we know what we're looking for. But a PSA is a simple blood test. It's a screening test. So it doesn't tell you yes or no, you have prostate cancer, but it's a quick and easy way to say, okay, maybe you're at risk. But there's other things that can increase your PSA. That can be inflammation. So you might have had masturbated or you might have sat on a bike seat or you might have like had some sort of low-grade inflammation that you didn't really know and that can cause an increase in PSA.

2:09:24You can have bleeding in the genital urinary tract for whatever reason, that can increase your PSA. If you went to the hospital and you had a catheter placed or anything in the urethra, that can increase your PSA. So there's a variety of different things that can increase your PSA. So this is why it's a screening test. It's not yes or no. It just says, okay, you might be at risk. Now what do we do? So if it's high, usually we'll check a second one to make sure it's not inflammation, it's not, you know, anything else. And if it's still high, then we talk about what's the next step. So before we used to be straight to biopsy, right?

2:09:52You go and you get a biopsy of your prostate. Now we have a lot of different things, but the biggest and most sort of revolutionary in urology has been just a prostate MRI. Because now they've looked at prostate MRIs and they found this sort of grading scale to say like, okay, you do an MRI and you see if there's any areas that look concerning and you grade them based on the way they look and from one to five one being like very unlikely cancer five being like very highly likely cancer so that gives you more of a degree of confidence on like okay do we need to biopsy this and if so where are we biopsying because when we do a biopsy in urology when i was training it was like we're just poking 12 areas in the prostate randomly like i mean obviously throughout we're doing it systematically so we get a little bit of every little bit of it but we just go you know we're just getting 12 random cores in the prostate.

2:10:40Now we can do it with a little bit of degree of like, okay, now we have this MRI, we can, you know, overly it on the ultrasound and see where we're going to biopsy. And so that's helpful. And also if you have, like, if you have a high prostate and your prostate is huge, which is also another reason that your PSA can increase, and there's no lesions on your MRI, I might say, hey, let's keep an eye on it. Everything looks good on this MRI and you have a very big prostate, which also causes an increase in PSA. let's keep an eye on it you know we don't need to do a biopsy at this time so it can sort of help us decide and there's a bunch of different biomarkers that um and urine markers that we can test if you know we want to sort of get a little bit more granularity now there's not like one that's better than the other and i would say talk to a specialist in prostate cancer a uro oncologist when you're deciding if you want to get more testing before you either get a biopsy or get treatment if you do find that you have prostate cancer.

2:11:34I mean, what are some symptoms that people should be looking out for? Most people have no symptoms. This is why we have screening. This is why we do screening. Most people have no symptoms. And by the time they get symptoms, it's actually a problem. It's usually like a more advanced cancer. So symptoms could be that you have blood in the urine. Could be that you have back pain. Could be that you have night sweats or weight loss. Could be that you are going to the bathroom a lot or more frequently or having trouble peeing. but those can also be signs of an enlarged prostate. So that's why we do screening.

2:12:05We don't rely on symptoms. And absolutely, if you're having symptoms, we should screen you for prostate cancer at that time too. But in general, that's why we do screening on people who have no symptoms because that's when we find it. Okay. So when it comes to an enlarged prostate, can it be reduced? Yeah. So an enlarged prostate, so I will say 80 % of 80-year-olds have an enlarged prostate and 80 % of 80 year olds also have prostate cancer. So if I took all like autopsy studies and you look at the prostates of 80 year olds, they all have some focus of prostate cancer. So before I get into enlarged prostate, I want to round out that discussion because I think it's important to understand this is that if I diagnose you today with prostate cancer and you are 70 years old and you are really unhealthy and your dad died at 75 and you also have so many medical issues that you will likely pass in the next 10 to 15 years, I should do nothing about that prostate cancer because something else is going to kill you long before the prostate cancer does because it is very slow growing.

2:13:10And it's really important for people to understand. Nobody wants to face their mortality or think about how long they're going to live. But I'll give you a personal example. My grandfather got prostate cancer in his 70s. No one talked to me about it. Like I was in residency and they put him through radiation. And a couple of years later, he died from a heart attack. And if they had asked me, I would have told them, don't do anything about this prostate cancer. He's not healthy. He's 70 years old. And he just went through this radiation for no reason, right? Now, if he was 60 and he was healthy or even 70 and healthy, I would have said, yeah, treat it.

2:13:44But I think this is a really important discussion because not all prostate cancer needs to be treated. and some can even be watched. So we have protocols like active surveillance protocols where we can do routine MRIs and biopsies and keep an eye on it because as I mentioned it's slow growing and some people will never become a problem. And so we're trying to find those people and not put them through surgeries or radiation that have multiple side effects and potential complications because they won't eat it. So I think it's really important before we talk about enlarged prostate to just get that point out there because I see so many people who are like, no, I just want to know.

2:14:21I'm like, do you really want to know though? Because once you know, then the urge is to do something about it. And then you might do something about it that you didn't need to do and have a side effect that you have to live with for the rest of your life. So there's a lot of regret in some guys who have prostate cancer treatment because they may develop erectile dysfunction or urinary problems afterwards. And now they could have lived without those things because they maybe didn't even need the treatment. Now, it's very individual. It's a very individual discussion to have because every prostate cancer is a little bit different.

2:14:53And some look more aggressive and some are less aggressive. And we grade them and we use all these nomograms to do that. I'm not going to belabor all the specific nuances, but I just think it's really important to have that discussion. Thank you for saying that. Enlarged prostate. Yes. So enlarged prostate prostate is very common as well. Enlarge prostate occurs because of a variety of different things. So one, we know genetics. So if your dad had enlarged prostate and he was young, you are likely also going to have an enlarged prostate. And sometimes you'll know because he won't tell you that, but you might remember, oh my dad was always going to the bathroom or he was in the bathroom for so long trying to empty his blood.

2:15:31You might remember those things or he might tell you that. So that's one. Two is we know like as you are more unhealthy that causes more inflammation in your entire body right. So if you have other metabolic issues your prostate will also get inflamed and then that inflammation causes growth and then growth causes more inflammation that then causes growth. So it creates a sort of vicious cycle in the prostate. Those are the common reasons why prostates grow but very most guys have some degree of enlargement. Now what does that mean for you, right? So can you prevent it? Let's start with that. So people always want to know, can I prevent it or can I shrink it?

2:16:08Once it's grown, I don't think you can necessarily shrink it, but you can definitely prevent it. So there's some data, there's not a ton of data on this, but basically they did trials looking at people for prostate cancer prevention, and they looked at a whole bunch of different factors. But in that, they also looked at enlarged prostate. And what they found was that people who ate more vegetables tended to have less prostate, less enlarged prostate people who ate um who walked more so two hours of walking a week even was good so exercise generally speaking tended to have a lower risk um maybe lycopene so like tomato this is red based uh tomatoes watermelon like fruits and vegetables that are red in color may have a protective benefit so i'll tell people like generally leading a healthy life exercise and diet can help potentially reduce your risk of prostate cancer.

2:16:59Whereas like if you have that enlarged prostate, if you have diabetes, your risk goes up of having enlarged prostate. If you have high blood pressure, your risk of having enlarged prostate goes up. So again, the same sort of things, the unsexy things will help prevent that. Now, when you have an enlarged prostate, I think people always assume like it's very simple, like, oh, you have an enlarged prostate, you have a problem with urination, that's all there is to it, but it's actually a little bit more complex. You can have a big prostate and have no problems, and you can have a small prostate and have problems.

2:17:29It's really based on how it's shaped and how it's blocking the flow of urine, because the prostate sits underneath the bladder around the urethra. So when it gets big, it can get big on the outside or get big on the inside. If it gets big on the inside and it blocks the flow of urine, you can start having trouble peeing. Now, it can also affect your bladder, because now your bladder is pushing to get urine through that prostate. So sometimes guys will present with what we call, there's two categories. There's voiding symptoms. So that means that they can't pee. They're waiting for their stream to start.

2:18:03Their stream is weak or stopping and starting takes a long time and they don't feel like they're empty. That's one type. And oftentimes with both types, they'll wake up a lot at night to pee. And then with the other type, which is called storage symptoms or bladder symptoms. So the bladder is responding to this blockage because the bladder is like, oh, I can't, it's not clear. So I'm going to, I'm going to work harder. So I'm going to have more overactivity. I'm going to go more often. I'm going to feel the urge to go more often. And it's going to be really just really bothersome to me. Right.

2:18:33And so that those are, those are also common. Now, which kind of symptoms you have doesn't really necessarily affect what we do unless you have other issues. So if you're like diabetic or you've had nerve injuries, then we're wondering, is it the prostate or is it the bladder? Because those things can affect the bladder. But for most guys, it's because of the blockage. And when we fix the blockage, all the symptoms get better. And we can fix the blockage in a variety of different ways. For again, lifestyle, you can do some things to reduce the irritation related to enlargement. So you can limit how much you drink before bedtime.

2:19:10So you're not waking up as often. So we'll tell people don't drink like two hours before bed. We'll also tell people like, look at what you're drinking and eating because certain things can irritate the bladder, which can then make things a lot worse. So things like caffeine, alcohol, for some people, spicy foods, acidic foods, like tomatoes and citrusy fruits and juices, even artificial sweeteners for some people. So I tell people, make a journal, see what you're eating and drinking and take a note of your symptoms and pay attention. You're smart. You can figure out like, oh, I had a coffee. I had three coffees this morning and I'm going to the bathroom more often.

2:19:45So maybe I should just drink one and drink two decafs if I love my coffee, because you won't take my coffee from me. I won't take your coffee from you. So, so I think like those are, those are things you can do. Also, if you're constipated, so many people don't know this, but when you're constipated, you're affecting your bladder. So it will worsen all your symptoms, whether you're having more trouble peeing or you're going more often and more urgently. So if you're constipated, you need to correct that. So whether that's with adding more fiber in your diet, adding supplemental fiber, or taking medication to help you go better or moving more, those things can all help improve constipation.

2:20:20So those are things that you can do in your lifestyle to improve. And then also like trying to go twice. So for some people, some guys, sitting is actually easier to empty their bladder when they have an enlarged prostate. For some guys, they still want to stand. But it could be that you need to pee standing up and you got to sit down and pee again and try to empty your bladder completely. Or you need to like take a deep breath and sort of relax the muscles a little bit, try to work on that and then pee again. So there are little things that you can do to make your life a little better. But very often we'll do, there's medical options and there's surgical options to help reduce the prostate.

2:20:54And so that's important to talk to your doctor about. But really the thing that I want all guys to know is that a lot of these treatments do have side effects that can affect ejaculation. So a lot of guys feel like when they ejaculate, that is a big source of pleasure for them. Not just the orgasm, but the actual act of ejaculation. And so a lot of these treatments, medical or surgical, can affect how much ejaculate comes out. And so if that's important to you, because sometimes if you're with someone who's rushed that day and may forget to tell you that that's a side effect, right, of the medication they're going to give you or the surgery they're going to give you, then you will be really unhappy after the fact.

2:21:34And so I just want people to know that because there's always trade-offs, right? Sometimes we treat something and there may be a side effect. But if you are literally not emptying your bladder and you're getting recurrent bladder infections or bladder stones or you're bleeding a ton, like we need to do something. Whereas other times it's just quality of life. We want to improve your quality life. Time doesn't slow down and really you shouldn't either. We all sit around and say, oh, I'll get to that later, but something shouldn't wait, like protecting your family's financial future. Fabric by Gerber Life is term life insurance you can get done today.

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2:23:29A short questionnaire helps identify your needs and preferences. And if you're not happy with your match, switch to a different therapist at any time from our tailored recommendations. With over 30 ,000 therapists worldwide, BetterHelp is one of the leading online therapy platforms, having served over 5 million people globally. This month, don't wait to reach out. Whether you're checking in on a friend or reaching out to a therapist yourself, BetterHelp makes it easier to take that first step. Our listeners get 10 % off their first month at betterhelp.com. That's betterhelp.com. slash srs what about a i mean what about a prostate massage does that help at all i mean what what is that is that simply for pleasure yeah so prostate massage um actually when we were probably when i was younger um before long before i trained urology it was actually a thing that urologists did so it's um essentially like a prostate exam you insert a lubricated finger into the anus and you actually massage the prostate with your finger so you like sort of correct, like stroke the prostate and all the zones of it.

2:24:38And that was thought to sort of help alleviate some potential, usually for prostatitis. So when people had inflamed prostate, they would do it for that because they thought that it might actually sort of cause some relaxation maybe of the muscles. It might cause some expression of fluid that's stored up in the prostate when you ejaculate or when you pee the next time. And so that was thought to maybe help. and so the studies originally showed potentially some benefit ultimately didn't show any long-term benefit um so i would say that prostate massage some people still find it useful like just because a study said doesn't do something doesn't mean that an individual can't find it helpful some people still do find it helpful to massage their prostate for prostatitis or for other issues um but in terms of like something that we do as a medical community not not so much anymore based on the data we have.

2:25:31A lot of guys find it pleasurable to have their prostate massage or include prostate play in the bedroom. And so I think that it's great if you're open to exploring that. Yeah, you might find it unlocks a little bit of pleasure for you. You might not. But I think it's really a very individual choice. And if that's something you're interested in, by all means. Okay. Let's talk about the effects of pornography in your real sex life. Yes. So, pornography has really changed. So, when I was younger, right, you had to get a VCR, you had to go to a sketchy store and find a tape and find a place to watch it.

2:26:14It was very difficult. Or you had to have a magazine that was hidden under somewhere. And so, it was not easy and it was not accessible. And it was definitely very different than what porn looks like today. Now, I think that porn, there are some things I feel strongly about in terms of like, I don't think children should watch porn. I don't think that it should be so readily accessible to people. Like, I think there should be some challenges in getting access to porn, because I think that that makes it much more difficult to want to engage in real life, like desire and sex and like, you know, it does sort of make it more difficult for some people to enjoy regular sex or even seek out regular sex because they have these like very exotic and erotic things very easily accessible.

2:27:04However, a lot of people, adults who are fully frontal, like fully formed frontal lobes can use pornography in a very normal, healthy way. And I think it's very individual. People tend to know when they have an issue with pornography, right? They're like, oh, I'm using it all the time. I don't enjoy my partner as much. Nothing is as good as what I feel like when I watch porn. I find myself using it more than I actually want to have sex with my partner. I find I'm using it more than when I want to go out and hang out with my friends. And so like you sort of start seeing the issues, right? You start seeing it in yourself, but it creates a shame spiral, right?

2:27:40So you're like, oh, I use porn, it makes me feel bad. And some of that may be also because you have a moral incongruence. Like you think porn is bad and you use it, you feel bad. Right? And then you're like, oh man, I feel bad, but I need to feel good again. So I'm going to use it because it temporarily makes me feel good. And I feel even worse. And it creates a sort of shame spiral, which can be really debilitating for people. Now, what I'm seeing in the younger generation is that they've only learned about sex through porn because no one talked to them about it. And so they watch porn, they think this is how I have sex and this is how I get my partner to orgasm.

2:28:12And when they actually go to have sex with their partner, it does not go anything like that because porn is a produced product. It is a meant for entertainment is not real life. It is meant the camera angles, everything is meant for the viewer's enjoyment. It is not for the pleasure of the actual people having sex. They are actors. And so when they go and they have sex with their partner, it doesn't go the way they thought it was. And now they think they're broken and think something's wrong with them. And so that's a real problem because it creates these unrealistic expectations on both sides, right?

2:28:44Men feel like they don't look or have the same results as the porn star. And women also feel like I don't climax immediately upon penetration or I don't look like that and something's wrong with me. And so it creates these really unrealistic expectations. So that's a problem. But when you have a fully formed frontal lobe, you understand that it's a fake product, you can use it as a way to have arousal from time to time. Should it be your only source of arousal? No, I don't think so. Can it be used in a healthy way? Yes, I think it can. And I think most people do use it in, most people use it, period.

2:29:21And I think a lot of people can use it in a healthy way. But I do think there are some caveats. And I do think it should not be like freely accessible because I worry about kids. And on average, kids see porn at 10. Man. And so long before my kid turned 10, I talked to him about porn. I said, you might see this. You might see something that makes you confused. You might see people having sex. Your friend might show you on their phone. Something might happen. I want you to know this is not real. And I want you to talk to me about it and feel open to talk to me about it. Because I don't want you to be confused.

2:29:55That's, you know, I don't want you to feel like that's what real sex is like. Mm-hmm. I mean, when you talk to patients about, you know, porn addiction or just porn in general, I mean, do you, and we covered this a little bit earlier, but I mean, do you feel like it would be, is it healthier to save that for your partner? I think it depends on the person. So I think that like, you know, you should vary your arousal. It should not all be based on pornography, right? So you should be able to get aroused by thinking. You should be able to get aroused by fantasizing. And if you want to use porn occasionally, it can be nice to explore other areas of things that might be of interest to you, to learn maybe something else that might turn you on that you never thought of before.

2:30:43It can be, as a couple, if you are both on the same page and you watch it together, it can actually increase sexual satisfaction and relationship factors. We've seen that in studies. But again, I think it's very individual. And I think that if you are finding yourself solely relying on porn, like you cannot masturbate without porn, then that's a red flag to me. You should be able to have arousal without that. I remember when I was in medical school, I had a friend be like, I love springtime in New York. And I was like, why? He's like, because it's the sexiest time. Girls are all wearing skirts and you can see more skin.

2:31:21And I was like, it's so funny to me now because nobody would ever say that now. Because it's like, you don't need to wait till springtime. Like you just look at your phone and you'll see whatever you want. And so like, there's no like, it's like the simple thing. And think about even like way back when you would have to court a partner. You would have to walk with them and talk with them and you would barely be able to touch their hand. There would be this buildup, this tension, this like, oh, I'm so excited to be with you. and to touch you. And I feel like we've lost a lot of that. That actual enjoyment of being with someone else and glamorizing that versus, oh, I can just watch this on porn and have fun for a few minutes.

2:32:07Yeah, I think it's a big problem in the entire world right now. Yeah. And again, I think that it's just about, I really feel like it's dangerous that our kids have access to it. Yeah, me too. We've covered that a lot on this show, which actually we were talking about it this morning with Ryan Montgomery and you watched Tim Tebow one, it sounded like. And those were cornerstones of both of those interviews. But, you know, we're kind of winding down the interview now. And, you know, one thing I wanted to ask is, you know, what are some of the most common sexual health problems in men that go ignored?

2:32:51Yeah, well, number one is, I mean, the most common is erectile dysfunction. And I think that, like, it's not that it gets ignored, but I think that men are embarrassed. And they don't come and see the doctor. or when they do, they just get given a prescription and say bye. And I think if, and that's why I'm writing my book that's coming out next year is, is I want people to know like, you can fix this, you can fix your life and you could, you have the power to do that. And you can improve your health and by way of then improve your erections, because sexual health is health, right? But I think like they get very discouraged.

2:33:26And when they finally do go get help, they just get a prescription. They don't get any information, right? So I think that's a big one. And then they're embarrassed too. And I guess, you know, Now there's a little bit more where you can get these online companies, which will at least prescribe you the medications. But at the same time, they're not still giving you that education, which is really what I think is the missing piece. And they're charging you a lot more for the medications than you could get an online pharmacy. You can get them for cents on the dollar. So I think that that's a big one.

2:33:57Another one is whenever they feel less masculine. So, like, if they feel like maybe their desire is not there, maybe they're struggling with premature ejaculation, they don't ask for help. They struggle in silence, and they live in silence, and it is heartbreaking. Because by the time I finally see these patients, they have been through a lot. And they have, it has shaped who they are as a person. Man. And they cannot, and they can't talk to anybody, right? Men are just have this, they don't talk to, like, women talk to women, right? They'll be like, oh, I have a problem. It'll come up somehow.

2:34:33They'll feel comfortable confiding in another woman. A man will never talk to another man about his issues in the bedroom, or really many issues. They just don't. They're stoic. They tend to be problem solvers. They don't want to sit there and whine or complain, right? And so they just sort of grin and bear it. And they grin and bear it in front of their partner. They may, I mean, it can go so deep where they've even had divorces or ruined relationships because they won't talk to their partner about their issues, right? And they run so deep that they're just suffering in silence. And it really, I just, like, I want anyone listening is if you're struggling, like, please at least talk to a urologist, at least talk to your doctor.

2:35:11Like, talk to somebody. I don't care who you talk to. Talk to somebody. Because even just saying the issue out loud can help you sort of process it and deal with it. And, you know, learn, educate yourself, watch content, mine or anyone else's, like, learn about your body and give empower yourself to like take the actions you need to fix it and then you know working being a va doc i mean i come from a special operations background a lot of tbi a lot of pts a lot i mean what are some of the commonalities that you see within you know war fighters who are coming home who have these kind of invisible injuries i mean how does that The most common is PTSD, right?

2:35:56So I think on at all, like, the majority, like the large majority of patients that I see have PTSD. Large majority. And they're all on, you know, medications to help with nightmares and they're struggling, right? And we know that with men who have PTSD, their rate of erectile dysfunction is significantly higher, like three times higher. Three times? Mm-hmm. Than guys who don't have PTSD, than veterans who don't have PTSD. So just even within the military community, If you have PTSD, your risk is significantly higher. Wow. So it is, I mean, mental health and sexual health are very, very intertwined.

2:36:32And I know that the VA tries to do a really good job of getting help for veterans in terms of PTSD and mental health, but like, it is a real struggle. And it is something that is really, really challenging. So, you know, I think that's a big one. And then also, like, it's crazy to me that, you know, my vets will come see me and I'll like, do you want something for your erections? And they'll be like, oh, no one told me I could have that. Or no one's even asked me about that. Right? So beyond, they're already at high risk, right? And from TBI. So TBIs can affect hormone health. So a lot of guys with TBIs will have low testosterone.

2:37:08And so they usually will get tested for testosterone, but they're not asked always about their erection. So even with those patients, like, it's like they may be given medication, but they're never educated on it. And no one's really linking that mental health aspect. Like, we need to fix the mental health aspect so you can actually... I mean, think about it. If you're having better sex, you're probably helping your mental health too, right? It all goes hand in hand. So I think it's really a challenge because they have so much going on that those things become forefront and sexual health goes in the back.

2:37:43I mean, is there... Do we know why PTSD can, can, makes it three times more possible for somebody to have erectile dysfunction? I mean, all mental health issues are linked with sexual dysfunction because, um, it's sort of like, if you're, I mean, just very simplistically, and this is not, this is too simplistic, but if you're sad, you can't get aroused, right? You're not going to get turned on because you're sad, right? Like, it's just, you don't, like, sex is not on your mind. You're, like, thinking about all, and you're in a sort of a fight or flight sympathetic nervous system. So when we think about erections, to get an erection, we call it point and shoot.

2:38:24You need a parasympathetic nervous system, which is your rest and digest, your relaxed nervous system, to be activated for you to get an erection. You need to not be in a state of anxiety or stress. And then when you have your ejaculation, that's when your sympathetic nervous system turns on. So if you are constantly stressed, depressed, anxious, PTSD specifically, there's a lot of sympathetic nervous system activity when you have PTSD. So you just can't get into the mind state, the nervous system state, to be able to get an erection. Okay. Is there anything that men can do to last longer in bed?

2:39:01Yeah. So a lot of guys think, oh, if I just think about my grandma or something super non-sexual, it's going to work. Now, for some people, if you don't have any issues and you're just trying to last longer, sometimes that does work. But most times it doesn't, it actually hurts, right? Because now you're like introducing this very non-sexual, non-pleasurable thought in a moment that you should be like feeling really good, right? So I think a lot of it is, I mean, of course there are medications and things, but I don't, I think that just talking about non, like things that you can do that are like actionable.

2:39:34One is interestingly is breathing. So like doing diaphragmatic breathing. So like really deep into your diaphragm is actually going to help rev up your parasympathetic nervous system. And so people who do this type of breathing, even outside the bedroom, and they do it regularly, have been shown to last like 900 % longer. So I made a video on that. 900 % longer? There was one study that said 900 % longer they do diaphragmatic breathing. Plus they'll do some exercises, which are like the stop-start technique. So you get almost to the point of climax and then you kind of bring your arousal down and then you go again.

2:40:11You do like three times and then on the fourth, it's sort of like edging. And on the fourth time you ejaculate. So those sort of actions as the same time with breathing has been shown to increase the ability for people, at least men with premature ejaculation to last 900 % longer. So and then sometimes doing those breaths during arousal. arousal. So like sort of calming things down, because as you can think about it, like you're, it tends to be like a very like, quick sort of like, oh my god, oh my god, man, like, you know, when you're having sex, you get really excited, right? So you just need to calm things down.

2:40:46And then you can last longer. Now, another thing that has been shown, these are small studies, but I think they make sense. And they actually are so easy to do that, like, I'm like, every man should be trying to do these in general, right? They're good for your health, too. They're good for your mental health. Another one is using exercise. And the reason certain exercise, specifically high intensity interval training, because it helps your brain sort of get, understand where your body is in time and space. So you get what's called interoception. And that then as you do that in practice, when you're exercising, then when you're in position with your body, you can start figuring out the cues like, oh, I'm getting close.

2:41:23You can follow your arousal like when are you getting close to climax and sort of dampen things down a little bit so you sort of learn your body better because you're doing those exercises and the study was seven minutes of high intensity interval training daily showed an improvement in as quick as two weeks in terms of increasing length now they looked at other exercises too yoga and running because again those are also very mindful exercises like long distance running yoga fastest to do improvement was the hit followed by running and then followed by yoga. But again, they all can help. And so I think it's just really about being mindful of where your body is, learning what does it feel like when I'm getting close to ejaculation and being able to be present in the moment.

2:42:09And mindfulness, again, exercises like meditation and just really learning how to be one with yourself. It's really like understanding your body so you can say, hey, I'm letting my arousal sort of climb slowly rather than, you know, and I'm sort of enjoying the process of getting there. Not like so fixated on like, you know, all the stressors of like, oh, when's it going to happen? Is it going to happen too soon? Like, you know, that's also revving up your sympathetic nervous system. Mm-hmm. Mm-hmm. Last question. Second to last question. Mm-hmm. What, I mean, you have kids. How do we talk to kids about all of this stuff, sexual health?

2:42:53What age did you start talking to your kids about? So I started talking to my kids, just basics, anatomy, when they were little. So this is your penis. I mean, for boys, it's easier. I think for girls, you have to tell them what is so funny, because I have so many funny stories with my kids, because they've always been very open with me. and so like when they first started having I hope they never watch my podcast interviews because they're going to be so mortified but like like but when they were little and they the first time like they would get erections uh they're like mommy why is it getting big right and I think this is completely normal so you're just having an erection it's a completely normal thing whereas I know other friends like oh my god what do I say you know what I mean they would sort of freak out and I'd be like look and they would ask me I said just tell them it's normal like it is normal to get random erections there is nothing wrong with it um so that was one i would also tell them they would be like oh like my son would go like on a roller coaster they go it tingles down there i'm like yeah that's okay that's like a normal sensation but he would just when he asked these questions i would ask i would answer them as best i can i remember one time he asked me about sex i was like not prepared in that moment to answer it right and i was like okay give me a second like i will answer this question later and i talked to my husband about it and i was like okay how do we go about this.

2:44:05He's like, no, you should talk to him about it. Like you're obviously more skilled at talking about sex. And I was like, he's like, and we decided like, it's obviously going to be better for me to talk to him about it now when he's curious rather than him going to ask someone else. Right. So he asked me, I told him, this is what happens during sex. And this is how it happens. And then when I had the same conversation with my younger son, he's like, so wait, if it, what if I just like fall, like, what if I fall onto her? Will we be having sex? And I was like, no, no, no, that's not how it works.

2:44:31So like, it's so, it's so innocent, their conversations, but it's also like this is and so we've been doing it so long and so now we have sort of a routine we'll go on walks and they'll know that if that's a time they want to talk to me alone they'll sort of like be like hey mommy can we can we talk and they'll ask me questions or they'll they'll you know they might have seen something in a movie or maybe their friends had something at school and so they know that they can ask me anything right and then I will also like I remember I had I talk about sex all the time but I had forgotten that like oh I need to talk to him about wet dreams because they're going to happen.

2:45:04I don't want him to feel embarrassed, right? Because you kind of, I mean, you probably can recall when you had that happening. You're like, oh my God, what happened? Like, this is horrible. This is scary. Like, am I dying? What's going on? Right? And everyone has a different reaction, but I was like, didn't want him to freak out. So I remember telling him like, this might happen. It's okay. Just let me know. We'll wash the sheets and it's totally normal. Right. But it's just simple thing that like, you don't even think, especially as a mother, like I'd never had that experience. So I had to like, remember, oh yeah, this is something I need to tell him before it happens.

2:45:32So he doesn't freak out and think something's wrong with that. I mean, what do you, how do you, what age was that when you were having a discussion with your children? We've had so many for so long that I think I started, because the average age where kids see porn is 10, I think I started talking to my son at eight about porn because I was like, I didn't, you know, I don't know who he's going to see it from. I'm going to do my best to like, you know, put all the locks on my phones and anything that he has access to. And, you know, but like, I don't know what his friends have locks on their phones.

2:46:02or if they have phones, right? Like, all those things. I just don't know what he's going to see when I'm not with him. I'm not with him 24 hours a day. So I had to prepare myself for the fact that he might see something. And even though I don't want him to see it, and I wish he doesn't, I know he might. And he's actually told me that some kids in school have talked about porn. Now that we've had this, he's 12 now, but he's told me that kids have talked about it. Like, oh, you know, we watch porn. And I was like, he's like, I'm like, have you seen it? And he's like, no, I haven't. I'm not really that interested because we've talked about it, right?

2:46:35And I think like he realizes like, it's not really all that cool. Like it's a, it's a fake thing, you know, and it, and it's not necessary right now. Um, so, you know, I think, uh, and he knows he can come to me. Like I can tell him any question he wants, I'll answer it. I might answer it right that second, but I will think about it and I will answer it. And so, yeah, I mean, I started talking to them, like I said, when they're little, just about their anatomy. And so like slowly, but But the sex question, he came to me. And I think he was, I think it was around eight. He came to me and asked me about it.

2:47:05And I was like, okay, now is the time to answer it. He's asking the question, so I have to answer it. You know, and so I made this routine where we go for walks and I tell him about whatever. And he knows that's a great time where he can ask me. I don't have to look at him in the face either. I can look straight ahead and answer and he can look straight ahead. And we don't have to have like an awkward, like, you know, face-to-face interaction. But, you know, we're just talking. And I think you gotta find, you obviously know your kid, and you know how you want to parent. But I think, like, we as parents have a responsibility in today's society where we have less control over what they're gonna see, because they're out in the world at school, and kids have phones, which is crazy to me.

2:47:47Like, you know, we don't have as much control as we would like. And I mean, so we have to be responsible and teach them. And because the other thing is, it's sort of scary. Like some of the things they're going to see. So for example, choking is a big thing in porn right now. And so I had a researcher on my podcast, Debbie Herbenick, who wrote this book called Yes, Your Kid. And so she did research on college age students. And she found out that choking became very, very common in sexual encounters. And it's fine if someone finds it pleasurable, but it's dangerous, right? Like you're asphyxiating someone, you could cause really serious harm.

2:48:26But they're doing it so casually. like it's almost like kissing and and when you when they did the surveys they found that women were most often getting choked women and a lot of them were not that into it i mean they were okay they're like yeah you can do it they were getting asked but they were like really not that into it they were just doing it because they felt like that was what was done and so that's just one example of how these things are being perpetuated from what they're seeing and they're not these things are not focused on pleasure they're just focused on getting you entertained and so like They're not learning how to pleasure each other.

2:48:58They're not learning how to have a meaningful, intimate encounter. And it's really sad. Yeah. I love the walking method. Yeah. It's a good one. That's great. Like you had mentioned, it's not face-to-face. You can look. And I tell even couples, do talks when you're not looking at each other. Because in the beginning, no one taught us how to have sex, right? Or how to talk about sex, or have sex, really. But no one taught us how to talk about sex, right? So it's super awkward. And it's not a one-time conversation. If you want to have a meaningful, really robust, amazing sex life with your partner, you've got to talk about it.

2:49:35And so I tell people, like, when you're in the car, when you're on a walk, so you don't have to, like, look at each other across the table. And definitely never in the bedroom. Like, just have these conversations in places where, you know, you have a little room to, like, wiggle and look and feel awkward, but don't just show it to each other. Love that. Love that. All right, last question. If you could recommend three people for this show, who would they be? Oh, gosh, three people. Okay. Well, if you want to do more sexual health, I had Dr. Barry Kamisarik, who is a researcher who researches female orgasm and brain MRIs.

2:50:12That was a really interesting conversation. Who else? I'm trying to think. I think your audience would be like Dr. Alok Kanoja. He's a physician who really focuses on gaming, but he has a lot of insights into the psyche of the young man right now, and how to manage these gaming addictions, and also people who struggle with pornography and things like that. All in the same... Yeah. And let me think of a third one. hmm I think um

2:50:55do you know any sex therapists oh yeah I know a lot of sex there but I think of the best one for you let's see um let me think on that one all right I want to give you the right name perfect perfect yeah well rena this was a fascinating conversation like I said thank you so much for coming and uh and I'd love to see you again yeah thank you so much for having me all right cheers

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