The Diary Of A CEO with Steven Bartlett - Sex & Infertility Expert: You Need To Grow Your Sex Span! This Is Killing Your Fertility! This Daily Habit Transforms Your Sex Life!
Episode Date: January 9, 2025Over 300 million people worldwide are affected by erectile dysfunction, and Dr Mohit Khera has the scientific solutions you were afraid to ask for Dr Mohit Khera is a Professor of Urology at ...Baylor College of Medicine specialising in male and female sexual dysfunction. He is also the co-author of the book, ‘RE-COUPLING: A Couple's 4-step Guide to Greater Intimacy and Better Sex’. In this conversation, Dr Mohit and Steven discuss topics such as, the benefits of healthy testosterone levels, how erectile dysfunction impacts your mental health, the link between obesity and erectile dysfunction, and the 4 components of female sexual dysfunction. 00:00 Intro 02:17 Who Is Mohit and What Does He Do? 02:47 What Is a Sexspan and Why Does It Matter? 03:58 Is It Possible to Make Sexspan Last as Long as Lifespan? 05:15 Mohit's Professional Experience and the People He's Worked With 07:14 The Most Popular Things People Ask Mohit and Why They Come to See Him 11:26 Most Common Reason for Low Libido: How Much of It Is Related to Compatibility? 15:35 What Is Libido? 15:54 Connection Between Erectile Dysfunction and Low Libido 18:53 What Are the Side Effects of ED Pills? 21:34 The Biggest Side Effect of Cialis 22:00 Who Shouldn't Take Cialis? 23:42 Treatment for Sexual Dysfunction in Women 25:52 Connection Between Stress and Dopamine 27:21 Types of Activities That Raise Dopamine Levels 29:37 How Much Does Pornography Contribute to Low Libido? 31:08 Why Do People Have Less Sex Nowadays? 32:30 Role of Pornography in Shifting Sexual Behaviors 36:42 Connection Between Obesity and Sexual Dysfunction 39:23 Losing Weight Boosts Testosterone Levels 40:29 Impact of Testosterone Therapy on Sexual Activity 42:37 Should Someone Like Steven Be Taking Testosterone? 44:31 Testosterone Therapy in Women 47:25 HRT for Women 49:05 The Decline in Testosterone 50:38 What Lifestyle Changes Should We Make to Increase Fertility? 55:53 If a Couple Came to You With Sexual Problems, What Would You Focus on Naturally? 01:00:11 40% of Men at 40 Will Have ED 01:01:38 The Stigma Around ED 01:03:31 Personal Experiences With Sexual Dysfunction 01:06:07 The Impact of Kids on Sex Lives 01:07:03 Premature Ejaculation 01:10:15 Is Testosterone Dangerous? 01:11:41 Will Taking Testosterone Injections Reduce My Lifespan? 01:13:53 Links Between Depression and Testosterone 01:15:14 The Importance of Communication for Sex 01:16:18 Improving Sexual Dysfunction in Men and Women 01:17:13 Pain During Sex for Women 01:18:47 How Do We Improve Communication in the Bedroom? 01:20:58 Are There Any Risks to Vibrators? 01:23:54 Abnormal Curvature of the Penis 01:25:20 Cures for ED That Aren't Pills 01:27:11 The Role Trauma Plays in Sexual Dysfunction 01:28:08 Erection Devices 01:32:43 Is There Anything You Cannot Explain? Follow Dr Mohit: Instagram - https://g2ul0.app.link/L3Z03S4WqPb Twitter - https://g2ul0.app.link/JlcpMx8WqPb Website - https://g2ul0.app.link/T7gIUo6WqPb You can purchase Dr Mohit’s book, ‘RE-COUPLING: A Couple's 4-step Guide to Greater Intimacy and Better Sex’, here: https://g2ul0.app.link/xExobrcXqPb Watch the episodes on Youtube - https://g2ul0.app.link/DOACEpisodes DOAC Community Notes: drmokhere.tiiny.co My new book! 'The 33 Laws Of Business & Life' is out now - https://g2ul0.app.link/DOACBook Join the waitlist to be the first to hear about the next drop of The 1% Diary! https://bit.ly/1-Diary-Megaphone-ad-reads You can purchase the The Diary Of A CEO Conversation Cards: Second Edition, here: https://g2ul0.app.link/f31dsUttKKb Follow me: https://g2ul0.app.link/gnGqL4IsKKb Sponsors: Linkedin Jobs - https://www.linkedin.com/doac PerfectTed - https://www.perfectted.com with code DIARY40 for 40% off Learn more about your ad choices. Visit megaphone.fm/adchoices
Transcript
Discussion (0)
This term sexpan, which I've never heard before, what is that?
Sexpan is how long you are able to engage in satisfying sexual activity.
And most men, most women, want their sexpan to last as long as their lifespan.
And there's many things you can do to significantly prolong your sexpan.
And I call it the four pillars.
So let's talk about sex.
Dr. Mohit Kara is a board-certified urologist and professor
who specializes in male and female sexual dysfunction.
His groundbreaking research has significantly contributed to improving sexual health and fertility.
Millions of men and women are suffering from sexual problems like infertility and sexual dysfunction.
For example, in the US, roughly 43 to 48% of women suffer from female sexual dysfunction,
which involves four components that we're going to talk about,
but we also know that premature ejaculation affects 30% of men globally,
and also 40% of men at 40 will suffer from erectile dysfunction.
And it's the first sign of other major adverse medical problems.
For example, 66% have some degree of depression,
and 15% of them will have a heart attack or stroke within seven years.
And if you look at the causes for ED, one of the biggest factors is obesity,
which causes testosterone levels to go down.
But men need testosterone for sexual function.
So do women, because low testosterone
increases low libido.
But the issue is that people don't
talk about their sexual problems.
They suffer in silence, and they start avoiding sex.
But it's curable.
And I have two ways to raise their testosterone.
Techniques to significantly improve
the quality of your erections, and natural ways
to improve sexual function in men and women. So number one most important.
Quick one before we get back to this episode, just give me 30 seconds of your time. Two
things I wanted to say. The first thing is a huge thank you for listening and tuning
into the show week after week. It means the world to all of us and this really is a dream
that we absolutely never had and couldn't have imagined getting to this place. But secondly, it's a dream where we feel like
we're only just getting started. And if you enjoy what we do here, please join the 24%
of people that listen to this podcast regularly and follow us on this app. Here's a promise
I'm going to make to you. I'm going to do everything in my power to make this show as
good as I can now and into the future. We're going to deliver the guests that you want me to speak to and we're going to continue
to keep doing all of the things you love about this show. Thank you. Thank you so much. Back
to the episode.
Dr Mo Aaron, who are you and what have you spent your life doing?
So I'm a urologist and I specialize in male and female sexual dysfunction, testosterone
placement therapy and infertility.
For the past 17 years, I've been working as a professor at Baylor College of Medicine
in Houston looking at ways to improve sexual health, improve testosterone, improve fertility.
And we talked just before we started recording about this term sex pan,
which I've never heard before.
Yeah.
What is a sex pan and why do you care about it?
Yeah.
So Stephen, you know what lifespan is.
It's how long you're going to live.
Right.
And you also know what health span is, how long you're going
to live in a healthy lifestyle.
But you may not have heard of the concept of sex span.
Sex span is the ability to engage in sexual activity, satisfying sexual activity.
And so how long you are able to engage in sexual activity is important to most men, right?
So let's give you an example.
The average lifespan in the United States is 77 years old.
The average health span in the United States, believe it or not, is 67 years old.
In fact, if you look at the CDC and they talk about how long you'll live without a disability,
it's actually 63.
So there's a delta here.
There's at least 10, 15 years where you will be in some kind of disability and cannot live
to your fullest.
Now think about the concept of sex span.
How long you'll have the ability to engage in sexual activity,
satisfying sexual activity. We, most men, most women, want their sex span and their
health span to last as long as their lifespan. So I think it's important.
And there's things that I can do to make my sex span last as long as my lifespan.
There's many things you can do, and I call it the four pillars. The first is diet, exercise, sleep, and stress reduction.
I don't have a pill on the planet stronger than diet, exercise, sleep, and stress reduction.
Each one of those can significantly improve a man and a woman's sex span, but also their
health span and their lifespan.
The other is hormones.
Testosterone, extremely important.
Testosterone supplementation can significantly improve a man and a woman's sexual function.
Unfortunately, for women in the United States, we don't have very many options.
Actually globally, for women, there's not many options.
But I think it's important, hormone replacement therapy.
One more thing, I think about the couple.
Think about sex ban as a couple's disease.
Let me give you an example.
Tomorrow, Stephen, are you married or?
You're well in a long-term relationship.
You're your partner.
So let's say your partner tomorrow says to you,
I am no longer gonna have sex with you
unless you cheat on her or you leave her.
You're not gonna have sex again, right?
Think about the importance of the couple.
So I talk about this quite often.
Keep your partner engaged.
Keep your partner healthy if you want to prolong your sex span.
So I've got two questions here.
The first of which is who have you worked with in your career?
And the second question is what is your CV?
Give me a rundown of your professional experience.
Yeah. So I started my residency in 2000, and I did my residency, it's in 2000, one year
of general surgery, I did five years of urology training and then I did one year of a fellowship
in men's health.
As soon as I finished my training, I joined the university at Baylor College of Medicine
and I started a basic science laboratory where we do basic science research in sexual medicine
and testosterone for the past 17 years. And I just started a clinical trial, so I started a clinical arm, we do basic science research in sexual medicine and testosterone for the past 17
years.
And I just started a clinical trial.
So I started a clinical arm.
We do clinical research.
I see approximately 150 patients a week every week.
I do approximately six to eight surgeries every week.
And I still work at the VA hospital, so veteran government hospital, one half day a week working
with the veterans.
So it's quite busy.
But, you know, my passion really is education, research, and clinical care,
and that's what we do.
And so when I started my, how I really got into this was when I finished my training,
I was so proud of myself.
I was able to get these men these amazing erections, these great libidos.
And I realized one day this woman called me and she was frantic.
And she said, look, you're treating my husband, you're able to get him these great erections,
great libido, but I don't want to have sex with him.
And he wants to have sex with me all the time and now we have a terrible relationship.
You've ruined our relationship.
And I thought to myself, wait a minute, this doesn't make sense.
But she was right.
In sexual medicine, either leave both libidos low or raise them
both, but don't raise one or the other. It's a setup for disaster.
So very quickly that year, I went out and flew out to meet with Dr. Erwin Goldstein,
who's considered one of the godfathers of female sexual dysfunction. I spent some time
with him, went to his courses, and for the past 16 years, I've been treating women
as well. You can't just treat one patient without to his courses. And so for the past 16 years, I've been treating women as well.
You can't just treat one patient without addressing the other.
And so therefore, it's a couple's disease.
And give me a flavor of the types of conversations you have on day one when they walk into your
practice, when they come to see you.
What is the issue that they say they have and how do they express it?
Like, what are the words that they use?
And if you could just give me like five of the most popular things people say to you
when they come to see you.
So listen, first of all, men and women are very different how they express it.
You know, so we'll talk with men.
Most men, let's backtrack.
Most men and women do not get any kind of medical care when they see their primary GP.
In fact, most GPs don't address sexual dysfunction.
There was a study looking at medical students. Only 65% of US medical students get training in sexual medicine.
And of those 65, 50% of those students said that the training was terrible.
So we don't get the sexual medicine training to address the problem for patients.
So the majority of patients are never discussed about their sexual problems.
But when men come in, most of them are coming in because they already have tried some medications
that haven't worked and they're looking for other solutions.
Now there's two simple questions you can ask a man.
They're very straightforward.
Are you able to get an erection sufficient for penetration?
It's either yes or no.
Now are you able to maintain that erection till orgasm or pleasure?
It's either yes or no.
The answer is no to either one of those questions.
He suffers from erectile dysfunction.
And so it's very important to get a detailed history.
You want to ask particularly, are you able to get an erection on your own?
Are you able to get an erection with masturbation?
Do you wake up with morning erections?
If he says, look, doc, I get great morning erections or with masturbation, I have great
erections, then this has to be psychogenic.
With my partner, I cannot get an erection.
But when I'm by myself, everything works fine.
Psychogenic.
Psychogenic ED.
It's a big component.
What is psychogenic?
Maybe something in the mind that's bothering you or inhibiting you from engaging in sexual
activity.
And that's where the sex therapist comes in, right?
Because if someone tells you, I get great erections by myself, but with my partner,
I'm not able to get good erections, myself, but with my partner I'm not able
to get good erections, psychologically, whether with their partner, they're not able to achieve
a good erection.
Sex for men and women has a huge psychogenic component.
So I think it's very important to get detailed history.
Are they able to get erection?
What did they try?
What medications have they tried?
You have to query about depression.
66% of men who come in with ED have some degree of depression.
66%, right?
And that's important.
Anxiety, 35%, is very important.
And more importantly, we'll talk about this.
ED is the first sign of other major adverse medical problems.
For example, if a man comes into my office today, 15% of them will have a heart attack
or a stroke within seven years.
15%.
The day they get ED, 15% will have a heart attack or a stroke within seven years.
It's the first sign.
Other studies, Dr. Montorci showed that if a man presents to the emergency room with
a heart attack, on average 39 months earlier, that's when the ED started So it is the first sign now there are many reasons for this
One theory is called the arterial diameter theory the penile arteries are the smallest arteries one to two millimeters
The coronary arteries are three to four millimeters the carotid six to seven millimeters
So if you remember from physiology if you're going to block an artery
50% occlusion of
an artery causes damage.
So if you're going to block an artery, you're going to block the penile arteries before
the coronary arteries.
You're going to block the coronary arteries before you block the carotid, right?
So men will get ED before they get a heart attack, more likely to get a heart attack
before they get a stroke.
That's a theory, but it makes sense.
So I worry when a man comes into my office, could this man have a cult cardiovascular
disease?
In fact, there was a wonderful study that came out of Greece.
They looked at 50 men that walked in and they gave them an echocardiogram or stress test.
If it was positive, they wanted on to a coronary angiogram.
What they found is that roughly 20% of men, one in five, actually had some occlusion in
their heart, whether it was one vessel, two vessel, or three vessel disease.
So I think to myself every time I'm writing that prescription, is this one of the five
that could have some occlusion?
And is there an opportunity to intervene at this point?
So it's really important to think about cardiovascular disease as well.
One of the big subjects that I hear a lot about,
even in my friendship groups, is about libido.
I've got so many stories in my friendship group
of either one or both partners losing their libido.
So on this subject matter of libido,
it's kind of where I wanted to start this conversation.
What is the most frequent and popular reason
why men and women struggle with libido problems and how much of that is about compatibility?
Yeah, good question.
Libido is multifactorial.
There are many pieces of libido.
It's very complex and I'll give you some important components.
First, it could be hormonal and the mnemonic I teach the residents is PET. The four hormones that can affect someone's libido are prolactin, estrogen, thyroid, and
testosterone.
So you have to check the PET.
If the prolactin is elevated, the libido goes down.
The testosterone is low, the libido goes down.
So maybe it's a hormonal issue, which could be it.
And particularly many women who go through menopause suffer from hormonal issues, and
it could be a hormonal issue.
The second is something called neurotransmitters.
So in other words, serotonin, norepinephrine, dopamine.
Dopamine goes up, libido goes up.
Serotonin goes up, libido goes down.
So these all regulate how someone's libido will function.
So one of the biggest culprits for low libido are antidepressants.
What do antidepressants do?
They increase serotonin and they decrease libido.
So sometimes it's a medication or something that a patient's taking that will shut down
their libido.
For example, a medication that men take for urinary function called finasteride shuts
down their libido.
So there are certain things that you have to look at.
The other components are lifestyle, diet, exercise, sleep,
and stress reduction, particularly fatigue and stress.
If a woman is tired and she's exhausted
and she has to choose between sex and sleeping at night,
many times she may choose sleep.
Me as well.
Right, I'm just saying.
Yeah, yeah, yeah.
So fatigue is important.
Stress, and there's this cliche, this mnemonic, this saying that with stress is kind of interesting.
Typically if a man has a very stressful day, he will want to have sex to relieve his stress.
Women have to relieve their stress to engage in sexual activity.
It's kind of the opposite.
You know what I mean?
So I tell men, if you really want to have sex with your wife, do the dishes, take out
the trash, do everything you can to tuck the kids in bed early, relieve her stress because
that will significantly increase her desire to engage in sexual activity.
But the other one is psychogenic.
So we talked about that earlier.
Sex has a huge mental component, your relationship with your partner, how close you feel with your partner.
So sometimes patients come to me and they're in an abusive relationship and they say,
give me the pill that improves my libido.
I say, it's not going to work.
I mean, the essence, the core, the foundation is not working and therefore it's really
important for them to see a sex therapist.
One thing for men that actually shuts down their libido is when they start developing
erectile dysfunction.
So, if a man starts getting erectile dysfunction, let's say he gets a good erection 50% of the
time and he's starting to have some problems and it's 10 o'clock at night and he says,
look, I can try to engage in sexual activity, but it may or not work and it may be frustrating
and embarrassing or I can just go to sleep.
He's probably just going to go to sleep, right?
And it becomes a vicious cycle because the less sex he has,
the more difficult it is to engage in sex activity later on.
And so you may interpret this as a low libido,
but he's really just avoiding it because he doesn't want to deal with it, right?
But the partner also looks at this as maybe I'm not attractive anymore,
maybe there's something about me that's not appealing and it becomes a vicious cycle.
So one thing you can do is significantly improve the quality of the erections in a man and
that actually helps improve his libido.
So for example, if I tell a man if every night you have a great erection and every morning
you wake up with a great erection, what are you going to probably do?
Probably going to use it.
So libido inherently goes up.
So I think ED and libido are tied very closely.
How do you define the term libido?
It's a desire to engage in sexual activity for men and women.
When it's a true problem, they have to be bothered by the condition.
So I just want to be very clear.
There are women who have low libido and say, I really don't care.
I'm happy that I have a low libido.
Well, then it's not an issue, right?
You have to be bothered by the issue.
So on this psychogenic element where it becomes a vicious cycle, I've seen this in my own
life several times, well, at least once.
And I've seen it in some of my friends where because there's a bedroom issue, when you go to the bedroom, you're both a
little bit anxious and then one of you can't perform and if you can't perform, it exacerbates
the issue and it creates this sort of vicious downward spiral of like it makes the bedroom like
a really awkward place to be and this is how I think about when you're talking about psychogenic
component. So in the case of erectile dysfunction, if you're thinking
as a man, God, if I go to the bedroom, I'm not going to be able to get it hard. I'm not
going to keep it up. It's going to be embarrassing. She's then going to ask me questions. She's
going to think I'm not into her, which just makes it even harder. Because as a man, like,
I perform best when I'm really not thinking about it and I'm like not anxious when I'm
stress free. And it seems to me that the like antithesis,
the opposite of great sex is like overthinking.
You're 100% correct.
And this is what happens.
Let's say a man gets ED just one time,
just one time, young man.
He says, that was really odd.
And what's wrong?
You know what he does next time he has sex?
As he's having sex, he says to himself,
I hope I don't lose my erection.
I hope I don't lose my erection.
The second he says that to himself as he's having sex,
he's gonna lose his erection, right?
Because he's so worried that he's gonna lose the erection
and not enjoying the experience.
So now it's happened twice.
So now he engages the sex for the third time.
And now he's even more freaked out
because it's happened twice.
And it happens again.
We call this the vicious cycle, right?
Because now sex has become an anxiety event, anxiety-provoking event.
And so you really have to work on decreasing that anxiety and not thinking about it.
That's where sex therapy comes in hand.
And that's where a medication called daily Cialis has become unbelievably helpful for
my young patients.
Because daily Cialis is a medication that men take daily.
You've heard of Cialis, right?
It's like Viagra.
Yeah, it's like Viagra, right?
So there's Viagra, there's Cialis, Levitra, there's Stender, there's four different brands.
But one of the four is meant to be given daily.
It's a lower dose, five milligrams every day, and the larger dose is 20 milligrams.
When you give a man Cialis, five milligrams every day,
what it does is essentially is having that medication on board all the time.
When he engages in sexual activity, he doesn't have to take a pill,
he just has sex whenever he wants to,
and I found that to be unbelievably helpful in breaking psychogenic ED.
Because now, that's exactly what that is.
On the table.
Yeah, that's exactly what it is.
Yeah, and so these are pills that are in the US.
But what's nice is they used to be very expensive.
Now, with you look at Mark Cuban and a lot of the good Rx companies,
men can get 90 pills for $15 or $20, which is very cheap.
You use the word young men.
Yes.
Young men presumably shouldn't be taking pill.
They shouldn't. But what happens when they have psychogenic ED
because they think about it the most is they need to break the cycle.
What's the cost?
Because I'm going to be honest, I'm a pill skeptic.
Yes.
So I try and avoid taking pills to solve my problems if I can.
Right.
Obviously, there's going to be situations where I can't,
and I accept that.
But my bias is towards figuring out if there's another way before I take a pill.
Right. Because everything in life comes before I take a pill. Right.
Because everything in life comes with a cost or things.
Yeah.
So there must be a cost to taking a pill to solve this problem.
Well, the actual monetary cost is unbelievably cheap.
Monetary cost is... I'm thinking about like, do I get them get dependent on this?
Yes.
Do I have to take this for the rest of my life?
So there's no dependency. Let me tell you why I think that drug is so important.
That daily Cialis has one of the only things in my opinion that actually reverses erectile
dysfunction.
So let's backtrack.
Let me give you an example.
Let's say today you break your leg.
Okay?
I have two options, Stephen.
I can fix your leg or I can give you Vicodin, a narcotic.
And if I give you the Vicodin or the narcotic, you'll still be able to walk
until the Vicodin no longer works and we're in trouble.
Viagra is a Vicodin.
It is not a cure for your erectile dysfunction.
It's just masking the problem.
Daily Cialis, in my opinion, is one of the few things
that helps cure ED.
If you look at studies and you look at a penile tissue
and we biopsy the tissue
and then you biopsy three months later on daily Cialis, it physically gets stronger.
So let's say you go to the gym today and ask you to lift dumbbells. What's going to happen to your arm? It will hypertrophy.
With daily Cialis, we see hypertrophy of the smooth muscle, meaning it gets physically stronger.
So in my opinion, it's one of the best things to prevent ED in the future, help reverse the ED process.
More importantly, daily Cialis protects the endothelium
and we have to spend some time talking about that.
That is the lining of the blood vessels.
It's the brains.
And the lining of the blood vessels is very important
because once that gets injured,
you start getting clot or plaque,
which will get a heart attack,
a stroke and erectile dysfunction.
So it protects the lining of the blood vessels.
Two other indications, it's FDA approved to help a man urinate better, FDA approved.
It's FDA approved to protect the heart in terms of something called pulmonary hypertension.
So in my opinion, it's an excellent medication.
Patients say, do I get dependent on it?
I say, you do not get dependent on it.
And I feel like you're better had you taken it than had you not.
You take it for three months, you get strengthening of the penile tissue.
What happens if I stop taking it?
If you stop taking it,
there's a wonderful study by Aversa.
And what he showed was that those patients
that stopped taking it after three months versus placebo
still had benefit in terms of endothelial function protection
and erectile function protection
than those people that took placebo.
So thinking about saying,
hey, if I go to the gym and I work out for three months, what
happens if I stop?
I say, well, Stephen, you're better off had you gone to the gym for three months.
That's my opinion.
What is the downside?
There are side effects.
So every drug has side effects, right?
But they're low with five milligrams.
Back pain, stuffy nose, headache can occur in these, but it's quite small.
But I do think that this is one of the medications that really can make an impact in men's health.
Think about it, if I told you there's a medication
that protects your heart, helps your prostate,
and helps men with erections, and it's affordable,
I think that most men would say, I'm in.
What are the big side effects
that people report when they're on Cialis?
So on the larger dose, headache, stuffy nose,
back pain is more common with Cialis and other medications,
but it can be reported.
Remember, you shouldn't take these medications if you're taking a nitrate because it can drop your blood pressure.
But other than that, these are very commonly used medications throughout the world.
And they're not suitable for certain people that have certain cardiac disorders, I'm guessing?
Well, you know, the way this was invented, this came out, first one, Vygra came out in 1998.
Vygra was in the clinical trials designed to be a blood pressure medication Well, you know, the way this was invented, this came out, first one, Viagra came out in 1998.
Viagra was in the clinical trials designed to be a blood pressure medication and accidentally
men were getting erections in the trial.
So these medications are, in my opinion, cardio protective.
A guy named, a very famous physician named Dr. Kloener published an article recently
showing that those men who took daily Cialis had a 13% reduction in cardiac
events and a 25% reduction in mortality just came out because of the potential effects
of protecting the endothelial lining of the blood vessels.
How does this work to solve for the sort of psychogenic component that we talked about,
that vicious cycle people get into with like, I'm guessing you're telling me that it increases
your probability of having a good erection.
Right.
But this still isn't really working on a libido, is it?
Right.
So let's say you started falling through the vicious cycle and you started having ED and
it was two times, three times.
And now I put you on this medication.
And every time you have sex, you have the most amazing erection of your life.
And 30 times, 40 times, three, six months go by, and you're having these amazing erections,
you're relaxed and you're calm.
Then I start going to every other day,
you still get amazing erections.
Then I go to once a week, you still get amazing erections.
Then I stop, you still get amazing erections, right?
I just need to show you that everything is perfect again.
And that has a huge value.
What about for women?
This is the unfortunate part.
We don't have a lot of treatment options for women.
And if you look about it, I want to give you an example.
In 2015, if you and I went into the drug store in the US, Walgreens, and said,
give me all the drugs to treat men for sexual dysfunction,
they would put 30 drugs on the counter.
These are all the wonderful treatments for men.
In 2015, there was not a single FDA-approved drug to treat
women for any sexual dysfunction. Very sad. In 2015, the first drug to treat women for
female sexual dysfunction came out, and it was called Adi or phlebanthrin. Phlebanthrin
basically is a drug that a woman takes every day and increases her desire for sex. That's
it. That's the FDA indication. Increases her desire for sex. Several years later, the second drug for women came out.
This was called Veilisi or Brimelianotide.
Essentially, it's an injection that she takes 45 minutes prior to intercourse,
and it increases her desire for sex.
But again, we have only two drugs.
The reason being is because the research, the funding that we have for female sexual dysfunction
is far less than we have for female sexual dysfunction is far less than we have
for male sexual dysfunction.
And it's unfortunate because as I mentioned earlier, this is a couple's disease.
And so many times I have to use drugs that I use for men to help treat women.
So I do use Vigra for women, but Vigra for women helps arousal.
So let me explain.
Female sexual dysfunction has four components.
One is decreased libido.
The second is decreased arousal.
Third is orgasmic dysfunction.
And the fourth is pain with intercourse.
These are the four.
If a woman has any one of these four,
and she's bothered by it,
she suffers from female sexual dysfunction.
In the U.S., roughly 43 to 48% of women suffer from female sexual dysfunction. In the US, roughly 43 to 48% of women suffer from female sexual dysfunction, significant
number.
Only 19% seek therapy, will get therapy.
So there's a huge number of women that I say are suffering in silence.
They suffer from the condition.
They don't know where to get help.
And unfortunately, there are not many treatment options available.
So it's a big problem and a big unmet need.
And on the hormonal component, you talked about how if dopamine is up, we're much more
likely to be aroused. And if serotonin is up, then we're much less likely to be aroused.
So this kind of ties into something I was thinking when you were talking about stress
and tiredness.
When I'm stressed and tired, is my dopamine down?
It can be.
Your cortisol goes up.
Okay.
Your cortisol goes up.
So your ability to get excited will go down.
Your fatigue goes up.
So it makes it much more difficult.
There's more than just dopamine and serotonin.
There's norepinephrine.
There's melanocortin.
There's many than just dopamine and serotonin. There's norepinephrine, there's melanocortin, there's many other neuro steroids.
And it's really just what we call a plus minus game.
If I have more positives than negatives,
I'm gonna have desire and I'm also gonna have orgasm.
That's important also.
So if you give someone too much serotonin
and it goes this way, not only does the libido go down,
but it's difficult to achieve climax on orgasm.
So one of the ways I treat premature ejaculation is I give them an antidepressant because it
delays the orgasm.
So we have to be very careful on these neurotransmitters, how we use them.
But if you talk about ADID, the drug I mentioned, all it does is it increases dopamine and norepinephrine,
which increases libido.
So they increase neuro steroids. Many women, particularly with the history of breast cancer,
like this because they don't want to use testosterone
or estrogen hormones.
This is non hormonal, right?
It's just neuro steroids increasing the desire for sex.
Can I think about dopamine and serotonin as like a scales?
Yes.
If I put weight on one end, the other one goes up.
And if I put weight on the other end, the other one goes up.
Yes, there is a very famous, Michael Prorman came up with the tipping point, and it's basically
a scale looking at the pluses and the minuses.
If you have more pluses than minuses, libido goes up, orgasmic function goes up.
If you have more minuses, essentially your ability to orgasm and your libido will go
down.
So if I want to be aroused and have a desire for sex and have good sex, then I want my
dopamine levels to be high.
Dopamine high, oxytocin high, norepinephrine high, serotonin low.
What are the types of activities that make my dopamine high?
Well, exercise can be a really high dopamine.
Other things increase dopamine as well, right?
So gambling, there's
certain things that are high. Anything that gives you a high. Certain foods will cause
a dopamine rush, but they're temporary, right?
And that's a problem, right? Because if it goes up, it goes back down.
It goes back down. It crash. So you want your dopamine to go up in men and women. So we
use medications like Welbutrin. Have you heard of Wel buterin? It's an antidepressant, but that antidepressant increases dopamine.
So I use that to help men increase their libido or women to increase their libido or sexual function.
I use addy in men and off-label in men and in women to increase dopamine.
I don't want to do drugs though.
Yes.
I don't want to take any pills.
So then I would say that I need you to exercise and you do but exercise is critical. I need you to sleep.
I need you to reduce your stress, right? Those things will significantly improve
your libido.
So
What things then lower dopamine because I've spoken to a few like dopamine experts from the show before and they talked to me about this
Sort of meaning Andrew Huberman was telling me that yeah when you do an exercise like let's say gambling or go on tick-tock
Your dopamine is gonna go up but then's going to crash below the base point.
Yes.
And some of us live in this kind of dopamine roller coaster where we're doing
these dopamine-inducing activities, our dopamine goes up, it then crashes below.
Yes.
And when it gets low, we have cravings for dopamine-inducing activities.
So we go out and want to gamble or go on TikTok again or eat something.
And then it goes up again and then we kind of live in this kind of roller
coaster of dopamine. One of the things that I was told by a dopamine expert
on the show recently that does that as well that links to some things I found in your
work is pornography.
Yes.
And when we talk about this psychogenic component, we talk about dopamine levels. How much is
pornography causing this libido crisis?
Yeah.
Pornography and ED and libido is somewhat controversial.
There's some data to suggest that it does not cause an issue and there's some data to
suggest that it does.
The first question I ask a patient, when I ask a man, I say, is your ED present with
pornography also?
So if he says, look, I have erectile dysfunction with my partner and I have erectile dysfunction
with pornography, that's very different than when he says, I have erectile dysfunction
with my partner and I have amazing erections with pornography, right?
Because then I know that there's a psychogenic component as well.
This is what I believe.
I believe that when a man watches excessive amounts of pornography, what his expectation
is becomes hair and his reality becomes hair.
That delta causes them to have erectile dysfunction and low libido.
They're not getting what they're expecting to get.
Many times I question men when they come in.
When all men who come in, you they ask how much pornography are you watching?
In men who watch excessive pornography, if I ask them to stop watching pornography for
a while, many will report improvements in their rectal function and libido.
So again, I do think that pornography in excess can have a negative impact only because of
your expectation and your reality, the Delta can be an issue.
Reading some stats here from JAMA Network that says the percentage of men between 18 and 24
reporting no sexual activity in the past year increased from roughly 18% to roughly 30%
in the space of what looks like just a few years. And similarly, the average number of
times American adults engaged in sexual activity per year has decreased from 60 between 1989 and 1994 to 50, roughly 50, between 2010 and
2024. These shifts suggest a notable shift in sexual behavior over recent decades. Why
do you think this is happening?
I think it's multifactorial. So I think one is I think that ED and sexual dysfunction is on the rise.
And if you look at the causes for ED, it's very simple.
You look at obesity, diabetes, metabolic syndrome.
It's a pandemic.
It's an epidemic throughout.
If you look at just diabetes from 1990 to 2022, 100% to 7% to 14% of the population.
One out of eight people globally are obese.
One out of eight people.
So these can make it very difficult as obesity and diabetes go on the rise, what happens
testosterone levels go down, right?
So testosterone levels go down.
So the ability to engage in such activity, the desire to engage in such activity will
be impaired by these conditions.
I've got some, some graphs here, which show global obesity trends, global
diabetes trends.
I'll put them on the screen for anyone that's watching on video.
Also, there's been an increase in pornography consumption from what I was
able to tell from doing some research.
A 2020 study by the University of Antwerp found that 40% of people aged 35 to 45
who watched 300 minutes of porn a week had erectile dysfunction. In a 2021 study by
GEMMA, Public Health and Surveillance, and 3,400 men between 18 and 35 years old, 20% of the
participants suffered from erectile dysfunction. And researchers found that the greater the viewing
frequency of pornography, the greater suffered from erectile dysfunction, and researchers found that the greater the viewing frequency
of pornography, the greater the development
of this dysfunction.
Yeah, and that's 300 minutes is quite a bit of time a week.
It's five hours.
300 minutes is five hours.
Five hours a week, right?
So that's quite a bit.
Yeah, that's quite a bit.
How important do you think that is as a component
to this sort of fracturing in relationships?
We think about people having sex with each other less.
Yeah.
We're heading towards a world of virtual reality and AI and AI. What role do you think that's genuinely
playing? And you must have private conversations with men that are really suffering with these
things.
So I definitely think it's a role and definitely it plays a factor, but not as much as the
epidemic of diabetes, obesity, metabolic syndrome. We are as a population becoming more and more unhealthy as time goes on.
I look at it again as a pie.
It's multifactorial.
Most of us now are not—our socialization is virtual.
We are not engaging and going into the scene.
Everything is done virtually.
I think that's an issue.
I really believe that pornography is a component, but the decline in overall health
is a major component.
The decline in testosterone levels decade by decade is also another component as well.
It's pretty terrifying that young kids at the age of like 12, 13, 14, when they open
their phones these days, will be exposed to sexually graphic images, whether they chose
to seek them out or not.
Yes.
And I've always wondered what that's doing to a developing brain.
You know, how it's adjusting your expectations,
how it's creating some of those psychogenic factors
that are making you less aroused.
And it's difficult, right?
It's difficult to go out and find a partner.
You have to put on the aftershave, shave, take care of yourself.
You have to risk rejection, spend some money, be interesting. So it seems like
if from an evolutionary perspective, if I was just trying to like get my nut off or like,
I don't know, ejaculate, I've got this really easy way now. Like it's so easy. Three clicks on a
computer, we're off to the races versus like all the effort and rejection and pain of trying to
find an actual human being to have sex with.
And then when I do do approach number one, when I log on to some website and click a couple of times,
I'm getting no headache, I'm getting whatever I want.
I can order from an endless list of menus and I'm sure in the near future I'll even be able to make my own.
Yes.
And not so just in future, I'll have it in my house and it'll talk to me.
Yes, yeah.
So I just think.
It's a problem.
And you think about it, it's making it more difficult
for people to socialize, right?
So in other words, now when patients or people engage
in sexual activity, and they're usually having sex
on the internet or with pornography,
when you actually engage in sexual activity
with another person, it can cause anxiety, right?
You get anxious.
It's not something that you're doing regularly.
And so I think that it can become an issue.
I saw an article this week from an OnlyFans creator who posted that
one customer of hers had given her $4 million this year.
Oh my God.
And you think about what it would take for you to spend
four million dollars on a parasocial relationship
with an OnlyFans creator sending you explicit pictures.
And I don't quite believe we fully understand
what's around the corner.
I agree.
These stats, I think, are nothing compared to
what's around the corner.
And I don't know, I think about it a lot,
because when I read these stats about erectile dysfunction
being on the rise and I read that we're having sex less and less, and then I see this rise
in these parasocial relationships, I go, I think we're just at the start of an exponential
curve.
Let's talk about obesity then.
Because these stats here are pretty shocking.
This one shows the global obesity trends, which just shows them going straight up, which
is horrific.
This one shows global diabetes trends, which is pretty much straight up as well.
Has there been any studies done that show the link between being overweight and your
probability of having low libido and some kind of sexual dysfunction issues?
Yes, numerous. And so let's start with this. So obesity, it's not surprising that diabetes is going up because as obesity goes up, it causes insulin resistance.
So obesity and diabetes typically go hand in hand. The problem with obesity is the following.
Obesity significantly drops testosterone levels. So fat cells contain something called aromatase.
Aromatase eats up the testosterone
and converts it into estrogen.
So the more fat you have, the less testosterone you'll have
because you'll convert it into estrogen.
Fat cells also secrete something called cortisol and leptin
which shut down your own natural testosterone production.
So it's not surprising that decade by decade,
as you see an increase in obesity,
you see a decline in testosterone levels in men
because the testosterone levels will come down
as people become more obese.
Low testosterone equals low libido.
Low testosterone increases low libido.
The number one driver, the number one hormone for libido
in men and women is testosterone.
It's a strong driver.
Men and women.
Men and women. And don't forget that testosterone's also really important
in erectile function.
Men need testosterone for sexual function, so do women.
It's extremely important.
So now I have a hormone that's going down
that's gonna make it more difficult to get an erection.
I have a hormone that's going down
that's gonna decrease my libido
and it's mainly due to this obesity that's occurring,
one of the biggest factors.
So obesity.
Obesity also, if you look at the risk factors for ED, obesity, diabetes, cardiovascular disease,
these are all risk factors.
And so as obesity goes up, erectile dysfunction goes up.
And the number one condition is diabetes.
Diabetics are four times more likely to have ED than any other population. Four times.
So I get worried when we see this obesity, diabetes pandemic going up
because it's increasing only the erectile dysfunction.
Steven, if you look at the obesity, the group that's having the greatest rise in obesity
is adolescence obesity, not adult obesity.
The kids, younger and younger ages, are having that age group has the greatest
rise of obesity.
So what does that turn into?
The younger population are starting out at lower T levels and has an implication on fertility
because you need testosterone to produce sperm.
That's very important.
So if I just lose a little bit of weight, that will have a big impact on my testosterone
levels.
Let's talk about that. It's not a little bit of weight, that'll have a big impact on my testosterone levels. Let's talk about that. It's not a little bit. So the best study was the European male aging
study, Fred Wu, and what he showed was this. It's a bi-directional relationship. If you
lose 10% of your body weight, you can actually gain 85 nanogram per deciliter in serum testosterone.
If you lose 15% of your body weight, you can actually gain 250 ng per dL in serum 2.
So it's actually significant if you can lose, but it also goes the other way.
You gain weight, you drop the T proportionally as well.
The only issue is I can get the patients to lose the weight, but I can't get them to sustain
it.
Many times they gain it back, right?
But if they can keep the weight off, it significantly increases the testosterone levels.
The best data we've seen is in the bariatric surgery data.
If I do bariatric surgery on a patient to help them lose weight, you can shrink the
stomach.
We do surgery to help them lose weight.
They lose quite a bit of weight.
Their T-levels go quite up, right?
And so again, there is a strong correlation between weight and testosterone.
Have you got any examples of patients where you've given them testosterone treatment in some form?
You've done something to increase their testosterone and you've seen a remarkable
reported difference in their sex life? All the time. Yeah, so first let's backtrack.
There's two ways to give a person testosterone. If I give a young man testosterone, remember, it causes infertility.
So you would never give someone testosterone if they're planning to have children.
That's very important.
So I have two ways to raise their testosterone.
I can give you medications to raise your natural testosterone.
There's several. There's a pill called clomiphonocytrate.
There's HCG.
I can use medications
to raise your own natural testosterone
and they preserve your fertility.
The second option is I can give you medications
like testosterone, there's seven of them,
but they will shut your natural production down.
Not only will they shut your natural
testosterone production down,
but they will shut down your sperm production.
Now, if you've already had your kids,
you're 60 years old,
your testosterone level's already low in the first place,
what are you preserving?
Okay, it makes a lot of sense.
And there's seven ways to do it.
My favorite way are the injectables
and the oral testosterone, they are fantastic.
Oral testosterone's quite interesting.
First of all, testosterone was invented in 1935.
This is not a new drug, 1935.
And oral testosterone initially was feared
because it would actually cause
liver toxicity and liver cancer.
And it wasn't until the 1970s
when they were able to make oral testosterone undecanoate.
And what's nice about undecanoate,
it bypasses the liver, no cancer,
but it had to be taken three to four times a day. It was available in the UK as a drug called Andreol all over the world, but not the US.
The US, we did not get our first oral testosterone until 2019.
And then in 2022, we received two more.
And now we have Tolando, Jitenzo, and Kaisertrex as our oral.
They're taken twice a day with a meal.
What's nice about Kaisertrex, it's actually available in the UK. So in the UK now, they can actually get Kaisertrex is our oral. They're taken twice a day with a meal. What's nice about Kaisertrex, it's actually available in the UK.
So in the UK now, they can actually get Kaisertrex as well.
But oral testosterone, most patients don't mind taking a pill and it seems very easy
to do.
So should someone like me be taking testosterone?
If your levels are low and you're symptomatic, and I think that's very important.
If a man comes in with low levels of testosterone and says,
I feel great, I have no symptoms.
I said, I'm not giving it to you.
These are the symptoms, low energy, low libido,
erectile dysfunction, decreased muscle mass,
increased fat deposition, poor sleep, and depression.
These are some of the common symptoms you'll see.
Most sensitive symptoms are the sexual symptoms,
erectile dysfunction, and low libido.
So if he says, I have these symptoms and my levels are low and I recheck it and confirm
that it's low, that man is a candidate for testosterone therapy.
But if he's young, hasn't had kids and children yet, I'm going to say, look, let's hold off
on giving you testosterone and use medications to make you make testosterone.
And if you don't want to take medications,
actually there are many things you can do
on lifestyle modification to raise your testosterone.
We talked about weight loss as well.
So let's live in this area here.
You are too young to take testosterone now.
But conversely, let's say a patient comes in
and has every single sign and symptom of low testosterone,
but his testosterone levels are normal.
I'm not giving him testosterone
because it could be something else.
Maybe he's depressed.
Maybe he has a low thyroid.
Something else is going on.
So you must have signs and symptoms and a low T-level to be a candidate.
And if you fit that, then you may benefit.
What about women?
So this is important.
In 1935 when testosterone was invented, it wasn't many years later until they actually
started using testosterone in women.
And early reports of testosterone in women were actually quite remarkable.
The earlier manuscripts describe improved quality of life, improved libido.
And if you and I walked into the drugstore today and said, give me the testosterone for
women, it does not exist.
There's not a single FDA-approproof testosterone for women in the United States,
but we have well over a dozen for men.
Can you explain this to me just because I want to make sure I'm clear? Why would a woman
take testosterone? Because when I think of testosterone, I think of men.
Yes. So women make more testosterone than any other hormone in their body. Make more
testosterone than any other hormone in their body, right? And when women have higher levels of testosterone, they tend to see a greater improvement in
libido, muscle mass, bone mineral density, sense of well-being, some reported improvements
in cognition.
As the testosterone level goes down, we start seeing these symptoms, particularly low libido.
If you give a woman back her testosterone, many of these women see a significant improvement in their libido. If you give a woman back her testosterone, many of these women see a significant improvement
in their libido. But the issue is that we don't have an FDA approved product for testosterone
in the United States. I think in the UK you call it off-license. We call it off-label.
Now in the UK they did have one. They had a wonderful patch called Intrinza. And the
women in the UK could get the patch for testosterone, go into the drugstore, NHS covered it and it was fine.
Then they had Androfem and Androfem was actually approved and now no longer is approved.
So now in the UK you also don't have an on-license medication.
You can still get Androfem from Australia but unfortunately it's very difficult to get.
So what do we do?
We use the drugs for men and we give it to the women in one-tenth the dose.
That's all we do.
So if we have a packet that a man puts on a day, we say use one-tenth of the packet
every day for the women and they can see significant improvements.
It is not illegal to give a woman testosterone.
It's just considered off-label or off-license.
But they see significant improvements.
In what?
Sexual function by far the most.
Lobedo goes up, no question.
Many women report that.
Muscle mass.
If you think about testosterone, bodybuilders take testosterone for a reason.
Why?
It significantly improves muscle mass.
It can decrease fat deposition.
Many patients will import improvements in cognition.
It can help with bone mineral density as well in men and women.
And I also believe in depression.
So I think testosterone does help with depression.
I just want to make a very important point.
Testosterone is not just about sex.
There are five other things that you need to think about in men and women, and I want
to talk about those.
Men with low testosterone levels are much more likely to have a heart attack, non-negotiable.
Men with low testosterone levels are much more likely to have diabetes, obesity.
Men with low testosterone levels are much more likely to suffer from depression.
Men with low testosterone levels are much more likely to have a bone fracture.
So it's not just about sex.
It's about their overall health.
And if you were to check one blood test to assess a man's overall health, it's his testosterone level. One blood test to check his overall health. And if you were to check one blood test to assess a man's overall health,
it's his testosterone level. One blood test to check his overall health, it would be because
it affects heart, diabetes, obesity, bone marrow density, energy, muscle mass, erections,
libido. One blood test. I can't think of another blood test that has a better barometer of
overall health.
I want to get clear on something because I've heard people talking on my podcast before about HRT and women taking HRT because of menopause and things like that.
Should they be, does HRT have testosterone in it?
No.
So typically when we say HRT, we're talking about estrogen and progesterone typically.
And typically when we talk about TRT, testosterone placement therapy, it's a little bit different.
In a woman, there's something I call the triangle.
And it's just basically estrogen, progesterone, and testosterone.
Just simple.
And if you have a woman who's deplete in estrogen, progesterone, and testosterone, and replace
it, many of those women feel better.
So many of them do.
There are other hormones that are also important.
I call it the outside circle.
Cortisol, thyroid, growth hormone.
We look at those as well.
And so I think those are also very important.
And I tell them, we're going to optimize your hormones, and we're going to optimize your
medical condition, but that is only 50% of the story.
The other 50%, again, is diet, exercise, sleep, and stress reduction.
And if you do your part, and I do my part, we're on fire.
We're absolutely on fire.
But you have to do your part.
Same with men.
I put you on the testosterone.
I optimize your medical conditions.
But you've got to exercise.
You've got to eat right.
Why aren't women being prescribed testosterone then?
Right, because it's considered, well, in many countries, in Australia it's available, in
the UK it was available, and many women are being prescribed testosterone. It's just off
label.
It is the first time that I've seen someone on my show, anyway, really emphasize the point
that testosterone isn't just for men, it's for women as well.
And it can significantly improve their quality of life.
Talking about testosterone, one of the big conversations that's rattling on the internet
is about this decline in male testosterone over the last couple of years.
What exactly is that decline, if you had to sort of quantify it?
If you look at the original studies, we call it the Freemium Heart Study back in the 70s,
testosterone levels were roughly around the 700s.
Average men between the ages of 18 and 40 were around the 700s.
Every decade we're starting to see a decline almost by 15 nanogram per deciliter.
So the latest 2015 numbers were roughly in the mid 400s.
So we've seen almost a 300 nanogram per deciliter decline in serum testosterone, which is significant
because it has two implications.
It's not just about the way you feel and energy, muscle mass, rectal function.
But that low testosterone can have implications on fertility.
That's really important, so we didn't talk about that.
But fertility, sperm need testosterone.
Low testosterone decreases your sperm count.
Sperm counts have also been on the decline as well.
So I think it's really a testament to the fact that decade by decade,
we're becoming a more unhealthy population.
Do you think that's really the heart of it? Is that is this sort of our diets and the
way we live and becoming more sedentary, less exercise, more processed food, etc. Do you
think that's the heart of it?
I think that's the key. That's absolutely the key. The types of foods we eat, the processed
foods that we eat, high fructose, high carbohydrate diets and the way we know that is just look at the obesity, look at the diabetes.
There has to be a reason why it's on the rise, right?
And on that point of fertility, I'm in a season of life where I'm going to be trying to have
kids pretty soon.
What's the most important things I should be thinking about from a lifestyle perspective in your view?
Yeah. So I tell patients Darwinism, in other words, survival of the fittest. Healthier
people are more fertile, right? You're passing on the genes. So essentially we tell patients
the number one cause of infertility in the world for men is a varicoseal. A varicoseal
is the swelling of the veins around the testicle.
You know how women sometimes can get swelling
of the veins in their legs?
You see those veins that are kind of obvious?
Well, men can get those veins dilated around the testicle.
And those varicoseals can impair sperm production.
Now, 15% of men in the world walk around with varicoseals,
but up to 40% of men with infertility will have varicoseals.
So it's really important to assess for the varicoseals.
But lifestyle modification, each one again,
diet, exercise, sleep, have been shown
to help improve fertility in men as well.
So I say healthier people are more fertile.
I need you to start getting healthier.
That's very important.
We raise the testosterone level in many of these men,
naturally, we don't give it to them,
to help improve their fertility as well.
But check, Stephen, check your semen analysis.
That's the simplest thing you can do.
I've done that.
Check it.
I did that.
Yeah.
It's a great predictor.
It's not just, you know, there were so many amazing studies showing that a semen analysis
is a phenomenal predictor of overall health.
Many studies showing that if your semen analysis today is impaired, it's a predictor of you
having comorbid conditions today like diabetes, obesity, metabolic syndrome.
It's also a predictor of prostate cancer.
So we know that if you have infertility, you're at a higher risk of having testicular cancer
than those that don't have infertility.
It's also a predictor of who will have problems in the future.
Mike Eisenberg once showed a very nice study.
Men who have low sperm counts can have a 30% increased risk in diabetes, 50% increased
risk in ischemic heart disease in the future.
Tom Wall showed those men can have 2.5 times higher risk of high-grade prostate cancer
in the future.
So again, to me, it's just a marker of overall health.
Check the semen analysis.
I did that and it was quite, I was actually, to be honest, I was really quite nervous about
it because as someone who's in my early 30s and wants to have kids, I was really scared that it would come back
and say that my sperm is dysfunctional and I've got a huge amount of empathy and feelings
for people that do those analysis and get bad results back.
15% of all couples in the world, 15% suffer from infertility.
That's a lot.
And if you think about it, 30% of the time, it's a male factor.
30%.
20% of the time, it's a male and a female factor combined.
So indirectly, a male is involved 50% of the time when you have an infertile couple.
And it can be devastating for that couple.
I mean, psychologically devastating.
And what's also interesting is that most couples,
most couples, 50% of couples don't seek therapy.
And of those couples that do seek therapy,
this is globally, only 25% of those couples
actually go forward.
And so I call this a group of individuals
that also suffer in silence.
They should know that there are
excellent treatment options available.
This graph that I had printed out is just shocking to me. It's going back to the point
about testosterone, but the really shocking thing is how quickly this has happened.
Because this is the year 2000, and this is the year 2015-16 year, and the decline there
is from roughly 600 nanograms, is it?
Yes, nanogram per deciliter.
Nanogram per deciliter to roughly, for some age groups here, 400 nanograms per deciliter.
And that's only in 16 years.
So if you play that forward another 16 years, there's going to be a bit of an infertility
crisis.
There is.
Fortunately, on that graph, it's plateauing a little bit, which makes me feel a little
comfortable.
Okay.
Oh, yeah, it is actually.
It's plateauing just a little bit.
But you're right, it could be a significant crisis.
And again, as I mentioned, it's the adolescents, the younger folks who are having the greatest
rise of obesity.
And that's where fertility comes in.
Because obesity in someone in 60s is not concerned about fertility,
but a young patient who has infertility,
that obesity will have a higher risk of infertility.
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If me and my partner came to you and we said, listen, we've got sexual problems in the bedroom,
what are the steps that you would, the things you'd look at that we haven't focused on so
much today?
Is there anything particularly you'd say, okay, and I'm trying to stay away from being prescribed a pill,
so I want to do anything natural I can before I get to that, and then we'll talk about some of the other more drastic measures one can take.
So let's talk about natural things, because everyone wants to know about what's the natural things I can do.
So when we talk about diet, there's certain diets that have been helpful to improve sexual function. For me, it's the Mediterranean diet.
The Mediterranean diet is rich in whole grains, legumes, fruits, vegetables, and if you look
at red meat and sweets, it's once a month.
If you look at poultry, it's maybe once a week, but mainly fish.
Those diets have typically been anti-inflammatory diets.
Many studies have shown that that diet can significantly improve erectile function.
In one study, the Medida trial actually showed that it improves sexual function in men and
women. So I'm a big believer in using the Mediterranean diet.
When Esposito did her first trial, it was a prospective trial, 110 obese men, 55 men
get a Mediterranean diet, 55 men don't get any intervention at all.
She falls in prospectively for two years.
What does she find?
Not only a significant improvement in endothelial function, remember that lining of the blood vessel, but a significant improvement in erectile function in these
men. No Viagra, no pills, nothing. Simply changing the diet improved the erectile function.
And the same with sexual function in women. So that's an important one. The second is
sleep. Let's talk about sleep. So studies show that if you're getting less than six hours of sleep a night, it significantly
increases your risk for sexual dysfunction in men and women, right?
Ideal amount of sleep should be seven to eight hours.
Now let's say you say, well, that makes sense.
Maybe I'm going to get sleep for nine to 10 hours because the more sleep I get, the better
my sexual function.
But that's not true.
It plateaus.
So above nine hours, it does not increase your ability or sexual function.
So, seven to eight hours of sleep a night, I need you to get.
Third is I really need you to focus on exercise.
So, I published a very nice study looking at, it was a meta-analysis on how much exercise
one needs and what type of exercise to actually improve erectile function.
In this study, typically you need 160 minutes a week, so 40 minutes, four times a week,
for a course of six months of moderate to severe exercise, vigorous exercise.
And so most people can get 160 minutes in a week of exercise, but that's getting your
heart rate up and doing the exercise.
Significantly improved erectile function.
And then, if you did that, and the more severe your ED was,
the greater improvement you saw in erectile function strictly by exercise alone.
No other intervention, Stephen. Just exercise.
So here you have a patient that now starts doing some exercise,
starts sleeping better, starts changing the diet.
It's all additive.
You are now significantly improving erectile function
just by lifestyle modification alone.
Pretty profound that exercise can have such a big impact, isn't it?
Is that the same for women?
It is true because many of the things.
So unfortunately, once again, the research we have in women is not close to what we have
in men.
But the medida trial was also in women.
The sleep studies were also in women. The sleep studies were also in women. And so these studies also show that sexual function can be improved with sleep and with
diet.
I think that men and women are not that different.
I mean, if you see a significant improvement in a male's sexual function with diet, exercise,
and sleep, you can also see it in women as well.
Actually, there was a great study.
This looked at 110 women, and they had coronary artery stenosis.
They did angiograms on 110 women and they showed that the greater her stenosis she had,
the worse her sexual function.
So the greater the blockage in her heart, the worse her sexual function.
They put those women on a cardiac rehab program to actually improve their cardiac function.
So a diet and exercise program.
Those women that actually were through the program, fourfold increase almost in their sexual function, so a diet and exercise program. And those women that actually were through the program, fourfold increase almost in their
sexual function.
Well, 400%.
Fourfold, yes, because we use a questionnaire called the FSFI, which is a questionnaire.
So significant improvement in sexual function just on improving cardiac function.
So remember, cardiac function and sexual function are related and it's bidirectional.
You improve one, you improve the other.
It's very important.
We talked about this earlier.
40% of men in the world at 40 will suffer
from erectile dysfunction.
40%.
Jesus.
50% at 50.
60% at 60.
70 at 70.
80 to 80.
You do the math.
It essentially is a very prevalent condition.
This condition is associated with increased cardiovascular events.
It's the first sign of a heart attack.
We talked about that.
This condition is associated with two and a half times more likely to be anxious, three
and a half times more likely to suffer from depression.
And this condition is also associated with diabetes.
In other words, men with ED, two times more likely to have undiagnosed diabetes.
And yet, only 50% of men even talk about it
because they're so embarrassed.
So you show me another condition in the world
that affects more men's lives,
that's associated with more adverse conditions,
and they're too embarrassed to speak about it.
They suffer in silence.
There's not another condition.
There's not another condition.
But yet we're embarrassed to discuss it.
I used to give these lectures,
and I would look out to the audience and say,
please raise your hand if you suffer from hypertension.
And many people raise their hand, they have high blood pressure.
I'd say, okay, please raise your hand if you suffer from sexual dysfunction.
No hands go up.
But statistically, you know that over 50% of those people had sexual dysfunction.
So why is it okay to raise your hand if you have hypertension, but not okay to raise your
hand if you have sexual dysfunction?
It's got to stop.
We have to de-stigmatize.
It's okay to have sexual dysfunction.
It's a common condition.
It's curable.
Why don't men raise their hands from a psychological standpoint?
Why is that?
I think they're embarrassed.
Why?
I think that historically sexual dysfunction looks as a weakness.
I'm not a man, less of a man.
You know, if you have hypertension, it doesn't mean you're less of a man, right?
But they have this assumption that it's a weakness, less of a man.
And I think that it's okay.
You have to be comfortable saying that you have sexual dysfunction.
There are amazing treatment options for sexual dysfunction, amazing, that work very, very
well.
You just have to raise your hand and let me know that you have it.
I just want to make one other comment about diabetes.
There was a study that came out of St. Louis looking at young men, 18 to 40 years old,
and they were screening them for erectile dysfunction.
And what they found was when those men came in for erectile dysfunction, 30% of those
men had pre-diabetes or diabetes
on that day, on the day they were being diagnosed, 30%.
And I thought to myself, young men do not go get screened.
I remember when I was 30 years old, I didn't go in for my annual blood pressure check and
my sugar check.
There's no way I'd get my glucose checked.
But if a young man gets erectile dysfunction, he is at my front door first thing tomorrow
morning.
They show up.
That's the first thing they're going to do because it's a very big condition to them
and they want to get treated.
And that is the opportunity to treat these young men and treat the condition.
If you see a young man or someone who comes for ED and you screen them for diabetes and
I catch the diabetes at 30 as opposed to 40.
That is 10 years of damage on the vessels that you're saving because you catch the
disease early.
So ED is the gateway to men's health and to treating men early before it's too late.
So I really use sexual health as a tool, a vehicle to improve overall health because
men take sexual health much more seriously,
particularly young men.
Have you ever had sexual dysfunction?
I have not.
Never in your life?
I have not.
I have.
I have not.
I've been in situations where I've been...
But it doesn't mean that it's not,
but it's okay if I did.
It's not, there's nothing wrong with it.
Right, there's nothing, it's normal, it's okay.
And it's transient, it can be temporary and come back.
Right, it's nothing wrong with having sexual dysfunction. We must destigmatize it. It's normal, it's okay. And it's transient, it can be temporary and come back. Right, it's nothing wrong with having sexual dysfunction.
We must destigmatize it.
It's completely okay.
The reason I'm showing this is because if anyone else has been in the situations, the
situations I've been in are generally my sex life has been good my whole life, but there's
been certain times with certain partners or you know, you might be drunk a little bit or in the day when I was single, there was like the old person who for some reason, it just wasn't working for
me. And all there was other instances in a previous relationship where near the end of
the relationship, I'd like lose my erection during sex. And that became a little bit bothersome
for me because I was like, Oh my God, it's like, it almost made me not want to have this person or it convinced me that maybe I don't
like them anymore or something else was going on. And for me, it has always been, what's
the word you use, psychogenic. It's always been in my head that the problems have arose.
And the other part of the thing that I've experienced a lot is in terms of libido, I have like no libido when...
Actually, it's like different. When I'm... When work is very, very busy and I'm very, very tired and I come home very, very late, it's not that I'm not horny, but I just...
The act of sex is just really unappealing.
But you're just like everyone else.
You're not unique when it comes to that.
Yeah.
But that much of my life is like that.
Like I come home late a lot.
Right.
So I'm like tired and stressed quite a lot.
Right.
But what if I took you and your partner and put you on a beautiful island in Hawaii for two weeks?
Oh, we have great sex.
Okay.
Yeah.
So that's what we kind of like, how we've orientated our life, honestly.
Okay.
That's genuinely how we've orientated our life because I just don't think the way I
obviously want to make lifestyle changes to make sure that I'm not always coming home
tired and stressed at 11 p.m.
But one of the things that's really helped us is, you know, going away on the weekends
and going away maybe on Friday and coming back on Monday and getting out of the same
context.
So like getting out of the house and going to a, even like going to a hotel room, it's
actually a bit of a game changer that you can just like go to a hotel room
in the same city, like book a staycation.
And that seems to have a big impact because it just removes you from the context.
And then like, yeah, going away for the weekends, holidays and stuff.
A lot of my friends say to me, they go, when they're struggling with their sex life, they
just like book a local, a local sort of staycation.
And I wonder why, and also I don't have kids,
so I've not experienced the impact
that kids can have on the video.
Which can have a significant impact.
Really?
Right, because it increases your stress.
Right, okay.
Particularly for your, many times for the partner as well.
So if you both are stressed because of the children,
sex goes lower and lower on the totem pole.
And under slept as well.
Right.
If you're not sleeping, if you're having to wake up
and be like, oh gosh.
Isn't there stats that say like when someone has a kid, their sex life like vanishes for
18 months or something?
I don't know, I'm not familiar with that stat, but I believe it.
I believe it.
I believe it.
I read something about post-having a kid, libido, but also just like sexual function.
It makes sense.
I see it in couples.
And particularly, you know, many times it can take years for them to start engaging
sexually because the stress is so high, particularly when they originally have the child.
There was a British study done that found over 80% of women experience sexual problems
three months postpartum with nearly two-thirds still affected at six months.
Yes.
Which is a lot of women.
It's a lot of women.
A lot of women and that's a significant amount of time.
What about premature ejaculation?
Let's talk about it.
It's very important.
So sexual dysfunction, we've been talking about ED today, right?
But there are many different types of sexual dysfunction.
There's premature ejaculation, there's Peyronie's disease,
there's delayed ejaculation.
We're just focusing on one aspect.
Premature ejaculation affects 30% of men globally.
30% of men.
How do you define that?
There's two ways to think about it.
When they come in, you have to figure out, is this lifelong, going their whole life,
or is this acquired?
It's very important because it takes me down two different roads.
If you say, look, I've never had premature ejaculation and yesterday it started.
That's very different than if you come to me and say, my whole life I had premature
ejaculation.
And we now define premature ejaculation as having an ejaculation less than two minutes,
used to be one minute less than two minutes.
You have to have a loss of control, like I couldn't control it, and you have to be bothered
by it.
So if you tell me, Stephen, look, I ejaculate in 30 seconds and I'm happy, and I say, great,
then we're done.
You know, you are content.
You have to be bothered by the condition.
The average ejaculatory time in the United States is 5.4 minutes on average, right?
The average time for a woman to achieve orgasm is typically 13.4 minutes,
so there's a big discrepancy here as you can see, right?
So 30% of men suffer, but we know that only a small percentage of these men,
9% of these men will ever seek therapy.
And it can be a significant problem in a relationship that needs to be addressed.
Okay, so there's not like a time limit.
It's not like, okay, if you're coming within two minutes, then you've got a problem.
Well, let's say you're not bothered by it.
Let's say you and your partner are completely satisfied with it.
What's the problem?
Okay.
What's the problem?
And sometimes, if you think about acquired, it means that typically we define it as 50%
less than your normal time.
So if you say, look, I typically used to ejaculate in eight minutes, and now it's four minutes,
and it's bothering me.
I'd say, okay, that's an issue.
So if we talk, it's relative.
What's comfortable for you?
And some men will say, so I think it's very important to look at the definition.
The treatment options are actually quite simple.
One of the best treatment options is sex therapy, because we can train your mind, we can train
you to delay that ejaculation.
There's techniques, the start-stop technique, the squeeze technique, how we can delay it.
No, but there is.
But most men say, just give me a pill.
I don't have the time for this.
Just give me a pill.
But there are ways to do it with sex therapy, which I think are fantastic.
Sex therapy is a cure.
The pill is just a band-aid, right?
Sex therapy is a cure. The pill is just a band-aid, right? Sex therapy is a cure. But the pills that we use, the most commonly used pills,
are antidepressants because they increase serotonin and make it harder to ejaculate.
Well, that's what we want in this situation. We want to delay the ejaculation.
So we can use antidepressants. They sometimes have to be taken daily,
which work better, or you may have to take it on demand.
But if you take it on demand, six to eight hours ahead of time.
So you need some notice.
But there's going to be significant side effects
of taking antidepressants.
Yeah, there are side effects of antidepressants.
So I try to stay away from them.
And the other ones I try to use are topical lidocaine sprays.
Because if I decrease the sensitivity of the penis,
you're more likely to be able to engage in sexual activity
for a longer period of time.
So those are commonly used. So sex therapy and sprays are very easy to use. of the penis, you're more likely to be able to engage in sexual activity for a longer period of time.
So those are commonly used.
So sex therapy and sprays are very easy to use.
You don't need a prescription for sprays, and they're commonly used.
One thing that we have to talk about that's really important is the Traverse Trial.
It's really big.
Everyone historically has always said that testosterone is dangerous.
It causes prostate cancer, and it causes a heart attack and a stroke.
In 2015, there were some studies that suggested testosterone may cause a heart attack.
Before 2015, all the studies suggested that there was no increased risk.
So in the United States, they mandated that there be a large trial, 5,200 patients, six
years long, strictly to decide, does testosterone increase the risk
of a heart attack?
So myself and eight others designed the study, ran the study for six years, and we published
it last year.
It finally came out.
And it showed that there was no significant increase in cardiovascular events.
Finally, but until that time, until that came out, many people said, I still believe that
testosterone causes a heart attack. But when the Traverse Trial came out, many people said, I still believe that testosterone causes a heart attack.
But when the Traverse Trial came out,
the largest randomized placebo control trial ever published,
we finally showed that giving testosterone
did not increase the risk of a heart attack.
In fact, the study also showed
it did not increase the risk of prostate cancer.
Many people are worried that testosterone
causes prostate cancer
and no negative effect on urinary symptoms.
So many people have thought that if I give testosterone,
the urinary symptoms become worse.
The study showed no worsening of urinary symptoms.
So very important study, the Traverse trial finally came out.
It's the largest trial in men ever published on testosterone.
Will it reduce my lifespan?
Will, low testosterone, I believe,
will reduce your lifespan.
I mean, taking like testosterone injections and stuff.
Sometimes I think about like, again, I don't really know what I'm talking about here,
but I think about athletes taking steroids.
Different. Those athletes are taking supraphysiologic steroids.
So the normal range is typically 300 to a thousand is a normal range,
and they will take testosterone levels to much higher,
2,000, 2,500.
Okay.
There's a reason for that.
There's something called the plateau effect.
So if you take testosterone and you have better libido, you intuitively would think, if I
take more testosterone, I'll feel even better in libido.
But that's not true.
There's a certain point at which it plateaus.
So the more you take, you've already hit an on-off button, you've hit it, you're done.
The exception is muscle.
The more testosterone your body sees, the more it upregulates antigen receptors in the
muscle and you put on more muscle.
So bodybuilders are addicted to higher levels of testosterone, but they're also taking other
off-label medications, Anivar, Deco, Winstral.
They're taking other medications,
and those testosterone formulations
have a lower androgenic ratio.
Androgenic means facial hair, acne.
They're more anabolic.
So it's very different than what you're taking.
You're simply, or you would be taking,
is just all you're trying to do
is take a medication that you had before
and put yourself back into the normal range.
Nothing fancy.
So the more I've learned about testosterone,
the more I've started to think that maybe when I've had my kids
and I'm done having kids and maybe I'm 45,
I should consider it, providing that my levels are low.
And you're symptomatic.
If you're 45 and you say, I feel great,
I'm going to say, Steven, you're not getting it.
Right, I feel great.
So if you say, look, I'm 45, my levels are low,
and I'm starting to have symptoms.
I say, okay, now's the time to consider taking the medication.
Those symptoms you said were like tiredness, energy levels.
Well, the most specific are my libido's gone down,
my erections are worse, my energy's gone down,
increased fat deposition,
decreased muscle mass, poor sleep, and depression.
We have to talk about depression.
So early on in my career, I conducted a very large trial looking at depression and testosterone.
We had almost 850 patients.
We showed that men with low testosterone levels were much more likely to suffer from depression.
Almost 92% of those men with low testosterone had some degree of depression.
And when we treated—17% of those men actually had severe depression.
We treated these men for one year with testosterone supplementation, and that 17% dropped down
to 2%.
Now, I'm not advocating to treat major depressive disorder with testosterone.
But what I am advocating for is to at least check a testosterone level in men who are
depressed because it can help them.
In fact, in our study, even the men who are on an antidepressant, like say Prozac, we
put them on testosterone.
Those men also saw significant improvements in depression.
So maybe there's some synergy between testosterone and what we call SSRIs.
So again, it's very important to check a testosterone level in men who suffer from depression.
You wrote a book called,
Recoupling. Yes.
A Couple's Four Step Guide to Greater Intimacy
and Better Sex. Yes.
What are the four steps in this book?
And you wrote this alongside it.
Over 10 years ago, yes.
So I wrote it with a sex therapist.
She's an amazing sex therapist.
Her name is Mary Jo Rapini. And we decided to write a book together to really help couples get through
So the four steps really are number one for almost communication. You got to communicate
You got at least be able to tell each other
Did you know that for only 44% of men who start developing ED even tell their partners now think about that
You say what do you mean? They don't tell their partner. You know what they do. They just start avoiding sex
They just start avoiding sex. So they
got to communicate, number one.
And making excuses, right? If I lost my erection, I'd probably say, oh, sorry, I'm just tired
of all this. You know, because I want to just, on this point, there's much of the reason
why it's hard to communicate is because it can sound a lot like blame and it also can make
someone feel like you're not into them.
So if I said, and maybe you're not that into them, and also maybe you're not that attracted
to them.
So that could be really-
That's a problem.
That's an issue.
And that's why the sex therapist is amazing.
That's what they do.
That's what they do.
They work through these issues with couples
and they're fantastic.
But the number one step we put in the book
was communication.
You have to communicate.
The second chapter was my main chapter,
what I wrote about.
What can we do to improve sexual dysfunction
in men and women?
Testosterone replacement therapy, using Viagra,
vaginal lubrications, local vaginal estrogen therapy.
We didn't talk about that.
It's critical for postmenopausal women.
Local vaginal estrogen therapy is very important.
Decreases this risk of UTI, decreases pain with intercourse, so very important.
The third chapter really...
So what is that vaginal?
So younger women have estrogen in the vagina.
That estrogen is so important.
It keeps all the bad bacteria away and keeps the good bacteria within the vagina.
It keeps the lining of the wall thick.
It allows for the vagina wall to function with arousal properly.
And as she gets older and she goes through menopause, the estrogen goes away, the bad
bacteria come in, the risk
of urinary tract infections go up, the wall starts to atrophy, it means it gets thinner,
it's more susceptible to injury and tear.
It hurts, right?
So you can't ask a woman to enjoy sex if it hurts every time she has sex.
A lot of women, I've heard a lot of women talking about that, about this idea that the
reason they don't like to have sex is because it hurts.
It hurts because when they lose the estrogen, the wall gets very thin and it can tear.
It hurts.
But even young women?
Young women, but it's usually typically a different reason.
They could suffer from vaginismus.
There's other things that could cause vasibulitis, but in older women, the most common cause
is atrophy of the vaginal wall because of
the lack of estrogen.
So what do you do?
You give back local estrogen therapy.
It can be in the form of a suppository, form of a cream.
It doesn't happen overnight.
I tell my patients it can take up to three months.
But after three months, they notice a difference.
And the urinary tract infections go away.
The pain goes down.
Right?
So these are simple things that women can do to help.
Because again, if someone's having pain within, of course, man or woman, they will tend to
avoid it.
Right?
It's an important concept.
So the second chapter is really important on what are the many different things that
you can do to improve your sexual function.
The third chapter is really about intimacy.
It's really the intimacy.
And the fourth chapter really is ways to improve
your sexual experience. It was written by my sex therapist. She talks about vibrators,
masturbation. So there's a four-step guide that I think is very helpful. And I think
what's unique about this book is that really it's really two perspectives. It's one who
is the medical care that I provide and the psychological care that she provides.
Now, she's obviously handling the psychological side of things and she's not here.
But just on this point of improving communication, what is the best advice you'd give to people
that are currently in a situation where they're both kind of suffering in silence because
they're just not communicating with each other?
Yeah. Number one, most important is time. We don't spend enough time. It's basically
the shadows in the night. You're coming in, I'm going out, and you have to make time.
That's extremely important.
And the second one is open dialogue.
You have to be able to express to your partner what you're suffering from.
Otherwise, you can't get treated.
You just have to be able to express it.
But time, I think, is important in open communication and dialogue.
There's nothing embarrassing about this.
It really is something that needs to be de-stigmatized and the consequences of addressing it.
So couples who engage in regular sexual activity have a significant improvement in their quality
of their relationship.
They tend to be happier and suffer from less depression.
There are physical and emotional benefits
from regular sexual activity.
In the opener of the book where you start talking
about communication, there's a sentence that says,
when sex isn't going well, it can become 90%
of the relationship, and couples seldom know how
to communicate about any of these problems.
And that is true.
We've done a couple of conversations now on the diarhavacy
about sex and intimacy in these subjects,
and the amount of messages that I get from couples saying that everything else in their relationship is great.
Yeah.
Everything is great. Love this person so much, but there's this massive elephant in the room.
Right.
No pun intended, which is the lack of sexual intimacy. Now, when we talk about sexual intimacy, does it mean penetration?
Yeah, it doesn't.
Because the definition of sex ban is the ability and the desire to engage in satisfying sexual
activity.
I have patients that come to me and say, we do not have penetrative sex, but we have a
wonderful sex life.
I say, great, if this is working for you because it's satisfying sexual activity, you're set, right?
It's if you want penetrative sex and you cannot have it, then we will address it and we can fix it.
But you get to define, Stephen, you define what is satisfying sexual activity.
On chapter four, where you talk about things like vibrators and stuff like that,
I know that was a chapter handled by your sex therapist according to what you said. Is there any risk that using vibrators
or other toys and tools will impact normal intimacy
without vibrators?
Like, is there any studies that say,
okay, you get desensitized to the real thing
if you start using a vibrator?
Yeah, I've seen the opposite.
I've seen that the studies showing that vibrators
and these kinds of toys can actually enhance
the ability of the relationship so that you can, because you're communicating as you're doing it, right?
So you're communicating with your partner, what is giving me pleasure, what is not giving
me pleasure. You're learning about each other. And it's a great tool to use to learn about
each other. So when you're engaging in sexual activity, you're more aware.
I think it was a game changer for me. I think like just having other things. You know why? It's a game changer.
And I'm not just talking about vibrators. I'm talking about all toys in the bedroom,
whether it's like dice or handcuffs or whether it's something else, a blindfold is just because
novelty, doing new things for me is so critical as it relates to being excited sexually and there's only so many things you can do.
There's a relatively limited list of things you could do
if you're not bringing in other tools and toys and stuff.
So I think that for me it actually has helped me to prolong the novelty of my sexual relationship
in a way that nobody told me about before.
Because I think as a guy especially, I think you kind of think that toys are something
your partner buys for herself maybe, something she uses for herself.
And now I think if anything, I'm the instigator of using other things.
Yeah, chapter four.
I mean, and we prescribe vibrators for men.
We use something called Viborect.
It helps with men with delayed orgasmia.
These toys can be very helpful in a relationship.
I think she prefers the toys to me personally. But that's another conversation for another time.
In terms of energy, there are so many reasons why I'm a big matcha fan, if you don't already
know by now. And so much so that I actually invested in the UK's leading matcha company called
Perfect Ted. And one of my favorite Perfect Ted products is these delicious matcha pouches
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One of my favorites is this vanilla flavor,
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What's the most important thing we haven't talked about that we should have?
Well, there's a couple of things I want to talk about. One is we didn't talk about Peyronie's
disease. It's an important disease. Nine percent of men in the world suffer from Peyronie's
disease. Nine percent of men in the world. Peyronie's disease is an abnormal curvature
of the penis when it's erect.
So I want you to think about this.
The way I can describe it is if I have a balloon,
I put a piece of tape on the balloon,
I blow the balloon up, what's gonna happen?
It's gonna curve in the direction of the tape, right?
So if a penis curves greater than 60 degrees,
it's prohibitive for intercourse.
These men, many of these men suffer from severe depression.
It's disfigurement.
It's disfigurement of the penis, right?
So think about it.
Nine percent of men in the world suffer from this condition and most men have never even
heard of what Peyronie's disease is.
And essentially in the US, we have now one FDA approved treatment for this.
It's an injection called collagenase where we can put an injection into the rock plaque and break it up. There are surgeries that we can do to make the penis straight again.
But again, it's very important to realize that patients who have Peyronie's disease
are also suffering in silence. They don't know where to get the treatment. And there are many
good treatment options, whether it be surgical or medical, to solve this condition. So,
you know, my whole takeaway from this is this, is that I know that millions of people right
now, men and women, are suffering from sexual dysfunction.
I know they're silent and they're not saying a word because they don't know where to go.
They don't know what to do.
But they have to realize that there are excellent treatment options available and they should
seek therapy.
They're not suffering alone.
What else?
I want you to think about sexual dysfunction as no longer a band-aid.
We are not looking for Viagra.
We are looking for a cure.
We want a cure for ED.
And a cure for ED can be based on many things, as I mentioned earlier, diet, exercise, sleep,
stress.
We've also moved into a new generation of regenerative therapies in my field, stem cells,
PRP, shockwave therapy.
Now we're starting to look at radio frequency in our laboratory.
We're looking at hyperbaric oxygen.
Men are looking for ways to cure this condition.
They no longer want to take a pill to solve the problem.
And so I think that's very important.
And many of these new therapies are promising.
I think shockwave therapy is very promising where we have a device that delivers shocks to the penile tissue.
We've been doing this. It's like...
It's fucking making me go...
I got like goosebumps when you said that.
Well, but I'll tell you, we've been doing it now for five years,
and it was invented in 2010. It's actually quite brilliant.
If I take your finger, and I take a hammer, and I hit your finger multiple times,
what do you think your finger's going to do?
Your finger's going to start bringing in new blood vessels
and new ways to heal your
finger.
So before urology, the cardiologists have been doing it for the heart for many years,
and they would shock the heart many times, and you would see new blood vessels form.
It's called neoangiogenesis.
Orthopedic surgeons have been doing it for a long period of time.
In terms of injury, in terms of healing injury, they use shockwave therapy.
We are new to the game, but what we see is when you give these shocks,
it can potentially improve the blood flow and sexual function in men.
And I think the new era could potentially be hyperbaric oxygen therapy and
also radio frequency.
Radio frequency is a way to increase heat within the tissue and
improve sexual function as well.
So again, I think what you're going to see five to ten years as we move forward
is new ways to cure erectile
dysfunction, stem cells potentially have some problems as well, but patients don't want
a pill anymore.
One thing we haven't talked directly about, but we talked about indirectly, is the role
that trauma plays in sexual dysfunction and trauma in all of its forms.
I think I had a partner who was very public again about the fact that the reason why they
had sexual dysfunction was because, in their view, because they had been through a sort
of traumatic experience.
How often do you see that in your office?
How often do you see a patient come to you, man or woman, with some kind of trauma?
We query all men and women if they've had any kind of trauma, sexual or just physical
trauma.
It doesn't have to be sexual trauma.
It can be any kind just physical trauma. It doesn't have to be sexual trauma. It can be any kind of physical trauma.
I will tell you that most patients don't disclose or not very commonly described to
have having it, but they will many times disclose it to the sex therapist and I'll find out
on the back end to be honest with you.
But I think when someone discloses sexual trauma or trauma, it takes more of a relationship
and time.
On the first visit, sometimes they're not forthcoming.
What's that that you have in front of you on the desk?
I've been hesitating talking about it.
This is a penile implant.
Oh, gosh.
Yes, that's exactly what it is.
And this is a device that was invented in 1973 by a very famous urologist named Dr. Brantley Scott.
Brantley Scott, I'll have to brag a little bit, was from my institution at Baylor College
of Medicine and has been around for 51 years.
And the penis actually has two bodies sitting on top and it has the urethra sitting on the
bottom.
And those two bodies have muscle inside them or casing.
And what this device is, it's the surgery that I go on quite often, we put these balloons
or cylinders into those two bodies and fill them up.
There's a small pump that goes into the scrotum and there's a small reservoir that just holds
water, normal saline, that goes behind the pubic bone.
Typically, when a man squeezes this, he starts filling up these cylinders with water, and it gives
him a very rigid, very good erection.
When he finishes engaging in sexual activity, he'll press this button here, and it will
actually release, and all the fluid will come out of the penile bodies and go back into
that reservoir.
So, theoretically, anyone who's willing to have this surgery, we can cure ED, but it's a surgery.
And what's the consequence and cost of that in terms of sexual experience?
Monetary costs, I would say that in the US, Medicare covers this product, so that's actually quite good.
In terms of pleasure, and men report no significant decline in pleasure.
If you look at overall satisfaction, it's greater than 92% for patient and partner with
the penile prosthesis.
So it is a very, it's a game changer.
It really is a game changer.
Most patients have never heard of it or most people have never heard of this penile prosthesis.
But you know, let's be honest.
You know, if you had a bad shoulder, you'd get a prosthetic.
If you had a bad hip, you'd get a prosthetic. If you had a bad hip, you'd get a prosthetic.
It's a prosthetic that fixes an organ.
And, Stephen, the satisfaction rate is extremely high.
But I'll tell you something, you owe me something because when I brought this on the plane
and I went through security, they maybe pulled this out and explained what this was,
and nobody had heard of it. No one had seen this.
They'd be beefy.
Well, I had to explain it and I had to pump it up and show them.
But I had a little bit of an audience.
But yes, but I will tell you this.
This is something that really has revolutionized the treatment for erectile dysfunction.
But this is surely like a last ditch attempt.
It is because it is a last ditch attempt.
Because if I take it out, no other treatments will ever work again.
Oh really?
It's the end, right?
So if I take it out, no other treatments will work again.
So I want you to try every single option before we come to this.
What situation does someone have to be in for you to insert this into their penis?
Remember when I told you that 40% of men at 40, 50% at 50, and most patients will take
Viagra but I told you Viagra is not a cure, it's a band-aid.
So what's going to happen?
That Viagra is just like that pain pill.
And that pain pill eventually is going to happen is you can't walk.
Well the same thing happens with ED.
Eventually the meds stop working.
So once the meds stop working and then the second level we use something called penile
injections, some men will use penile injections.
Once you've tried everything and nothing works, what are you going to do?
OK, so this is like a last...
What are you going to do?
If you still want to get...
But if I look at satisfaction rates, if I give men questionnaires for the pill,
for the injections, vacuum reduction device for the implant,
highest satisfaction with the implant.
At what point?
What do you mean? their starting point to?
Right.
Because if I'm starting at a point where I'm completely unable to get an erection, if anyone
helps me get that thing up, my satisfaction is going to be really high.
Right.
But let's say you have an erection with a pill, you get an erection with an injection,
you get an erection with a vacuum, and you get an erection with this. Over time, it gave you an erection with an injection, you get an erection with a vacuum, and you get an erection with this.
All four, you know, over time gave you an erection.
Which gave you the best erection and which one were you most satisfied with?
This will win.
That's crazy.
And can you still ejaculate with this?
Yes. No issues.
Gosh.
No.
I mean, again, I have tremendous sympathy because it ruins people's lives, right?
It does.
If you can't perform in that way and it destroys your relationships, and relationships are
like the essence of life.
But essentially, you're taking someone who can't have sex who can now have sex again.
And some would argue that they can have sex whenever they want, as long as they want with
this device, right?
It only goes down when you tell it to go down.
Dr. Mo, we have a closing tradition on this podcast
where the last guest leaves a question for the next guest
not knowing who they're gonna be leaving it for.
Yeah.
And the question that has been left for you is,
have you ever experienced anything that you cannot explain
from a position of rational materialism?
I mean, I think so many things in science
that we can't explain.
So many things that are idiopathic that I have no explanation for.
For example, for fertility, which is something we talked about, 40% of men who come to me,
our explanation is no explanation.
We don't know why you're infertile, right?
So obviously that's very uncomfortable for many patients to hear that.
But many things in science I have no explanation for.
And many things that I do have an explanation for, we find out 10 years later we're wrong.
So I think that's what comes to mind.
What about any personal experiences at all in your life?
Spiritual, religious?
Yeah, I'm very spiritual, I'm very religious.
Sometimes death. It's hard to explain.
It's hard to understand.
Why?
It's real. I see it every day. We see it at work. I see it personally in my own life.
My father passed away at an early age from idiopathic pulmonary fibrosis.
It's a condition where your lungs start to scar.
It's probably the worst condition you could ask for.
And he had a lung transplant at 70.
So he was pretty young.
He retired at 69 and said – he worked very hard.
He was a general surgeon, solo practice.
And he said, one day I'll enjoy, one day I'll enjoy.
And then at 69, he retires, he's ready to enjoy.
At 70, he gets idiopathic pulmonary fibrosis.
At 70, he gets a lung transplant and lives for five years with someone else's lungs,
which is pretty tough.
And his one message was, you know, don't wait till the end, enjoy the ride.
I wish I'd enjoyed the ride because waiting till the end, sometimes there may be no end.
And by that I interpreted that to mean that he'd worked his whole life very, very hard.
Extremely hard.
And he'd sort of delayed the gratification to a point that it didn't really come necessarily.
He thought it would come at 70. And he'd enjoy the last 15 years and enjoy but at 69 he got
idiopathic pulmonary fibrosis at 70.
We got a lung transplant and at 75 he passed away.
And I think that if anything I learned was don't wait to the end, enjoy the ride.
Are you doing that?
I am. Every second I can.
And how do you do that sort of practically when you're so busy?
So I make time, I meditate every morning, I work out every morning, I have my own time
to myself, I pray, I'm very religious, I think those are very important things that
keep me going. I spend, it's God family work, patience, I mean, it's an order. My family is extremely
important to me and I make time for them as well. And I think that keeps me grounded.
Dr. Mo, thank you. Thank you for the work you're doing. Because as you say in your
work, there's a huge proportion of people, couples, men, women that are suffering in
silence and they are in search of answers. And there's not a lot of people in your friendship
group that are necessarily going to know this stuff or even talk about their own experiences with
this. So I think it's important to have these kinds of conversations that anyone in the
private or comfort of their own home or with their AirPods on can tune into to get a better
understanding. If there was a closing message for those people that are suffering in silence
in some way, whether they're couples, individuals, what is that closing message to them?
It's okay to suffer from sexual dysfunction. It's normal as we age. And there are many treatment options, good treatment options that can help you today. And I ask you to seek therapy, raise your
hand, tell your doctor you suffer from sexual dysfunction, because there are excellent treatment
options. And if people want to learn more about you and your work, where's the best place for
them to find you?
Well, it's my website drmohitkira.com and sexsbandhealth.com.
I have sexsbandhealth.com where you can learn all the different ways to improve lifestyle
modification.
I started a nonprofit, I just want you to know, called The Testosterone Project, just
so you know that.
It's really geared at education, advocacy for testosterone. We're trying to get testosterone proof for women
in the United States. I think that's important. We're trying to get testing done as well.
We want everyone to be tested for testosterone. It should be norm as well. And we're trying
to get it deregulated. So the testosteroneproject.com is a great way to get information as well.
I'll put all of those links below. Dr. May, thank you so much for the work that you're doing. Thank you so much.
And please do keep doing it,
because it's so incredibly important.
Thank you, Stephen.
Pleasure to talk to you, thank you.
Thank you.
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