What's the deal with hypoactive sexual desire disorder (HSDD)?

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21:18Emily Oster:All right, we are back. We're asking, what's the deal with hypoactive sexual desire disorder? Okay, Emily, this is one of the topics, maybe not HSDD per se, but like sexual activity, sexual function in my age group, in my cohort, presumably in your cohort as well, is something a lot of people sort of allude to without really digging down on. There's a lot of like, there's a lot of sly comments, like sort of the boomer humor stuff that I hear about, you know, like, uh, you know, my wife's got a headache, like that kind of thing. But no one ever really sits down and, and compares notes. I mean, I think fortunately, but, but that's sort of what we're here to do because if something is a disorder and it's out there, people might naturally wonder, like, do I have it?

22:09Emily Oster:What do I have it? And I think maybe the place to start before we talk about like a disorder of sexual function is what is normal here? Like when we think about this, especially, you know, for people our age, you know, 40s, kids, that kind of thing, you actually have some really interesting data on this. Yeah. So I want to start by, I once did a really great podcast with Emily Nagoski, who is a writer who writes about sex. And I asked the question, what's a normal amount of sex? And she was like, that is the worst possible question. And I came to think that she was right because of course, there's average.

22:54I can tell you in the data, what is the average, but the word normal has this connotation about what is appropriate or what you should do. And I think that's actually not very helpful in a place where people are going to vary in what makes them happy. So I'm going to tell you the average, but I'm not going to tell you what's normal.

23:14Emily Oster:I think that is very well said. It doesn't imply that if you're less than the average or more than the average that you are per se abnormal or pathological, but please go on. Okay. So I got very interested in this question a couple of years ago because I talked to a lot of parents of young kids and it comes up all the time. The question of, you know, are, are people having sex and how much are they having? And it's a place where people just like to have data. So we did this big survey of parents and people were very, I do a lot of surveys actually on my website. And this was by far the most popular.

23:51So I got 26 ,000 people to report their sexual frequency data. It's pretty amazing.

23:58Emily Oster:It's one of the largest studies of its type, as I was looking through the literature too. So the answer is that for parents at least, sex varies quite a lot with the age of the youngest kid. So in the data for people with kids under a year, the modal frequency was once to twice a month. For people with kids over five years, the mode was more like one to two times a week. There's a reasonable share of people who say that they never have sex or less than once a year. It's not very high, but it's certainly, you know, for almost 10%, basically, for people with very small children. And there are a very small number of people, like less than 1%, even with older kids who say they have sex every day.

24:46So, you know, like we're kind of, if you ask what's the average, it's something in the range of twice a week to once a month.

24:56Emily Oster:I think one of the really interesting things that was in your data was this relationship with age of parents and age of kids. So what you found is that if you holding the age of kids steady, like statistically, the older the parents were sort of the less frequently they would have sex, which kind of makes sense, right? You get older, like things happen. But then the older the kids are, the more often the parents would have sex. And of course, those are correlated because older parents tend to have older children and everything. So it's this really complex interplay between biology, which is as we get older, like the hormones that drive our sex drive decrease.

25:37Emily Oster:And then like logistics, which is like as our kids get older, there's just more opportunity. Do you think that's true? This is a different topic. But I feel like there are some ways in which having older children presents less opportunity. Okay. I mean – Because then they could catch it. Well, anyway. Okay. Oh, no. I think this is a critical thing to discuss. And if any of my children are listening to this, please turn it off. Turn it off. Go to bed. Go to bed. It's bedtime. Go to bed. Sleep is important. Stay in your room. So one of the things I thought was interesting, which maybe sort of leads into the question of how we sort of pathologize this is actually a pretty large share of people said that they were not having enough sex.

26:29This was so fascinating. Or not as much as they would want to.

26:32Emily Oster:Right. And so even the people who are having sex one to two times a week, about 40 % of them said they were having somewhat too little or way too little sex. As you get to people who are having sex a few times a year, almost 100 % of them say that's not enough. And this for me was actually a much more telling piece of the data than the frequency. Because I think if you say, you know, we're having sex twice a year and that works for us, like that feels like enough, then it's great. It is more concerning when you have almost everyone saying, well, actually, I'd love to have more, but something else is happening that's getting in the way.

27:11Men obviously are more likely to say they don't, they're not having, men would like to have more sex than women.

27:19Emily Oster:Oh, yeah. When you stratified by sex. But many women in your survey, in fact, the majority are also saying, yes, I'd like to have more. So in theory, you've got these couples, right? Both members of the couple are like, I really wish we'd have more sex, and yet we don't. Yeah. And I mean, it's interesting. Okay. I'll just say one more thing about this, which is that people left a lot of comments, like thousands and thousands of people left comments. And some of this is just, I'll just read this because I think it summarizes a little bit of how people often feel with little kids. It's not that the sex is bad or that I don't love my spouse as much.

27:57It's just that we're both so tired all the time that the sex is very bland and feels like something we do quickly just for basic maintenance while the kids are temporarily asleep. The best analogy I can think of is forcing yourself to eat because you know you should, even though you're not actually very hungry. Okay.

28:12Emily Oster:That's a little bleak. It's bleak, but I think we should come back to it later because actually there is some stuff in the data suggesting that that actually may not be a terrible approach to sex in some cases. So that's probably a good place to move into what we actually mean when we say hypoactive sexual desire disorder. Right. So let me start by saying we don't mean like everyone like sometimes isn't in the mood. right? Like that's normal. That's natural. It's not, you're, you know, you're not going to be there all the time. This is, um, hypoactive sexual desire disorder is a clinical disorder.

28:54Emily Oster:Um, and because it's clinical disorder, it now appears in the DSM five. So the diagnostic and statistical manual is the big book of psychological diagnoses. It's where you find like, oh, what do I, you know, what criteria do you need to fulfill to have major depressive disorder or bipolar disorder or schizophrenia or anything. And as of the fifth edition, which is the most recent, HSDD was put in here, although in the DSM-5, they call it female sexual interest slash arousal disorder. This actually engendered some controversy, which I'll get to in a second. But just to say it, in order to be diagnosed with this, you need to have decreased or absent three of the following things.

29:35Emily Oster:Interest in sexual activity, sexual erotic thoughts or fantasies, initiation of sexual activity or unreceptive to partners' attempts to initiate, sexual excitement or pleasure in almost all encounters, sexual interest slash arousal to erotic cues, genital or non-genital sensations during sexual activity. It needs to be going on at least five months. It needs to not be better explained by something else, like a medical condition or medications you're taking or stress or the million other things that obviously can cause all these things. And here's the kicker for all psychological disorders. It has to be causing you significant distress.

30:09Emily Oster:You have to be upset about it. So the piece of this that I find a little hard in diagnosis is all of these things are kind of in the abstract, but most of the time we're thinking about sexual behavior in the context of a relationship. And so there's actually maybe an important distinction between like, am I interested in sexual activity or initiation from the person who I have available, or am I interested at all? I think there is an important distinction here, which is, would you like to have sex with someone, or would you like to have sex with the person that you can have sex with? And those things may not be the same.

30:48And in principle, that seems like quite an important distinction because a sexual interest arousal disorder is not a marriage problem. It's not like there's a partnership problem, it's supposed to be a thing about your sexual function, not about the other person, but it feels almost impossible to separate those.

31:06Emily Oster:Yeah. And as I said, there was some controversy about this in two parts. Number one, the DSM-5 links sexual interest and sexual arousal in the same disorder, which is really not the same thing. One is a physiologic thing, you know, Like arousal is a little clearer to document in a man because of penises and erections. And so men have an arousal disorder. Men can have impotence. And there's like a drug to, there are many now drugs to treat that. That's different than interest. And it's the same with women. And so the DSM did get some criticism for that because those things are separable. There are women who are very interested in sex, but just physically don't become aroused in that way.

31:52Emily Oster:Lumping these together doesn't seem necessarily appropriate. The other controversy is that you'll see some people arguing that hypoactive sexual desire disorder basically was created to sell drugs by the pharmaceutical industry. And we'll get to what those drugs are and they're FDA approved and whether or not they work. But this is kind of a new thing. And I think it's important to tease out, as you say, like, whether this is truly something inside the woman with hypoactive sexual desire disorder, or if it is a result of external things, whether that's the relationship, whether that's the result of life stress, et cetera.

32:29Yeah. I mean, this feels to me like, you know, if you think about some of the symptoms we associate, say, with perimenopause or menopause, like vaginal dryness, it's like a very specific reason that you might not be like that you might have trouble having sex or not find it as pleasurable because of this particular symptom. and that is something that deserves treatment. It has various kinds of treatment, is totally different from interest, but is going to show up in some sense in the same way. Like if you are not, if you're not going to enjoy this, you're not going to want to do it. Again, those things are not the same.

33:04And so you almost want a diagnosis like, well, do you like watching porn? Like, if you watch the porn, like how do you react to that? And that's separate from do you want to do yourself or would you enjoy doing this?

33:15Emily Oster:Yeah, absolutely. I mean, that's what one of the criteria of in the DSM-5 is like a difficulty or decreased or absent arousal to erotic cues. So it is clear that like, you know, this is supposed to be something, right, regardless of what you're watching, regardless of whether you're reading, you know, Fifty Shades of Grey or you're with a partner that you love or you're with the partner that you hate, like it's all the same, Right. Yeah. Let's talk about distress, though. So can I ask another thing about the diagnosis also, which is are they looking for changes over time? So I think, you know, we can there's so much variation of in just general interest in sex, I think, across across the pipe.

33:56Some people have a higher taste for sex than others. Just in general, I would have thought that we'd be looking here for things that are changes from your norm. Is that part of the diagnosis or not?

34:11Emily Oster:No, it's not. That's not in any of the criteria. It does have to be persistent for five months. But of course, if that has been your norm forever, that's your norm. And it has been persistent for more than five months. But again, it has to be causing distress. So they actually call out in the DSM-5, they call out asexual orientation. And as like, this is not hypoactive sexual desire disorder. So if you are asexual, if that's your sexual orientation and it's not causing you distress and you've been that way, then that's it. You don't have a disorder. That's just who you are. I think this distress thing, though, is the one I keep getting hung up on.

34:50Emily Oster:And by the way, this appears in every DSM-5. It's almost like for every diagnosis you can have psychologically, there's always like and it is harming your everyday life or it's causing you distress or something. Same with like alcohol use disorder and everything. But when it comes to sex, there's other people involved often. And so I do wonder how you tease out like this is causing me distress because gosh, I wish I could get more interested and it's just a fun zesty part of life that I'm not engaging in and I wanted that to change versus it's causing me distress because my partner is upset with me.

35:28And like, how do you know the difference? Yeah. I mean, there's a thing in the DSM about this is not explained by relationship stress, but it seems awfully difficult in the context, particularly of long-term marriage and so on, for this to not be wrapped up in disconnects between people and in relationship stress. I mean, this is a huge source of stress in many marriages. So I guess I worry with this diagnosis in general that we are pathologizing a set of issues which are really not at all about something physical and are just things we should be trying to address to make people happier. And we've gotten to, well, we're going to give you some drug for it.

36:16Yeah.

36:16Emily Oster:Yeah. Yeah. Well, that's much more profitable. Totally. Than just trying to make people happy. Yeah, so true. You know, you've alluded to the fact that there are baseline libido differences in people. And I think that's true and relatively well-established that like there's some kind of libidinal set point that people have. And yes, it changes over time. And generally, as you get older, well, at least post-puberty, as you get older, that sort of wanes, kind of difference between men and women. What that means, of course, is that in partnered relationships, there is the potential to have a discrepancy.

36:51Emily Oster:And this is, again, where I kind of keep coming back to with HSDD is like, is it the discrepancy that's causing the problem or not? And so I was looking into this a little bit into the data, and there's actually like a really rich body of literature about like assessing libidinal discrepancies in married couples of all genders and sexual orientations. And it's fairly robust. So let me tell you, I'll go through one of these from the Archives of Sexual Behavior in 2014, and I'm curious what you think here. So this is a study that looked at over 1 ,000 married couples. They assessed the desire, like they asked each member of the couple how often they would like to have sex, how often they were having sex.

37:35Emily Oster:And I'm wondering if any of these findings are surprising. So 52 % of females indicated the desired frequency was equal to the observed frequency. So they were like, this is, we're at the right spot. 37 % of males said that. 48 % of husbands reported a higher desire reality score. So that's like they want more than what is happening than the wives did. 18 % of wives reported higher than their husbands. Greater discrepancies between this were associated with lower relationship satisfaction, greater conflict, lower positive communication, all with sort of modest effect sizes. So how do you take this literature?

38:17Emily Oster:I mean, this is both men and women actually saying that they could do more, but men, again, men wanted more and more than women. I don't find any of these things in this space surprising. I think exactly what they mean is, again, a little hard to tease out. So one issue that comes up all the time is the question of what direction is the causality? So is it that people have a discrepancy in their desire and that's leading to relationship dissatisfaction, which is leading to more just desirable discrepancies? Is it that they have relationship dissatisfaction? That's leading to the discrepancy, You know, and then when we think about the amount, the sort of desire for more, there's a glass half full, glass half empty, which kind of comes back to some of this discussion of, you know, what happens with kids.

39:14Like a lot of what happens when people have children, I should say, which is that a lot of what people are saying when they talk about wanting to have more sex is almost like it's almost a positive frame. it's like, I wish I had more time for this as opposed to like, I wish I were involved with someone else that I was more interested in having sex with. It's sort of like, I want to do this. When we do it, it's great. It's just hard to find the time, but it's a positive statement. And that feels different than I'm frustrated that my partner doesn't want to have sex with me as much as I want. Yeah.

39:52Emily Oster:I like thinking of it that way. And I think to some extent, even being able to communicate that between partners can be helpful, right? There's like, just like, hey, by the way, we're on the same page here. It's not always going to work. But, you know, it's still, the desire is still there, right? Because there's, you mentioned that one of the comments that you got was someone talking about sex is just kind of like maintenance on a car, right? Just like something that, you know, you got to do periodically to kind of keep things together. And yeah, I said that feels bleak, but the truth is some of the data, and maybe you can walk us through this, like suggests before we get to drugs and stuff like that, that this is a strategy.

40:37Yeah. So before I talk about the data, I want to read you this quote, which I love so much from someone. We're both so tired, but when we do it, we're always like, man, that's great. We should do that more.

40:47Emily Oster:I know. That made me very happy because I think that is, for some set of people, this is really about – it's not a phase of life in which this is a thing we're doing as much as we would like. Of course, there are many other people who will say, I just don't want to do this anymore. It doesn't make me happy. And of course, there's other things that we don't have time to do. Like I didn't get to go to the gym today. I wanted to go to the gym. I didn't have time. You know, I had, there was too much other stuff going on. So this is not like exclusive to sex for people with kids. No, totally. People actually also say they want to talk to their spouse more.

41:27Yeah. Go on dates. Talk to them or have sex with them. Either one. All right. Sometimes both at the same time.

41:35Emily Oster:Got to multitask people. Multitask. All right. So there are a bunch of strategies that people have tried to use to mitigate these issues, which have some, at least I would say, survey-based evidence that they work for some people. So one is communication. Talking about how you feel about things is almost always a good idea. and a very large share of people, more or less 100 % of couples say that having some communication about differences in sexual desire is helpful. This is why therapy is helpful. But another thing, perhaps almost as helpful as communication is an activity people call Have Sex Anyway, which is actually a core part of some marital counseling advice when people are struggling with this, which is just to say, you know, just even though it's like eating your vegetables, the starting of it may feel like eating your vegetables, like just put it on the schedule.

42:43Say twice a week, we're going to have sex on these times and it's going to be on the schedule and we're going to do it. Partly because for many people you do it, you're like, oh, that was pretty fun. And there's a moment of connection. And then you kind of get reminded that this is an enjoyable activity, have sex anyway.

43:00Emily Oster:Yeah. I mean, this is, you're quoting data. The numbers I'm looking at are pretty impressive. So you're quoting data from this study of 230 couples from the archives of sexual behavior in 2020. And as you say, 0%, not a single couple said communication was unhelpful. Like every single couple said, you should talk about this. That's the number one thing, but coming in hot at number two of the coping strategies with only 5 % of couples saying it's not helpful was this have sex anyway. Have sex anyway. There are other things which seem to work for some people. So engagement in another activity with the partner.

43:41So doing something else to try to connect with your partner. About 88 % of people said that that was helpful. Date night. The other thing people say is, you know, do it by yourself, which this study refers to as engagement in activity alone. Masturbate. And I will say 80 % of couples here said that that was useful. And I think part of it is, you know, if really the issue is one person just wants more orgasms than the other person, it may be that the compromise is that they get to have some of them by themselves. But it is a thing that people found, almost no one found helpful was doing nothing.

44:18Disengagement. Nobody likes that. So don't do nothing.

44:21Emily Oster:Don't do nothing. And this can be obviously something that's difficult to talk about, going back to communication. In part, and it's not just because it's like, ooh, it's a taboo subject and whatever. Most people, after they've been married for a while, have talked about a lot of things. But in part, it's because that also takes time, which we've already established we don't have a lot of. And so it's like, and by the way, let's cut out some extra time to talk about our sex lives and stuff like that is also something else that fills up the schedule, which I think can be, you know, it's easy to put off, I guess, is maybe the way to say that.

44:59I also think you're understating how difficult people find it to find to discuss this with a partner, you know, particularly if it wasn't something that you needed to discuss as much, you know, but you like in earlier parts of relationships and there was more time and, you know, people were. But we get older, people's bodies change. They want different things. Like maybe they're feeling like the idea of bringing up, you know, well, why aren't we doing this more? Like, is it because you aren't as excited about me? and or is it like I think people have this is hard talking about sex and talking about money are really hard even with people that you love this is fair and there I think we're all afraid

45:36Emily Oster:of opening a can of worms too right like you know what am I going to hear and am I going to hear something I don't want to hear especially hard from people you love so Emily let me put on my uh pharmaceutical hat and say like talking is tough and takes time how about you just pop a pill How about that? You don't even have to do it. You don't even have to tell your partner. Sounds amazing. I mean, look, it works for men. Okay. I think part of the thing here is, you know, this is all coming out of, again, like a very clear medical diagnosis, right? Erectile dysfunction is like a real thing. It's like a real physical thing.

46:15You need the penis to be away. It's not the way. We came up with a system to make it the way that you need. Like that was like a solid and they made a really just an absolute ton of money on that.

46:28Emily Oster:Yeah. Yeah. Banger drug. That's a banger drug. It's one of our best drugs. It's really one of our best drugs. You know, I think most people know this, but just to say that Viagra was originally developed for pulmonary hypertension, it's a vasodilator. And this was just a very pleasant side effect that the initial trials revealed as part of adverse event reporting. People were like, something's going on here. Um, so, and Pfizer was like, uh, pivot. Screw you pulmonary hypertension. Fuck you, lungs. Those are not important. Um, yeah. Yes. So, um, let's talk drugs. We have two FDA approved drugs for hypoactive sexual desire disorder, whatever that may be.

47:14Emily Oster:One is flabanserin or Adi. Adi? Adi? which is taken. Why do they name them these things? I don't know. It's a pill that is taken daily at bedtime. The mechanism, it's always like, it's really interesting. Like we don't know enough about sex and arousal and desire and the complexities of the human mind to actually know why a lot of these drugs work. So like this drug, flabanserin, is a partial serotonin agonist, which like, okay, serotonin is important. But like we have SSRIs, which, you know, have a well-described side effect of decreasing sexual interest. Like it's way too complicated to fully understand.

47:59Emily Oster:One of the things, I'm curious what you think, Emily, is in these trials, right? So if you're going to get a drug approved by the FDA, you have to say there's a disease that it treats. Okay. So, all right, we've created hypoactive sexual desire disorder. It's a disease that it treats. And there's an outcome that we can show with statistical tests improves. And so these researchers and pharmaceutical companies had to come up with that outcome, something measurable that they could send back to the FDA and say, look, this thing increased. And the thing that they used in all the flabanserin trials was an outcome called satisfying sexual events.

48:39Emily Oster:So a satisfying sexual event is a sexual event that could happen with or without a partner. It could happen with or without an orgasm. It could, you know, anything that the woman taking the drug would define, but it had to be satisfying and however she wanted to define that. And the pivotal trial for flibantarine showed that the change in satisfying sexual events per month was 1.2 in the placebo group. So placebo effect, once again, rearing its beautiful head. One extra sexually satisfying event in the placebo group. Two extra sexually satisfying events in the flibantarine group. Is that the correct outcome should this have been FDA approved?

49:27I mean, I don't – it's very difficult to say what would be the right outcome. You know, you could say how many times, you know, there's a more direct thing, which is like how many times did you engage in a sexual event, either alone or with a partner? My guess is that they didn't, the issue with that is that the placebo effects are like too strong, particularly if you start taking this drug and people are like, okay, now I'm taking this, I'm going to have more sex with my partner. My guess is the placebo effect is too big and that you don't get anything.

49:56Emily Oster:Right. It's like oysters, right? Which have no aphrodisiac effect, actually. But like, if you think they do. Yeah. So I can see why they didn't go with just counts and they went with something else. But it's sort of oddly defined. I mean, it's just an unfortunate aspect. Like, I guess you could go with something more sciencey, which I would have been inclined towards if you really thought this worked, which was like, you know, put a there are ways to like probe how much blood flow there is to the vagina. Right. And so you could say, like, I'm going to put a probe in the vagina. I'm going to have people watch porn.

50:28And I'm going to see whether this drug gets them more aroused in those settings. I think that would have been an interesting alternative approach to this. It's a little more science-y, a little less real world. You probably also get some placebo effects, but I suspect that you would get much more minimal effects. So this feels like...

50:51Emily Oster:Yeah. I mean, these are effects... It's hard to know. Is this important? Is this meaningful, right? The meta-analysis here is a half a satisfying sexual event per month. So it's like, I don't know. Like every day I got to take this pill every day and then like one half of one time every 30 days like something good happens. I don't know. Yeah. It feels like, wow. And I'll tell you, this pill is not entirely benign. It can cause significant hypotension, low blood pressure, and fainting. And I think 40 % or so of women in the pivotal trial complained of nausea on this pill, which I don't know how that is compatible with having more sexually satisfying events, but here we are.

51:39One half of the one day when you don't feel nauseous, you have, I don't know.

51:44Emily Oster:Like, okay, I'm not nauseous. Let's go. Is there anything else? I'm not, this, I, the ad campaign for this is, it's so pink. It's like the pinkest ad campaign I've ever seen. The little pink pill that everyone's talking about. It's so pink. Yeah, they really leaned into this being emailed by Agra. Ladies love pink. Let's say you don't want to take a drug every day. The other FDA approved medication is called Bramalanatide or Vilisi. It is, Emily, a peptide. Our favorite. Yeah. So one of the few. Part of the Wolverine stack? It's not. Not in the Wolverine stack. No. It would be the, if we're going to stick with the X-Men, it would be like the Rogue or Jean Grey stack, I guess.

52:26Emily Oster:Gene Gray Stack. That's solid. I like it. Okay. Okay. Gene Gray Stack. So this is a subcutaneous injection as needed. So the recommendation is take it 45 minutes beforehand. So maybe a more Viagra-ish. More like Viagra. It works by binding another brain receptor we don't fully understand called the alpha melanocortin receptor. They appear to modulate sexual behavior in mice. It also seems to do something in humans. The trials in this case looked at a survey was their outcome called the female sexual function index. And they use the desire score, subscore of that index. So this is a survey asking like how much, how's your sexual desire doing?

53:16Emily Oster:And there was a significant increase in sexual desire by 0.3 points or so. And there's also less distress by a similar amount. These are very modest effect sizes, but at least it's taken as needed. I don't know. There's no difference in sexually satisfying events. It makes 40 % of people nauseous and it causes you to tan. It can make you a little tan. Yeah, that's right. It's a variant of, seen in the, we talked about in the peptide episode, there's a peptide called melanotan, which literally like causes your melanocytes to make more melanin and like you inject yourself and turn yourself tan. It's kind of crazy.

54:00Emily Oster:And this is a related peptide. So it's not, you don't get quite as tan, but it is listed on the side effects. And, you know, tan people have more sex. Have more sex for sure. Did you watch Baywatch or whatever? um my read of let me let's talk about before we can like overview this like i think the the third thing that is testosterone which we talked about in the testosterone episode which probably does work uh actually right probably not fda approved for this but but not fda approved for this but in there are a bunch of trials that show kind of i would say comparable effects to the uh little pink, the Adi, little pink pill, you know, about one increase, one more satisfying event per month.

54:44Yeah.

54:45Emily Oster:Testosterone clearly works. You can listen to the hormone replacement therapy episode to hear more about that. But those are the drug options. Again, if you don't want to talk about it. Look, I think that you should talk about, like, I find this space pretty hard to think about because it doesn't, it feels like, I'm kind of with the people who were complaining that the DSM has, you know, created a disease for a drug because so much of what actually seems to be going on feels like it's just people are struggling through some things in their partnerships that they could do a better job communicating about and telling them if you just take this pill, it will fix your relationship problems is misleading.

55:34and probably will leave them in a worse position, having not improved their marriage and having one half of one additional sexually satisfying event per month, possibly alone. Right.

55:45Emily Oster:Yeah. All right, let's do it then. So Emily, with that said, smash, this is the most appropriate smash or pass ever. Okay. What am I smashing or pass? You got to be like a little more specific here. Here's the rules. like hypoactive sexual desire disorder as a, I don't know, as a treatable condition, smash or pass? Pass. I think this is something people should be talking more about with their partner if they have one. They should be thinking about it. I am passing on medical treatment options for it. But what I am smashing, if you are listening to this and you are thinking this is really resonating.

56:26What I am smashing is Emily Nagoski's book, Come Together, which is a really, really good book talking about some of these issues in relationships. And I would really, really recommend to people. Pass on the drug. I am going to smash here.

56:44Emily Oster:I think that we've done - Yeah, it's a gender difference. I think we've done a bad job exploring female sexuality, understanding female sexuality. And I am cautious about too quickly attributing everything to the environment as opposed to acknowledging that there's the possibility that there are underlying biological things that could be addressed here. I don't want to write that off. So I'm going to smash further research, but probably I would do testosterone before some of these other agents. Amazing. All right. That's it for hypoactive sexual desire disorder. Your mailbag question of the week after the break.

57:34Emily Oster:Hey, Donald. Really flying on that treadmill. I'm trying to run as fast as T-Mobile 5G home internet, Zach. Well, you better pick it up because now T-Mobile has the fastest 5G home internet according to UCLA Speed Test. Really? How's this? T-Mobile's faster than that, bud. And it's still just$35 a month. Speed up. No! Plus, they've got a five-year price guarantee. Come on, faster! How can I go any faster? Channel the speed of T-Mobile 5G home internet. Think 100-meter dash fast. Think drag racing fast. Think speed skating fast. Now let's bump up your speed a notch. Hey, whoa, whoa, that's too fast!

58:13You'll be all right, just walk it off.

58:14Emily Oster:Get on the fast track. T-Mobile now has the fastest 5G home internet. And it still starts at just$35 a month with auto pay and a voice line. Plus a five-year price guarantee. Plus taxes and fees. Fastest according to Uglow Speed Test Intelligence data. Second half, 2025. All rights reserved. Guaranteed for monthly price of 5G internet data on eligible plans. Find exclusions and details at T-Mobile.com. Protect your pet with insurance from PetsBest. Plans start from less than a dollar a day. Visit PetsBest.com. pet insurance products offered and administered by pets best insurance services llc are underwritten by american pet insurance company or independence american insurance company for terms and conditions visit www.petsbest.com backslash policy products are underwritten by american pet insurance company independence american insurance company or ms transverse insurance company and administered by pets best insurance services llc one dollar a day premium based on 2024 average new policy holder data for accident and illness plans pets age zero to ten let's talk about modern home shopping.

59:07It's sort of become a fun side hobby, right? Scrolling listings at night, dreaming about kitchens you've never seen, or backyards you haven't even stepped foot in. All from the comfort of pretty much anywhere. Redfin knows a lot of people like you want to own, but are stuck in this browsing mode loop. That's where Redfin flips the script. With listings that update within minutes and tours you can book right from the Redfin app, you can see your dream home the moment it appears. Now, liking a listing is easy, but actually landing it, that's where Redfin comes in. Redfin has over 2 ,200 agents with local expertise.

59:44And Redfin agents close twice as many deals as other agents. That means they want to help you win, not just window shop. Redfin is built to help you go from just looking to wait. This could actually be home. So become the newest neighbor on the block. Visit redfin.com to start finding and start owning. That's redfin.com. Hi, Emily and Perry. This is Tamar, your producer. My question is, even though we all know that

1:00:17Emily Oster:sticking Q-tips in your ears is probably the greatest feeling in the world after the topic of this episode. Why shouldn't I do it, even though I don't want to know the answer? Thanks. Does this creep you out, Emily? Like, is this one? Yeah. When you like think about it? Yeah, I get a little bit of. Yeah, I don't. I don't. I don't like it. My impression was the bad thing is that it compacts all the wax all the way into your ear where it can be potentially problematic. And I will say once one of my children had to have like some impacted wax removed from their ear, not because of Q-tips, but like they'll stick like tweezers into the ear and like it's horrible.

1:01:04Emily Oster:Yeah. Disgusting. Is that correct, doctor? Yeah. No. So that's definitely part of it. Like earwax naturally like gets slowly comes out of the ear and like on its own. But yes, if it gets compacted, it can get stuck in there and build up. There's also risk of damaging the eardrum itself if you push too far. That's a sensitive area. And lastly, the cotton on Q-tips and particularly on off-brand Q-tips, but also on Q-tips, can come off the tip and get stuck in there. And then you have cotton in your ear that someone needs to pull out. So I know everyone kind of does this because it's satisfying, but you probably shouldn't do it.

1:01:42So when I, sometime during the pandemic, I started getting fed and I do not know whether this was COVID related or else elsewhere. Instagram started feeding me ads for like this product that was like, it was like, it went in your ear and it had like a little camera and then you could like watch what you were doing on your phone and like, and like sort of clean out the earwax with like your like phone camera. Is that a good idea? Yeah.

1:02:12Emily Oster:That seems also dangerous. I think like the middle ear, which you're coming up to when you get to the eardrum, is a really important part that gives you hearing. Yeah, you're using that. And balance and stuff. Yeah. Well, the inner ear is balance. But yeah, just don't mess with it. I don't know. Nothing larger than your elbow and your ear, like my mom said. That seems right. Thanks, Emily's mom. All right, that's it for today. Stick with us next week when we'll ask, what's the deal with sleep? Wellness Actually is produced in association with iHeart Media. Our senior producer is Tamar Avishai.

1:02:51Our executive producer at iHeart is Jennifer Bassett. Our theme music is by Eric Deutsch. And our content is for educational purposes only.

1:02:59Emily Oster:If you like the show, help other people find us. leave a rating and review on Apple Podcasts or your podcatcher of choice and help us spread the word about the show. You can follow us on Instagram at wellnessactuallypod. And don't forget, we want to hear from you. Head over to wellnessactually.fm and leave us a question for our mailbag or suggest a topic for a future show. We'll let the influencers have the last word. What the heck is female Viagra? Why the heck have I never been offered this medication? Why have I never heard of this medication? What is it? tell me all the things. Today we're going to talk about Addi.

1:03:34Addi does not increase blood flow to the genitals like Viagra or the Cialis's of the world do. It works on your brain and it is less a sexual dysfunction performance drug and more of an increasing your libido and sexual desire so you actually want to have sex drug.

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1:04:59Save up to 30 % your first year. Visit LifeLock.com slash iHeart. Terms apply. There's a difference between liking a house and actually getting it. Redfin is built to make up that difference and close the gap between finding and owning the home for you. Redfin agents close twice as many deals as other agents. So when you find a home you love, you're not a step behind when it comes to making an offer. That means less watching great homes disappear and more focus on the one you'll call home. Redfin helps turn saved listings into real addresses. Get started at redfin.com. Own the dream. This is an iHeart Podcast.

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