Why Older Couples Stop Wanting Sex — And How To Fix It

Summary

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Podcast Summary: “Why Older Couples Stop Wanting Sex — And How To Fix It”

Podcast: Rena Malik, MD Podcast
Host: Dr. Rena Malik
Guest: Dr. Anna Maria Giraldi, Psychiatrist (University of Copenhagen)
Release Date: May 8, 2026

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Episode Overview

This episode tackles why sexual desire and activity may decline in older couples, breaking down the complex interplay of biological, psychological, medical, and cultural factors. Dr. Rena Malik hosts Dr. Anna Maria Giraldi, an authority on sexual health in older adults, for a wide-ranging discussion centered on dissolving cultural shame, updating the medical approach, and offering evidence-based guidance for couples and clinicians. The episode combines personal stories, research highlights, practical advice, and memorable anecdotes, emphasizing that pleasure and intimacy are lifetime rights and needs.

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Key Discussion Points & Insights

1. Changing Cultural Perceptions of Older Sexuality

• [04:38] Changing Expectations: Dr. Giraldi shares a critical study about intergenerational shifts in sexual expectations amongst 70-year-olds in Sweden; newer generations expect continued, active sexual lives.
  • “Almost all of them had an expectation of being sexually active and sex being important when you get older.” — Dr. Giraldi [06:00]
• [13:11] Ageism in Medicine: Both host and guest cite medical training biases underestimating older adults’ sexual activity.
  • “We, we are ageist. [...] we can't be digging our head in the sand and think that doctors are not ageist or we're not doing these things. We absolutely are.” — Dr. Malik [13:13]

2. Barriers for Older Couples

• [01:00] Biological Changes: Age brings decreased nerve sensitivity, changes in hormones (declines in estrogen and testosterone), and increased need for stimulation for both men and women.
• [11:30] Double Pause Phenomenon: Both partners may experience sexual changes, but frequently only one receives treatment, causing mismatched needs.
  • “If we only treat one of them, we’re really not doing a good enough job because we need to think about and involve the partner.” — Dr. Giraldi [15:10]
• [17:20] Intimacy vs. Intercourse: Most older couples prioritize intimacy and communication over intercourse itself.

3. Biological & Psychological Dimensions

• [27:08],[30:19] Menopause, Andropause, and Beyond: Hormonal shifts impact desire and function — women struggle with lubrication and pain post-menopause, men require more stimulation and recovery time.
  • “It needs more stimulation. It takes longer to recover. And it's the same with women... what they used to do is not good enough.” — Dr. Giraldi [27:45]
• [32:17] Body Image & Relationship Dynamics: Adults often misattribute sexual changes to lack of attraction, infidelity, or self-worth, when it’s simply physiology.
  • “You can help people if you tell them, actually that's what happens when you get older. It has nothing to do with you as a partner.” — Dr. Giraldi [33:03]
• [30:19],[31:50] Physical Health & Desire: Sexuality correlates strongly with overall health; chronic disease, frailty, and mental health strongly influence function.

4. Communication, Shame, and Social Scripts

• [01:00],[23:29] Shame and Anxiety: Harmful myths about masturbation and pornography foster shame and performance anxiety, affecting all ages.
  • “We need to deconstruct all these shameful perceptions... people become very anxious and they're very anxious about do I do it right?” — Dr. Giraldi [01:00],[23:29]
• [24:29],[26:57] Pornography Myths: It’s often the moral anxiety around pornography, not the act itself, that creates dysfunction, confirming modern research.
  • “If you feel that pornography is bad, that's when the shame spiral creates this problem...” — Dr. Malik [24:29]

5. Clinical Practice & Interventions

• [08:33],[12:05] 2024 Sexual Medicine Guidelines: For the first time, international recommendations urge clinicians to routinely address sexual health in older adults, avoid ageist assumptions, and support special populations (e.g., those with dementia).
  • “Age should not be a barrier for treatment. Absolutely.” — Dr. Giraldi [08:33]
• [35:45] Best Strategies: Communication within couples and with clinicians, normalization of desire and intimacy as lifelong needs, and partner-involved consultation are most effective in improving late-life sexuality.
  • “Normalizing and communication ... are very, very important because then people can start helping themselves.” — Dr. Giraldi [35:45]
• [36:43],[39:40] Sexual Rehabilitation for Cardiac Patients: Multi-faceted pilot studies (e.g., Copenheart SF trial) show exercise, pelvic floor therapy, and sex counseling improve erectile function and psychological well-being post-heart disease.
  • “They actually had a better erectile function... but also there was a very supported atmosphere... They felt sexually empowered.” — Dr. Giraldi [39:40]

6. Pharmacology and Hormones

• [33:28],[34:40] Testosterone & Hormone Replacement: Decline is expected with age; most healthy individuals don’t require supplementation; comorbidities influence deficiency.
  • “Sometimes you give testosterone to people and nothing changes... sometimes, for some people, it’s very, very good. For some people, you need to look at something else.” — Dr. Giraldi [34:40]
• [46:22],[48:40] SSRIs & Sexual Side Effects: New research (EEG, PET imaging) seeks to identify individuals at risk for persistent sexual dysfunction post-SSRI, inching closer to personalized medicine.
  • “There might be people that are more vulnerable to treatment with SSRIs, and they might have higher levels of sexual side effects than other people.” — Dr. Giraldi [49:20]

7. Research Highlights & Ongoing Questions

• [53:46] Androgen Receptor Studies in Women: Testosterone influences female desire, but relationship context and psychological health are equally crucial; receptor variations may moderate effects.
  • “Of course, testosterone has an impact on women's sexual desire, but there are also other aspects, especially relationship and depression.” — Dr. Giraldi [57:26]
• [60:08] Special Populations: Current research explores sexual health in bladder cancer survivors and in individuals with psychiatric illness—fields with significant unmet needs.
• [65:01] ADHD and Sexuality: Preliminary findings suggest attention/focus challenges may impair sexual functioning; requires further study.

8. Generational and Societal Observations

• [17:17],[20:29] Denmark’s Sex-Positivity: Despite liberal attitudes and early acceptance of pornography, sexual difficulties and shame persist—showing cultural context matters but does not “solve” the conversation.
• [75:00] John Dillerman Anecdote: A Danish children's show featuring a character with an absurdly long penis sparked international debate—showcasing vast differences in sex education and cultural taboos.
  • “He’s called John Dillerman... it’s a Danish national TV that created him… It tells a little bit about the environment in Denmark that you can have a person like him in children’s television.” — Dr. Giraldi [75:09]

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Notable Quotes & Key Moments

• On Ageism in Sexual Medicine:
  “If we only treat one of them, we're really not doing a good enough job because we need to think about and involve the partner.”—Dr. Giraldi [15:10]

• On the Importance of Intimacy:
  “Most of the time people say, I want us to have more intimacy and communication... because that's what really matters to people.”—Dr. Giraldi [17:20]

• On Guidelines for Older Adult Sexual Health:
  “Age should not be a barrier for treatment. Absolutely.”—Dr. Giraldi [08:33]

• On Sexual Rehabilitation for Cardiac Patients:
  “They felt sexually empowered, that it was nice to have more information about it and speaking to someone about it. And that itself would create more desire.”—Dr. Giraldi [39:40]

• On SSRIs and Sexual Side Effects:
  “We found that overall, if you treat depression, the better depression is treated, the better desire is.”—Dr. Giraldi [49:35]

• On the Holistic Perspective:
  “It has really become very evident for me that it’s so important that we have a more holistic approach to sexual health, because it's also about pleasure. It's not only about function.”—Dr. Giraldi [71:16]

• Core Message:
  “Sexuality is individual and it changes during your lifetime.”—Dr. Giraldi [71:37]

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Timestamps for Major Segments

• Changing Sexual Attitudes & Expectations: [04:38–08:23]
• International Guidelines & Double Pause: [08:33–16:10]
• Communication and Intimacy: [16:10–18:24]
• Shame, Anxiety & Pornography Myths: [23:29–26:57]
• Biological & Psychological Changes with Aging: [27:08–34:40]
• Sexual Rehabilitation (Cardiac): [36:43–44:10]
• Partner Involvement and Cultural Differences: [44:10–45:44]
• SSRIs, Hormones, and Personalized Medicine: [46:22–53:21]
• Research: Androgen Receptors, Bladder Cancer, Psychiatric Illness: [53:21–63:46]
• ADHD & Sexuality: [64:18–66:10]
• Holistic Changes in Sexual Medicine: [71:16–73:26]
• John Dillerman Cultural Anecdote: [75:00–77:56]
• Rapid Fire: Life Lessons & Personal Reflections: [78:07–80:49]

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Key Takeaways for Listeners

• Aging changes sexuality, but does not erase it. Older couples face unique physical and psychological adjustments, but intimacy and pleasure remain core needs and rights.
• Cultural narratives must shift. Both society and healthcare suffer from ageism and sexual ignorance that limit older adults’ quality of life.
• Treatment is best when partner- and communication-focused. Isolated, single-patient treatment may backfire without addressing both partners’ needs and expectations.
• Physical health and sexual health are deeply intertwined. Exercise, disease management, and mental health all substantially affect sexual function.
• Shame is a major barrier. Open and positive conversations around topics like masturbation, pornography, and aging bodies are essential.
• Personalized, holistic medicine is the future. As research advances, individual vulnerabilities to side effects and personal desires will increasingly guide sexual medicine.

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For more resources:

• Sexual Medicine Reviews (editor: Dr. Giraldi): Contemporary research and guidelines
• University of Copenhagen Faculty Page (for Dr. Giraldi’s work)
• newsletter.renamalikmd.com: Dr. Malik’s weekly urology and sexual health research digest

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Transcript

[Dr. Anna Maria Giraldi]

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[Dr. Reena Malik]

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[Dr. Anna Maria Giraldi]

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[Dr. Reena Malik]

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[Dr. Anna Maria Giraldi]

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[Dr. Reena Malik]

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[Dr. Anna Maria Giraldi]

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[Dr. Reena Malik]

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[Dr. Anna Maria Giraldi]

we need to like deconstruct all these shameful perceptions of oh now I ruined my sexual life because I had, I've masturbated, I watched pornography. People become very anxious and they're very anxious about do I do it right? And we always think that what's happening in the neighbor's house is much more good or nice or more exciting that what we are experiencing with newer generations of 70 years old people. They had higher expectations of being sexually active and meaning that sex would be something that's important. When you get older. Men need more stimulation to have an erection. They need more stimulation to have an ejaculation and maybe it takes longer time before they can function again. So when they were used to, when they were 18, it only took one minute and then they were ready again. Now sometimes it takes a week because the whole system is like slowed down. So it needs more stimulation. It takes longer to recover. And it's the same with women, that women can still lubricate it when they go into the menopause, but it takes more stimulation. And I think that's where some of the problem starts with people that get older, that they are doing what they used to do and suddenly what they used to do is not good enough.

[Dr. Reena Malik]

Sex can get a little bit more challenging as you age. And recently I had an elderly patient ask me, things aren't working that great, should I just let it go? And I told him that really everyone deserves a life filled with pleasure and intimacy. I'm Dr. Reena Malik, urologist and pelvic surgeon. And welcome back to The Rena Malik, MD podcast, your trusted guide for leveling up your health, relationship, relationships and sex life with evidence based tools. Today I'm bringing you a master class in sexual medicine across the lifespan with Dr. Anna Maria Giraldi, a psychiatrist at the University of Copenhagen and a researcher who's published extensively on hormones, depression and sexual function. She's an editor of the Sexual Medicine Reviews and a key contributor of the International Consultation of Sexual Medicines for first ever guidelines on sexual health in older people. In this episode, we're covering the biological changes that happen with aging, decreased nerve sensitivity, hormonal shifts, vascular changes and the psychological barriers like internalized ageism and body image concerns and the double pause phenomenon where both partners are undergoing changes but oftentimes only one partner gets treatment, sexual rehabilitation for cardiac patients and the complex relationship between SSRIs, depression and sexual sexual desire. We also cover many of her research studies, including those on looking at androgen receptors in women using EEG to predict ssri, sexual side effects and sexual health in populations with dementia, bladder cancer and psychiatric illness. If you guys love this podcast, you are also going to love my newsletter, Urology. It is a quick read that you get every week in your inbox where we cover one research article for men, one research article for women. We talk about what's going on with me and we summarize what you might have missed on my channels. It is super easy to read, it is super fun and you, I promise you will learn something. Check it out at newsletter.renamelicmd.com Dr. Giraldi, thank you so much for being here.

[Dr. Anna Maria Giraldi]

Thank you for having me.

[Dr. Reena Malik]

All the way from Denmark.

[Dr. Anna Maria Giraldi]

Yeah, it's a long trip, but it's so nice to be here. We have a snowstorm in Denmark. So nice waking up this morning with sunshine.

[Dr. Reena Malik]

That's wonderful. Well, you are so prolific in our field and I'm so excited to talk with you. And what I wanted to start with is that culture tends to treat sexuality as something that is really just belonging to young people. But from your research and clinical experience, what's the truth about desire, sexual activity and satisfaction as people age?

[Dr. Anna Maria Giraldi]

My experience, and I think it's supported by research, is that it's changing. And as you say, culture has a very high impact on how we see older people and sexuality and so that some kind becomes internalized in older people too. But I think that what we are seeing right now and what we also see is that many factors that somehow determine sexual life of older people. So there's no doubt that when you become older, function decreases and maybe also your wishes for a sexual life is changing and then also life circumstances are changing and then we have like the perception of how older people should behave. So having said that, there's a lot of research showing that with newer generations of older people, older People have more expectation of having an active sexual life. I usually refer to now it's a little bit old, but there was a very, very nice study from Sweden where they interviewed older people. So they were all 70 years of age, but they were born in different times. So some of them were born in the 1910s and 20s and 30s and they talked to them about sexual health.

[Dr. Reena Malik]

That must have taken a long time to get that study together.

[Dr. Anna Maria Giraldi]

Yeah, I think, I think it did. But it's really a nice study.

[Dr. Reena Malik]

That's great.

[Dr. Anna Maria Giraldi]

And so it was a study that I really like because they actually, it took a long time because they have to find different generations. But what they looked at was what do did these 70 years old people expect about sexual life when they became older? And two things that are interesting in this study and there are many interesting things, but two things are really interesting. The one is that with NEWER Generations of 70 years old people, they had higher expectations of being sexually active and meaning that sex would be something that's important when you get older. And the other thing is that in the younger generations of women, they had lower expectations than men. But in the end, men and women had the same expectations. So in the first generation of the oldest or 70 years old, about 2/3 of the men had an expectation of sexuality as a part of being older and only about one fourth of the women. But with the newer generation of 70 years old, they had, almost all of them had an expectation of being sexually active and sex being important when you get older. So I think it tells us that with newer generations we will have other expectations for all people. And then we also as healthcare providers need to recognize that. And the other thing is that now we have, at least where I come from, we, we talk about that we have all the boomer generations, we have the 60s people from the 60s that were part of the liberation in the 60s, they, they have other perceptions and the culture in, in their, you know, the way they have been brought up, their lives is different from maybe the people that were, you know, before the Second World War. So I think that times are changing, culture is changing, so we have more aspects, more positive. I'm involved in the international consultation of sexual medicine and for the first time we actually had a committee coming out with recommendation about sexual health in older people because we also have more older people now the world demographic is changing, so we have more older people and we're going to people live longer. So I think that all in all we need to recognize that older people are changing and they are also More healthy. Yeah, we know that sexual health and mental health and physical health goes hand in hand and people live longer, they're more healthy. And a healthy sexual life is part of that.

[Dr. Reena Malik]

Absolutely. So this consultation that you guys are organizing, are they guidelines? What are you looking at specifically in sexual health and older people?

[Dr. Anna Maria Giraldi]

They came up with. It's just to explain what the consultation is. It was the fifth consultation, it was in 2024 and it was organized by the International Society for Sexual Medicine, also the European Society and the North American Society for Sexual Medicine and What we call ISWIs, which is the International Society for the Study of Women's Sexual Health. It's an expert groups gather. This time it was in Madrid. So experts from all over the world gather and then we have committees and different topics. There were about 25 different committees. And what they focus on in this committee, they have a lot of recommendations, I think more than 50 recommendations, but they have specific focus on that. We as health care professionals need to focus on sexual health in older people. That we need to ask the questions, we need to be sensitive to. How do we talk about sex with older people? Because they have might have been brought up with other values and other ways of looking at sexual health. We need to inform them about the effect of age. I mean, what are the changes, what are the physical changes, what are the hormonal changes, what are the psychological changes? Relationship changes, maybe. And we need to be sensitive to different cultures and religious groups and ethnic groups. I think that goes for all sexual medicine. But that is one of the things that they emphasizes. Then they also say that age should not be a barrier for treatment. Absolutely. So the fact that you are old shouldn't be, oh, then we can't treat you, then it's not relevant. Because I think younger people tend to think it's not relevant for older people. It's only relevant, as you say, for younger people. And then they have a focus on special groups like people with dementia, saying there might be different cultures or certain problems that arise when, maybe in a couple, when one person has dementia, one of the partners has dementia. How do we manage that? Because you still have the right to a sexual life, but maybe how can you give consent if you have dementia? I think that's a very, very important and very fascinating and very something that we really need to have a focus on. Because there have been cases where it has been discussed, can people with dementia, can they give consent? So how do we deal with that? They also discuss that if people with dementia have sexual lives or want to have it. It shouldn't be the children or the caregiving people where they live, but you need to include the partner and you need to really try to. To protect the person and also protect the. The right to having a sexual life, but also protect the person. So I think that's looking into the future about older people being sexually active. We also need to look at maybe the more negative sides and how do we deal with that. And then they also discuss that there are different, like Parkinson medication that might increase sexual desire and have suddenly persons with Parkinson having the treatment. They might have, like, change their sexual behavior and be more sexually active. And how do we deal with that? So they actually try to focus on the responsibility of the health care takers of introducing. Talking about treating sexual problems, but also like introducing new things that we might face in the future with a growing older population.

[Dr. Reena Malik]

I mean, this is such an important discussion, not only for the healthcare providers, but the patients as well. So I had a patient this morning who was like, Oh, I am 65. Things are not working that great. Should I just let it go? And I said, you deserve pleasure and intimacy. And I don't think you should just let it go. It doesn't mean that you have to have. If you're struggling with erections, you have to have an erection to have intimacy. But I do not think you should say, oh, I can't have an erection, and so I should just stop trying to be intimate. And I think that's a big misnomer in our aging population. Oh, maybe I'm just too old for sex.

[Dr. Anna Maria Giraldi]

Yeah. And I think that's. I agree with you. It's very, very important. And one of the recommendations from this committee is also that we need to open the discussion because a lot of older people might say, oh, this is something that I need to accept, so I won't even open the discussion. Your patient is open and actually went to you to get some help. But a lot of people won't do that. And so they also have a focus on how are we as healthcare providers, ageists. I mean, how do we look at older people and how do open the conversation in the best possible way?

[Dr. Reena Malik]

Absolutely. You know, it's interesting. I did a study when I was a resident, and the study was, what do we as urology residents think? Like, how sexually active are elderly patients? And it was remarkable how many people undervalued the percentage of people who were sexually active in older age. And I was like, look, we're residents. We know a little bit more than the average Medical practitioner, because we are training in urology, but it's still so low. And so I think it's so interesting because we, we are ageist. Like, we can't be digging our head in the sand and think that doctors are not ageist or we're not doing these things. We absolutely are.

[Dr. Anna Maria Giraldi]

We're part of the culture.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

I think it's such an important aspect and the other aspect I've been a little bit involved in is what we call the double pause. That very often our healthcare system is built up the way it. It's a little bit different depending on which country you are in, but. But usually as a gynecologist, you'll see the female partner. If you're a urologist, you'll see the male partner. If you're gp, you might only see one of them in your practice and the other one is in another practice, no matter whether it's a male or female partner you have. So what we talk about with the. With the double pause is that very often if you have an older person presenting with problems, a man with erectile dysfunction, you need to be aware that there's a partner at home. So it might be a female or male partner, but this partner also maybe has the same age, so there's a risk that this partner also has problems. So if we only treat one of them, we're really not doing a good enough job because we need to think about and involve the partner. And that's one of the recommendations too, that we really need to involve the partner both in the assessment. Because if I give a PD5 inhibitor to a man with erectile dysfunction and. And he has a wife who is in the menopause, she has problems with pain and lubrication and she actually doesn't want to have sex, then we didn't really solve anything because we've actually created more problems. Yeah.

[Dr. Reena Malik]

Because they were probably blissfully not having sex.

[Dr. Anna Maria Giraldi]

And I think that's also so important. And I think we need to think about not only treating one person, but really include the partner. And here we see barriers. We have healthcare system where I'm working in a place where we are able to. To invite the partner to come as a part of the treatment. But that's very rare.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

And we need to create a system if we want to take care of older people's sexual health, where we can actually have both of them and also discuss what you are saying. What is sexual health? What is sexual intimacy? Because maybe they don't have an intercourse, but maybe they have A lot of kissing and intimacy and bodily contact. And maybe they have other goals than just having an erection or an orgasm. So it's also about involving both of them. And sometimes they don't have the same goal when we treat them. One of them might have one goal and the other one says, that's not my goal. Or maybe a problem. Typically an erectile problem for a man, it doesn't matter a lot for the partner. And the partner would say, oh, we can do something else. But for this guy, it's very important.

[Dr. Reena Malik]

Yeah, it's a huge opportunity when you have a couple in the office with you. And I do see some couples, and I think that it's so valuable because you can then figure out what the problems are. They're probably not even talking to each other about it. Right. And so when they're finally with you, they open up and you can actually see, like, well, where do we need to work on things for both partners?

[Dr. Anna Maria Giraldi]

You're like the mediator of the communication. Because I think it can be very, very difficult for people to talk about sex. And it's. Even though you have known each other for years, and when it works, you don't talk a lot about it. And when it doesn't work, it might be very difficult because you also. People are very vulnerable, but they also care about the other one. So very often it can be very difficult to say, I really think we need to do something different, or this doesn't work for me, or I never liked that, or whatever it can be. And then it's good that you have a third person that can, like some kind mediate that conversation, because it's. People really want to protect each other and themselves. So it can be very difficult to talk about sex.

[Dr. Reena Malik]

Yeah. And everyone. I think everyone to some degree, wants intimacy. They may not want sexual intercourse as they see it or as they believe it to be, but they. I think everyone wants closeness with another human being.

[Dr. Anna Maria Giraldi]

I agree. Very often when. When I see couples, I ask them, what is the goal of your treatment here? So we need to set a treatment goal. Most of the time people say, I want us to have more intimacy and communication. I mean, some of them say, I want to have more intercourses. But that's actually intimacy and communication are the first choices because that's what really matters to people. That's intimacy. And sex is where we really get close to each other, and that's where we have intimacy. So that's why it's so important. So sometimes if you can get the intimacy, the intercourse or the orgasm or the erection isn't that important because it's intimacy that they really say, I miss that. I miss that. We depart. We depart from each other. We move different directions. We don't.

[Dr. Reena Malik]

And for a lot of relationships, I say this often, but that sex is the only form of intimacy that they know. Right. Not be very physically affectionate. And so sex is a time that they feel physically close. And when that is gone, it feels like a huge rift in the relationship.

[Dr. Anna Maria Giraldi]

Yeah, it's a catastrophe.

[Dr. Reena Malik]

Yeah. And you mentioned something interesting. You said the way we talk to older people may be different than the way we talk to younger people because there's a big generational difference. I can talk to my son about something in a very different way. I'll share a funny story. I made a little short video, and the video said, someone cooked here. And cooked is a slang term for the younger generation that means something good happened. Like, I did something really good. Whereas in the older generation, cooked means, oh, you're cooked. That's a bad thing. And so when I posted this piece of content, it was showing something good happened. And then, oh, someone cooked here in a positive way. And people were like, why are you saying this is negative? Like, there was so many comments. And I realized, like, there's such a divide here in how we talk to the older generation. But I also find that when I bring up things like, maybe you should try this or do this or try maybe a toy in the bedroom. And that's very foreign to patients who are older. A lot of them are like, well, no one's ever talked to me about this, and I'm kind of excited about it. And there's others that will shut down and be like, oh, no, no, no, no, we don't do that. And I think it's okay to broach it, but being cognizant that you might not get a response the way you expect it to be.

[Dr. Anna Maria Giraldi]

Yeah. And I think that's also it. It says a lot about our role as healthcare professionals. And just also, I think that if you sit there, I'm a little bit older than you are. So it's like, how would I feel if sometimes when I meet a healthcare professional, I think, oh, did they even finish high school? They're so young, so how can they talk to me about this? So we also need to think about the barrier between generations. As you say, we have different languages. And sometimes when I talk to younger people, I think I'm just too old for this. But because I don't know the Language. I wouldn't know that about cooked.

[Dr. Reena Malik]

The cooked. Right.

[Dr. Anna Maria Giraldi]

Yeah. So it's, it's.

[Dr. Reena Malik]

Well, I wouldn't know either, but I have kids.

[Dr. Anna Maria Giraldi]

That's. It keeps you young,

[Dr. Reena Malik]

you know, I wonder, is it. I think of Denmark as a very, like, sexually positive country. And do you find that, I mean, you travel a lot, you see doctors and people from all over the world. So what is your experience?

[Dr. Anna Maria Giraldi]

My experience is that Denmark is a sex positive. It was the first country that had pornography allowed. I mean, I don't know if that's positive and negative, but I think it has a very positive attitude towards sexual life and sex. We accept that people have sex without being married. We accept that teenagers have sex. We have very low rate of teenage pregnancies. We have high information about, you know, contraception and things like that. But still, I think that sexual life is still difficult.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

So even though you have a positive attitude and even you have an open society where you're not like moralizing and say, this is not allowed, it's still difficult. It's still difficult to talk about. Still difficult to find your way. I think that that's quite interesting. So we think it should be so easy, but it isn't. But what I see in our clinic is that we see younger people coming for help. And I was, in the beginning, I was like, oh, why do we have all these young people? Shouldn't they just find another partner or something like that? But I think on the other hand, maybe it's a positive thing that they actually say, okay, now something isn't working, so we need some help, we need to get some help from someone. So. And then we have a healthcare system where, you know, it's free and you can actually go to a GP and get a referral. But I think that also especially for women, when you ask about traveling, especially for women, there's a huge difference in how we look at sexuality in women, depending on the culture you live in. Because in a lot of countries we have absolutely no information to women about sexual health. Everyone thinks it's something that hurts. It's something that you. You don't do it before you. You get married, you do not masturbate. We also have cultures where it's not allowed for men to masturbate. And I think that it has a negative impact. It might have a negative impact because if you don't learn anything about it, if you don't know how your body works, if you don't know, what do I like, what don't I like, Then you are very inexperienced. And then, and we also know that from research, then it increases the risk of having problems. Of course a lot of people will find out and how they do, but I think that's really the impact of the culture when we talk about what has an impact, because I think the bodies are the same all over the world. But the impact of the culture and the shame that's connected to sex, especially for women, is not very good for a healthy sexual life.

[Dr. Reena Malik]

The shame is really the problem. And so you know what was so interesting for me when I started making content on YouTube, I would get a lot of comments and one of the comments I would get was, how do I stop my nightfall? And this blew my mind that people thought that having nocturnal emissions or ejaculating at night was a bad thing. And like I had never, you know, I just knew it was normal. And granted, obviously I'm a urologist, but I think I knew that from a young age because it's not a, it's not a, not really taboo in the US and it shocked me and I was like, why are people are so stressed? How do I stop this? What's wrong with me? I'm broken. How do I stop this? And it was just a normal function.

[Dr. Anna Maria Giraldi]

Also, when you go on the Internet, you'll find a lot of different stories about, you know, if you get into the, like the, the wrong line on Internet, you can have a lot of things. Also we see a lot of people now, young men that are referred with erectile problems and then they go on the Internet and they find, oh, it's because I watch pornography. And really, I really disagree with that. Then they have all this shame about, oh, I watch pornography. And we know that, you know, 99.9% of men and a lot of women have watched pornography and then they get this impression, oh, I have to stop that. And then there's a lot of shame, a lot of anxiety. So we need to deconstruct all these shameful perceptions of, oh, now I ruined my sexual life because I've masturbated, I watched pornography. So people becomes very anxious and they're very anxious about do I do it right? And we always think that what's happening in the neighbor's house is much more good or nice or more exciting than what we are experiencing.

[Dr. Reena Malik]

Yeah, well, there's science that shows that pornography is not the problem. Right. I don't think it's just your personal opinion. I think there's really real science behind the fact that it's not the actual visual aid that you're using that's creating dysfunction. It's the moral incongruence. If you feel that pornography is bad, that's when the shame spiral creates this problem where you feel negative after doing the act of masturbating while you're watching pornography, and then you continue to do it, to feel that little bit of dopamine and then it just becomes this vicious cycle.

[Dr. Anna Maria Giraldi]

Yeah. And I completely agree and I think that was a very nice study. I don't remember the authors, but they showed that young men that were anxious, they were anxious. So they were the one that, you know, when they had watched pornography and masturbated, then they felt a lot of guilt and shame and anxiety. But the one that weren't anxious and had no problems or anxiety, they used it and they felt good. And then we know there's a lot of research. We have one researcher, Dr. Hal, in Denmark, that did a lot of research in pornography. And I said there might be a small group that watch too much and have a vicious circle and watch more and more violent pornography. But they are, it's not only pornography. They have a lot of other alarming signals. So it's not pornography alone, but they are the one that you should be a little bit concerned about. But that's really a minority.

[Dr. Reena Malik]

Yeah, there's often a lot of concomitant depression and psychological factors. Right. And maybe there's a theory that there might be some untreated psychological factors that they're self medicating almost with the pornography. Yeah. And I think the other thing is there is so much information online. Right. Oh, quit pornography. How do I quit? There are coaches who are like, you know, take my ten step program to quit pornography for good. And those don't even work. Right. There's science that, that actually there's evidence that doing these sort of very drastic interventions of complete abstinence don't actually work.

[Dr. Anna Maria Giraldi]

Yeah. And, and that's, yeah, it's talking against research actually. And it's talking against what we like also would like to, you know, be sex positive. And it becomes a very negative thing. And you have like this 12 steps or 10 steps programs, like if you have, have been drinking or taking drugs or something like that.

[Dr. Reena Malik]

Yeah, yeah. And it's easy, it's easy to, I mean, it sounds good, right? Oh, you're this like morally righteous person saying porn is bad, it's ruining your life. If you quit this, you're gonna have a much better life. And I tell people, look, if you cut back and you Feel better, great. Like, by all means, you don't have to watch pornography, but you shouldn't feel shame about it.

[Dr. Anna Maria Giraldi]

I think the shame is really bad for sexual health.

[Dr. Reena Malik]

You did mention that there are changes that happen in sexuality as we age from a biological standpoint. So can we go over some of those?

[Dr. Anna Maria Giraldi]

We know that changes in hormones. We know that in women, we have the decrease or the lack of estrogens after the menopause, which has an impact on especially lubrication, but also somehow on desire. We know something happens with desire when people go, when women go into menopause, but especially it has an effect on lubrication and pain and feeling dry. We know that that testosterone is declining both in men and women. We know that has an impact on desire. So we have like the hormonal changes. We have just the fact that you need more stimulation. And that goes for both men and women. We need that. Men need more stimulation to have an erection. They need more stimulation to have an ejaculation. And maybe it takes longer time before they can function again. So when they were used to, when they were 18, it only took one minute, and then they were ready again. Now sometimes it takes a week because the whole system is like slowed down. So it needs more stimulation. It takes longer to recover. And it's the same with women, that women can still lubricate it when they go into the menopause, but it takes more stimulation. And I think that's where some of the problem starts with people that get older, that they are doing what they used to do, and suddenly what they used to do is not good enough. And then it's very, very difficult to say, actually need more stimulation. I are not just turned on by you saying, oh, should we do something? And then it's very difficult to find out how do we do that stimulation and how do we talk about it? How do we help each other in finding out what do we like now? And it takes longer time. So I think that's the major changes. I mean, we have the hormonal changes and more physiological changes with the genitals. And then we also have the more psychological changes. Maybe people have known each other for a very long time if they're still in the same relationship. We always doing the same things. You might feel older, your butt, body image might change. Yeah, you only asked about the physical ones. Now go into the other ones. And also the internalized ages. I mean, do I think I can have sex when I'm older? Do I like my body? Do I like my partner's? Body. So also, oh, now I'm getting old. You're a little depressed. What does. I don't have a long time. I'm getting older. And all the more psychological things. So I think. And also the change in roles. The children are leaving home. What is my role now? How do I have a value? I stop working. So it's really like the whole biosocial approach is like a lot of things happens when you get older. So there's a physical thing which can be quite dramatic, and then you have all the other aspects that also are very important. There was a very nice study by Lorraine Dennistein, who, she is still there, but she did a study a long time ago looking at estrogens and women's sexual health when going into the menopause. And she found out that the psychological factors are just as important for desire and pain as the decrease in estrogens, meaning that the transition of becoming an old woman, now I go into the menopause, is as important as the more physical factors.

[Dr. Reena Malik]

I think that's so important to emphasize because I think we, I mean, of course, as physicians, we focus on the things that we can, you know, we can fix with a. With a treatment. Right. But I think the other things, the psychological factors and the stressors are different. Right. As you mentioned, you go through retirement, perhaps you don't feel as much purpose. And I think that's a big thing that we don't talk about enough. Right. That when you go through retirement, if you don't have a plan, you can only golf so many days, you can only travel so much, like you need to feel like you have a purpose. And I think a lot, a lot of my patients come in and I feel like they really have one. And that's really a big struggle.

[Dr. Anna Maria Giraldi]

Yeah. So it's both about mental and physical health. And then we, of course know that when you age, the risk of having cardiovascular diseases, rheumatoid arthritis and, you know, a lot of diabetes, I mean, they also have a negative impact on sexual health. So we know that physical health declines with age for a lot of people. And there's some very nice study by her name was Lindau, where she looked at how long can you expect to be sexually active. And she can, like, show that it's correlated to how physically healthy are you. So. So if you have a good physical health, then you are in a higher. Have a higher chance of being sexually active a longer time when you get older. So they go hand in hand. And just the feeling of not being physically Fit like you used to be also have, like a psychological impact. So it goes hand in hand.

[Dr. Reena Malik]

Yeah. There's so many things I did want to point out, the stimulation thing, because I think people feel like there's something wrong with them. But just like you're aging, your nerve cells are aging. Right. So they don't respond the same as they used to. And that's kind of. I don't think that we yet have anything that can combat that. Right. Like, I don't think you can't exercise out your nerve cells to work better. You know, I mean, those things will help potentially, but they're not going to completely eliminate aging of the nerve cells.

[Dr. Anna Maria Giraldi]

No, but we know that. But there is a little bit you can combat. But I agree with you. I mean, we have to recognize we're getting older and it works differently. I mean, it does on many other levels. And then you need to change your sexual script. You need to change that. We need to do something differently. And I think it's. As we discussed, it's difficult to communicate about. I think I see a lot of women that if the man starting having erectile dysfunction, they think, oh, something is wrong with me. He is in love with someone else. He's not attracted to me anymore. And she might have, like, body image concerns because she's getting older. She might have gained weight and then he's not able to have an erection and because he needs more stimulation or he's just having a decreased function of his erectile function. And then he thinks, oh, my God, now I'm not attractive anymore. And, you know, he becomes very nervous because he knows that he's going to confirm her, you know, well, being by having this erection. So there's so much pressure on it functioning. So. So you really need to. You can help people if you tell them, actually that's what happens when you get older. It has nothing to do with you as a partner. It has nothing to do with you. It has to do with becoming older.

[Dr. Reena Malik]

Yeah. I think nowadays we're talking a lot about testosterone declining. And while we know estrogen declines to zero, basically, for women, testosterone declines at a sort of expected rate per year. But there are things. So in general, most people should not need testosterone replacement if they are healthy, functioning, normal individuals. Would you agree with that?

[Dr. Anna Maria Giraldi]

Yeah, I would. And we know that especially if you're overweight, that testosterone is lower. So we might be able to help ourselves by staying fit and staying not too overweight, but it climbs with age. And I'm a psychiatrist, so I'm not really an endocrinologist, andrologist, but I think that for most people, we don't need to supplement anything. And I think we need to see in other factors because it's also, I think we all want the quick fix. But sometimes you give testosterone to people and nothing changes. You need to focus on, okay, then what was it then? And for some people it's very, very good. And for some people, you need to do look at something else. You need to look at what's happening in their relationship. Do they have a depression? Are there other factors that are more important than the testosterone?

[Dr. Reena Malik]

I mean, I think we know that low testosterone is becoming more common because of all the comorbid conditions. Right. Because people have more high cholesterol, more diabetes, more overweight. And so getting to that level where testosterone becomes low enough to create problems is more common. But I just want to reassure people. I think my point is to say that, yes, we know that there is a hormonal decline, but if you remain healthy in your body and you're exercising and moving your body and doing all the things that you need, eating correctly, that you should be able to maintain a reasonable amount of testosterone.

[Dr. Anna Maria Giraldi]

Yeah. And sometimes it's a little bit easier if, if, I mean, some people come into the clinic and they just wish it's the testosterone. Because that's the easy thing. Yeah, that, that you, okay, then you can have a supplemental testosterone and, and then everything is fixed. And then when we say, no, your testosterone is normal or we don't think it's that. Oh, then it's really difficult because then. Then what?

[Dr. Reena Malik]

Yeah, yeah, absolutely. What do you think in terms of a psychological standpoint? What helps older adults sort of reclaim their sexuality the most in terms of

[Dr. Anna Maria Giraldi]

people who are strugg think that communication is a good thing. Both communication in the couple, but also communication with healthcare providers, that you are assured that it's okay to have the desire for being sexually active, that it's something that's normal. I think normalizing and communication is, that's very, very important because then people can start helping themselves. A lot of people, they really, if you speak to them, they're very capable of thinking about what's the problem. And if you give them like a safe space where they can discuss it together or they can discuss it with you, I think it's. A lot of people can see, okay, I can see that maybe we should do a little bit more of this and a little bit less of that and put more focus and intimacy. And I think that can Help a lot. So basically, I think sometimes it's not very drastic what you have to do because you can help people with, with education and information.

[Dr. Reena Malik]

Yeah, yeah, that's great. You were part of this trial, the Copenheart SF trial, where you looked at testing sexual rehabilitation programs on cardiac patients. So let's talk about how that trial sort of started and what was the impetus for doing that?

[Dr. Anna Maria Giraldi]

I have to say I was only a small part of the trial because I had. The primary investigator was a nurse called Penilla Palm. She was, was like the main investigator. It was partly based on another study that was done in, in the heart association in Denmark where I was also part of that, where they looked at people with heart problems. So they actually looked at old people that had their first time event related to heart disease. So it could be many different types of heart diseases. And then they looked at whether they had been asked about or counseled about sexual life and the impact of heart disease and sexual health. And not surprisingly, we would say we found out that the older people were. The less information did they receive about heart disease. And the other thing was that women, older women were the one that received almost no information about heart disease and sexual health. So it again talks into, we think about older people, they're not so sexually active, but if we think of someone being sexually active, it's the men. We all recognize, oh, men, they want to have sex, but the women, they were forgotten. So that put a focus on sexual health in people with heart diseases. And Penelope was very interested in can we use exercise to help people with men with erectile dysfunction. So she created an intervention where they had quite a good support in exercising three times a week. They could either have, they could come to the hospital and be part of an exercising program, or they could have a personal trainer in a fitness center. And they were instructed to do both cardiovascular and lifting weights. Strengths, resistance training. Yeah. And it was combined also with physiotherapy. So it was also a. Something about if we do pelvic floor exercises, if you give that to men, can that also improve erectile function? And then they also had a counseling with a sexologist. They had two counseling sessions. So I think that it was more than exercise. It was like a package of an intervention with men with ischemic heart disease and men that had a pacemaker. And what she showed was that they all had better shape, they had a higher oxygen VO2 max Vomax, and they actually had a better erectile function. So that was like the very quantitative

[Dr. Reena Malik]

measures that Was the outcome.

[Dr. Anna Maria Giraldi]

That was the outcome. The primary outcome was to look at how was the erectile function. So it improved the erectile function. I think it was a 12 weeks intervention. I mean, it was positive. But the other thing was that she also did some qualitative interviews with the men. And this again, emphasizing that it's more than just erectile function, that they said that there were like three themes that, that came out when she did the qualitative interviews. The first one was that it was so nice to have a place of understanding at somewhere where you could actually discuss it with other men. And that there was like a professional environment that actually took it seriously and guided you and gave you something about sexual health, she said. The other one was that there was a very supported atmosphere. So it was very nice for the men that some of the things they said they gained from the study. The fact that they trained together motivated them. I think we know that from a lot of research about motivating people to do exercise. And they also develop friendships with the other people. And they also said they felt sexually empowered, that it was nice to have more information about it and speaking to someone about it. And that itself would create more desire because they now were more empowered in their sexual life. So I think that all the more soft benefits are very valuable too. So it's not only about how do you measure your erectile function and how's the scale. So it had a lot of good impact on the men.

[Dr. Reena Malik]

And when these people joined the site, like, was their goal to return to sexual activity? Were they not? Like, was that kind of the premise of it? Or were these just people who had heart disease and were sort of interested in.

[Dr. Anna Maria Giraldi]

I think they were recruited because they had a heart disease and they were asked whether they would like to be a part of the study. I don't think she really discussed what were their goals, but they reported a lot of benefits from the study. Well, that's.

[Dr. Reena Malik]

You know, I love this idea of sexual rehabilitation because I think that there's so many people where we don't realize that their goal is actually like, not maybe not you or I, because we talk about sex all the time. But I think when you see a primary care doctor or surgeon, you know, a orthopedic surgeon or, you know, somebody for your back pain or your heart disease, that really your goal is to be able to have sex again. And there's so many patients where that's a big goal. And I think if you're like, hey, we have a sexual rehabilitation program for you. With the goal of you being able to improve your sexual function. And for men, it's a little bit easier to measure with erectile dysfunction. But I think even for women, you could measure that. I think that would be really valuable. Yeah.

[Dr. Anna Maria Giraldi]

And also, what was nice about that study because they also had the talk with the sexologist, they could also discuss alternative solutions. If, if you don't get your rectal dysfunction, you know, good enough for having an intercourse, what do you then do? And there was some kind of information about, you know, other ways to do it and, and how. What is sex? Sex is not only intercourse. And I think that's where we should go. And we see the same with a lot of programs for men with prostate cancer or a very large group. And I think it's the same that we should not only focus on the erectile function because sometimes it won't come back. And then we need to have an alternative because else you're going to just like, wow, then what are we going to do if we can't give people an alternative?

[Dr. Reena Malik]

Yeah. In Denmark, is sexual rehabilitation available readily or is that just for that study?

[Dr. Anna Maria Giraldi]

No, I think we have more focus on it. We have a quite good health care system. So I think that, I mean, we, we, we can be better. Yeah, I think everyone can be better, but it's not that we have a sexual rehabilitation program for all people, but we have a lot more focus on it. We have in. We have like five regions in Denmark, healthcare regions in the country. And I think most of the centers have what we call rehabilitation centers when people have cancer. And I think in most study centers now, there's a focus on sexual health too. It's not only about rehabilitation regarding sexual health, it's about rehabilitation living with having had a cancer diagnosis, having been treated. So there's more focus on the impact of diseases and getting older. And then we have a system where you can be referred to a clinic with special interest in sexual health. And I think that's the way it works. So it's not that old people have sexual rehabilitation, but there's a possibility of having it, especially if, if people recognize you have a problem. So we need to take the discussion, we need to ask people about it.

[Dr. Reena Malik]

Well, I love this idea. I think that, you know, it would be so wonderful if just like people get cardiac rehab after they have a heart attack, that people got sexual rehabilitation at some point after some sort of intervention that was just available to them and accessible, you know, don't you think that would be something helpful?

[Dr. Anna Maria Giraldi]

We, we and, and I think we have a focus on it. So at least people with diabetes, especially men, because it's. It's a little bit easier with men because it's very measurable. And we have treatment for erectile dysfunction.

[Dr. Reena Malik]

So, yeah, it's easier to prove that it's useful.

[Dr. Anna Maria Giraldi]

And it's also easier because you have something you can offer them. Yeah, but especially with men with cardiac problems, diabetes, prostate cancer, we. We have programs many places and, and a lot of nurses are very interested in it. So it's. It's very often something that the nurses, because they know the patients a little bit better, they see them more often,

[Dr. Reena Malik]

and they could have more time to do education.

[Dr. Anna Maria Giraldi]

So they have a focus on them asking about how is it going? And we also have focus on. I've just participated in a program for women with breast cancer where some of my. I'm only like a part of it, of the sexological part, but there's a. The cancer rehabilitation in Copenhagen. They have a focus on women with breast cancer, about living with breast cancer and being treated. And after you've been treated, and there's like, they made an intervention with like an app with modules, and one of them is about sexual rehabilitation and intimacy. So not only about having intercourse, but about intimacy. And how do you get back to intimacy? What are the barriers? What are the problems?

[Dr. Reena Malik]

I mean, I think we can extrapolate from the cancer rehabilitation programs because as you mentioned, prostate cancer has it widely, like it's become a very common thing post prostectomy, you know, sexual rehabilitation program. So, yeah, I think that's great. So we're gonna switch gears a little bit. So you published work predicting what type of person might be more likely to have sexual side effects from medication based on EEG findings. And this was so fascinating to me because we know that some subset of people, a small subset, but some do have severe sexual dysfunction after medications like, like SSRIs, antidepressants. And so what did you find in the study?

[Dr. Anna Maria Giraldi]

Again, I have to say it's not. I'm not really the. The main person in this study. I was just so lucky to be a part of a group that's looking at the serotonergic system and depression and treatment. Yeah, and it talks into a larger focus that we're trying to build up. I'm. I'm a part of Psychiatric Center Copenhagen, and we have. Have quite many professors. We have a lot of research in depression and treatment of depression. And the colleague that did start this study, Christian Rebels, is like the the main author of the study is looking at can we predict the effect of. Of treatment of depression, people with major depressive or moderate depression. And then there's another arm in it, which I have a very good colleague Vibe, who's a professor, looking at hormones and depression. And the good thing about our center is that we somehow try to combine research. So we have been talking about, I mean, what about sexual health in these people with depression? And we know that when. It's a long story now, so I'm going to unfold it. But we know that people who are depressed, they have less desire. We know that antidepressants, as you say, especially ssri, have a lot of sexual side effects. We were just thinking, wow, how do we. Can we get. Can we combine our knowledge about this? So the whole. The overall idea is that when we look at sexual desire and sexual. Sexual desire and depression, I think maybe it's two sides of the same coin, because if you are depressed, you don't have desire for eating, you don't have desire for doing anything, you don't have desire for living, you don't have desire for sex. So we wanted to see, are there some mechanisms that are common when we look at depression and sexuality and sexual desire? That brings me then down to that. They are looking at what is the impact of the serotonergic system on depression. And then we wanted to add sexual desire. So that was a long story. To come to Christian's very nice study, where they looked at eeg, so they stimulated electrical responses in the brain by audio stimuli, and then they got these EEGs, and then they looked at, can we look at how is the effect of our antidepressant medication? But then they also looked at sexual health. What they looked at was that depending on the pattern of the eeg, you might say that some people are more. The serotonergic system is like having an impact on your sexual desire. They found that the lower signaling that might predict if you would have sexual side effects. So it's not that we now think that now we can just make an EEG on people with depression, and then we're going to find out they're going to have sexual side effects. But it tells us that some people might be more vulnerable because they have a different serotonergic level than other people. So some people might be more vulnerable to sexual side effects. So it's in a bigger picture where we think about how is the serotonertic system modulating depression, how is it modulating sexual desire, and how do we respond when we get treated with the SSRIs. And then Dr. Feuerka and I did another study where we looked at people that had a moderate depression and we measured sexual desire before they were treated and then we measured sexual desire after treatment. In that study, we found that overall, if you treat depression, the better depression is treated, the better desire is. So there was like, no. So we shouldn't be that afraid of giving SSRI and say, oh, we can't give that for depression because then you'll have sexual side effects. But we know that if you treat the depression, desire becomes better. But the other study with DEG might say that there might be people that are more vulnerable to treatment with SSRIs, and they might have higher levels of sexual side effects than other people. So it's a little bit like basic research trying to find out what are the mechanisms, how do we see sexual desire. And what's so nice about my two colleagues here are they actually have a kind of picture into the brain because Christian Rebels is measuring the eeg, the electrical output from the brain, saying something about what's happening in the brain. And. And Dr. Fricker is measuring the serotonergic receptor activity. So we also can see how is that relating to anhedonia and sexual desire. And they go hand in hand.

[Dr. Reena Malik]

And how is he measuring the serotonergic receptors?

[Dr. Anna Maria Giraldi]

So they do that by PET scan. PET scan? Yeah. So they actually have. See the activity of the receptor and it's quite exciting. So now we're just like looking into it and trying to see what, what, what can we see? So I, I'm quite excited about can we use it in the future? Because, I mean, you cannot do a PET scan of all people, but we can g have some information about some basic structures and basic mechanisms that goes hand in hand when you have depression. And andhedonia is a part of being depressed. And. And we see that goes hand in hand with Lotharisaria. And it seems like, of course it does, but no one else have actually looked at it together. And I think that's the beauty of being in a center where you are able to combine research from different groups. We are going to develop that.

[Dr. Reena Malik]

I mean, I think that's really like a window into personalized medicine eventually.

[Dr. Anna Maria Giraldi]

Right?

[Dr. Reena Malik]

Because it is so important. There are, you know, even if it's 3% or 1% of people taking SSRIs who have debilitating sexual side effects, you know, we would love to be able to recognize those people in advance. And so I think that's so exciting and so needed. And I really think that, you know, this work is going to change the game.

[Dr. Anna Maria Giraldi]

We hope so.

[Dr. Reena Malik]

I mean, obviously this is early, but I really feel like as you move forward and do more testing, I think hopefully there'll be an easy, cost effective way to screen people and say, hey, before I put you on this, you're at high risk. You can still make the choice.

[Dr. Anna Maria Giraldi]

But, you know, and that is, that is actually a part of the overall project from my colleagues is to do the more personalized medicine that they. We need to, we need to be better, to predict when we treat depression, who will benefit from the treatment and who are more resistant and maybe need some other treatments or. So it's, it's, yeah, it's fascinating and it's also a nice illustration of if you combine research areas that sometimes we can do something new.

[Dr. Reena Malik]

Yeah, it's, it's great. How is, how just this is out of my personal curiosity. How is research funded in Denmark? Like, how does that work?

[Dr. Anna Maria Giraldi]

I mean, you need to, to, to. I guess it's like in, in, in the States you need to like the rage. Yeah, yeah, yeah. And we have like national grants that you can apply for. We have a lot of private grants. So it's, yeah, so it's funding like you have to raise money.

[Dr. Reena Malik]

So. Another study you looked at is looking at the androgen receptor specifically and female sexual function because we know that low testosterone is related to low desire in women. But I don't think we talk enough about how the recept receptor, which basically attaches to testosterone, how variations in that affect people differently. So can you tell me a little bit about what you found in that paper?

[Dr. Anna Maria Giraldi]

Yeah. And again, remember, I'm a psychiatrist because, but we were so interested in the whole discussion. For the audience, it's important to say that for many years it was discussed a lot whether testosterone has an impact on women's desire or not. So it's very interesting because I think of course it has. But, but the problem was that in a lot of studies you weren't able to show that there's a real correlation between testosterone and sexual desire in women. So we have a much clearer picture in men that if you. And now you're the expert, but if we come below a certain level, there's a very, very high risk that first sexual desire is going to be decreased and then in the end when it becomes very low, you'll have problems with erectile function. So there was a lot of discussion about what is the impact of testosterone in women. So many years ago, we had a PhD project with the researcher Sarah Bolin, who wanted to look into that. The discussion was that how do we find out if testosterone has an effect on desire? Because if we measure desire and we measure testosterone, a lot of studies weren't able to show a real convincing effect of, of the level of testosterone desire. So then it was discussed that maybe you're not measuring the right thing. Maybe the way you measure it is not good enough. Then there was a lot of discussion about how do we measure. This is more a methodological thing because maybe all the assays you had to measure testosterone weren't good enough. So the first thing we wanted to do was to measure it the right way. So we were sure that we had a good way of measuring it. Then the next discussion was that that when you measure what's in the blood, maybe that's not what's active in the cells. So then we had like an end product of testosterone. So if we measured that, we would say that instead of measuring how much testosterone is in the blood, we would measure what is the end product of testosterone, because then you would know that it has been kind of used, so it has been active. And she did some very nice studies. We had women with just like random size sample of women, and we could see that there is some kind of influence on desire by testosterone levels. So if you have lower levels, there was a higher risk that your desire was lower. But we also showed that if you had depressive symptoms, if you have relationship problems, that also had an impact on desire. So it didn't rule out, I mean, it didn't really say desire is not only influenced by testosterone, but testosterone has an effect. The next step was we couldn't see any effect if we measured the end product. We had hoped that, oh, wow, the end product is real measure because that tells us how much testosterone has been active in the cells. But there was nothing. So total testosterone was better than the end product. So to come to the receptor in the end, we found out that when the testosterone is in the cell, it has to bind to the receptor to become act, to give the effect of the testosterone. And we know from studies in men that that receptors are different because they have different length of their. You could call the arm of the receptor, so they have different structures, so some of them are more active than others. So that was like the last key. We wanted to look at that. Maybe it's not because what is the level of testosterone, but it's about how does it bind to the Receptor. And does that have an impact on whether it's more active or not active? And there have been some studies in men showing that there are some men who have more active receptors than others.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

So we tried to do the same in women, and we didn't really show a lot. We showed that the structure of the receptor might have an impact on their orgasmic capability, but we didn't have any impact on desire. So I think it left us with the picture that we know testosterone has an effect on women's sexual desire, but it's not the only thing determining sexual desire. I mean, we became a little bit wiser and we know a little bit more. And there were some kind of complications in how do we measure the receptor structure? Because it's related to the X chromosome. So it means that men only have one.

[Dr. Reena Malik]

Yeah. So it's a little easier to.

[Dr. Anna Maria Giraldi]

It's easier because they only have one. So women can have, like, two because they had two X chromosomes. So they have, like, two components of the receptor. So one can be. It's about the length. It can be long or short. And then it was a little bit more difficult because how do we calculate? So we had needed to find something in between, but that was more technical thing. But I think that it's really what was so nice about. The studies are, like, it took, like, on a journey that we wanted to see what is it about testosterone in women? And then we just measured testosterone and said, okay, maybe we don't get the full answer here because something more is happening in the body. So we found out. Then we look at the end product, Then we looked at where it binds in the body, where it actually has its action. And it was like a puzzle. And I think that what we concluded was that, of course, testosterone has an impact on women's sexual desire, but there are also other aspects, especially relationship and depression. So that was the long story about this study, but they were quite nice.

[Dr. Reena Malik]

Well, I think it's so important to hear, right, Because I think what people are hearing now are these short snippets of conversations about testosterone in women, even in men. Right. And it is much more complicated than that. Right. The way a hormone. Hormone functions in the body and the way it functions in different tissues is so different. Right. The same testosterone functions differently in your genitals than it does in your brain or your, you know, or your cardiac tissues. Like, it's just. It's different in every tissue. And so.

[Dr. Anna Maria Giraldi]

And I think it's. It's the beauty about research. It's the beauty about medicine that, that we can, I mean you don't have one black and white answer. It's, it's, it's more complicated and we, if we can gain knowledge and, and do research together and other specialties and also know, yeah, the receptor is important, but it's not the whole picture. We also need to look at the relationship and we need to look at your physical and psychological well being. But it has an impact.

[Dr. Reena Malik]

Absolutely. You've done so much work in the field and what are you working on now that you're really excited about?

[Dr. Anna Maria Giraldi]

I'm getting a little bit older so I'm decreasing a little bit the activities. But we have the projects that I'm. My special interest is actually disease and sexuality health. So I did a lot of studies. We did the one with testosterone and we have done something about prostate cancer and other cancers and sexual health. So right now we have some projects about bladder cancer. I think that's related to our discussion. It's very interesting. I'm supervising a brilliant young PhD student who is looking at bladder cancer. And here people are older, so they are older than people that have prostate cancer. And so we're really facing both the, the taboo about older people having sex and, and also looking into what happens when you have a bladder cancer. And I just got a message from her this morning and she's doing both. She's doing a mixed method study so she's doing some qualitative interviews and some quantitative measures. And she just texted me this morning and said why. I had my first qualitative interview and I was so touched by the responses I got from the patient. So it is saying this is something that really means something. I didn't talk to her. It was 4 o' clock in the morning. So she was really, I mean she, she texted me and, and she said I was so, so this is a project, we have a project on pulmonary disease, obstructive diseases that are almost finished. We have, have. I have a few projects on cancer still going on and sexual health. And then my focus now is a lot of psychiatric disease and sexual health because that's also an overseen field. We know that people with depression, as we discussed, have a higher risk of sexual problems. But a lot of people with psychiatric problems have an increased risk of having a sexual problems. But they also receive medication that impair the sexual health a lot. So we just finished study on bipolar disease and sexual health and find that they have challenges, especially when they're in the depressive phase. We have what we discussed, the people that do depression and all the studies on depression, we try to include some sexual health measures. And then we have something completely different going on. When we started having a program a our transgender adolescents and children are. And we're the only center in Denmark, so we have like the whole populations of all children and adolescents that were referred for assessment and treatment. So we are doing a follow up and see how did it go, how many went through treatment, how many weren't offered any hormonal treatment and how do they do. So that's a huge project. So it's completely different.

[Dr. Reena Malik]

Yeah, yeah, yeah. That's. I mean, you're busy, busy, busy. Bladder cancer is interesting. So I've treated a lot of bladder cancer in residency and it is a very different disease than prostate cancer. And I think that part of it is it's so intense, it requires so much recovery if you have surgery, for example, and it can really change the way you sort of function in the world because if you have surgery, you become more frail, you become nutritionally maybe not as robust as you used to be. And so I think it's often very much not thought about because the cancer takes so much front and center for these patients. And I think it's so important, and

[Dr. Anna Maria Giraldi]

that's what we hear about a lot of cancers is that people are just, you know, they think, I have to be happy I'm alive. But then we still need to recognize that you also need to live when you're alive and sex is a part of it.

[Dr. Reena Malik]

Absolutely.

[Dr. Anna Maria Giraldi]

So we, the PhD student is also like uncovering what do you actually offer people with bladder cancer in the Nordic countries? So doing a survey, trying to find out because we have an idea that there's not a lot of focus on it. So that's a part of the program too.

[Dr. Reena Malik]

And for women, obviously they don't always do vaginal sparing surgery. And so that can really affect their sexual function afterwards.

[Dr. Anna Maria Giraldi]

So we're trying to, I mean, she just started a program, but I think in three years we'll know more in

[Dr. Reena Malik]

terms of other psychiatric conditions. What about things like adhd? Do you look at that at all?

[Dr. Anna Maria Giraldi]

I just had a graduate student or a master student that did a scoping review on it. And actually there's not a lot of data on it, but it's something that we need to know more about because we have a clinical impression that, for example, like premature ejaculation, that very often, if you have hghd, that, I mean, it's so difficult to be like present at the moment. So she looked into it and it's a little bit inconclusive. But I think that we can say that there might be some challenges, but it's difficult to know exactly what they are because there's not a lot of studies on it. So we have had a focus on it.

[Dr. Reena Malik]

Yeah, I think it's really important because people are definitely. From what I've talked to from other experts, it seems that there's a very difficult. With focus, which makes it difficult to be in the moment, be present and actually achieve orgasm or. Or potentially maintain your erection or whatever the situation may be.

[Dr. Anna Maria Giraldi]

And it is a clinical feeling. We have the same. And sometimes we treat the adhd and then sexuality becomes easier. But I think we need to have more focus on it and do more studies and actually see if that's how it is.

[Dr. Reena Malik]

Yeah. And the stimulants that they use to treat ADHD also have sometimes positive and sometimes negative effects. Right.

[Dr. Anna Maria Giraldi]

That's a huge problem with psychopharmacological treatment, that. But they are the treatments that have most sexual side effects. I mean, we know that if you treat breast cancer and prostate cancer, it has a huge effect because the effect on the hormones. But besides of that, I think that the treatments we use in psychiatry, they really have a lot of side effects because they have an effect on the brain and they have an effect on the same regions of the brain where we have the sexuality happening. Yeah.

[Dr. Reena Malik]

It's really interesting. What I think, just for the audience listening, what are some of the treatments for, let's say, depression that have the least sexual side effects?

[Dr. Anna Maria Giraldi]

I think that I would start to like to turn it around and say that the one that have most side effects, that's the. The SSRIs. So if you go outside the SSRIs, I think it's antidepressants with other effects, like having an effect on the Nordreno system or the Melania. No, Sin system. I think these are the one that are the one with least side effects. But having said that, we also need to see that maybe they don't have the same effect on depression and balance. Yeah, it's a balance because depression is a very, very dangerous disease. A lot of people die from it if we don't treat it. So we should always treat it, but we also should recognize that there are side effects. And maybe at least when people are treated and become better, as I told in the beginning, some of them actually have better sexuality when you treat the depression. So it's about following up and say, okay, if you still have Side effects or if you have side effect, maybe we can switch you. So, yeah, I think it's important that we treat people with depression the right way. And SSRIs are the first choice for many people and in many countries. But, but we need to talk to people about the side effects. And very often they will say, I don't care right now because they are depressed. But when they are not depressed anymore, we need to reevaluate, reevaluate. And we also use SSRI for many other conditions like OCD and anxiety. And a lot of people get them and we need to be aware they have sexual side effects.

[Dr. Reena Malik]

Do you think there's going to be newer medications in this space for depression that maybe don't affect the serotonergic system the same way?

[Dr. Anna Maria Giraldi]

Yeah, maybe they. My colleague Wieber Froicker, which I did some of the studies where she looked at the. Another receptor, the 5ht4 receptor, which has an impact on the reward system and maybe that might be a new target for antidepressant treatment. And I think that's why we also were quite interested in looking at sexual desire. So I think there's a lot of research going on because we can be better and we want something with less side effects.

[Dr. Reena Malik]

Absolutely. Yeah. Well, there's no free lunches is what I always say to my patients. You can't, unfortunately, there's nothing that you're going to take as a pill that's going to be without side effects.

[Dr. Anna Maria Giraldi]

And that goes for all medication.

[Dr. Reena Malik]

Sometimes people get that, even a supplement. Right. Everything.

[Dr. Anna Maria Giraldi]

And that's why personalized medicine is so important that we need to discuss it with the individual patient. And I think that practicing medicine has changed a lot over the years because people go on the Internet and they know something about it. It's a, it's really a challenge for us as, as doctors because they know something. We can't just say, oh, you do this because the doctor says it. And, and I think that's a good thing.

[Dr. Reena Malik]

I do too.

[Dr. Anna Maria Giraldi]

It's more difficult, but. And it's challenge you as an expert. But I think that's. We need to discuss with the individual patient what, how many side effects can you tolerate if you get this effect? And that goes with, like with the PD5 inhibitors?

[Dr. Reena Malik]

Absolutely.

[Dr. Anna Maria Giraldi]

Some people say, just give it to me and I don't care about the side effects. And other people are very vulnerable to the side effect effects. And they say, no, it's, it's not worth it. And that goes for all medication.

[Dr. Reena Malik]

Absolutely. I mean, I Do a lot of bladder medication, treatment, and there's a lot of serious side effects, you know, that affect people's quality of life. And I talk about it all the time, and I think it's, it's so important.

[Dr. Anna Maria Giraldi]

Yeah, we need to be open. And I think that some people don't have side effects. Yeah, that's why I tell my patients, too. I mean, everyone.

[Dr. Reena Malik]

Yeah. Hopefully, you know, in, in the next 50, 25 years, we'll have some more personalized medicine. We'll be able to see who's more vulnerable to side effects. But it will. For each medication, you know, it'll take time. You know, in your many decades of work, what's something that you changed your mind on? Something that you thought very. Held strongly when you were younger, perhaps, and now you realize it's not. Not true?

[Dr. Anna Maria Giraldi]

Maybe a little bit. Another perspective is that I started out in. I'm just going to start again. Maybe another way to see it is that I started out in basic research where I was looking like. I have a PhD on cells, how they communicate with, with the cells from the penis, how they communicate. I really moved into becoming a psychiatrist. So it's a big move from being like looking in a small plate with cells and how do they communicate and how is the calcium running from one cell to the other to me looking more at the whole person. And I think where I really changed my view is that we really need to be more holistic in the way we see it. And it's also reflected in my research a little bit. Like, then we do this and we do a study on mindfulness. We do something on a PET scan and. But it's, it's, it's to get a more broad picture. And I think that's where I have moved. Maybe I would have said when I was young that we need to do the same. But it has really become very evident for me that it's so important that we see we have a more holistic approach to, to, to. To sexual health, because it's also about pleasure. It's not only about function. So maybe the cells can communicate in a way, but if the person is, is not functioning well and do not have the right, you know, circumstances for having a good sexual health, then it doesn't matter.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

So I think that's where that has been my journey, I would say.

[Dr. Reena Malik]

What would you say if you had one message that everyone needs to learn from today's talk or about sexual medicine? What would that be?

[Dr. Anna Maria Giraldi]

One message is that sex is very important for most People because it brings you closer to other people. But you also need, if you don't feel like having a sexual life, that's okay too. I don't think we should like put it's a balance because we need to recognize it's important, we need to put focus on it. But we also need to let people decide their own way because if they don't want to have sex then we should put the pressure on them saying oh, then you don't have a good life. So I think the take home message is that sexuality is individual and it changes during your lifetime. Effy.

[Dr. Reena Malik]

Yeah, absolutely. What do you think is the most exciting development that's coming in sexual medicine right now?

[Dr. Anna Maria Giraldi]

Yeah, I mean you gave me, you sent the question before and I felt a little bit bad because I couldn't say, wow, this is really happening now.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

Being a psychiatrist, to me the most exciting thing is that we have much more focus on integrating the partner and also have much more focus on the whole person and not only, you know, a genital function or my very small aspects of sexual health, but it's not like we have one invention that, that we have now so that I think that's, it's more trend and also I think that we have over the years it's very exciting. We start talking about medication for women. That was a taboo for a long time. It's, it was a struggle to, to get them on the market. Yeah, they're not going to solve everything. But I think that the way we see women's sexual health is better because we say it's also biology. And on the other hand, I think, at least I think most places we also see men's sexuality being other things than biology.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

So I think we are getting a more full picture of what is important of sexual health for both men and women. And the other thing. So this is, you know, a psychiatrist speaking because I think also that we have more focus on pleasure. Not only function, that is also about having pleasurable sex for both men and women.

[Dr. Reena Malik]

Absolutely.

[Dr. Anna Maria Giraldi]

And for minorities we have now we have more focus on minorities because other things might apply for them.

[Dr. Reena Malik]

Absolutely. Different cultures, different factors, orientations and.

[Dr. Anna Maria Giraldi]

Yeah.

[Dr. Reena Malik]

Where can people find more about your work, your research, everything you're doing?

[Dr. Anna Maria Giraldi]

Yeah, I'm a very old fashioned person. I don't even have an Instagram account, I'm not on Facebook. But I think that people can go into the University of Copenhagen. That's where they can find link to me. And then I would say if you're a little bit More professional. Depending on who you are, you can always go on pubmed where you can find research. But I'm also the editor of a journal called Sexual Medicine Review Journal. And for example, we have all the recommendations from the consultation where there it is not. Basically it is not my work, but it is a lot of updates on what is happening in sexual medicine for both men and women. I think that is where you can find a lot about what we have been talking about.

[Dr. Reena Malik]

Yes, that is wonderful. Oh, I forgot to ask you this question. Maybe we will delete it. But there is a cartoon, I think it was from Denmark where there was a cartoon with a boy with a very long penis. Was that in Denmark?

[Dr. Anna Maria Giraldi]

Yeah. For children's television?

[Dr. Reena Malik]

Yes.

[Dr. Anna Maria Giraldi]

What is it with the stripe? The white.

[Dr. Reena Malik]

Yes. I can't remember the name of this.

[Dr. Anna Maria Giraldi]

Yeah, it's what I, I. John Dillerman.

[Dr. Reena Malik]

Yes.

[Dr. Anna Maria Giraldi]

Like a slang for. For the penis.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

So he's called John Dillerman and. Yeah, he's from Denmark and he's actually reflecting that it's a national tv, you know, it's a Danish national TV that created him.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

And it sells a little bit about the environment in Denmark that you can have a person like him in children's television about having this long penis that gets him in trouble all the time. Because it's getting in the way. Yeah, it's going in the way. And actually we had an employed in our clinic when he had birthday. You could actually buy a John Dillerman cake. So you would buy this long cake with red and white stripes. So he was always, you know, treating us with this cake when it was his birthday. It doesn't have this. The shape of a penis, just like a tube thing. Yeah, yeah. So, yeah, that's. That's from Denmark.

[Dr. Reena Malik]

That's crazy. So do kids like watch it? Is it like very popular?

[Dr. Anna Maria Giraldi]

I think I. My children are grown up, so I. But I think they did it. But it created more fuss than it actually, you know, it was just one program and it creates more fuss than then it was actually enjoyable or funny. Yeah. I mean that people actually watched it,

[Dr. Reena Malik]

I think create a lot more discussion.

[Dr. Anna Maria Giraldi]

Yeah.

[Dr. Reena Malik]

But was it positive discussion or people like learning about sexual anatomy from it? I think that was the intention. Right?

[Dr. Anna Maria Giraldi]

Yeah, I think that there was a lot of positive discussion and there was a lot of positive response to all the negative moralistic responses from outside Denmark. And the other thing was that there were a few negative responses about moral. Oh, should we teach children that men have this penis and they don't know what it's doing and it creates all these problems. But I think that most of the discussions were actually that this is funny. This is something naive. This is something like for children. It's nothing more than that.

[Dr. Reena Malik]

Yeah, that's so interesting. I think people would lose their minds in the US if there was actually

[Dr. Anna Maria Giraldi]

maybe not going to put this, but I saw or yesterday that we're discussing about a German book about animals kissing each other and showing and I mean cartoons of animals in the States. There was one state where someone were.

[Dr. Reena Malik]

I don't know. Yeah.

[Dr. Anna Maria Giraldi]

So it's, it's, it's always creating a lot of discussions.

[Dr. Reena Malik]

It's interesting. I so long ago I did a reaction video to John DILLERMAN and on YouTube and I don't, I really can't remember like the comments, but I think people were shocked. Like they were like, this is offensive. Like how could this be?

[Dr. Anna Maria Giraldi]

Yeah.

[Dr. Reena Malik]

And I just, I thought it was

[Dr. Anna Maria Giraldi]

so interesting, but I think we actually forgot about John Dillerman and Denmark. I mean it's not a big deal. He might still be there, but it's not like his every day in the television. Yeah, it might be there or you can find it, but it, it, it's just, it's just there.

[Dr. Reena Malik]

No big deal.

[Dr. Anna Maria Giraldi]

No big deal.

[Dr. Reena Malik]

So we end our podcast with four questions that we ask everyone. They don't have to be about sexual medicine or your work. They can be about anything. Anything. So what is something you know now that you wish you knew earlier?

[Dr. Anna Maria Giraldi]

Something I know now that I would have liked to know when I was younger was that everything is going to be all right. I think that when you're young you're sometimes so serious about oh, what is going to happen and I think that's everything goes okay. I think.

[Dr. Reena Malik]

Yeah. Well, eventually it has to.

[Dr. Anna Maria Giraldi]

It has to. Yeah. But I think actually it's right that, that the. You can manage most of it.

[Dr. Reena Malik]

That's good. We're more resilient than we give ourselves credit for. What's a non negotiable something you have to do?

[Dr. Anna Maria Giraldi]

Every day I think about my family. I'm a family person so I'm not in contact with my family every day, but almost I. With some part of my family.

[Dr. Reena Malik]

Yeah.

[Dr. Anna Maria Giraldi]

Yeah. I have to think a little bit about my family.

[Dr. Reena Malik]

Yeah. That's lovely. What's a life hack or health hack? Something that you think really important improves people's lives that, that they don't know about necessarily.

[Dr. Anna Maria Giraldi]

Effy being a family person, I think family is very, can be Very negative, but it's very, very positive. It's like the foundation of my life is family.

[Dr. Reena Malik]

When it's positive, it's great.

[Dr. Anna Maria Giraldi]

Yeah, it's great. And I say that something I would like to have known is I would like have more children. I have one. I have two children.

[Dr. Reena Malik]

Yeah, me too.

[Dr. Anna Maria Giraldi]

And I should have had more. Now I have grandchildren. That's wonderful. So a life hack, if I understand it right, the only thing is a life hack is really family.

[Dr. Reena Malik]

And if your family is not great, make the family that you want. That's the one beauty. When you're an adult, you can choose those things.

[Dr. Anna Maria Giraldi]

And then another thing is that I'm so fortunate to have been working with something that has been very, very interesting all my life, since medical school. I started in sexual medicine in medical school. And I think something that makes your life really enjoyable is to have a work where you feel you make a difference and where you can develop yourself and the field. I think I've been very fortunate being the right place at the right time. So that's also very important. Sometimes I tend to forget that because a lot of people don't have a work that's very interesting or they would like to do something else. I think having a job that's interesting is really, really a blessing.

[Dr. Reena Malik]

We spend a lot of time at work.

[Dr. Anna Maria Giraldi]

We spend so much time at work.

[Dr. Reena Malik]

You want it to be something you like?

[Dr. Anna Maria Giraldi]

Yeah.

[Dr. Reena Malik]

If you couldn't be a physician or a researcher, what would you be?

[Dr. Anna Maria Giraldi]

An archaeologist. Is that what you call it? Archaeologist.

[Dr. Reena Malik]

Archaeologist.

[Dr. Anna Maria Giraldi]

Archaeologist.

[Dr. Reena Malik]

Okay.

[Dr. Anna Maria Giraldi]

Yeah. That's what I wanted when I was a child. I wanted to be an archaeologist and travel to Egypt and find all the mummies.

[Dr. Reena Malik]

Oh, that's so cool. I've never thought about that. But that, that would be fun. That would be fun.

[Dr. Anna Maria Giraldi]

You know, when you retire in Denmark, a lot of people start studying in university. So I. I was thinking of studying archaeology or maybe theology, religion. So I think religion is so interesting too, because it really shapes the culture you live in.

[Dr. Reena Malik]

It does. It absolutely does. It's interesting. I feel like we go through waves. Waves in history where people are very attached to religion, then people become less attached. But ultimately it always comes and goes.

[Dr. Anna Maria Giraldi]

Yeah. And a country like Denmark, I mean, people, if you ask them, they say they're not religious, but every moral thing, all the ethics, everything we, we think have value in the society is based on. On religion. So. So maybe people don't feel they're religious, but. But the way we think is really influenced by religious religion.

[Dr. Reena Malik]

Absolutely. Well, thank you so much.

[Dr. Anna Maria Giraldi]

You're welcome. Thank you for having me.

[Dr. Reena Malik]

Wasn't that a great conversation? If you guys thought so, too. You got to do one thing that's going to take only a second, and it's completely free. Got to subscribe to the podcast. Look on whatever platform you're listening or watching on and subscribe, because this tells podcast platforms that, hey, this is a podcast worth listening to, and it shares it with more people. And we need to get the message of education and sexual health being important to more people. And, as always, want to take care of yourself because you're worth it.