The Diary Of A CEO with Steven Bartlett - The Better-Sex Doctor: The Link Between Masturbating & Prostate Cancer! This Is The Perfect Amount Of Times To Have Sex! Strong Pelvic Floor = Better Sex! Dr Rena Malik

Starting point is 00:00:00 Quick one. Just wanted to say a big thank you to three people very quickly. First people I want to say thank you to is all of you that listen to the show. Never in my wildest dreams is all I can say. Never in my wildest dreams did I think I'd start a podcast in my kitchen and that it would expand all over the world as it has done. And we've now opened our first studio in America, thanks to my very helpful team led by Jack on the production side of things. So thank you to Jack and the team for building out the new American studio. And thirdly to to Amazon Music, who when they heard that we were expanding to the United States, and I'd be recording a lot more over in the States, they put a massive billboard in Times Square for the show. So thank you so much, Amazon Music. Thank you to our team. And

Starting point is 00:00:37 thank you to all of you that listened to this show. Let's continue. Men who ejaculate 21 times or more a month are less likely to develop prostate cancer. Jesus Christ. Why? It's because... Dr. Reena Malik. Board-certified urologist. Expert on sexual health. And a rock star in educating the public...

Starting point is 00:00:55 On the facts and myths of sex. Reena, I want to start with this idea that other couples are having significantly more sex than we are. Big myth. People are having sex about once a week. Will my penis get smaller as I age? It can. So in terms of how do we maintain our penile size, you need to have sex.

Starting point is 00:01:13 Is there a disparity between how long we think sex should take and how long it actually takes? Yeah, we all think it lasts longer. Women want it to be 18 to 25 minutes. Men are a little on the shorter side, like maybe 12 minutes. Is there like an average time? 5.1 to 5.7 minutes. And then is too much masturbation going to have an adverse effect for men and women? Masturbation is generally safe as long as you don't. That's when it becomes a problem. Rina, do we understand our bodies as it relates to our

Starting point is 00:01:43 sexual health? Not at all. For example, the pelvic floor. It's involved in orgasm. It's involved in sexual function. But no one really talks about it. In fact, men will be shocked. Oh, I have a pelvic floor too. And there's a whole host of issues that can come from having a weak pelvic floor,

Starting point is 00:01:59 including erectile dysfunction. So how can I strengthen my pelvic floor? Pelvic floor exercises. They're going to increase orgasm. They're going to make your semen propel further. And ultimately it would be something as simple as... Quick one, quick favor to ask from you. There is one simple way that you can support our show. And that is by hitting that follow button on this app that you're listening to the show on right now. This year in 2024, we're trying really, really hard to level up everything we're doing. And the only

Starting point is 00:02:26 free thing I'll ever ask from you is to hit that follow button on this app. It helps this show more than I could probably articulate. And it allows us, enables us to keep doing what we're doing here. I appreciate it dearly. On to the show. Dr. Reena Malik, with all of your work, what is it that you're seeking to do? So what I'm seeking to do is have people understand that sexual health is health. I think we have so much misunderstanding about, one, what is good sexual health? How do you, why is good sex important? Why is it good what is good sexual health? How do you, why is good sex important? Why is it good to have good sexual health? And that creates a lot of despair and devastation

Starting point is 00:03:14 and people don't talk about it. So they ruminate, they feel bad about themselves and it's pervasive throughout their entire life. So I think ultimately my goal is to make education freely accessible and understandable so people can know what's going on with their bodies, what's normal, what's not, and what's available to help them. How do you define sexual health? So sexual health is sort of an individual thing, but most people would say that you are able to have sex, you are able to have an orgasm, you are able to have pleasure and achieve the benefits of that. Do we understand our bodies as it relates to our sexual health?

Starting point is 00:03:52 No, not at all. I will tell you. So I talk about, for example, how it's normal to have erections at night or have even nocturnal emissions, so have a wet dream, how that's a normal physiologic function. And so many people will message me and say, how can I stop having what they call nightfall? Or how can I stop waking up with an erection? Because they think for some reason it's shameful or it's a bad thing. And when realistically, it's just normal. And part of it is media, right? So when you see TV, you see a man getting an erection very quickly. He's immediately penetrating a woman and she's immediately orgasming. And the whole act is like really hot and heavy. And in reality, that's not what sex is like. So if you're not seeing what normal sex is like,

Starting point is 00:04:45 what normal foreplay is like, what the fact that it's normal to sometimes have difficulty getting an erection, that's normal sometimes to not have an orgasm for a woman, or it may take more time to get a woman aroused and require more foreplay, that you are essentially looking at a script that's not real.

Starting point is 00:05:03 And then you're like, what's wrong with me? Am I broken? You know, is something wrong with my body that it doesn't function the way I'm seeing on TV or on media or on erotic films? Where does your experience on this subject come from? So I'm a urologist by training a board-certified urologist. So we are the medical and surgical doctors

Starting point is 00:05:23 of the genitourinary tract. So we're essentially the plumbers. So when you the medical and surgical doctors of the genitourinary tract. So we're essentially the plumbers. So when you have a problem with your kidneys, the tubes that drain the kidneys, the bladder, or your genitals, we're the ones who are going to fix those if they're a surgical issue. And also we deal with the medical aspects of some of those things. And so that's what my training was in. But when I started my social media, my channel, I wanted to offer education to people. And as I started making this education, I realized how badly people wanted to know

Starting point is 00:05:52 about sexual health, how much they didn't know and how they really wanted to be empowered with this information. And people are not being asked about sexual function. Even when you go to see your primary doctor, when was the last time they asked you about anything? They might ask you about erections, but that's probably where it ends, right? Even if they ask about that, they're definitely not asking women, are you having orgasms? They're definitely not asking anyone if sex is pleasurable. They're not asking them if

Starting point is 00:06:17 they feel satisfied with the way things are going, right? And if they are enjoying desire, do they feel normal? And so I realized there was such a disconnect here with what people wanted to know and what was available to them. And so then I started really making content about sexual health and spending more time investigating in that area, treating patients in that area. And it totally became a all-encompassing field for me. You're an expert in the pelvic floor as well. What was your sort of training with the pelvic floor? So when you do a fellowship in what we call pelvic, female pelvic medicine, a lot of what we do is related to the strength or weakness of the pelvic floor. And so the pelvic

Starting point is 00:06:58 floor, just to start, is a bowl of muscles that sits in your pelvis. So your organs, the bladder, the rectum for women, the vagina, the uterus, the urethra, all run through the pelvic floor. It attaches to the bones on your pelvis, and it is extremely important for a variety of functions. It offers stability. So when you're standing, sitting, it offers stability. It offers the ability to defecate and urinate normally. It offers when women have pregnancy, the pelvic floor becomes very important. It's involved in orgasm. It's involved in sexual function, but no one really talks about it. No one really knows it. In fact, men will be shocked. Oh, I have a pelvic floor too, because we talk about it a lot with women,

Starting point is 00:07:41 right? We talk about it in terms of, oh, I might leak a little after I've had babies when I cough or sneeze or jump on a trampoline. But the pelvic floor is much more complex than that. And so very often we'll see people when they have weakness of the pelvic floor, yeah, we'll see leakage of urine. But sometimes their pelvic floor can be discoordinated or it can be too tight or have elevated tone. And so what that means is that you can develop a whole host of abnormalities. And that can be that you may have constipation. You may have issues emptying your bladder. You may feel like you have to go to the bathroom a lot.

Starting point is 00:08:17 So you may urinate frequently. You may feel the urge to go often. Sometimes it can cause pain. So it can cause pain when you urinate, might feel like you're having a UTI. It may cause pain with erection or ejaculation for men. So there's a whole host of issues that can come from having pelvic floor abnormalities. And even if you've had, say, lower back injuries or hip injuries, they can affect the coordination of the pelvic floor because it's all interconnected. And so I will see patients who are like, you know, I've had a bunch of hip issues because I played sports when

Starting point is 00:08:49 I was younger and now I'm having issues with sexual function. And so it's all interconnected. And I think we don't spend enough time talking about how important it is and how valuable it is to people when they're having problems. I want to go into the pelvic floor in more detail and really figure out how I can improve my pelvic floor and what I'm doing to harm or hurt it. But you said something there about doctors don't ask about sexual health. They don't ask if we're orgasming. They don't ask if we're ejaculating, those kinds of things. Why should they be asking about that? Because I think of a doctor as, I don't know, fixing other parts of my body. I don't think of them as sifting through my sexual life. So if you have a normal sexual life

Starting point is 00:09:28 and you're satisfied with it, it wouldn't even bother you, right? You wouldn't think about it. But people who have difficulties, they may be walking around feeling shame. They may be walking around wondering what's wrong with them. This can be pervasive because they may have relationship issues

Starting point is 00:09:44 and they may have problems in their life with their relationship. They're then causing them to be less productive at work, less happy, less satisfied with life, feeling more depressed, more anxious. And so it all comes together. And in fact, the other really important thing, at least for men, we know that when they develop issues with erections, so say you're having erectile dysfunction and you are diagnosed today with erectile dysfunction, seven years later, about 15% of those men will have a heart attack. And the reason for that is because if it's a blood flow issue, the arteries to the penis are about one to two millimeters. The arteries to the heart are about three to four millimeters. And when you have about a 50% occlusion of a blood vessel because of high

Starting point is 00:10:30 blood pressure, high cholesterol, heart disease, that organ will start to have problems. And so you will start to see erectile dysfunction in men who have vascular problems before you start having chest pain or other signs of heart disease. So it's, and probably similarly in women, all of the data is not as, we don't have that data for women that maybe if they all of a sudden are developing problems with arousal, that maybe that's an indicator. But again, that's more complex and we don't have the data for that. But certainly for men, we have a clear indication that a problem with erections could precede really serious heart consequences. And when you look at people who've had a heart

Starting point is 00:11:11 attack, about 50% of men will have had erectile dysfunction prior to that. 50%? Mm-hmm. Is pelvic floor dysfunction in men also linked to erectile dysfunction. Because I heard in some of your work that sitting every single day, in the way that I do here, I sit sometimes here for 10 hours a day, could be creating erectile dysfunction. Well, so it's more that sitting every day can cause your pelvic floor to not stretch appropriately, right? Like if you're not moving your body regularly and your body tenses up from sitting all day, then your pelvic floor is not relaxing and contracting in a normal fashion.

Starting point is 00:11:50 And so some people will develop some tension in the pelvic floor and through the pelvic floor runs a whole bunch of arteries and nerves that then go to the penis to provide blood flow. And so if your pelvic floor is clenched really tight, then it can cause problems in getting blood flow and then problems in getting erections. So while that's different than having vascular problems, this is a muscular problem more so that can be an issue in terms of causing erectile dysfunction in some men. Because I heard during COVID there was a rise in pelvic floor dysfunction as people were sitting all day. Yeah, I mean, I definitely saw it. I don't know if it's been actually studied, but I definitely saw it in my own clinical setting and many of

Starting point is 00:12:32 my colleagues did where people would come in and they would start having either they'd be having more erectile dysfunction, they might be having more urinary urgency, meaning they got to go, got to go to the bathroom or they're going more often, which wasn't a huge issue because the bathroom was right near them. But they did sometimes notice that it was a change. And also sometimes they would, some people even deal with pain, like they would have more pain in that area or women would think they were having urinary tract infections when they truly were just having discomfort from the pelvic floor being tense. One of the things that you're particularly good at is taking on some of the big myths as it relates to sexual health.

Starting point is 00:13:07 And I want to start with one of the big myths around sexual health, which is this idea that we all think other people and other couples are having significantly more sex than we are. Yeah. So that's interesting. I think that is a big myth. And so when you look at,

Starting point is 00:13:21 people want to know like, what's normal? How much sex should I be having? Right. And there's no ideal number. But when you look at, people want to know like, what's normal? How much sex should I be having? Right. And there's no ideal number. But when you look at studies, right, which have looked at large numbers of people, people who are in partnered relationships are having sex about once a week on average, if they feel they're in partner relationships where sex is always available. But it's so variable person to person.

Starting point is 00:13:43 And what I really like to say is it's not the quantity of sex that matters. It's the quality of sex, right? So if you're having good sex once a month, that may be sufficient for you rather than having mediocre or bad sex four times a month or 10 times a month even, right? And so ultimately, there's no right number. It's really what's right for you. And I think focusing on some like benchmark, right, of sex is actually harmful, right? Because now you're like, oh, well, I need to have sex this many times. What is the purpose of sex, right? The purpose of sex is pleasure. And sometimes people derive a lot of benefits from orgasm. We know that there's

Starting point is 00:14:25 physiologic benefits to orgasm in terms of stress reduction, more focus, potentially better sleep, and even maybe lower blood pressure, things like that. So if people are deriving benefit from the orgasms and the intimacy with their partner and the pleasure they derive from sex, that's what matters, right? Not the number of times you're having sex. Another big myth around sex, which I thought I'd get your take on, is about pain during sex. It's one of the sort of most popular questions that I often get whenever I speak to someone that is an expert on sexual health is, is sex supposed to hurt? Because for a lot of people it hurts. No, it's not supposed to hurt. So if it hurts, you want to assess, you know, what, usually it's the female partner who feels pain, right? So is it that you're not lubricated enough?

Starting point is 00:15:18 Is it that you have not had enough foreplay? Because the body prepares for intercourse, particularly in the female. So what happens is you go through arousal, your body self-lubricates and the vagina actually lengthens and widens almost double in size to accommodate the phallus or whatever you're using, whether it's a toy or a finger or anything. And so if you don't have sufficient time to allow those things to happen, then it will be painful. And sometimes lubrication can be variable person to person. So some people may have copious amounts of lubrication and some people may have less. And it could be based on genetics.

Starting point is 00:15:57 It could be based on the age they are, what stage of their hormonal status. It can be based on what medications they're on that might decrease lubrication. I think there's another big myth is that lubricant is not for everybody. And I argue that lubricant is for everybody, that it makes things more fun. It makes things more slippery. It makes things more enjoyable. And it certainly makes pain less of an issue for a lot of people. Now, there can be other issues that cause pain. So if you've tried all these things, you know, you're fully aroused, you know, you're lubricated, you know, that you're still having pain, then it's really important to get evaluated to understand what exactly is causing the pain. It could be hormonal changes in the vestibule, which is a part of the vagina that is very

Starting point is 00:16:40 hormonally sensitive that can be painful. It can be pelvic floor dysfunction. It can be things like endometriosis or other factors that may be going on that need really advanced help. But most of the time, a lot of people can feel and enjoy sex more readily if they just increase the amount of foreplay and increase the amount of lubrication. You said there that the vagina expands during sex. So how much does it expand by and how long does that take? Because I think men don't really understand this process. A lot of men just like to rush in there, you know? Yeah. So usually it expands by about double, double in length and double in width. And so it will expand and basically the cervix is moving

Starting point is 00:17:20 up and out of the way. The vagina is expanding to accommodate the length of a phallus. And, and it takes, we think on average, about 18 to 20 minutes. So that's sort of the amount of time and some people faster and some people longer, but ultimately, you know, sort of like understanding that, but also the lubrication is another big part of it. And so I think both those things together, you know, you together, you need some time. And some people, like I said, they may not take 18 minutes. They may take a couple minutes. And so it's very reasonable to get in there if that's what your partner wants. But again, I think the bigger issue is that we're not communicating about sex. No one taught us how to talk about sex, right? I didn't grow up talking about sex with my family. Many of my friends and colleagues did not

Starting point is 00:18:04 grow up unless they were in a family that was very progressive talking about sex or even learning about sex from their parents. And at school, you don't learn much. You learn how to put on a condom. You learn how to ask for consent. You learn about STDs. And that's if you're lucky.

Starting point is 00:18:19 In the US, 13 states don't have to have accurate sex education. Like it's not a requirement for sex education to be accurate in 13 states in the US, 13 states don't have to have accurate sex education. Like it's not a requirement for sex education to be accurate in 13 states in the US. Where are we learning sex from? So the large majority of young people, I mean, this data shows that at least one in four adolescents are learning sex from porn. And it's probably more than that. So I think a lot of people are learning either from pornography, from their friends, a small subset are learning from their parents. There still are people learning about sex

Starting point is 00:18:49 from their parents, but ultimately it's not enough. And so if people are learning about sex through porn, porn is entertainment. It is doctored, it is not real. And I think people then take that and they say, why did not my sexual encounter not look like that? Why didn't I have as much semen volume? Why did my partner not orgasm as quickly?

Starting point is 00:19:10 And it can be on both sides where women can be like, well, why didn't I react like that? Why didn't I get so excited right away? And I think there's, it's a real problem in terms of if people are only learning about sex through pornography, then they're already set up to be let down when they have their first sexual encounter. And on that point of communication, we don't talk about it as a society, but then even within our own relationships, you know, we don't talk about things we're struggling with, with our own partners and the insecurities that we have. And I think that can cause a spiral of misunderstanding.

Starting point is 00:19:41 And I've seen that in my own sex life historically, where maybe there was something I was insecure about or there's something I was thinking about, and instead of communicating it, I might have just acted in a strange way, and then that's misinterpreted, and then the other person gets a little bit insecure or whatever, and then you kind of have this downward spiral of misunderstanding, which leads to sexlessness.

Starting point is 00:20:00 Absolutely. You're just avoiding the situation because nobody wants to talk about it. And this is the problem. Like, you know, people ask me, like, what's this? What's the key? What's the key? What's the secret? The secret is you have to know what you like, right? You have to know what you want and you have to communicate it with your partner. How? Because no one taught us how to have these conversations and they're charged with a lot of emotion, right? You feel insecure, you feel inadequate, or you feel resentful because you're not getting what you want out of the relationship. And so it has to come from a place of understanding that this conversation is not a one and done. There's no the talk.

Starting point is 00:20:40 There are multiple talks over multiple periods of time. And the first time you have the talk, it might be a total disaster. But, you know, if you are in a relationship where someone really also has the same goals as you of having a great relationship with a good sex life, then ideally that won't continue and you will continue to have conversations. So what I tell people is don't have conversations in the bedroom, not right before, not right after sex. You want to wait until you're out of the bedroom. Not during. Or during. Definitely not during. That's happened

Starting point is 00:21:09 before. It fucking was. Yeah. That's pretty bad. That's pretty bad. So, you know, one, and then two, have it in a place like somebody, you don't do looking at the person, right? You can be sitting in a car, you can be going on a walk because it's really awkward to look at someone in the face and be like, you know what? I felt like this wasn't really great, you know, and, and so then to be like, okay, like, you know, again, using the same sort of communication techniques that you use for other things, talking about I statements, not being you did this, you didn't do this more about like, how I feel what really turns me on what I would really like in the relationship. And then sort of realizing

Starting point is 00:21:45 that they may not react well, they might be like, oh my God, I can't believe we're talking about this. They have their own stereotypes and biases that they're bringing into that conversation too, or their shame or whatever they grew up with in society, whatever they think about sex can be very charged, right? And so it's sort of a lot of work to get through that, but realizing that it could take time and sometimes getting help. So seeing a sex therapist or someone who has expertise in psychology and sex to learn how to talk about sex with them and navigating the difficulties of it, but it's worth the investment, right? It's not easy, but nothing in life that's good or worth getting is easy, right? Okay. So there's a couple listening right now. There's probably one member of the

Starting point is 00:22:28 couple listening right now. And they've had everything you've said, but they have reached the point of no return in their relationship as far as they're concerned. They've not been having sort of a functional, healthy sex life for maybe one year, maybe six months, maybe five years. And it's just become the new normal. What is the case you would make to that person to get them to take action to try and rectify the situation? Well, I would ask them first, how important is sex to them, right? If it's not that important

Starting point is 00:22:53 and the other things in the relation, and that's okay, right? Some people find that, okay, everything else in their relationship is excellent. I love this person. We're still intimate. We still love each other. We still cuddle.

Starting point is 00:23:04 We still have a lot. We still cuddle. We still have a lot of great things in our relationship. And sex right now is not working, right? Or it's not working for us. So I'm okay with that. That's fine. You don't have to feel bad about that. But I think that if it is a problem, then I think it's worth working on, right? Like if you have a relationship that you value and that person you're with values their relationship, then it's worth keep trying. Like try to have the conversation, try to bring them into the conversation. How much have you tried, right? Like, have you really had enough attempts at a conversation, a true conversation where

Starting point is 00:23:41 you didn't get frustrated too, right? Like where you were like, okay, I understand that you have, this is a difficult conversation that we're going to have. And I understand you might have feelings about it, but I love you. And I really want to try to have this conversation and to keep at it. And I realized that that's not easy, right? That's not easy. I'm not saying it is, but I'm saying that when you're in a relationship that's worth having, that ideally at some point, the other partner will see how much this matters to you and want to work with you on it, right? If they love you, if they're with you there, they want what's best for your relationship. They're not like hiding, they're not hiding their head in the sand and being like, oh, I'm like, they're, they realize

Starting point is 00:24:18 they're just don't want to talk about it. They, they, they're not stupid. They just sort of don't want to talk about it because it's embarrassing to them. They feel like they're the one that has something wrong with them maybe. Or maybe they have an issue that they haven't brought up. Maybe they're having a lot of pain with sex. Or maybe they're going through hormonal changes and their tissues are really dry or whatever. There's a whole host of things that could be going on that they don't feel comfortable talking to you about. So I think it's valuable to say, is there something I'm not doing? Like,

Starting point is 00:24:46 tell me what you feel about sex, like leaving it open ended to really find out what's going on with them. Because usually not that they're like, I just don't want to have sex. And that's it. There's usually a lot more to it. It's so hard for us to know, isn't it? When it comes to sex, what the root cause of the issues are. And I think some relationships are like a frog in a frying pan. The frog in the frying pan analogy for anybody that doesn't know is this old tale about a frog jumping into a frying pan. And then because the water heated up gradually, it ends up dying. But if the water was hot from the moment it jumped in, it would have jumped straight out. The idea that it's a gradual death for the frog. And in relationships, it's kind of a slow day by day,

Starting point is 00:25:24 month by month decline in intimacy. And you end up it's kind of a slow day by day, month by month decline in intimacy. And you end up finding yourself like a dead frog in a frying pan. You end up finding yourself in a sexless relationship and you think, how the hell did we get here? And it's, and it's, so it feels like a long way back from that point. It is. It's going to be right because you let it sort of dwindle and you didn't talk about it and it's going to take work. And I think that's the key is like, if you want to fight for that in your relationship, it's going to take work and it's going to take buy-in on both sides, right? You have to work for anything in your relationship. Relationships are not easy, right? You want to have children, that takes work. You

Starting point is 00:26:00 want to decide to buy a house together. That takes work, deciding and figuring out what kind of house you want, how much money you want to spend. Like there's all sorts of things that take work. And this is one that people just don't know how to talk about. And so they just ignore it because it's harder to bring up for both parties, right?

Starting point is 00:26:17 What the one who maybe is not wanting sex or is being the one who says no and the one who always wants sex and then feels rejected because they're not getting it. Is there a sort of a difference between men and women's sexual desire as we age? You know, because I think there's a myth that says men just always want to have sex and women maybe not so much. Is that a real myth in terms of something that you hear?

Starting point is 00:26:43 But also, is it true? So let's talk about desire. Desire comes in two flavors. So there's the spontaneous desire where you see somebody, you're like, oh man, they're so attractive. I can't wait to sleep with them. I'm immediately turned on. I want to have sex right now. Right? You didn't have to do anything. You just saw them and it happened. And then there's responsive desire where you're sort of with them. You might be touching them. You might not really be thinking about sex, but like you're touching them. You're with them. You're like, oh, this feels sort of nice. I sort of like this. Like, oh, now I'm turned on after we've sort of started being a little romantic with each other, being a little

Starting point is 00:27:18 more intimate with each other. And both desires are normal and both desires are fine to have. Now in the literature, you'll find that men tend to more often have spontaneous desire and women tend to more often have responsive desire, particularly when you're in longer term relationships. So there's this disconnect, right? Women are like, why don't I see you and want to jump you anymore? Right? I used to feel like this, but I don't anymore. What's wrong with me?

Starting point is 00:27:43 Am I broken? Right? And then they don't realize that, okay, maybe we'll just like be together and let's see what happens. And they don't even want to start because they're worried that what if I don't want to have sex? And we've now initiated this like touching, cuddling thing where, oh, that person's getting really turned on. What if I don't get turned on? And what if I disappoint them? And so there's a lot of charged emotions there, but realizing that this is normal and common and responsive desire is not wrong.

Starting point is 00:28:10 It's just different. And people just don't know that it exists because again, media attention is like, you see somebody jump them, you're horny right away, you have sex. And that's not what happens all the time. And that's okay. And so like, you can be with your partner and be like,

Starting point is 00:28:24 look, I have no expectations from you. I just want to be with you physically and see if it turns into sex. So often we'll give people homework, like put it on the calendar, put it on the calendar that you are going to be intimate together at this time. And I know that sounds weird, right? Like you're looking at me like I'm crazy, but we put on the calendar when we want to work out, we put on the calendar when we want to have brunch with our friends, we put on the calendar when we want to work out. We put on the calendar when we want to have brunch with our friends. We put on the calendar when whatever, right? And when we were younger, when we used to have dates with people, we would say, okay, we're going to go on a date on Friday night.

Starting point is 00:28:54 We would know that sex is on the table with our partner on Friday night. So we'd get really excited about it. We're like, okay, I'm going to shave. I'm going to look real pretty. I'm going to smell good. I'm going to do all the things that make me desirable and feel confident and be ready to have sex. Right. And so you'd be like really excited about it. And then you would have all this anticipation about how fun it's going to be. But the anticipation can wreak havoc, can't it? It can. It can. So

Starting point is 00:29:19 the opposite is true, but that's because if you expect, that's why I say intimacy and not sex. So if you say you're going to have sex, it can be like, oh my God, what if I don't perform? What if I don't do right? What if I don't want sex? What if it hurts? Right? So you can also have that sort of rumination and spiral. But if you're like, look, all we're going to do is be together and be intimate.

Starting point is 00:29:37 We're not going to just go have dinner and talk. We're going to like literally be together, not have our phones with us, maybe like touch each other, maybe get undressed, maybe just, you know, feel what it feels like. And that's it. There's no expectation of sex from either side. We're going to go in knowing that and then slowly work our way towards like, okay, you know what? Like maybe sex will happen and maybe it won't. And over time, as you keep putting it on the calendar, prioritizing your intimacy with your partner, then eventually you'll get to a point where,

Starting point is 00:30:05 oh, you remember, you recall that connection you used to have, and then you can actually find that joy again of connecting sexually. That's the sort of the aspect of desire, which is, I guess, is a bit more psychological, but there's also sort of a physiological element to desire as it relates to hormones levels. So if someone's got a low libido, is that a hormone dysfunction? It can be. So testosterone is the most notorious hormone for desire, right? In both men and women. And I think this is a big misconception is that we don't talk about testosterone in women, but testosterone in women is more predominant than actually estrogen. We have more testosterone in our bodies than we do estrogen. And testosterone is very important for desire in both men and women. But anything that

Starting point is 00:30:49 interacts with testosterone is also important. So thyroid hormone can cause issues with testosterone. Prolactin, which is another hormone made by the brain, can also interact with testosterone. So essentially evaluating those things and making sure that your levels are normal or appropriate for your age can be helpful. That's probably the number one thing. But the other thing outside of physiology is that stress, even though stress is sort of an abstract thing, stress affects our physiology, right? So when you have a lot of stress in life, whether it be work, relationship stress, kids stress, whatever it is, right? It raises your cortisol level. And when your cortisol level is high, you can't produce

Starting point is 00:31:30 testosterone. It goes down. And so if you're chronically stressed, which many of us are, right? You spend like in today's modern society, chronic stress is like a real problem. Then that is going to really impact your libido. So yeah, your hormones may suffer because of it. But if you don't fix the stress, like you're not going to fix the root cause of the problem. Can't I just inject myself with loads of testosterone though to get my libido back? It won't work for everybody. So if it's not truly a low testosterone, meaning you have normal levels of testosterone, likely your testosterone receptors are completely saturated, more testosterone is not going to fix the problem. So it depends on your individual level of hormones. But at some point, more is not better. In fact, more can be

Starting point is 00:32:14 dangerous. And so it's really dependent on your individual levels. So giving yourself like if I give a guy who has completely normal testosterone levels, both free and total testosterone, all completely normal, and I give him testosterone, probably nothing's going to change because his testosterone receptors are already fully saturated with testosterone. So more is not going to do anything. What are the other ways that I can increase my testosterone? If I go and get tested and it says that I have low testosterone levels and I don't want to just inject myself with testosterone, are there natural ways that I can increase it? Absolutely. So number one is sleep.

Starting point is 00:32:51 So sleep is really, really important for testosterone. We know that when you reduce the amount of sleep you have, so for example, you sleep less than five or six hours, you're going to have at least 10 to 15% reduction in testosterone. And so because our body follows a circadian rhythm. And so when your testosterone is highest is in the morning and it starts to decline over the course of the day, there's a little bit of a bump again, and then it goes back down. At nighttime, it's low and your body, when it's sleeping, replenishes that testosterone. And so if you're getting either less number of hours of sleep or poor quality sleep, meaning you're not feeling very rested when you wake up, that's a sign of poor quality sleep. Both of those things can dramatically affect your testosterone.

Starting point is 00:33:31 The other thing that you can do is exercise and specifically resistance exercise. So doing the largest muscle groups, so usually the lower extremities, and using those have been shown to boost testosterone more significantly than any other type of exercise. In fact, when you do cardiovascular, high intensity cardiovascular endurance training, so say you're doing ultramans, marathons all the time, long bike rides, long swimming, you know, swimming for long periods of time, that can actually increase your cortisol, your stress, because your body's having a stress response and that can actually reduce your testosterone. So it's important to do cardiovascular exercise, aerobic exercise, but in moderation,

Starting point is 00:34:16 because we do see some people who are great athletes who run miles and miles and miles, but their testosterone is low because they've been doing this chronic, long duration endurance exercise. So sort of HIIT training is fine, but it's when you start doing these big Ironman, thousand mile run things that the cortisol suppresses testosterone. That's not a large percentage of people, right? But it's certainly, you know, it's like, I'm so healthy. I'm the healthiest I could ever be. And I'm having low testosterone. Why is that? And what about food and testosterone? So food, you know, there is a lot of data on food, but the most data is on the Mediterranean diet.

Starting point is 00:34:56 And that's because that's the most well studied in medicine, but essentially having vegetables, fruit, low amounts of processed foods, good healthy fats, nuts and seeds. So a lot of people don't realize, but you need good fat to have testosterone. Testosterone as a production is in the cholesterol pathways. And so it comes from those pathways. And so you need to have some level of fat. If you have too low fat of a diet, that'll also affect your testosterone. So ideally what I tell people is while there's lots of data on different types of diets, the important thing to know is you want to avoid processed foods, avoid a lot of sugar and have good healthy fats in your diet. What about, you know, I've heard a few times that testosterone levels have been declining over the last couple of decades in men. Is this true? Yes, it is true. So we're not only seeing a decline in testosterone levels, but we're seeing a decline in sperm quality and sperm numbers. So the concentration of sperm and over the course

Starting point is 00:35:52 of the last 50 years. And there's a lot of reasons for that. One is that society has become more sedentary. We're seeing people less active, getting more and more metabolic conditions like diabetes, high blood pressure. These conditions then cause endocrinologic abnormalities. They cause problems with blood flow and all these things can affect the quality of your sperm as well as the quality of your testosterone production. And then also there's more, we think in the environments, we know there's more microplastics and more endocrine disrupting chemicals, right, in the environments, we know there's more microplastics and more endocrine disrupting chemicals, right, in the environment. So that is probably playing a role. Now, we don't have like exact quantitative data on that, but we think that is probably playing a role and

Starting point is 00:36:37 reducing the exposure to these endocrine disrupting chemicals. So we tell people, try not to drink out of plastic water bottles, try to warm up food in glass and avoid plastic. I mean, these are easy things you can do. But if you want to stress about the amount of plastics in the environment, like there's not much you can do as an individual level. So I tell people do the things you can control. And the other things sort of, you know, we have to work on as a society. That's really interesting, because I don't think I think about this much, but removing chemicals from my life in terms of what these kinds of things that I'm holding the metal mug in front of me. And then the plastic bottles I drink from could be having an impact on my

Starting point is 00:37:17 testosterone and my sperm count. It could. I mean, like it's not everybody, right? Think about how many people drink from plastic water bottles, but if you can decrease your exposure, right, it's probably additive. So the more exposure you have, the more likely it is to impact your body. How do they know this? Like, how does anybody know that chemicals are having an impact on our sperm and testosterone? where they're looking at the impact of these things on rats and other animals. And then also they're looking on the amount of exposure to things like phthalates in labs and seeing how that, you know, we can't, it's all cause, it's all correlation. We can't say it's causative because we don't, we're not going to do a random study where you drink from water bottles for 10 years and you drink from glass water bottles for 10 years and let's see what happens, right? That hasn't been done, but they can say, okay, the more your exposure based on whatever biomarker we can assess, so maybe urinary phthalates or other things, we can say that, okay,

Starting point is 00:38:16 these people who have more exposure to this are more likely based on the data to have lower levels of testosterone. And then, you know, looking at the mechanisms of how they interact with the production of testosterone. And I'm not an expert in those areas, but certainly there has been sort of plausible mechanisms of how these things work. How has sperm count been decreasing over the years? So if you look at the last 50 years, you'll see that the average sperm count

Starting point is 00:38:42 has declined almost 50%. And luckily, the average sperm count has declined almost 50%. And luckily, the average sperm count is still high enough for fertility rates. The average sperm count is probably around 50 million of fathers, people who father children. And so it's still above that, but it's certainly significantly lower than it was 50 years ago. And so that's where we're thinking, you know, it's probably more of a global environmental factor that's contributing to that in addition to this increase in comorbidities and poor health over time. I mean, the direction of travel there is deeply concerning. Because if something declines 50% in the last, what, 50 years, did you say?

Starting point is 00:39:20 Then if we go forward another 50 years and we assume the same rate of decline, that means we'll be at 25% of where we were 100 years ago. Yeah. And then what if you can't father children anymore? And what if you can't have offspring that will then propagate the species, right? So there's certainly concerns there. And I think we have to, as a society, do better in terms of the things that we can. So we can control diet. We can control exercise. We can control those things. There's certain things that we can't, but we can try to control what our people are exposed to. And that can be on a governmental level, right? Like having sort of laws in place. So we know in the US, there's less restrictions, whereas in other countries, there's more restrictions on things like food coloring and dyes that may have, again, I don't know the specifics, but certain, you know, there's certainly

Starting point is 00:40:08 more restrictions in other countries than in the US for some reason. And so maybe there needs to be a more critical evaluation of where we can actually put in place some things that would actually have more widespread changes. When we think about sperm count, we often think about fertility. And, you know, I don't know whether this is just because society has changed and we're trying to have kids later, but it does seem that people are struggling more and more with fertility. I mean, even in my own sort of circle of friends, there's, you know, there's a couple people that have reported to be struggling with fertility or that, you know, they're spending 12 months or 24 months trying to have children. Do

Starting point is 00:40:42 you think this is linked to this as well? It could be. I mean, when we look at fertility, we know that about half of fertility is due to women, half of fertility is due to men, and then some combination of the two, right? So definitely as women age, fertility goes down and we know women are waiting longer to have children. So that's a big part of it that society has changed.

Starting point is 00:41:04 Women are working and prioritizing their careers. It's not a bad thing, but it certainly will affect fertility. And then, yeah, there may be these issues that are affecting male sperm counts that are also causing issues. But I don't know if there's any updated data in terms of what are the causes or the numbers in terms of fertility rates. Fertility aside, is there any correlation between our health outcomes and our sperm volume? Not volume, but concentration. So volume is the amount of, right? So concentration of sperm in the semen is more of a predictor in terms of sperm volume,

Starting point is 00:41:43 not semen volume, let's be clear. So sperm volume, sperm concentration are sort of the biomarkers. And we would say that, yes, there is a correlation with overall health in terms of sperm concentration and sperm volume. But I think I don't want to make people worried that if they truly have a male factor infertility, then now their overall health is a problem. But it's certainly important to be evaluated and seen by your doctor regularly. And on that point of semen volume, is there a way to increase that? And is it similar to what

Starting point is 00:42:15 you said about increasing testosterone? Or is there another set of sort of practices we can do to increase our semen volume? Yeah, so semen volume is variable depending on the biggest one is how long has it been since you last ejaculated, right? So the longer you delay between one ejaculation to the other, the more semen volume you will get. That's probably the most predictive. You know, hydration can play a role. So if you hydrate more, certainly you may see more semen volume. Sometimes it's a low semen volume because you're actually having less force of ejaculation. So interestingly, when you're young, the force of

Starting point is 00:42:51 ejaculate can be really, really strong. It can be up to 30 to 60 centimeters away. Like when you ejaculate, that's how forceful it can be. As you age, after about 50, it can decline to 15 to 30 centimeters away. And so that can feel like you're having less volume because it's less forceful. And so in those cases, that's because of the pelvic floor muscles that are around the urethra, those muscles there that help sort of propel the ejaculate out. And so you can strengthen those muscles with, again, pelvic floor exercises, like Kegel exercises. I caution people because people are like, oh, they're going to, these Kegel exercises. I caution people because people are like, oh, these Kegel exercises are great. They're going to increase orgasm. They're going to make my semen propel further. And I think

Starting point is 00:43:29 that's fine if you're not having pain, you're not having discomfort, and you're doing them correctly. Because sometimes what we see is it can actually cause harm if your pelvic floor is tense, like we talked about earlier, or it can cause pain and dysfunction if you're tensing, tensing, tensing and not relaxing. And so if you don't know how to do them correctly, then you could actually harm yourself. But yes, they can improve semen volume by the parameter of increasing the force of ejaculate and getting more ejaculate out that may be left over if you're not having as forceful of a muscular contraction. Does masturbating improve my pelvic floor? Does it strengthen a pelvic floor muscle exercise, but it's doing it involuntarily. It's contracting for anywhere from five to 60 seconds, usually on average. And so you are sort of in that way, increasing pelvic floor strength. In fact, they've looked at

Starting point is 00:44:35 in women particularly is orgasming as good as doing pelvic floor exercises. And they've seen that, you know, you can see pretty measurable improvement in pelvic floor strength if you orgasm regularly. And it may be, you know, as good as doing Kegels, depending on how often you're doing it. So yes, orgasming itself can be very beneficial for pelvic floor strength. One of the big sort of myths that I've always, I'm yet to answer is the impact that our technology is having on our genitals. You know, there's kind of like a pervasive myth that if you put your phone next to your testicles, your sperm count's going to drop. Like whenever I'm in the car and I don't know, I'm sat there or I'm sat at home somewhere and I get my phone and I put it near my genitals,

Starting point is 00:45:21 my girlfriend has a go at me and she like pulls it out or tells me to pull it out because I think she's worried that we're not going to have kids if it's down there. Yeah. Yeah. So there is a little bit of data there in terms of, you know, when you have these devices like in your lap or near your genitals, they will increase the temperature. And so when you, the testicles are in the scrotum for a reason, right? It's because they need this very perfect environment with this specific temperature to create sperm.

Starting point is 00:45:50 And anything that disrupts that temperature can cause abnormalities in sperm production. So for example, when you have a fever, because you have the flu or you have a cold, people will get their sperm checked, their semen analysis, and they will see that their sperm count is zero because the temperature, the fever has temporarily stopped their sperm production. And so you can see that, you know, people also discuss like, oh, what about boxers or briefs? What about putting? And so all of these things can increase the temperature around the scrotum, which can then cause changes in sperm production. So I tell patients, particularly if you're trying to have babies, is put your phone in your back

Starting point is 00:46:30 pocket, in your chest pocket. Don't put your computer or your laptop right on your lap, right? I mean, it's easy enough to do and it does increase temperature. So absolutely, yes, these things can, not for everybody, right? There's people, so we say people like you shouldn't smoke a lot of marijuana when you're trying to get pregnant because marijuana can cause problems with sperm production. But you'll see people who smoke every day and they still have babies. Or you'll see people who do all of these things, right? They wear briefs, they put their phone in their pocket, they put their laptop on their lap, and they still have babies. So it's not all comers, but certainly things that you can easily just avoid putting near your genitals. Well, if I'm in the sauna every day, or if I'm in a steam room every day,

Starting point is 00:47:13 isn't that going to have an impact on my sperm count? Yeah, it does. And it's interesting because I think we'll see more of this as we're seeing the rise of, and there's benefits to saunas, no doubt. But as we're seeing the rise of people really doing saunas all the time, there can be, so we tell people when they're trying to have, if they're having fertility issues, don't go in hot tubs, don't go in saunas because it could affect your sperm production. So those are sort of the conservative things we tell people to do. Interesting. And this, this point about the phone next to genitals, it's not because of like the wifi and the Bluetooth are going to like zap my babies.

Starting point is 00:47:48 No, I mean, there's some, there's some question about that but we don't know i don't think we know but we know there's a temperature increase right because phones get hot we talked about masturbation briefly um one of the big questions that people often ask me when i'm speaking to someone that has expertise on sexual health is about masturbation and whether it decreases your testosterone levels. So it does not. There is one study, and it was done in 10 men who abstained from masturbating for 21 days. And these are young, healthy men, right? And so this is where I think everyone gets their data from is this one study. And so they took their testosterone before, they took their testosterone after. And what they found was that there was an increase by about 50, 50 nanograms per deciliter, 0.5, which is 50

Starting point is 00:48:31 nanograms per deciliter, which is not a huge amount at 21 days. But we know that testosterone changes all the time. And two, there's a lot of anticipatory cues when you've been waiting to masturbate for 21 days, like your brain is, is really excited. There's all these like, okay, I'm finally going to get to release. And that in and of itself can increase testosterone. So genesis, there's no empiric evidence that is convincing high quality level evidence that masturbating or abstaining from masturbation will increase testosterone. And so there, you know, people do report other benefits. And so I tell people, if you're getting other benefits from abstaining, by all means, go ahead, but don't do it for don't like white knuckle it to gain some theoretical increase in testosterone

Starting point is 00:49:16 that one was not even that large. And two is probably not going to be proven in a larger sample. What about the opposite, then is too much masturbation going to have an adverse effect on us for men and women? Yeah. So I think, you know, what I tell people is masturbation is generally safe as long as you are not masturbating to the point where you are now choosing to masturbate over doing anything else. So you're choosing to masturbate rather than have sex with your partner. You're choosing to masturbate over going to work or you're, I'm going to be a little late to work because I want to finish masturbating, or you literally can't sleep without masturbating every day, like those are the you become reliant on this particular activity for the enjoyment that it provides. That's when it becomes a problem. But if you're using it in

Starting point is 00:49:59 terms of like, I'm masturbating to get orgasm and the benefits of orgasm that I do achieve from that because maybe my partner doesn't want to have sex or maybe I have more of a sex drive than my partner or I don't have a partner. Like, let's be realistic. Like if you don't have a partner, you're going to have to, if you want to orgasm, you're probably going to have to masturbate. And so I think the problem also comes in is when people only masturbate the same way every time they only watch a certain type of erotic film, or theyate the same way every time, they only watch a certain type of erotic film, or they do the same thing every time and their body habituates to that. And then they have a difficult time climaxing with a partner because they can't replicate what they're doing,

Starting point is 00:50:35 whether what they're watching or how they're doing it with a partner. Are we teaching ourselves something there? Are we teaching ourselves how we're aroused and how we orgasm? Yeah. Your brain is very powerful, right? So when you're doing the same thing every time, your body's like, oh, this is what turns me on. This is what makes me orgasm. And then when you're with a partner, you're like, oh, I'm not getting that same kind of

Starting point is 00:50:53 stimulation. And so it doesn't happen to a lot of people, but I would say certainly I see people where this does happen. And so, you know, you have to sort of take a break and sort of reevaluate and try different things and get your body to habituate to different things, which takes a little bit of work. But sort of keeping it varied can be helpful. Another big myth, masturbation will make me go blind. Yeah, no, literally, I don't know where that came from. There's like hairy palms, blindness, like, I don't know where I think this this is all sort of like from religious rhetoric that

Starting point is 00:51:25 says, you know, you should not masturbate. And it, you know, where that came from, you know, is a whole other story, I think. What do you think of this idea of no nut November? Yeah. So I think it's, I'm not a fan. The reason being is because I think it makes people feel like it's something they have to do. And if you want to, like I said, if you find benefit from abstaining from ejaculating for 30 days or 28 days or whatever it is, then by all means, like go ahead. If you want to try something, there's no harm in it. But I think a lot of people, what they do is they feel like it's something that's going to bring them to some higher level and they're going to become this great person because they're able to, to, to conquer this goal, but they're like literally miserable. So they're, they're going to become this great person because they're able to conquer this goal.

Starting point is 00:52:05 But they're like literally miserable. So they're clenching their pelvic floor all the time because they're stressed about how they're not ejaculating. They may ejaculate at night. And so they'll have a nocturnal emission. And then they'll feel so bad because they've failed. It's nothing you can control. Nocturnal emissions are physiologic.

Starting point is 00:52:23 They're totally normal. And 86% of men have had a wet dream at some point in their lifetime. Like it's very you can control. Nocturnal emissions are physiologic. They're totally normal. And 86% of men have had a wet dream at some point in their lifetime. It's very, very common. And more likely the longer you are from ejaculating. So your body will take care of the ejaculate if you ejaculate or not. So you will either resorb the semen or you'll ejaculate at night. And so if you want to do it because you feel like, okay, I have a challenge, I want to conquer it. I want to see if I can do this. And you feel better because you're able to like not focus on sexual thoughts

Starting point is 00:52:52 or you're able to really find some other level of spirituality or something. By all means, go ahead. I don't have a problem with it. What I have a problem with is making people feel bad because they can't do it or they don't want to do it. And with people feeling forced or feeling like they need to do it to prove something to someone else. Yeah, because I mean, the way that I've had it explained to me is that it's something about

Starting point is 00:53:12 semen retention gives you some clarity of mind or something. Because a lot of athletes before they have their big fights or, you know, their biggest sort of Olympic competitions, they'll abstain from masturbation. I often hear in the UFC, for example, the mixed martial arts fighting championship, that athletes have not had sex or not ejaculated for two weeks before a fight or four weeks before a fight. Yeah, so there's a lot of rhetoric there, I think that comes from historical. So even in Greek times, they would tell people to avoid having sex or masturbating prior to big fights or whatever sport they were playing. And so is it true in data? So if you look

Starting point is 00:53:55 at the studies that have looked at people performing athletic feats, whether it's like cycling or running or whatever, they have not found that abstaining from ejaculation actually changes their ability to perform. And so in those cases, I say, well, there's no true scientific evidence that we have that it's going to improve. And in fact, if you are someone who, for example, has sex every morning or masturbates every morning, for whatever reason, that's a part of your routine, disrupting the routine can actually be harmful to performance. And sometimes the one thing you can say is in terms of disrupting performance is that after you masturbate, you do see an increase in heart rate a little bit. You have a rebound, so it decreases, and then you have a rebound increase in heart rate that can slightly affect

Starting point is 00:54:39 your ability to recover from performance. But ultimately, I think if you find benefit from it, because people report feeling more aggressive with abstaining, then by all means, if you find it helpful, I think it's fine. But is it mandatory? I don't think so, based on the evidence we have right now. Because I heard that rumor many years ago, and I think I assumed it was correct. I heard the rumor, and this was the sort of evolutionary story that was attached to the rumor, was that once upon a time when we were out, don't know looking for um a sexual partner we would need to be more articulate and more persuasive and more i don't know attractive basically so we were optimal attractiveness before we ejaculated then after we've ejaculated that kind of energy goes out of us and recharges and

Starting point is 00:55:22 rebuilds again so i was when i heard that i thought, so if I'm speaking on stage or I'm doing a podcast, I want to make sure that I'm, you know, my mouth and my brain are attached. I'm articulate, I'm persuasive, whatever I need to be. So don't ejaculate or masturbate anytime before doing anything where I need to use my brain and my mouth. Well, you know, some people describe post-nut clarity, right? So they actually, on the alternative, feel like, and there's no good data on this. The data we have is on people, the very small subset of people who have post-nut, post-coital, it partner, right? You're sort of trying to woo them. You're really focused on that one singular effort that once you've obtained that, that the very singular focus goes away. And now other parts of your brain can be activated to then be used for some people will describe

Starting point is 00:56:20 being more productive, more able to get work done after masturbation. It's very individualized or ejaculation, whatever it is. Post-nut clarity. I've never heard anybody talk about this before. And I've also been told over the years that it's something that just men experience predominantly. And for anyone that doesn't know what post-nut clarity is, the definition that I understand is, and that I have experienced, I'm going to be honest, is that after ejaculation, your desire for the other person reduces quite significantly. And there's a stereotype here that women don't experience this post-nut clarity in the same way. Now, if I asked all of my male friends, if I said to them, has there ever been a time in your life where you were maybe texting someone

Starting point is 00:56:59 you were attracted to, or, you know, had some sort of sexual attraction to and then you masturbated did your desire um diminish after you masturbated for that person that you were just texting i think about 90 of my male friends would say yes yes and they'll describe it as if someone like took some like sunglasses off them like a pretty extreme sudden change and i've always wondered about this whether this is just men if it's's just women, why it happens. So when you look at brain studies, right, of people having orgasm, and what happens is when you have an orgasm, like your whole brain lights up, right? Because your heart rate goes up, your blood pressure goes up, like your pupils, so all these different parts of your body are working. So your whole brain lights up.

Starting point is 00:57:40 And then after orgasm, it gets very like quiet. And so we see that in women, it may take a little longer to get really quiet. In men, it happens very quickly. And this may be associated with sort of the hormonal changes that occur after orgasm. So we know that prolactin increases after orgasm, dopamine decreases. And there's sort of some evolutionary theories about why this happens. So one is after you ejaculate, if you are having ejaculation with a woman, then you don't want to have sex again. Same thing with the refractory period, right? That there's some period of time where you're not going to want to have sex again, or you can't have sex even if you want to. And this is because evolutionarily, if you deposited your ejaculate into a woman, if you then had sex again, you could actually dislodge

Starting point is 00:58:25 the semen and then you have less ability to have fertilized an egg, right? And then the other thought is that you don't want to become overly exhausted, right? So that if you had the unlimited capability to have sex over and over again, that exhaustion could be a real thing. And so you're sort of a protective mechanism. And so those are sort of the theories as to why this is. And there is like an absolute refractory time where like you don't want sex at all. And then there's a relative refractory time where if you had a really novel or strong stimulus for sexual activity that you would be able to. In terms of clarity, because we know there's a little bit of differences in brain, it may not be as obvious in women in terms of it takes them a little longer to have that coming down after the orgasm from the brain activity.

Starting point is 00:59:16 But probably there is some, we just haven't studied enough. And I always say this, that when we look at studies for women's sexual health and men's sexual health, they're so lopsided. So if you type in penis in like a search engine for Google or for the PubMed, which is where you look up research articles, you're going to find 50,000 articles. If you look up clitoris, you're going to get 2,000 articles. So it's very lopsided in terms of what we study for sexual function. In and of itself, sexual function by many people is not seen as mandatory or important for health. And so the funding is

Starting point is 00:59:51 less often available for sexual health. That's why we have such little data in some areas. Going back to just closing off on the point about masturbation, is there a link between masturbation and prostate cancer? Because I've heard a lot of different things about it. Some people think that over masturbation is causing prostate cancer, and some people say the opposite. Yeah. So there's actually a really good study that was done looking at ejaculation frequency and prostate cancer. And it was a very well done study. They tried to control for a lot of other factors. And so what they found was that men who ejaculated 21 times or more a month were less likely to develop prostate cancer. This is just a statistical number. It is not a

Starting point is 01:00:31 number that sort of means anything in terms of, but we're seeing that like, okay, so more masturbation may help. Why is that? Right? So there may, there's a prostate stagnation hypothesis that the fluids that, you know, some of your ejaculate fluids come from the prostate. And so when you're ejaculating frequently, you're more often getting rid of that fluid and sort of replenishing it or cleaning the pipes, so to say. So that may be beneficial in terms of preventing prostate cancer. Now, do you have to masturbate or ejaculate or have sex 21 times a month? No, but, you know, there could be a benefit. Yes.

Starting point is 01:01:14 And so having a healthy and it may be that those people who had sex more often or ejaculate more often were just healthier in other ways, right? They were able to have sex more often or masturbate more often because they were, you know, sufficiently healthy to do so. And so while they tried to control for those things, there's always sort of uncontrollable variables that come into those sort of studies. Yeah, that's what I was wondering. Is there another glaringly obvious factor

Starting point is 01:01:33 that those people had more relationships, therefore their mental health was better, therefore X, Y, and Z? I think they tried to control for comorbidities, but again, I don't think they controlled for... I mean, they controlled for marriage, I believe, but I'm not sure that they controlled for in a relationship versus not and how healthy that relationship is. That certainly wasn't assessed.

Starting point is 01:01:51 I'll link to the study below so everyone can read for themselves about the controls in that study and how that was conducted. A link to this is the subject of porn. It was interesting because I was doing a lot of research on the subject of, that sounds a bit strange. I was doing a lot of research on the subject of that sounds a bit strange i was doing a lot of research on the subject of porn and where conversations at with the subject and one of the quite startling things is a lot of people are trying to figure out how to stop watching porn um a lot of people are asking themselves for mechanisms to install things on their computer that prevent porn time and searching for solutions around porn addiction. And a lot of people were searching about whether porn is a sin.

Starting point is 01:02:33 And I think there's something broader here about the idea of shame, which is linked to porn. What is your take on this? Is porn a bad thing? Yeah, so I don't think porn is a bad thing. I will start with that. Is it a sin? It's more of a moral question, right? And I think that that is something that you individually have to decide for yourself if you feel like morally it's inappropriate, but it's entertainment, right? It's just a different form of entertainment. And I think the issues with porn, because I would not say that it's 100% great. I think there are definitely issues that one, the big one that I've been very vocal about is children seeing pornography.

Starting point is 01:03:09 So we know now that the average age of a boy seeing pornography is 13. And that's the average, meaning that as young as 8 to 10, boys are being exposed to pornography, which was not the case when, for example, we were growing up, right? You had to, I always say this, you had to find a when, for example, we were growing up, right? You had to, I always say this, you had to find a tape, maybe find a VCR in a room that nobody was going to walk in, or you had to find a magazine and hide it somewhere and go find it. And so it was not readily available. You had to work to be able to see that. And now seeing pornography is very readily available. And so very often kids are seeing it, whether you as a parent don't want

Starting point is 01:03:46 them to, whether you've put blocks on their phones and devices, they may have access to it from a friend or they may see it somewhere else. And your brain is not fully developed to understand one, what you're seeing and two, to understand that this is not real unless your parent has talked to you about, you know, this is sort of a movie that's not real life and this is not real unless your parent has talked to you about, you know, this is sort of a movie that's not real life. And this is not what sex is really like. And so I think that has implications for how they view sex and how they then try to have sex with partners. And also, you know, because your brain's not fully developed, you're getting this big rush of dopamine from viewing something like that.

Starting point is 01:04:25 And that's not something that we traditionally got at that age, right? And so it can become very addictive. Now, as an adult, I think it's different because you have a fully formed brain, you understand the concept of this is not real, most people. And so it can be just a way to have pleasure, or even watch it with your partner and have pleasure. But yes, we are seeing some people who have problematic pornography use. In the literature, they say it's 4%. I suspect maybe it's a little higher now where people are finding that watching pornography is one easier than going out and trying to find a partner. You don't have to face rejection. You don't have to face the difficulties and awkwardness of having a first, a sexual encounter with someone that often happen. And so it can

Starting point is 01:05:10 become a way because it does relieve dopamine, just like anything else, release dopamine. It can then become sort of a way to feel better about anything, right? Like you can just be feeling down. Like I want to watch pornography because it makes me feel better. It may not be just that you're really into sex. It's just that you're really like wanting that rush hit of dopamine. And then there's obviously the shame that comes with, oh my God, why am I using pornography just because I feel bad? And then you're like, oh, but I feel bad.

Starting point is 01:05:37 And so I'm going to use porn again. And it becomes a sort of like negative, vicious cycle that can occur. But I think when used for entertainment and pleasure, I think it's fine. And many, many people use it for entertainment and pleasure without a problem. I, the other day, bought the Apple Vision Pro, that new headset. And I'll tell you what, Jesus Christ, that's an unbelievable piece of technology. This one feature they have on there is called Spatial Video. And I don't know if you've tried it yet, but you put it on, and if you've taken a Spatial Video, which you can now take on the new iPhone and also on the Vision Pro it basically

Starting point is 01:06:09 feels like a 3D video and it's like nothing I've ever experienced before one of our team members commented that you know they'd lost a family member and they wish they had this because it's like the person is back in front of you it's not like a photo or video anymore but then a little monster in my mind goes hmm there's going to be other applications of this technology and as it relates to pornography and we're getting you know if we just assume any rate of improvement with this technology just under five percent a year we eventually get so close to being indistinguishable from a human being that the incentive structure of going out and getting a day and you know for the

Starting point is 01:06:45 for the objective of having sex or whatever versus just popping your headset on which is going to get cheaper and cheaper and cheaper and better and better and better um becomes really lopsided i it's so clear to me that if we just go forward 10 years and we're on the Apple Vision Pro 17 air there's going to be so many people that are using that as a way to uh masturbate and to watch pornography and there's and it's going to reduce the amount of people that are seeking real intimate relationships IRL in the real world yeah it is a real concern, I would say. But, you know, we know from some data that people will find physical touch, particularly in the care bearing areas, very important in terms of intimacy with a partner. So intimacy in general.

Starting point is 01:07:38 And so I can only hope that that will continue, that you will want physical touch, because no matter what you can see with your eyes, it's not touching you. It's not like it's still you doing the touching. There's no element of surprise or excitement or buildup in terms of like there's someone else in the room with you, right? So I can only hope that that will be the case, but it still remained to be seen. However, I will share that there's some interesting applications of this in terms of fear. So if you are really scared of something, you can actually desensitize yourself using these VR headsets and it can actually be very powerful. So I was just speaking to a researcher, Lori Brotto, about how they're using it in their lab for women who have fear of penetration because

Starting point is 01:08:26 they've had either trauma or they have other conditions that are causing it to be painful. And so they can work with them to be using these headsets to simulate a sexual experience. And then they can sort of use a dial, like use a tool or a dilator or something to then penetrate in a safe space, right? Not like you're with a partner and you're like trying to have sex and you're, you know, you don't feel very safe, sort of allowing that. It's very preliminary research, but I think ultimately there are some positive things that maybe will come out of the use of these sort of VR headsets. And I can only hope that that will predominate and we can continue and people will inherently want

Starting point is 01:09:06 other people, right? That we're hardwired to be around people and to be intimate with people. That's how our brains work. So I'm hopeful that that will still remain to be the case, but I can't, I can't predict it. You don't look convinced. Well, you know, I mean, I think it's, I am worried, you know, I think that phones have changed lives too, right? Like now our kids, our younger generation doesn't communicate as well because when they hang out together, they're sitting all together looking at their phones, right? And so we have to actively work to prevent, like I make my kids have full-on conversations with people. I say, you got to come and hang out with the adults and have

Starting point is 01:09:41 conversations and talk to people. And we have to coach them on how to talk to people because I worry that people are too, even when they hang out with their friends, they're playing on devices, right? So I think there's like work that has to be done to prevent the easy dopamine rushes that these devices are giving us, right? So we actually have to actively work at it and people are inherently going to take the route of the easiest thing. And so as a society, we have to sort of work together to sort of prevent these easy wins, easy things, easy dopamines from taking over. Something you mentioned within there, though, was the idea of trauma. And I'm quite interested in the role that our trauma plays in

Starting point is 01:10:25 our sexual health and sexual dysfunction. What's important to know there, and does trauma play a role at all in the patients you see? Absolutely, 100%. So your body, when it goes through a trauma, it will then sort of, your body remembers, even if you don't, right? So these people, very many people who have pelvic floor dysfunction, meaning their pelvic floors are too tight or too tense, they've had some sort of trauma. Not all of them. Some of it's just stress and anxiety, but sometimes they've had some sort of trauma years ago. And it's been with, I remember having like a 70 year old woman and she had such terrible pelvic floor dysfunction for God knows how many

Starting point is 01:11:06 years that ultimately it caused really negative consequences for her bladder function. And so absolutely, when you have a trauma that's unresolved, in some shape or form, it will affect you, whether it's your mental health, your physiologic health. I mean, our brains are so powerful that when it's in a bad place, it can affect you negatively. When it's in a positive place, it can affect you more positively. The one thing I will say is if you have trauma, getting therapy, getting help to resolve that trauma is so, so important. I talk to all my patients and I say, yes, you may have an organic problem, meaning a physiologic bodily problem that's causing your sexual dysfunction. But

Starting point is 01:11:45 everyone who has sexual dysfunction has a psychological component because it is devastating. It is stressful. It is horrifying to feel like you're not normal. Your body doesn't function normally, especially in an intimate space like sex. So I'm like, everybody should ideally see a sex therapist if it was available to everybody, but it's not, right? How can we allow people to have access to things they need? Because we don't teach these things in school, right? School, I mean, this is my big gripe is like, how can we make education better for children? Like we need better sexual education. We need better education on how to resolve traumas or how to deal with them or how to get help, how to do digital health. Like how do you navigate the world with all this misinformation? How do you find good quality information? How do you assess it? Like there's

Starting point is 01:12:28 so many things, even how to balance your books, right? They don't learn that in school. So ultimately there's so many things that I think if we were really putting a critical eye on how we teach our young people that we could improve. And part of that would be including people to know and realize when they need help through whatever trauma they've suffered or stress or anxiety that they're suffering and how that can propagate itself over a lifetime and create real problems. I have to ask this question because people mention this quite often. Can you have sex while you're pregnant? Absolutely. Why not? I ask it because it was one of the most Googled questions online.

Starting point is 01:13:08 Really? Yeah. One of the highest search volumes I've ever seen for a search term was can you have sex while pregnant? Wow. I actually didn't. I mean, I've heard a lot of things, and I think that people feel like, I've heard that men think they're going to hurt the baby,

Starting point is 01:13:24 they're going to cause a problem. But no, absolutely, you can have sex. You're not going to create like a preterm labor. You're not going to harm the fetus. Like nothing bad is going to happen from having sex while pregnant. Okay. So let's talk about orgasms and the clitoris then. You mentioned earlier that there's disproportionately a lot less research done on the clitoris. As a man, what do I need research done on the clitoris as a man what do i need to know about the clitoris because i'll be honest i need very little i know where it is that's that's a plus yeah well not everyone knows that either yeah i didn't always know where it was a couple of misunderstandings but um i found i found it eventually and i i think i know

Starting point is 01:14:02 how to stimulate it but i don't really know what's going on there or how it works. Okay. So what I tell everybody and what men can think of is the clitoris is like the penis. So when you are a fetus, there's a thing called a genital tubercle. Before you're assigned sex, that genital tubercle, when you become a man, that genital tubercle becomes the penis and the shaft and the glands. And in a woman, it becomes the clitoris. And the clitoris actually then goes deep into the pelvis, just like the penis. It has a shaft in the pelvis, and then it goes around the vaginal canal. And so the clitoris is just as sensitive as a man's penis, right? So if you stimulate the clitoris, like your penis gets stimulated, then it will lead to orgasm. And it's probably the most reliable route for orgasm for women. So 85% of women need some form

Starting point is 01:14:52 of clitoral stimulation to climax. And so many women have difficulty climaxing through vaginal penetration alone. That's not that they're broken or something's wrong with them. It's just that they don't. And because the stimulus from the clitoris is so strong, it leads to a very reliable route for orgasm. Now, how you stimulate it is sort of very individually specific, but typically oral stimulation, vibratory stimulation, manual stimulation, all those things can work. But that's where the communication comes in, where like the partner ideally would know what they like and could tell you, or they, you could check like, does this feel good? Does this feel good? Do you like this? Is this, you know, or, and, you know, and so that's sort of,

Starting point is 01:15:34 again, a challenge because the communication issue we've talked about this whole, this whole talk, but that is really what's important. Now the clitoris, like I said, it goes deep above the vagina and around it. So people can still get clitoral stimulation through penetration, depending on how you stimulate. Now, the other areas that are important for orgasm are the G erogenous zone. It's actually not a spot, it's a zone. And that's where essentially, if you go look at the vagina on the anterior wall, which is the top of the vagina underneath the urethra, where the pee comes out, about two or three centimeters in is called the G erogenous zone. It's named after the person who identified it. I think it's Groffenhaus or something like that. But essentially, that area

Starting point is 01:16:20 is full of certain nerve endings, as well as the female prostate or the Skeen's glands. And so those are areas that are quite erogenous and that uses a different, so the clitoris is innervated by the pudendal nerve. The G erogenous zone is innervated by the hypogastric nerve, so a different nerve. And then the cervix is the last area where sometimes women feel a lot of stimulation

Starting point is 01:16:43 and that's stimulated by the vagus nerve. So all these different areas can lead to orgasm for women and they can be additives. So if you're stimulating all three, you might have a more strong orgasm and the orgasm may feel a little different. Now people like to call like, oh, you're getting clitoral orgasm or a vaginal orgasm. It's all an orgasm. It's just a matter of what stimulation is causing the orgasm. And so I think ultimately it's really important for the most easy, reliable route to orgasm is clitoral stimulation, which is not traditionally stimulated through penis and vagina sex, right? And so it does require some additional thought on how you're going to stimulate it and how you're

Starting point is 01:17:24 going to please the partner and to get them to orgasm. And oftentimes, if you think about the time it takes to orgasm, so in a man, the average length, if you look at studies that have looked at stopwatches, like they've had the female partner actually start a stopwatch at the beginning of sex and stop it at the end when the man climaxes, it's about 5.1 to 5.7 minutes, which in fact, UK men tend to last a little bit longer, which is sort of an interesting concept. So which sex is that? Men? Men. So from penetration to climax of men. So they've measured basically not including foreplay, but if they've measured, they've measured like 15,000 people through many, many different countries. And they've had the woman take a stopwatch and actually click on it when

Starting point is 01:18:08 they penetrate and click it off when they climax. And they've measured the length of time. And it's been about 5.1 to 5.7 minutes is the time. Now, a woman, when you look at the average time to orgasm for a woman, it's about 14 minutes. And so you can imagine that if the entire sexual encounter is around the male climax, right? And the male has this, as we've already talked about, sort of this post-nut clarity, like I don't want refractory time. They're not going to want to be more intimate. If you don't prioritize the female's

Starting point is 01:18:43 climax or stimulate her before you begin to penetrate, then she's probably not going to orgasm. And the interesting thing is when you look at sexual encounters and you look at men and women having sex for the first time, the woman will orgasm 45% of the time, the man will orgasm 95% of the time. When you look at women having sex with women on a first time encounter, they both have orgasms 95% of the time. So clearly there's an educational disconnect, right? Women know what they like and what stimulates them and men aren't getting the memo. I feel attacked. Totally not attacking,ting you know the facts. I know it makes sense though,

Starting point is 01:19:28 because I think men are still struggling to understand. Again, because of what you said, we don't really get a sexual education. So we learn these things from porn and obviously in porn. They're not showing it. Yeah. I mean, you don't typically have many women orgasming in porn as you do men orgasming in porn. What is an orgasm and what kind of, what role does it serve? Like why do we orgasm? And also when I say what is an orgasm and what kind of what role does it serve like why do we orgasm and also when i say what is an orgasm is an orgasm like a switch or is it like a spectrum so it's it's sort

Starting point is 01:19:54 of like a spectrum i guess i mean so let's talk about what it is exactly so an orgasm is a moment in time that is combined with a like a maximal tension and then a release. And during that time, you're completely unable to think about anything else. It is a very powerful, pleasurable sensation. And it occurs usually, like I said, five to 60 seconds. It can last. And in terms of how you get it, it's usually a culmination of stimulation over a period of time, even with a certain sort of like rhythm that's required to achieve climax that's different from person to person. So I can't give you the script on this is how fast you need to penetrate

Starting point is 01:20:36 or this is what stimulation you need to use. Okay, that's the end of the conversation. Okay, we're done. We're done here. So, yeah, because nobody wants to talk about it. They literally want me to tell them, like, this is what you do, A, B, C, D, right? Like an instruction manual. So, but yeah, ultimately, all of those things, they build this tension, right?

Starting point is 01:20:56 So over the course of sexual stimulation, arousal, you are getting to an excitement phase where your body's changing. So in women, for example, you will see that the labia become a little bit redder. They expand in size. As I said, the vagina lengthens and elongates. From three to six inches, I've heard you say. About double. Yeah. And it's different from person. That's the average, right? So there is sort of like this thought that like, okay, if it's really, really large, it's always going to be better. And that's not actually always the case because not every vagina can accommodate a very large phallus. But so when you're having orgasm, essentially your pelvic floor muscles are tensing up. They're

Starting point is 01:21:37 getting really tense and you're reaching this, like basically you're getting to the top of the hill. You're getting this really large amount of climax. And so your body is sort of going up and up and up. You're reaching like increasing dopamine and you're increasing. So when you think about what happens in the brain is your hormones are going higher and higher. And there's also an inhibitory. There's a stimulatory and an inhibitory pathway.

Starting point is 01:22:02 And so the stimulatory pathway is going up, inhibitory, stimulatory. You're basically trying to race up to the top of this mountain. And so the stimulatory pathway is going up, inhibitory, stimulatory. You're basically trying to race up to the top of this mountain. And when the stimulatory gets to the very, very top, then you have the orgasm. And so you release all this tension. And during this time, your heart rate's racing, your pupils are dilating, there's all these physiologic changes. And then when you orgasm, your muscles contract, as I mentioned before, and this every 0.8 seconds, they're having a contraction. Sometimes you'll have an involuntary phonation.

Starting point is 01:22:29 So people will, you know, moan or scream. And sometimes it's not in their control. Like there's actually an involuntary component of it. And then sort of it comes down. And so it's not necessarily a switch. It's sort of a climb up a mountain is the way I would describe it. It sometimes feels like blowing up a balloon with a little hole in it. And when I say with a little hole in it, I mean, because if you stop, it feels like some air comes out of the balloon. That's why I said that there needs to be a rhythm.

Starting point is 01:22:56 It should keep going at a certain pace in order to achieve that climax. Because if it doesn't, then you can, again, just like that's a very good description. You'll lose that little air in the balloon okay so in order to increase female pleasure okay we need to understand the person we're dealing with of course but um the clitoris is a great way to get to orgasm you've you're pro lubricants a lot of people feel like that's not natural so they kind of avoid it but you're pro lubricants and are you pro then scheduling sex or are you pro scheduling time for intimacy? Scheduling time for intimacy. So because sex ads, as we talked about, add sort of like a level of stress in terms of like, am I going to want to have sex?

Starting point is 01:23:38 Am I going to be able to get an erection? Am I going to enjoy sex? Whatever it is. And am I going to get rejected? Like all those things, because you're still a human being and you may just like be really stressed that day that you put on the calendar and you were like, I just can't, can't get in the right mind space to have sex. So if you're constantly ruminating or stressing about other things, you can't have a good sexual encounter. In fact, they've looked at mindfulness

Starting point is 01:24:03 in terms of how it improves sexual function, particularly in women. But we've seen very clear data that having a mindfulness practice leads to improved sexual function in terms of desire and other factors like arousal and lubrication and orgasm. But the biggest is desire. And so it's because if you can focus on what's happening during the sexual encounter, so you can focus on what it feels like, how you're enjoying that sensation rather than thinking about, am I going to come? Am I going to climax? Is it going to happen? Or whatever it is that you're thinking about during sex, because you're worried about how the other partner might react, then you're more likely to enjoy the experience,

Starting point is 01:24:46 feel and then have a good experience and subsequently have more desire for additional experiences. We talked earlier on at the very start of the conversation about comparisons and how that can really destroy sex. Is there a disparity between how long we think sex should take and how long it actually takes? Yeah, we all think it lasts longer. And when you ask people what the average time, and this is a hard question because people think of sex as the whole encounter.

Starting point is 01:25:09 And when we do it scientifically, we look at sex from penetration to the end of penetration. And sex is more diverse, right? Sex can include oral sex, anal sex, manual sex, any type of sexual stimulation, right? And so when you're thinking about the entire encounter, it can be very variable. Some people want a quickie. Some people want to have this long, luxurious, lovemaking scenario. And it really depends also like on what's going on in your life. Like you may not have that luxury. And so I don't, I think, again, it's not about reaching a certain benchmark or a certain number. It's really about the quality of the sex. If you have great sex and takes three minutes, that's great, that's fine. But as long as it's great to both of you, right?

Starting point is 01:25:47 If you're both like, this is awesome, I'm having great sex and it takes three minutes, that's fine. But how long do people think sex lasts on average versus how long it actually lasts on average? Yeah, so I think that most people definitely think it lasts longer. So women, we don't know what they think it lasts, but what they want it to be is about 18 to 25 minutes. Men are a little

Starting point is 01:26:10 on the shorter side, like maybe 12 minutes, but generally we all want it to be around that length, but you sort of lose sense of time, right? So you don't really, no one's really there with the stopwatch knowing exactly how long it takes. In fact, I've had friends tell me like, oh, I watched your video. And now like when my partner wants sex I'm like oh it's only going to take five minutes like I can I can have sex with them like I used to in my head used to think it would take a lot longer and now I've realized it takes less time and like I don't that that stress of like oh my god I'm gonna have to like waste like half an hour and I'm so tired like has gone out the window because I know it's really not going to take that long is there have they ever put people in like a laboratory or whatever and and i guess this goes

Starting point is 01:26:48 back to what you said earlier um is there like an average time people spend having sex was that the five minutes you talked about 5.7 minutes 5.1 to 5.7 minutes depending on the study you look at and they they looked at all commerce so it's actually different in different countries. So when you look at like Turkey, it was like four minutes. And if you look at UK, it was like 10 minutes. So it's actually variable. And that may be a cultural thing. But ultimately, the average is about five something. Interesting.

Starting point is 01:27:21 So women want sex to last between 18 and 25 minutes ideally men want it to last ideally about 16 minutes including foreplay but in reality it's lasting five five minutes yeah that's good to know let's talk about zoe who you may know because they're a sponsor of this podcast and i'm an investor in the company you You guys know health is my number one priority. Zoe's growth story has been absolutely incredible so far. They're doing science at a scale that I've never seen before. Because of their members and recent breakthroughs in research, they can now continue to offer the most scientifically advanced gut health test on the market. Previously, the test allowed them to analyze 30 bacteria types in your gut.

Starting point is 01:28:04 But now, thanks to new science, they've identified 100 bacteria types. This is a huge step forward and there's nothing else that's available, even close to it, on the market at all. So to find out more and to get started on your Zoe journey, visit zoe.com slash steven. You can use my exclusive code CEO10 for 10% off. Don't tell anybody about that, okay? Just for you guys. We talked about sizes of stuff a second ago, and we said we'd come back to this. So there's two sort of sizes that people often think about, the size of the vagina and

Starting point is 01:28:37 the size of the penis. There is a myth in society that the more sex a woman has, the bigger her vagina gets. Is that myth true or false? False. So the way that women's vaginas get, if you want to say loose, right, which is the term that people use, or they get a weak pelvic floor. And that's from having babies, having maybe neurologic conditions that affect the pelvic floor strength, having collagen disorders, having just from like having a job where you stand all day and you're like all the weight of your body is sitting on your pelvic floor, those muscles can

Starting point is 01:29:09 get weaker over the course of a lifetime. And then it can feel a bit looser because those muscles are maybe not squeezing as harder, but it is not related to how much sex she's having. Because as we mentioned earlier, when you have an an orgasm you're actually like strengthening your pelvic floor a little bit like you're contracting those muscles so actually probably the more sex a woman has likely her pelvic floor is probably stronger unless she's not you know but you know you add in the having babies and other things it's variable but probably the more orgasms a woman has the stronger her pelvic floor. But things like childbirth can make the pelvic floor looser? Weaker. Weaker.

Starting point is 01:29:50 Yeah. Yeah. So then when it becomes weak, that is the cause of things like stress incontinence. So when a woman lifts something heavy or she exercises or she jumps or she coughs or sneezes, she might have a couple drops of urine or a lot of urine leak out because of a weak pelvic floor. It can also lead to something like prolapse where it's like a hernia in the vagina where the pelvic floor sort of is so weak that now the vaginal skin and the organ behind it is sort of bulging out and can cause discomfort and sort of feeling maybe some dysfunction in the organ, but really mostly

Starting point is 01:30:25 discomfort. And so those are signs of weak pelvic floors, not, you know, not having a loose vagina during sex. And we can do something to strengthen our pelvic floor. Is that what the Kegel exercises are? Yeah, it's more than Kegels. I mean, Kegels the most has the best PR of any sort of thing I've ever seen in medicine. But yeah, it's pelvic floor exercise. The Kegels is one pelvic floor exercise, which is to strengthen the pelvic floor. And there are others. So it's essentially men never know. Like it's not your fault. Women sort of kind of know, but even women don't really know. So what it is, is there's those same muscles we talked about earlier is that you're basically doing a rep. You're squeezing, contracting and relaxing. Just to go to the gym, right? You squeeze and relax. Very similar. You

Starting point is 01:31:08 are squeezing those muscles and relaxing those muscles. I can do this sat down now. Yeah. So basically for men, what I tell people is it's like the feeling of when you're urinating and you stop your urine stream. You're using those same muscles. So that's one way. Another way to think about it is if you were trying to lift your penis off the ground without touching it. Okay. And the third one is you're trying to hold in a fart. So all those different ways you're sort of getting those muscles. So the one thing I tell people is they get the way they get it wrong is they don't relax enough. So just like when you go to the gym, you're not doing rep after rep after rep, you're actually taking a break and you're letting your muscles relax before you do another rep.

Starting point is 01:31:48 Same thing. You have to squeeze for five seconds, relax for five seconds, right? You actually have to relax. And just like any exercise, you don't want to overdo it. So I tell people start lying down so that the only thing you have to focus on from a muscular standpoint is that those muscles, as you get good at them lying down, you then do them sitting up. And then as you get good at doing them sitting up, you can do them standing or do them anywhere. But like, you're not going to be like there, you know, I remember the scene from Sex and the City where like, the character Samantha was like, I'm doing my Kegels right now. Like, yeah, she's probably been doing Kegels for a long time. And now she's so good at them that she can do them while she's brushing her teeth. But it's not like you're going to wake up one day and be perfect at

Starting point is 01:32:28 them just like any other exercise. So that's one exercise. There are certainly other things you can do to strengthen your pelvic floor. Traditionally, things like yoga and Pilates have some core work that does also help with the pelvic floor. But really, I recommend if you're having issues is to see a pelvic floor physical therapist because they're just like when you go to the gym alone, you can do it or you can go with a personal trainer. They're like the personal trainers for your pelvic floor. How do I know if I'm having pelvic floor issues? What are the symptoms?

Starting point is 01:32:54 So for, like I said, the obvious ones for women are leakage, are having prolapse for weakness. In men, we don't often see as much. But like I said, you might notice that your semen is not as forceful when it comes out. That's usually the most common sign of a weak pelvic floor. There's not as many for men, but in terms of an overly high tone pelvic floor, what we worry about then is then there's a whole host of symptoms. It could be as simple as just having lower back pain. It can be that you're having hip pain. It can be that you're having hip pain. It

Starting point is 01:33:25 could be that you're having pain with sex. You're having pain with erections, pain with ejaculation. You're going to the bathroom often, got to go, got to go. You are feeling like you're having difficulty emptying your bladder or you are going very, very often all of a sudden. So it can be a vague variety of these symptoms. And so generally, it's important to get evaluated to see, like examine, to get your pelvic floor examined by a professional, whether it's a urologist, a gynecologist, a pelvic floor physical therapist, someone who can assess your pelvic floor if you're having these issues, because it might be pelvic floor, it might not, right? How do they assess it? If I go to a urologist and say, listen, check my pelvic floor. So in a man, it would be a rectal exam. And so essentially,

Starting point is 01:34:09 that's how you sort of feel the pelvic floor muscles. So what I tell young guys who come to me and say, look, I can examine you. But I bet based on your story, like you're a young guy, you've sort of had these new stressors in your life. And you're otherwise healthy, it's unlikely that you have a vascular condition brewing and other things that like it's probably likely. So if you want to avoid the exam because it can be uncomfortable or and I will tell you if you have pelvic floor dysfunction and someone does an exam, it will be uncomfortable. It will be painful potentially because they're pushing on those already tense muscles and it can be painful. So I tell people like you might might hate me tomorrow because you'll be sore. And you'll say, what did she do during

Starting point is 01:34:48 that exam? And I kind of preemptively tell them because I just gently push, right? Like I'm pushing the pad of my finger, but that's enough to sort of cause a tension of the pelvic floor muscle and cause pain. Like on the muscles, on the pelvic floor muscles. So you can actually, so if you, if you put your finger in the rectum, if you push right straight down in a man, you're feeling the prostate. And if you push on the sides at a variety of different angles, you're going to feel different pelvic floor muscles, like the levator ani and the trans operator muscles. Those muscles are the ones that are part of the pelvic floor. We can't feel all of them, but we can feel some of them. And so that is sort

Starting point is 01:35:26 of where we're feeling in terms of for the pelvic floor muscles. Okay. So because I was thinking, if we go in the rectum, you've got the glutes there as well, which are like either side, I guess. So your pelvic floor is actually a part of your core, right? But your glutes are further back. They're not going to be felt from there. But anyways, if you think about your pelvic floor, it's actually, you know, people think about their cores or abdominals, but we know that it sort of encompasses your back, your front, and even your pelvic floor is sort of part of your core muscles. Got you. Okay. Interesting. Very interesting. On the topic of sizes then, one of the big things in men is penis size. And one of the big questions men often ask

Starting point is 01:36:05 is, is there ways to increase my penis size? There's in fact a whole industry around penis size, increasing pumps and all kinds of different things. Is it possible to increase one's penis size? Yeah, so it is. In terms of looking at the evidence, the safest and most reliable way is using a traction device. And these are devices that are made for essentially for penile lengthening, but they're also made for men who have something called Peyronie's disease, where they may develop a plaque on their penis and a curvature. And so there's one device that's actually made that bends away from the plaque to help sort of break down that plaque.

Starting point is 01:36:42 So there are two uses for it. But essentially, these devices are just like stretching the tissue over time. And so the original traction devices that were studied, you would have to use them for six to eight hours a day for several months to see a two centimeter increase in length. Now, that may be enough for some people. They were like, yes, I definitely want that. And some were like, you know what? It may or may not. I mean, two centimeters is the average. Some are going to be less, right? So it's sort of, do you have the time to do that? Do you want to do that? But now there are sort of newer devices where they've studied them and use them like twice a

Starting point is 01:37:15 day for 30 minutes. And they've seen some increase in penile length. They're generally pretty safe. It's more about, you might have some bruising from just putting the traction device on. And as long as you follow the instructions, you're probably not going to hurt yourself. Is that a penis pump? No, pumps are different. So pumps have not been shown to increase penile. What a pump is, it's got a cylinder that you put your penis into. And it uses sort of vacuum technology to sort of suck blood into the tissues.

Starting point is 01:37:43 And then you put, if you're having issues with erectile function, you would then put a ring at the base of the penis to maintain the erection. These don't help with length. They've looked at them in those cases. They've also looked at surgeries and different types of things to increase penile length. And ultimately many of them either have,

Starting point is 01:38:01 you know, a very high complication rate or risks that I would say are probably not advisable for most people. You know, I think that in terms of penile lengthening, people are always like, why would you want to do that? Why? A lot of people will sort of poo poo people who want to change the way their penis looks. And I've sort of evolved in my thinking and saying, well, you know what, this is a big part of, you know, a man's identity and how he feels about himself. And I wish we had something that was safe and easy for men to do, like we have breast implants, but we're not there yet, right? And so I just want people to be safe in terms of

Starting point is 01:38:35 realizing what our limitations are at this time, and things may change over, you know, as people become more interested in this area. Porn, the role it's played in our perception of what a normal size penis is. Do you know of any data on how big people think a penis should be versus how big the penises actually are? Yeah. So yeah, most people think it should be about six inches. So like we said, the average is around 5.1 to 5.3 inches. And so when you look at the data in terms of what people think it should be, men think it should be about six inches. In terms of women, where we found the data about what they prefer is sort of interesting. So now that we're having more surgeries for trans men, one of the surgeries that we do is a neophallus, is we create a new phallus.

Starting point is 01:39:26 And one of the types of surgeries we do is we use a forearm flap. And so it can be very, very long and very, very girthy. And in fact, they were doing these surgeries and they realized that some people were actually unable to have sex with it because it was too girthy. So they wanted to then look at like, well, how do we determine the right size and length, length and girth of this neophallus so that we, you know, they can then have sex with it. So what they did was they looked at the top, you know, the top five to 10 sex aids or toys that women are purchasing online. And they, you know, you can imagine that when you think of a dildo, they can go from one, you go from all the way to like the largest thing you've ever seen and the girthiest thing you've ever seen to like a

Starting point is 01:40:09 normal size. And so when you have the option to pick as many as you want, right, what do you pick? And so what they found was that women tend to pick the length of about six inches. But as you know, you're not putting the whole device in. There has to be a handle or something. So it's probably around what the normal size is. And the girth was also around the average girth of the male penis. And so generally speaking, women tend to want what is average or around average, right? And interestingly, there's a

Starting point is 01:40:38 product that is available called, oh, not, I'm not, I don't, I'm not sponsored by them or anything. But essentially you, you, for women who have pain with penetration with men who are too well endowed, the men actually wears it so that the entire phallus doesn't go in during sexual intercourse, but it's more comfortable for the partner. So we know that sometimes it can be really uncomfortable if it's too well endowed. And so I think ultimately, while I understand that pornography has made people really self conscious about the length of their penis, and I'm really sad about that, because I think you, as we've talked about earlier, clitoral stimulation is the easiest way for women to climax,

Starting point is 01:41:16 and you don't need penetration for that. So in order to have pleasure and give pleasure, you don't need a large penis. And in fact, some women may not even care what size your penis is. It's more of a societal thing that we talk about, right? Women joke about it, women talk about it. I mean, you can't go, you know, even I've accidentally made comments where I've been like, oh, that's great that he has a large penis. And like, well, I can't believe I just said that. Like, I'll say it and I'll be like, oh my God, I can't believe that came out of my mouth of all people. And I think it's just so ingrained in our brain to be like, oh, like to celebrate really well endowed organs when in reality it's not necessary and sometimes even painful.

Starting point is 01:41:54 Will my penis get smaller as I age? So not if you are healthy. So in terms of how do we maintain our penile health, right? Your body does a really good job of trying to maintain penile health because over the course of a nighttime, men will get five to six erections, three to six erections over the course of the night. And that will happen whether you have a sexual dream or not, whether you are sleeping in a certain way or not. It's because your body is sort of giving blood flow to the area periodically through the night. Whether you're having sex, whether you're not, you're getting good oxygenated blood flow to the penis. Now, if you develop other conditions where you cannot get blood flow to the penis, like you get high blood pressure, you get diabetes, you get heart disease,

Starting point is 01:42:38 and those arteries start getting narrowed, and then you stop getting nighttime erections, and you start having difficulty getting erections, over time the tissues can change and they can become what we call fibrotic and they can become a little less spongy and less elastic. And so in those cases, you can see a little bit of shortening. Now, people will also see shortening because they gain weight over the course of their lifetime. And as you gain weight, the penis is not shrinking, but the fat on the mons or the area right above the penis is sort of getting larger and obscuring how much penis length there is. There's one of the myths around penis size is that, you know, if I have big hands, because, you know, these aren't small hands, if I have big hands, then I have a big penis. Or if I

Starting point is 01:43:20 have big feet, then I have a big penis. Is there data to support this idea that the length of any part of my body is correlated to my penis size? Yeah, there's one study. It's a Japanese study where they looked at only Japanese men. So there are some limitations, but essentially, they measured all these body parts and penile length. And what they found was that nose length was correlated with penile length, not hand length or foot length. So how do I increase the length of my nose? Yeah, but I thought that was really interesting. Again, nothing you can control. These things are pre-genetically determined to some degree. And in fact, you know, we talked about some trends and while we've seen a sperm quality change

Starting point is 01:44:07 over the last 50 years, we've also seen penile length change average over many last, I don't know the exact number, but 50 years. And they've actually seen penile length is increasing. And they think that this is because the onset of puberty is changing and boys are getting exposed to factors that are making them go through puberty is changing and boys are getting exposed to factors that are making them go through puberty earlier. And hence they're getting more exposure to testosterone, they're developing longer penises. So sort of interesting theoretical thing. I don't know if that's true or not, but sort of what the theory is. Yeah, I actually read about that study. It

Starting point is 01:44:41 says that a study shows that men's average erect penis size has increased over the last 29 years from 4.8 inches to 6 inches. That's pretty dramatic. That's huge. Yeah. Wait another 29 years. You could be a, Jesus Christ. But I don't think women's vaginal lengths are changing. So I don't know what that means.

Starting point is 01:45:03 Oh, yeah. Oh, yeah. It's interesting because when we talked about the vaginal length enlarging as someone becomes aroused you mentioned that it goes from about roughly about three inches on average to about six inches that also correlates with the size of the flaccid penis to the size of the erect penis going from about 3.6 inches flaccid to about 5.1 to 5.2 inches erect. So you kind of see that these two things are actually made for each other. Yeah, they are.

Starting point is 01:45:30 I mean, I think in general, like we're all, I mean, we're designed, right? The biggest thing that we need to do as a species is have children, right? That is like sort of the goal of life is to propagate our species. And so it would make sense that we would be designed to be able to do that easily. A lot of people are having this new procedure called labiaplasty. Did I pronounce that correctly? Labiaplasty. Labiaplasty.

Starting point is 01:45:54 Yeah. What is this? Labiaplasty is essentially taking the labia minora and making them a little shorter or smaller, depending on what your preference is. And labia has come in all sorts of shapes and sizes. What is it? It's the inner lips of the vagina. They come in all sorts of shapes and sizes.

Starting point is 01:46:13 Sometimes they will be lopsided, so one will be longer than the other. Some will be longer, some will be smaller. And oftentimes we're seeing in pornography really small labia minora. And so people will tend to feel like maybe they should look like that. Now, not everybody.

Starting point is 01:46:28 Some people actually have discomfort. Their labia are so long that they cause friction or pain or discomfort. In those cases, it's absolutely reasonable. But just like people have insecurities about their genitalia when they're men, women also can have insecurities about their labia as women.

Starting point is 01:46:44 And so labiaplasty is essentially making those smaller and more cosmetically appealing when women desire that. But I think the important thing to take home is they are so diverse. They're as diverse as your fingerprint. Your labia is unique to you and there's no script of what it should look like. And so I generally tell people if that's something you want, that's absolutely script of what it should look like. And so I generally tell people, if that's something you want, that's absolutely fine. But again, this is not a pathology or a bad thing. This is something that, you know, is more cosmetic. And there's been an 80% increase in the surgery of labiaplasty from 2015 to 2019, which is, you know, a lot, a lot. It's a lot. Last thing about

Starting point is 01:47:22 women and ejaculation in the vagina is about squirting. Very misunderstood. Like, you know, as a man that doesn't have a vagina, I've seen squirting on pornography that I've watched. I watch pornography. I think that's important to say. I think a lot of people do watch pornography. And in the pornography that I've watched the woman squirts this liquid comes out

Starting point is 01:47:45 and like is that semen is that ejaculate or is that something else what is it yeah also should we be aiming to make our partner squirt yeah let's talk about it so this is important and it's actually interesting i just i just had a conversation with a researcher about this because it's so misunderstood and we still don't know. Like there's only been like three or four studies looking at female ejaculation squirting over the course of our history. There's different types of fluids the vagina makes. One is obviously lubrication. That's different. And that can be very copious for some, very not as copious for others. That's one type of fluid. The other type of fluid is female ejaculate. Now female ejaculate is similar to male ejaculate. It

Starting point is 01:48:25 comes from the Skene's glands, that same female prostate. It is a small amount of like sort of sticky white fluid that women ejaculate. And so they will release that fluid. And it's not like this copious amount of fluid that you're seeing in pornography. The next type of fluid is squirting. And squirting has been described as a clear, colorless, odorless fluid that's emitted from the urethra. When they've looked at analyses of these, they found that there is what we call PSA or prostate-specific antigen. Now that we think of traditionally as males, but the women's skeins glands make it as well. Now people are like, is it pee? Right? That's the big question. And so in the one study where they looked at the analysis, they found that it was, there was like dilute urine. And

Starting point is 01:49:15 then another study looked at like, okay, they scan people before squirting and after, and they scan their bladders to see like, did the amount of urine change? And they said it did. And now it's urine, but we really don't know. And what we what the limitation is that you never so women know when they squirt, like they know it's not urine. So if you talk to enough women who are squirting, they'll be like, you know, it's not urine. I'm sure it's not urine. But where is that fluid coming from that? That's where the question comes, right? And so like, if it's not urine, it's coming from the urethra, like it doesn't make sense. And so this is Dr. Barry Komisorek, who's done a lot of research on orgasm. He said, you know, it may be water imbibition. So when you think of like fluid filling the walls of the

Starting point is 01:49:56 uterus and the vagina during the process of arousal, and maybe during climax when you have actually contractions of that fluid of those of those organs that occurs during climax that it can actually release this fluid i don't know i think the jury remains out i don't think we have a conclusive answer because the studies are not perfectly designed we have a closing tradition on this podcast where the last guest leaves a question for the next guest not knowing who they're going to be leaving it for. And the question that's been left for you. If there was one message that you want your life's work to communicate to the world, what would it be and why? My message is that sexual health is health and that we need to be prioritizing our sexual health and educate our young people about sex.

Starting point is 01:50:49 And why? Because I think the impacts of having negative sexual health or negative sexual encounters can be so dramatic in terms of physiologic outcomes, interpersonal outcomes, work productivity. I mean, it can be very far reaching. And if we are able to educate and empower people, we can change the world. Dr. Reena Malik, thank you so much for your time today. And thank you so much for illuminating a bunch of issues on sexual health that I've never really understood or been able to discuss before. And I think these conversations are so unbelievably important because as you say there sex sort of permeates every facet of our lives and I think sometimes people wonder why I spend a lot of time on the show talking about sex when this is called the diary of a CEO but that's because it's the

Starting point is 01:51:37 same reason why I spend a lot of time talking about health and the brain and neuroscience and relationships and everything because I've come to learn that although I'm a CEO, I'm a business person, all of these things, as you've said, feed into my ability to be a CEO. And what is a CEO? A CEO is a human being. A CEO is just someone that has a sort of high intensity career. We all have high intensity careers and we're these multifaceted objects, but some parts of these multifaceted objects are still in the shadows because there's stigma and there's shame and there's not a lot of education around it and if i think about my career as a whole um sex and my relationships have been this huge um huge part of it that once i focused more energy on and started investing it in every other part of my career improved every

Starting point is 01:52:24 other part of my life improved my health improved my performance at work improved my anxiety levels dissipated and that's why i think these conversations are so unbelievably important and your work that you've done both in your your sort of clinical practice but also what you're doing on youtube as well which i'll link below so everyone can go and see is allowing this information to be accessible for everybody even those that that don't have the money to go and drive, as you said, to go see a therapist. I think that's an incredibly important work. And I'm glad that you're a real champion and a force behind that. So thank you so much on behalf of me, my team,

Starting point is 01:52:56 but also everyone that's consumed your work and gained value from it. Thank you. I would just say that I always tell people, because I mentor a lot of young medical students, and I always tell young women that the number one most important decision you're going to make is who you choose as your partner. And that's because that person, whether it's obviously emotionally, but also sexually, right, how they support you in your life is going to determine whether you're able to succeed or not. And I just was talking to another woman and she was like, my husband's wonderful. I was like, I'm not surprised. I was like, you don't get to be a successful woman and a happy, well-adjusted successful woman

Starting point is 01:53:37 unless you either are very happy being alone or you have an excellent partner to support you. Because if you have a toxic partner at home, it's not going to work. Amen. Thank you. Bye.

The Diary Of A CEO with Steven Bartlett - The Better-Sex Doctor: The Link Between Masturbating & Prostate Cancer! This Is The Perfect Amount Of Times To Have Sex! Strong Pelvic Floor = Better Sex! Dr Rena Malik

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