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The Diary Of A CEO with Steven Bartlett
Sex & Infertility Expert: You Need To Grow Your Sex Span! This Is Killing Your Fertility! This Daily Habit Transforms Your Sex Life!
01:39:15
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- [00:00]
A
This term sexpan, which I've never heard before, what is that?
- [00:03]
B
Sex span is how long you are able to engage in satisfying sexual activity. And most men, most women, want their sex span to last as long as their lifespan. And there's many things you can do to significantly prolong your sex span. And I call it the four pillars. So let's talk about sex.
- [00:19]
A
Dr. Mohit Khera is a board certified urologist and professor who specializes in male.
- [00:24]
B
And female sexual dysfunction.
- [00:25]
A
His groundbreaking research has significantly contributed to.
- [00:28]
B
Improving sexual health and fertility. Millions of men and women are suffering from sexual problems like infertility and sexual dysfunction. For example, in the U.S. roughly 43 to 48% of women suffer from female sexual dysfunction, which involves four components that we're going to talk about. But we also know that premature ejaculation affects 30% of men globally. And also 40% of men at 40 will suffer from erectile dysfunction. And it's the first sign of other major adverse medical problems. For example, 66% have some degree of depression and 15% of them will have a heart attack or stroke within seven years. And if you look at the causes for ed, one of the biggest actors is obesity, which causes the testosterone levels to go down. But men need testosterone for sexual function. So do women, because low testosterone increases low libido. But the issue is people don't talk about their sexual problems. They suffer in silence and they start avoiding sex. But it's curable. And I have two ways to raise their testosterone. Techniques to significantly improve the quality of your erections, and natural ways to improve sexual function in men and women. So number one, most important is.
- [01:30]
A
Quick one, before we get back to this episode, just give me 30 seconds of your time. Two things I wanted to say. The first thing is a huge thank you for listening. And tuning into the show week after week means the world to all of us. And this really is a dream that we absolutely never had and couldn't have imagined getting to this place. But secondly, it's a dream where we feel like we're only just getting started. And if you enjoy what we do here, Please join the 24% of people that listen to this podcast regularly and follow us on this app. Here's a promise I'm going to make to you. I'm going to do everything in my power to make this show as good as I can now and into the future. We're going to deliver the guests that you want me to speak to, and we're going to continue to keep doing all of the Things you love about this show. Thank you. Thank you so much. Back to the episode. Dr. Mo Hara, who are you and what have you spent your life doing?
- [02:25]
B
So, I'm a urologist, and I specialize in male and female sexual dysfunction, testosterone replacement therapy, and infertility. For the past 17 years, I've been working as a professor at Baylor College of Medicine, Houston, looking at ways to improve sexual health, improve testosterone, and improve fertility.
- [02:44]
A
And we talked just before we started recording about this term, sex pan, which I've never heard before.
- [02:48]
B
Yeah.
- [02:49]
A
What is the sex pan and why do you care about it?
- [02:51]
B
Yeah. So, Stephen, you know what lifespan is. It's how long you're gonna live. Right. And you also know what health span is, how long you're going to live in a healthy lifestyle. But you may not have heard of the concept of sex span. Sex span is the ability to engage in sexual activity, satisfying sexual activity. And so how long you are able to engage in sexual activity is important to most men. Right. So let's give you an example. The average lifespan in the United States is 77 years old. The average health span in the United States, believe it or not, is 67 years old. In fact, if you look at the CDC and they talk about how long you'll live without a disability, it's actually 63. So there's a delta here. There's at least 10, 15 years where you will be in some kind of disability and cannot live to your fullest. Now think about the concept of sex span. How long you'll have the ability to engage in sexual activity, satisfying sexual activity. We, most men, most women, want their sex span and their health span to last as long as their lifespan.
- [03:53]
A
Yes.
- [03:54]
B
So I think it's important.
- [03:56]
A
And there's things that I can do to make my sex span last as long as my lifespan.
- [04:01]
B
There's many things you can do, and I call it the four pillars. The first is diet, exercise, sleep, and stress reduction. I don't have a pill on the planet stronger than diet, exercise, sleep, and stress reduction. And each one of those can significantly improve a man and a woman's sex van. But also their health span and their lifespan. The other is hormones, testosterone. Extremely important. Testosterone supplementation can significantly improve a man and a woman's sexual function. And unfortunately for women in the United States, we don't have very many options. Actually, globally, for women, there's not many options. But I think it's important. A hormone replacement therapy. And one more thing. I think about the couple. Think about sex ban as a couple's disease. Let me give you an example. Tomorrow, Steven, are you married or.
- [04:50]
A
Well, I'm in a long term relationship.
- [04:51]
B
Your partner. So let's say your partner tomorrow says to you, I am no longer gonna have sex with you unless you cheat on her or you leave her. You're not gonna have sex again. Right? Think about the importance of the couple. So I talk about this quite often. Keep your partner engaged, keep your partner healthy if you want to prolong your sex span.
- [05:12]
A
So I've got two questions here, the first of which is, who have you worked with in your career? And the second question is, what is your cv? Give me a rundown of your professional experience.
- [05:22]
B
Yeah, so I started my residency in 2000, and I did my residency, it's in 2000. One year of general surgery. I did five years of urology training, and then I did one year of a fellowship in men's health. As soon as I finished my training, I joined the University at Baylor College of Medicine and I started a base basic science laboratory where we do basic science research in sexual medicine and testosterone for the past 17 years. And I just started a clinical trial. So I have a clinical arm where do clinical research. I see approximately 150 patients a week every week. I do approximately six to eight surgeries every week. And I still work at the VA hospital. It's a veteran government hospital, one half day a week working with the veterans. So it's quite busy. But, you know, my passion really is education, research and clinical care. And that's what we do. And so, you know, when I started my. How I really got into this was when I finished my training. I was so proud of myself. I was able to get these men these amazing erections, these great libidos. And I realized one day this woman called me and she was frantic and she said, look, you're treating my husband. You're able to get him these great erections, great libido, but I don't want to have sex with him. And he wants to have sex with me all the time. And now we have a terrible relationship. You've ruined our relationship. And I thought to myself, wait a minute, this doesn't make sense. But she was right. In sexual medicine, either leave both libidos low or raise them both, but don't raise one or the other. It's a setup for disaster. So very quickly that year, I went out and flew out to meet with Dr. Erwin Goldstein, who's considered one of the godfathers of female sexual dysfunction. Spent some time with him, went to his courses, and so for the past 16 years, I've been treating women as well. You can't just treat one patient without addressing, and so therefore it's a couple's disease.
- [07:11]
A
And give me a flavor of the types of conversations you have on day one, when they walk into your practice, when they come to see you, what is the issue that they say they have and how do they express it? Like, what are the words that they use? And if you could just give me, like, five of the most popular things people say to you when they come to see you.
- [07:27]
B
So listen, first of all, men and women are very different how they express it, you know, so we'll talk with men, most men. Let's backtrack. Most men and women do not get any kind of medical care when they see their primary GP. In fact, most GPs don't address sexual dysfunction. There was a study looking at medical students. Only 65% of US medical students get training in sexual medicine. And of those 65, 50% of those students said that the training was terrible. So we don't get the sexual medicine training to address the problem for patients. So the majority of patients are never discussed about their sexual problems. But when men come in, most of them are coming in because they already have tried some medications that haven't worked and they're looking for other solutions. Now, there's a very two simple questions you can ask a man. They're very straightforward. Are you able to get an erection sufficient for penetration? It's either yes or no. Now you're able to maintain that erection till orgasm or pleasure? It's either yes or no. If he answers no to either one of those questions, he suffers from erectile dysfunction. Right. And so it's very important to get a detailed history. You want to ask, particularly, are you able to get an erection on your own? Are you able to get an erection with masturbation? Do you wake up with morning erections? If he says, look, doc, I get great morning erections, or with masturbation I have great erections, then this has to be psychogenic. Right? With my partner, I cannot get an erection, but when I'm by myself, everything works fine.
- [08:46]
A
Psychogenic.
- [08:47]
B
Psychogenic, Ed. It's a big component. What is psychogenic? Something in the mind that's bothering you or inhibiting you from engaging in sexual activity. And that's where the sex therapist comes in. Right? Because if someone tells you, I get great erections by myself, but with my partner, I'm not able to get good erections psychologically. When they're with their partner, they're not able to achieve a good erection. Sex for men and women has a huge psychogenic component. A huge psychogenic component. So I think it's very important to get detailed history about are they able to get erection, what have they tried, what medications have they tried? You know, you have to query about depression. 66% of men who come in with ED have some degree of depression. 66%. Right. And that's important. Anxiety, 35% is very important. And more importantly, we'll talk about this. ED is the first sign of other major adverse medical problems. For example, if a man comes into my office today, 15% of them will have a heart attack or stroke within seven years. 15%. The day they get ED, 15% will have a heart attack or a stroke within seven years. It's the first sign. Other studies, Dr. Montorsi showed that if a man presents to the emergency room with a heart attack, on average 39 months earlier, that's when the ED started. So it is the first sign. Now, there are many reasons for this. One theory is called the arterial diameter theory. The penile arteries are the smallest arteries, 1 to 2 millimeters. The coronary arteries are 3 to 4 millimeters. The carotid, 6 to 7 millimeters. So if you remember from physiology, if you're going to block an artery, 50% occlusion of an artery causes damage. So if you're going to block an artery, you're going to block the penile arteries before the coronary arteries. You're going to block the coronary arteries before you block the carotid. Right. So men will get ED before they get a heart attack. More likely to get a heart attack before they get a stroke. That's a theory, but it makes sense. So I worry when a man comes into my office, could this man have occult cardiovascular disease? In fact, there was a wonderful study that came out of Greece. They looked at 50 men that walked in and they gave them an echocardiogram or stress test. If it was positive, they wanted onto a coronary angiogram. What they found is that roughly 20% of men, 1 in 5, actually had some occlusion in their heart, whether it was one vessel, two vessel, or three vessel disease. So I think to myself, every time I'm writing that prescription, is this one of the five that could have some occlusion? And is there an opportunity to intervene at this point? So it's really important to think about cardiovascular disease as well.
- [11:23]
A
One of the big subjects that I hear a lot about, even in my friendship groups is about libido. I've got so many stories in my friendship group of either one or both partners losing their libido. So on this subject matter of libido, it's kind of where I wanted to start this conversation. What is the most frequent and popular reason why men and women struggle with libido problems? And how much of that is about compatibility?
- [11:51]
B
Yeah, good question. Libido is multifactorial. There are many pieces of libido. It's very complex. And I'll give you some important components. First, it could be hormonal. And the mnemonic I teach the residents is pet. The four hormones that can affect someone's libido are prolactin, estrogen, thyroid, and testosterone. So you have to check the pet. If the prolactin is elevated, the libido goes down, the testosterone is low, the libido goes down. So maybe it's a hormonal issue, which could be it. And particularly, many women who go through menopause suffer from hormonal issues, and it could be a hormonal issue. The second is something called neurotransmitters. So in other words, serotonin, norepinephrine, dopamine, dopamine goes up, libido goes up, serotonin goes up, libido goes down. So these all regulate how someone's libido will function. So one of the biggest culprits for low libido are antidepressants. What do antidepressants do? They increase serotonin and they decrease libido. So sometimes it's a medication or something that a patient's taking that will shut down their libido. For example, a medication that men take for urinary function called finasteride shuts down their libido. So there are certain things that you have to look at. The other components are lifestyle, diet, exercise, sleep, and stress reduction, particularly fatigue and stress. If a woman is tired and she's exhausted and she has to choose between sex and sleeping at night, many times she may choose sleep.
- [13:20]
A
Me as well. Right?
- [13:21]
B
I'm just saying. So fatigue is important. Stress. And there's this cliche, this mnemonic, this saying. Saying that with stress is kind of interesting. Typically, if a man has a very stressful day, he will want to have sex to relieve his stress. Women have to relieve their stress to engage in sexual activity. It's kind of the opposite. You know what I mean? So I tell men, if you really want to have sex with your wife, do the dishes, take out the trash. Do everything you can to tuck the kids in bed early, relieve her stress, because that will significantly increase her desire to engage in sexual activity. But the other one is psychogenic. And so, you know, we talked about that earlier. You know, sex has a huge mental component. Your relationship with your partner, your, your, how close you feel with your partner. So sometimes patients come to me and they're in an abusive relationship and say, and they say, give me the pill that improves my libido. I said, it's not going to work. I mean, the essence, the core, the foundation is not working. And therefore it's really important for them to see a sex therapist. One thing for men that actually shuts down their libido is when they start developing erectile dysfunction. So if a man starts getting erectile dysfunction, let's say he gets a good erection 50% of the time and he's starting to have some problems, and it's 10 o'clock at night and he says, look, I can try to engage in sexual activity, but it may or not work and it may be frustrating and embarrassing, or I can just go to sleep. He's probably just going to go to sleep, right? And it becomes a vicious cycle because the less sex he has, the more difficult it is to engage in sexual activity later on. And so you may interpret this as a low libido, but he's really just avoiding it because he doesn't want to deal with it. Right. But the partner also looks at this as maybe I'm not attractive anymore, maybe there's something about me that's not appealing, and it becomes a vicious cycle. So one thing you can do is significantly improve the quality of the erections in a man and that actually helps improve his libido. So, for example, I tell a man, if every night you have a great erection and every morning you wake up with a great erection, what are you going to probably do? You're probably going to use it, right? So libido inherently goes up, right? So I think Ed and libido are tied very closely.
- [15:32]
A
How do you define the term libido?
- [15:34]
B
It's a desire to engage in sexual activity for men and women. And you have to, you know, when it's a true problem, they have to be bothered by the condition. So I just want to be very clear. There are women who have low libido and say, I really don't care. I'm happy that I have a low libido. Well, then it's not an issue, right? You have to be bothered by the issue.
- [15:51]
A
So on this psychogenic element where it becomes a vicious cycle. I've seen this in my own life several times. Well, at least once. And I've seen it in some of my friends where, because there's a bedroom issue. When you go to the bedroom, you're both a little bit anxious and then one of you can't perform. And if you can't perform, it exacerbates the issue and it creates this sort of vicious downward spiral of like, it makes the bedroom like a really awkward place to be. And this is how I think about when you're talking about psychogenic component. So in the case of erectile dysfunction, if you're thinking as a man, God, if I go to the bedroom, I'm not going to be able to get it hard, I'm not going to keep it up, it's going to be embarrassing. She's then going to ask me questions, she's going to think I'm not into her. Which all just makes it even harder because as a man I perform best when I'm really not thinking about it. And I'm like not anxious when I'm stress free, right? And it seems to me that the like, antithesis, the opposite of great sex is like overthinking.
- [16:52]
B
You are 100% correct. And this is what happens. Let's say a man gets ed just one time, just one time, young man, he says, that was really odd. And what's wrong, you know what he does next time he has sex? As he's having sex, he says to himself, I hope I don't lose my erection. I hope I don't lose my erection. The second he says that to himself, as he's having sex, he's going to lose his erection, right? Because he's so worried that he's going to lose the erection and not enjoying the experience. So now it's happened twice. So now he engages sexually a third time. And now he's even more freaked out because it's happened twice and it happens again. We call this the vicious cycle, right? Because now sex has become an anxiety event, anxiety provoking event. And so you really have to work on decreasing that anxiety and not thinking about it. That's where sex therapy comes in hand and that's where a medication called Daily Cialis has become unbelievably helpful for my young patients. Because Daily Cialis is a medication that men take daily. You've heard of Cialis, right?
- [17:48]
A
It's like the Viagra.
- [17:49]
B
Yeah, it's like Viagra, right? So there's Viagra, there's Cialis, Levitra, there's Stender. There's four different brands, but one of the four is meant to be given daily. It's a lower dose, 5 milligrams every day, and the larger dose is 20 milligrams. When you give a man Cialis 5 milligrams every day, what it does is essentially is having that medication on board all the time. When he engages in sexual activity, he doesn't have to take a pill. He just has sex whenever he wants to. And I found that to be unbelievably helpful in breaking psychogenic ed. Because now that's exactly what that is on the table. Yeah, that's exactly what it is. Yeah. And so these are pills that are in the us but what's nice is they used to be very expensive. Now they. If you look at Mark Cuban and a lot of the good Rx companies, men can get 90 pills for 15 or $20, which is very cheap.
- [18:40]
A
You used the word young men.
- [18:41]
B
Yes.
- [18:42]
A
Young men presumably shouldn't be taking pills.
- [18:44]
B
They shouldn't. But what happens when they have psychogenic ed? Cause they think about it the most is they need to break the cycle.
- [18:51]
A
What's the cost? Cause I'm a. I'm gonna be honest. I'm a pill skeptic.
- [18:54]
B
Yes.
- [18:54]
A
So I try and avoid taking pills to solve my problems if I can.
- [18:58]
B
Right.
- [18:58]
A
Obviously, there's going to be situations where I can't, and I accept that. But my bias is towards figuring out if there's another way before I take a pill. Because everything in life comes with a cost. All things.
- [19:08]
B
Yeah.
- [19:09]
A
So there must be a cost to taking a pill to solve this problem.
- [19:12]
B
Well, the actual monetary cost is unbelievably cheap.
- [19:16]
A
Monetary cost is. I'm thinking about, like, do I then get dependent on this? Do I have to take this for.
- [19:21]
B
The rest of my life so there's no dependency? Let me tell you why I think that drug is so important that daily Cialis has one of the only things, in my opinion, that actually reverses erectile dysfunction. So let's backtrack. Let me give you an example. Let's say today you break your leg. Okay? I have two options, Steven. I can fix your leg, or I can give you Vicodin, a narcotic. And if I give you the Vicodin or the narcotic, you'll still be able to walk until the Vicodin no longer works and we're in trouble. Viagra is a Vicodin. It is not a cure for your erectile dysfunction. It's just masking the problem. Daily cialis, in my opinion, is one of the few things that helps cure ed. If you look at studies and you look at a penile tissue, and we biopsy the tissue, and then you biopsy three months later on daily cialis, it physically gets stronger. So let's say you go to the gym today and ask you to lift dumbbells. What's going to happen to your arm? It will hypertrophy. With daily cialis, we see hypertrophy of the smooth muscle, meaning it gets physically stronger. So in my opinion, it's one of the best things to prevent ED in the future, help reverse the ED process. More importantly, daily cialis protects the endothelium. And we have to spend some time talking about that. That is the lining of the blood vessels. It's the brains. And the lining of the blood vessels is very important because once that gets injured, you start getting clot or plaque, which will get a heart attack, a stroke, and erectile dysfunction. So it protects the lining of the blood vessels. Two other indications, it's FDA approved to help a man urinate better. FDA approved. It's FDA approved to protect the heart in terms of something called pulmonary hypertension. So in my opinion, it's an excellent medication. Patients say, do I get dependent on it? I say, you do not get dependent on it. And I feel like you're better had you taken it than had you not. You take it for three months, you get strengthening of the penile tissue.
- [21:06]
A
What happens if I stop taking it?
- [21:08]
B
If you stop taking it, There's a wonderful study by Aversa, and what he showed was that those patients that stopped taking it after three months versus placebo still had benefit in terms of endothelial function protection and erectile function protection than those people that took placebo. So thinking about saying, hey, if I go to the gym and I work out for three months, what happens if I stop? I say, well, Stephen, you're better off had you gone to the gym for three months. That's my opinion.
- [21:30]
A
What is the downside?
- [21:32]
B
There's side effects. So every drug has side effects, Right? But they're low with 5 milligrams. Back pain, stuffy nose, headache can occur in these, but it's quite small. But I do think that this is one of the medications that really can make an impact in men's health. Think about it. If I told you there's a medication that protects your heart, helps your prostate, and helps men with erections, and it's affordable, I think that most men Would say, I'm in.
- [21:57]
A
What are the big side effects that people report when they're on Cialis?
- [22:00]
B
So on the larger dose, headache, stuffy nose, back pain is more common with Cialis and other medications, but it can be reported. Remember, you shouldn't take these medications if you're taking a nitrate because it can drop your blood pressure. But other than that, these are very commonly used medications throughout the world and.
- [22:17]
A
They'Re not suitable for certain people that have certain cardiac disorders, I'm guessing.
- [22:21]
B
Well, you know, the way this was invented, this came at first. One Viagra came out in 1998. Viagra was in the clinical trials designed to be a blood pressure medication. And accidentally men were getting erections in the trial. So these medications are, in my opinion, cardio protective. A guy named, a very famous physician named Dr. Cloner published an article recently showing that those men who took daily cialis had a 13% reduction in cardiac events and a 25% reduction in mortality. That just came out because of the potential effects of protecting the endothelial lining of the blood vessels.
- [22:55]
A
How does this work to solve for the sort of psychogenic component that we talked about, that vicious cycle people get into with like, I'm guessing you're telling me that it increases your probability of having a good erection, Right? But this still isn't really working on a libido, is it?
- [23:10]
B
Right, so let's say you started falling through the vicious cycle and you started having ed and it was two times, three times, and now I put you on this medication and every time you have sex, you have the most amazing erection of your life. And 30 times, 40 times three, six months go by and you're having these amazing erections. You're relaxed and you're calm. Then I start going to every other day, you still get amazing erections. Then I go to once a week, you still get amazing erections. Then I stop, you still get amazing erections. Right. I just need to show you that everything is perfect again and that has a huge value.
- [23:39]
A
What about for women?
- [23:40]
B
This is the unfortunate part. We don't have a lot of treatment options for women. And if you look about it, if I want to give you an example, in 2015, if you and I went into the drugstore in the US Walgreens and said, give me all the drugs to treat women, treat men for sexual dysfunction, they would put 30 drugs on the counter. These are all the wonderful treatments for men. In 2015, there was not a single FDA approved drug to treat women for any sexual dysfunction. Very sad. In 2015, the first drug to treat women for female sexual dysfunction came out, and it was called Adi or Flibansrin and Flibans, and basically is a drug that a woman takes every day and increases her desire for sex. That's it. That's the FDA indication. Increases her desire for sex. Several years later, the second drug for women came out. This was called vilice or Brimalanitide. Essentially, it's an injection that she takes 45 minutes prior to intercourse, and it increases her desire for sexual. But again, we have only two drugs. The reason being is because the research, the funding that we have for female sexual dysfunction is far less than we have for male sexual dysfunction. And it's unfortunate because as I mentioned earlier, this is a couple's disease. And so many times I have to use drugs that I use for men to help treat women. So I do use Viagra for women, but Viagra for women helps arousal. So let me explain. Female sexual dysfunction has four components. One is decreased libido, the second is decreased arousal. Third is orgasmic dysfunction, and the fourth is pain with intercourse. These are the four. If a woman has any one of these four and she's bothered by it, she suffers from female sexual dysfunction. In the US roughly 43 to 48% of women suffer from female sexual dysfunction. Significant number. Only 19% seek therapy, will get therapy. So there's a huge number of women that I say are suffering in silence. They suffer from the condition, they don't know where to get help. And unfortunately, there are not many treatment options available. Right. So it's a big problem and a big unmet need.
- [25:48]
A
And on the hormonal component, you talked about how if dopamine is up, we're much more likely to be aroused, and if serotonin is up, then we're much less likely to be aroused.
- [26:00]
B
That's correct.
- [26:01]
A
So this kind of ties into something I was thinking when you were talking about stress and tiredness. When I'm stressed and tired, is my dopamine down?
- [26:09]
B
It can be. Your cortisol goes up. Your cortisol goes up, so your ability to get excited will go down. Your fatigue goes up, so it makes it much more difficult. And there's more than just dopamine and serotonin. There's norepinephrine, there's melanocortin, there's many other neurosteroids. And it's really just what we call a plus minus game. If I have more positives than negatives, I'm gonna have desire. And I'm also Gonna have orgasm. Right. That's important also. So if you give someone too much serotonin and it goes this way, not only does the libido go down, but it's difficult to achieve climax or an orgasm. So one of the ways I treat premature ejaculation is, is I give them an antidepressant because it delays the orgasm. So we have to be very careful on these neurotransmitters, how we use them. But if you talk about addi, the drug I mentioned, all it does is it increases dopamine and norepinephrine, which increases libido. So they increase neurosteroids. Many women, particularly with the history of breast cancer, like this because they don't want to use testosterone or estrogen hormones. This is non hormonal. Right. It's just neurosteroids increasing the desire for sex.
- [27:17]
A
Can I think about dopamine and serotonin as like a scales?
- [27:20]
B
Yes.
- [27:21]
A
Where if I. If I put weight on one end, the other one goes up and if I put weight on the other end, the other one goes up?
- [27:25]
B
Yes. There is a very famous. Michael Perlman came up with a tipping point. And it's basically a scale looking at the pluses and the minuses. And if you have more pluses than minuses, libido goes up, orgasmic function goes up. If you have more minuses, essentially your ability to orgasm and your libido will go down.
- [27:42]
A
So I want my. If I want to be aroused and have a desire for sex and have good sex, then I want my dopamine levels to be high.
- [27:47]
B
Dopamine high. Oxytocin high. Norepinephrine high. Serotonin low.
- [27:51]
A
What are the types of activities that make my dopamine high?
- [27:55]
B
Well, exercise can be a really high dopamine. Other things increase dopamine as well. Right. So gambling, there's certain things that are high. Anything that gives you a high, certain foods will cause a dopamine rush, but they're temporary. Right. And so that's a problem. Right.
- [28:14]
A
Because if it goes up and then.
- [28:15]
B
Goes down, it goes back down, it crash. So you want your dopamine to go up in men and women. So we use medications like Wellbutrin. Have you heard of Wellbutrin? It's an antidepressant. But that antidepressant increases dopamine. So I use that to help men increase their libido or women to increase their libido or sexual function. I use ADDI in men and off label in men and in women to Increase dopamine.
- [28:38]
A
I don't want to do drugs, though.
- [28:39]
B
Yes.
- [28:39]
A
I don't want to take any pills.
- [28:40]
B
So then I would say I need you to exercise and you do, but exercise is critical. I need you to sleep. I need you to reduce your stress. Right. Those things will significantly improve your libido.
- [28:51]
A
So what things then lower dopamine? Because I've spoken to a few, like, dopamine experts on the show before and they talked to me about this sort of meaning. Andrew Huberman was telling me that, yeah, when you do an exercise like, let's say gambling or go on TikTok, your dopamine is going to go up, but then it's going to crash below the base point.
- [29:07]
B
Yes.
- [29:08]
A
And some of us live in this kind of dopamine roller coaster where we're doing these dopamine inducing activities. Our dopamine goes up, it then crashes below. And when it gets low, we have cravings for dopamine inducing activities. So we go out and want to gamble or go on TikTok again or eat something, and then it goes up again. And then we kind of live in this kind of roller coaster of dopamine. One of the things that I was told by a dopamine expert on the show recently that does that as well, that links to some things I found in your work, is pornography.
- [29:34]
B
Yes.
- [29:34]
A
And when we talk about this psychogenic component, we talk about dopamine levels. How much is pornography causing this libido crisis?
- [29:48]
B
Yeah, pornography and ED and libido is somewhat controversial. There's some data suggest that it does not cause an issue. And there's some data to suggest that it does. The first question I ask a patient, when I ask a man, I say, is your ED present with pornography also? So if he says, look, I have erectile dysfunction with my partner and I have erectile dysfunction with pornography, that's very different than when he says, I have erectile dysfunction with my partner and I have amazing erections with pornography. Right. Because then I know that there's a psychogenic component as well. This is what I believe. I believe that when a man watches excessive amounts of pornography, what his expectation is becomes hair and his reality becomes hair. And that delta causes them to have erectile dysfunction and low libido. They're not getting what they're expecting to get. So many times I question men when they come in, when all men who come in for ed, I ask, how much pornography are you watching? In men who watch excessive pornography, if I ask them to stop watching pornography for a while, Many will report improvements in their rectal function and libido. So, again, I do think that pornography in excess can have a negative impact only because of your expectation and your reality. The delta can be an issue.
- [31:06]
A
I'm reading some stats here from JAMA Network that says the percentage of men between 18 and 24 reporting no sexual activity in the past year increased from roughly 18% to roughly 30% in the space of what looks like just a few years. And similarly, the average number of times American adults engaged in sexual activity per year has decreased from 60 between 1989 and 1994 to 50, roughly 50 between 2010 and 2024. These shifts suggest a notable shift in sexual behavior over recent decades. Why do you think this is happening?
- [31:43]
B
I think it's multifactorial. So I think one is. I think that ED and sexual dysfunction is on the rise. And if you look the causes for ed, it's very simple. You look at obesity, diabetes, metabolic syndrome. It's a pandemic, it's an epidemic. If you look at just diabetes from 1990 to 2022, 100%, 7% to 14% of the population, one out of eight people globally are obese. One out of eight people. So these can make it very difficult. As obesity and diabetes go on the rise, what happens? Testosterone levels go down. Right. So testosterone levels go down. So the ability to engage in sexual activity, the desire to engage in sexual activity will be impaired by these conditions.
- [32:27]
A
I've got some graphs here which show global obesity trends, global diabetes trends. I'll put them on the screen for anyone that's watching on video. Also, there's been an increase in pornography consumption from what I was able to tell from doing some research. A 2020 study by the University of Antwerp found that 40% of people aged 35 to 45 who watched 300 minutes of porn a week had erectile dysfunction. In a 2021 study by Jema Public Health and Surveillance on 3,400 men between 18 and 35 years old, 20% of the participants suffered from erectile dysfunction. And researchers found that the greater the viewing frequency of pornography, the greater the development of this dysfunction.
- [33:08]
B
Yeah. And that's 300 minutes is quite a bit of time a week.
- [33:11]
A
Five hours.
- [33:12]
B
Five hours a week. Right. So this. So that's quite a bit. Yeah, that's quite a bit.
- [33:17]
A
How important do you think that is as a component to this sort of fracturing in relationships? We think about people having sex with each other less.
- [33:23]
B
Yeah.
- [33:23]
A
We're heading towards a world of, like, virtual reality. And AI, yes. What role do you think that's genuinely playing? And you must have private conversations with men that are really suffering with these things.
- [33:33]
B
So I definitely think it's a rule and it definitely plays a factor, but not as much as the epidemic of diabetes, obesity, metabolic syndrome. We are as a population becoming more and more unhealthy. Right. As time goes on. And I look at again as a pie, it's multifactorial. Most of us now are not. Our socialization is virtual. And so we are not engaging and going into seeing. Everything is done virtually. And so I think that's an issue. And so I really believe that pornography is a component, but the decline in overall health is a major component. The decline in testosterone levels decade by decade is also another component as well.
- [34:12]
A
It's pretty terrifying that young kids at the age of like 12, 13, 14, when they open their phones these days, will be exposed to sexually graphic images, whether they chose to seek them out or not. And I've always wondered what that's doing to a developing brain. You know, how it's adjusting your expectations, how it's creating some of those psychogenic factors that are making you less aroused. And it's difficult, right? It's difficult to go out and find a partner. You have to like, put on the aftershave, shave, take care of yourself. You have to like risk rejection, spend some money, be interesting. So it seems like if, from a evolutionary perspective, if I was just trying to get my nut off or I don't know, ejaculate, I've got this really easy way now. It's so easy. Three clicks on a computer, we're off to the races versus all the effort and rejection and pain of trying to find an actual human being to have sex with. And then when I do do approach number one, when I log onto some website and click a couple of times, I'm getting no headache, I'm getting whatever I want. I can order from an endless list of menus. And I'm sure in the near future I'll even be able to make my own.
- [35:21]
B
Yes.
- [35:21]
A
And not so distant future, I'll have it in my house and it'll talk to me.
- [35:25]
B
Yes. Yeah, it's a problem. And you think about it's making it more difficult for people to socialize. Right? So in other words, now when patients or people engage in sexual activity, and they're usually having sex on the intern or with pornography, when you actually engage in sexual activity with another person, it can be cause anxiety, right? You get anxious, it's not something that you're doing regularly. And so I think that it can become an issue.
- [35:52]
A
I saw an article this week from an OnlyFans creator who posted that one customer of hers had given her $4 million this year.
- [36:00]
B
Oh, my God.
- [36:01]
A
And you think about, like, you think about what it would take for you to spend $4 million on a parasocial relationship with. With an OnlyFans creator sending you explicit pictures. And I don't quite believe we fully understand what's around the corner.
- [36:17]
B
I agree.
- [36:18]
A
These stats, I think, are nothing compared to what's around the corner. And I don't know, I think about it a lot because when I read these stats about erectile dysfunction being on the rise, and I read that we're having sex less and less, and then I see this rise in these parasocial relationships, I go, fucking hell. I think we're just at the start of an exponential curve. Let's talk about obesity, then.
- [36:42]
B
Yeah.
- [36:43]
A
Because these. These stats here are pretty shocking. This one shows the global obesity trends, which just shows them going straight up.
- [36:50]
B
Yes.
- [36:50]
A
Which is horrific. This one shows global diabetes trends, which is pretty much straight up as well.
- [36:56]
B
Yes.
- [36:57]
A
Has there been any studies done that show the link between being overweight and your probability of having low libido and some kind of sexual dysfunction issues?
- [37:08]
B
Yes, numerous. And so let's start with this. So obesity. It's not surprising that diabetes is going up, because as obesity goes up, it causes insulin resistance. So obesity and diabetes typically go hand in hand. The problem with obesity is the following. Obesity significantly drops testosterone levels. So fat cells contain something called aromatase. Aromatase eats up the testosterone and converts it into estrogen. So the more fat you have, the less testosterone you'll have because you'll convert it into estrogen. Fat cells also secrete something called cortisol and leptin, which shut down your own natural testosterone production. So as it's not surprising that decade by decade, as you see an increase in obesity, you see a decline in testosterone levels in men, because the testosterone levels will come down as people become more obese.
- [37:53]
A
And low testosterone equals low libido.
- [37:55]
B
Low testosterone increases low libido. The number one driver, or the number one hormone for libido in men and women is testosterone. It's a strong driver.
- [38:03]
A
Men and women.
- [38:04]
B
Men and women. And don't forget that testosterone is also really important in erectile function. Men need testosterone for sexual function. So do women. Right. It's extremely important. So now I have a hormone that's going down that's going to make it more difficult to get an erection. I have a hormone that's going down that's going to decrease my libido. And it's mainly due to this obesity that's occurring, one of the biggest factors. So obesity, obesity. Also, if you look at the risk factors for ed, obesity, diabetes, cardiovascular disease, these are all risk factors. And so as obesity goes up, erectile dysfunction goes up and the number one condition is diabetes, diabetics are four times more likely to have ED than any other population. Four times. So I get worried when we see this obesity diabetes pandemic going up because it's increasing only the erectile dysfunction. Stephen, if you look at the obesity, the group that's having the greatest rise in obesity is adolescents obesity, not adult obesity. The kids, younger and younger ages are having that age group has the greatest rise of obesity. So what does that turn into? The younger population are starting out at lower T levels and it has an implication on fertility because you need testosterone to produce sperm. That's very important.
- [39:19]
A
So if I just lose a little bit of weight, that'll have a big impact on my testosterone levels.
- [39:24]
B
Let's talk about that. It's not a little bit. So the best study was at the European Male Aging Study, Fred Wu, and what he showed was this. It's a bidirectional relationship. If you lose 10% of your body weight, you can actually gain 85 nanogram per deciliter in serum testosterone. If you lose 15% of your body weight, you can actually gain 250 nanogram per deciliter in serum. So it's actually significant if you can lose. But it also goes the other way. You gain weight, you drop the T proportionately as well. The only issue is I can get the patients to lose the weight, but I can't get them to sustain it. Many times they gain it back. Right. But if they can keep the weight off, it's significantly increase the testosterone levels. The best data we've seen is in the bariatric surgery data. If I do bariatric surgery on a patient to help them lose weight, you can shrink the stomach. We do surgery to help them lose weight, they lose quite a bit of weight, their T levels go quite up. Right. And so again, there is a strong correlation between weight and testosterone.
- [40:26]
A
Have you got any examples of patients where you've given them testosterone treatment in some form, you've done something to increase their testosterone and you've seen a remarkable reported difference in their sex life all the time.
- [40:38]
B
Yeah. So first, let's backtrack. There's Two ways to give a person testosterone. If I give a young man testosterone, remember, it causes infertility. So you would never give someone testosterone if they're planning to have children. Right. That's very important. Right. So I have two ways to raise your testosterone. I can give you medications to raise your natural testosterone. There's several. There's a pill called clomiphene citrate. There's hcg. I can use medications to raise your own natural testosterone, and they preserve your fertility. The second option is I can give you medications like testosterone. There's seven of them, but they will shut your natural production down. Not only will they shut your natural testosterone production down, but they will shut down your sperm production. Now, if you've already had your kids, you're 60 years old, your testosterone level's already low in the first place. What are you preserving? Okay, it makes a lot of sense. And there's seven ways to do it. My favorite way are the injectables and the oral testosterone. They are fantastic. Oral testosterone is quite interesting. You know, first of all, testosterone was invented in 1935. This is not a new drug. 1935. And oral testosterone initially was feared because it would actually cause liver toxicity and liver cancer. And it wasn't till the 1970s when they were able to make oral testosterone undecanoate. And what's nice about undecanoate, it bypasses the liver, no cancer. But it had to be taken three to four times a day. It was available in the UK as a drug called Andriol all over the world, but not the US. The US we did not get our first oral testosterone till 2019. And then 2022, we received two more. And now we have to Lando Jatenzo. And Kaisertrex is our oral. They're taken twice a day with a meal. What's nice about Kaisertrex, it's actually available in the uk. So in the UK now they can actually get Kaizatrex as well. But oral testosterone, most patients don't mind taking a pill, and it seems very easy to do.
- [42:35]
A
Should someone like me be taking testosterone?
- [42:37]
B
If your levels are low and you're symptomatic, and I think that's very important. If a man comes in with low levels of testosterone and says, I feel great, I have no symptoms, I said, I'm not giving it to you. These are the symptoms. Low energy, low libido, erectile dysfunction, decreased muscle mass, increased fat deposition, poor sleep and depression. These are some of the common symptoms you'll see most sensitive symptoms Are the sexual symptoms erectile dysfunction and low libido. So if he says, I have these symptoms and my levels are low and I recheck it and confirm that it's low, that man is a candidate for testosterone therapy. But if he's young, hasn't had children yet, I'm going to say, look, let's hold off on giving you testosterone and use medications to make you make testosterone. And if you don't want to take medications, actually, there are many things you can do on lifestyle modification to raise your testosterone. We talked about weight loss as well. So let's live in this area here. You are too young to take testosterone now, but conversely, let's say a patient comes in and has every single sign and symptom of low testosterone, but his testosterone levels are normal. I'm not giving him testosterone because it could be something else. Maybe he's depressed, maybe he has a low thyroid, something else is going on. So you must have signs and symptoms and a low T level to be a candidate. And if you fit that, then you may benefit.
- [43:57]
A
What about women?
- [43:58]
B
So this is important. In 1935, when testosterone was invented, it wasn't many years later till they actually started using testosterone in women. And early reports of testosterone in women were actually quite remarkable. The earlier manuscripts describe improved quality of life, improved libido. And if you and I walked into the drugstore today and said, give me the testosterone for women, it does not exist. There is not a single FDA approved testosterone for women in the United States, but we have well over a dozen for men.
- [44:28]
A
Can you explain this to me? Just because I want to make sure I'm clear. Why would a woman take testosterone? Because when I think of testosterone, I think of men.
- [44:36]
B
Yes. So women make more testosterone than any other hormone in their body. Make more testosterone than any other hormone in their body. Right. And when women have higher levels of testosterone, they tend to see a greater improvement in libido, muscle mass, bone mineral density, sense of well being. Some have reported improvements in cognition. As the testosterone level goes down, we start seeing these symptoms, particularly low libido. If you give a woman back her testosterone, many of these women see a significant improvement in their libido. But the issue is that we don't have an FDA approved product for testosterone in the United States. I think in the UK you call it off license, we call it off label. Now in the UK they did have one, they had a wonderful patch called Intrinsa. And in the women in the UK could get the patch for testosterone going to the drugstore. NHS covered it and it was fine. Then they had Androfem and Androfem was actually approved and now no longer is approved. So now in the UK you also don't have an on license medication. You can still get Androfem from Australia, but unfortunately it's very difficult to get. So what do we do? We use the drugs for men and we give it to the Women in 1/10 the dose. That's all we do. So if we have a packet that a man puts on a day, we say use one tenth of the packet every day for the women and they can see significant improvements. It is not illegal to give a woman testosterone. It's just considered off label or off license. But they see significant improvements in what sexual function, by far the most libido goes up. No question. Many women report that muscle mass. If you think about testosterone, bodybuilders take testosterone for a reason. Why? It significantly improves muscle mass, it can decrease fat deposition. Many patients will import improvements in cognition. It can help with bone mineral density as well in men and women. And I also believe in depression. So I think testosterone does help with depression. I just want to just make a very important point. Testosterone is not just about sex. There are five other things that you need to think about in men and women, and I want to talk about those. Men with low testosterone levels are much more likely to have a heart attack. Non negotiable. Men with low testosterone levels are much more likely to have diabetes. Obesity. Men with low testosterone levels are much more likely to suffer from depression. Men with low testosterone levels are much more likely to have a bone fracture. So it's not just about sex, it's about their overall health. And if you were to check one blood test to assess a man's overall health, it's his testosterone level. One blood test to check his overall health, it would be because it affects heart, diabetes, obesity, bone marrow density, energy, muscle mass, erections, libido. One blood test. I can't think of another blood test that is a better barometer of overall health.
- [47:22]
A
I want to get clear on something because I've heard people talking on my podcast before about hrt.
- [47:26]
B
Yeah.
- [47:26]
A
And women taking HRT because of menopause and things like that. Should they be. Does HRT have testosterone in it?
- [47:35]
B
No. So typically when we say hrt, we're talking about estrogen and progesterone. Typically, yeah. And typically when we talk about trt, testosterone replacement therapy, it's a little bit different in a woman. There's something I call the triangle and it's just basically estrogen, progesterone and testosterone. Just simple. And if you have a woman who's deplete in estrogen, testosterone and estrogen, progesterone, testosterone, and replace it, many of those women feel better, right? So many of them do. There are other hormones that are also important. I call it the outside circle. Cortisol, thyroid, growth hormone. We look at those as well. And so I think those are also very important. And I tell them, we're going to optimize your hormones, but what you're going to. And we're going to optimize your medical condition. But that is only 50% of the story. The other 50% again is diet, exercise, sleep and stress reduction. And if you do your part and I do my part, we're on fire. We're absolutely on fire. But you have to do your part. Same with men. I put you on the testosterone. I optimize your medical conditions, but you gotta exercise, you gotta eat. Right.
- [48:38]
A
Why aren't women being prescribed testosterone then?
- [48:41]
B
Right. Because it's considered well in many countries. In Australia it's available. In the UK it was available. And many women are being prescribed testosterone. It's just off label.
- [48:51]
A
It is the first time that I've seen someone on my show anyway, really emphasize the point that testosterone isn't just for men, it's for women as well.
- [48:59]
B
And it can significantly improve their quality of life.
- [49:02]
A
Talking about testosterone, one of the big conversations that's rattling on on the Internet is about this decline in male testosterone, testosterone over the last couple of years. What exactly is that decline? If you had to sort of quantify.
- [49:14]
B
It, if you look at the original studies, we call it the Framingham Heart Study. Back in the 70s, testosterone levels were roughly around the 700s. Average men between the ages of 18 and 40 were around the 700s. And every decade we're starting to see a decline almost by 50 nanogram per deciliter. And so the latest 2015 numbers are roughly in the mid 400. So we've seen almost a 300 nanogram per deciliter decline in serum testosterone, which is significant because it has two implications. It's not just about the way you feel and energy, muscle mass, erectile function. But that low testosterone can have implications on fertility. That's really important. So we didn't talk about that. But fertility, sperm need testosterone. Low testosterone decreases your sperm count. Sperm counts have also been on the decline as well. So, you know, I think it's really a testament to the fact that decade by decade we're becoming A more unhealthy population.
- [50:09]
A
Do you think that's really the heart of it is that is this sort of our diets and the way we live and becoming more sedentary, less exercise, more processed food, et cetera. Do you think that's the heart of it?
- [50:18]
B
I think that's the key. That's absolutely the key. The types of foods we eat, the processed foods that we eat, high fructose, high carbohydrates, hydrate diets. And the way we know that is just look at the obesity, look at the diabetes. There has to be a reason why it's on the rise. Right.
- [50:35]
A
And on that point of fertility, I'm in a season of life where I'm going to be trying to have kids pretty soon. What's the most important things I should be thinking about from a lifestyle perspective, in your view?
- [50:46]
B
Yeah. So I tell patients, Darwinism, in other words, survival of the fittest, healthier people are more fertile. Right. You're passing on the genes. So essentially, we tell patients, well, the number one cause of infertility in the world for men is a varicocele. A varicocele is the swelling of the veins around the testicle. You know how women sometimes can get swelling of the veins in their legs? You see those veins that are kind of obvious? Well, men can get those veins dilated around the testicle, and those varicoceles can impair sperm production. Now, 15% of men in the world walk around with varicoceles, but up to 40% of men with infertility will have varicoceles. So it's really important to assess for the varicoceles. But lifestyle modification, each one, again, diet, exercise, sleep, have been shown to help improve fertility in men as well. So I say healthier people are more fertile. I need you to start getting healthier. That's very important. We raise the testosterone level in many of these men. Naturally, we don't give it to them to help improve their fertility as well. But check, Stephen, check your semen analysis. That's the simplest thing you can do. Check it.
- [51:47]
A
Right, I did that.
- [51:48]
B
Yeah. It's a great predictor. It's not just, you know, there was so many amazing studies showing that a semen analysis is a phenomenal predictor of overall health. Many studies showing that if your semen analysis today is impaired, it's a predictor of you having comorbid conditions today, like diabetes, obesity, metabolic syndrome. It's also a predictor of prostate. I mean, cancer. So we know that if you have, infertility you're at a higher risk of having testicular cancer than those that don't have infertility. And it's also a predictor of who will have problems in the future. Mike Eisenberg once showed a very nice study. Men who have low sperm counts can have a 30% increased risk in diabetes, 50% increased risk in ischemic heart disease in the future. Tom Walsh showed those men could have 2.5 times higher risk of high grade prostate cancer in the future. So again, to me, it's just a marker of overall health. Check the semen analysis.
- [52:39]
A
I did that and it was quite. I was actually, to be honest, I was really quite nervous about it because as someone who's in my early 30s and wants to have kids, I was really scared that it would come back and say that my sperm is dysfunctional. And I've got a huge amount of empathy and feelings for people that do those analysis and get bad results back.
- [53:01]
B
15% of all couples in the world, 15% suffer from infertility. That's a lot. And if you think about it, 30% of the time it's a male factor, 30%, 20% of the time, it's a male and a female factor combined. So indirectly, a male is involved 50% of the time when you have an infertile couple. And it can be devastating for that couple. I mean, psychologically devastating. And what's also interesting is that most couples, most couples, 50% of couples, don't seek therapy. And of those couples that do seek therapy, this is globally only 25% of those couples actually go forward. And so I call this a group of individuals that also suffer in silence. They should know that there are excellent treatment options available.
- [53:47]
A
This graph that I had printed out is just shocking to me. It's going back to the point about testosterone. But the really shocking thing is how quickly this has happened, because this is the year 2000 and this is the year 2015. 16.
- [54:02]
B
Yeah.
- [54:02]
A
And the decline there is from roughly 600 nanograms. Is it?
- [54:07]
B
Yes. Nanogram per deciliter.
- [54:09]
A
Nanogram per deciliter. To roughly, for some age groups here, 400 nanograms per deciliter. And that's only in 16 years. So if you play that forward another 16 years, there's going to be a bit of an infertility crisis.
- [54:24]
B
There is. Fortunately, on that graph, it's plateauing a little bit, which makes me feel a little comfortable.
- [54:27]
A
Okay.
- [54:28]
B
Oh, yeah, it is actually plateauing just a little bit. But you're right, it could be a significant Cris. And again, as I mentioned, it's the adolescents, the younger folks, who are having the greatest rise of obesity. And that's where fertility comes in. Because fertility, obesity in someone in 60s is not concerned about fertility, but a young patient who has infertility, that obesity will have a higher risk of infertility.
- [54:51]
A
If you're an entrepreneur, you're probably going to want to listen to this. It's a message from one of our sponsors on this podcast, which is LinkedIn. If you've listened to me on this podcast for a while now, you'll know that I've been on a bit of an evolution as a business owner and entrepreneur. And one of those evolutions that has become clearer and clearer as I've matured is that the single most important thing in building a business, in building a company, is hiring. The definition of the word company is actually group of people. And that is the first responsibility and job that any entrepreneur has and should focus on. But surprisingly, Most don't. About 80% of my team have been hired from LinkedIn. And I think there's very few platforms, if any, in the world that could give you that diversity of candidate with that much information and data on their profiles, it usually costs money. But for the entrepreneurs that are listening to me, I've got you a free job ad post for your company on LinkedIn. Just go to LinkedIn.com DOAC to post your free job ad today. That's LinkedIn.com DOAC terms and conditions apply. If me and my partner came to you and we said, listen, we've got sexual problems in the bedroom, what are the steps that, the things you'd look at that we haven't focused on so much today? Is there anything in particular you'd say, okay, and I'm trying to stay away from being prescribed a pill, so I want to do anything natural I can before I get to that. And then we'll talk about some of the other more drastic measures one can take.
- [56:12]
B
So let's talk about natural things because everyone wants to know about what's the natural things I can do. So when we talk about diet, there's certain diets that have been helpful to improve sexual function. For me, it's the Mediterranean diet. The Mediterranean diet is rich in whole grains, legumes, fruits, vegetables. And if you look at red meat and sweets, it's once a month. If you look at poultry, it's maybe once a week, but mainly fish. Those diets have typically been anti inflammatory diets. Many studies have shown that that diet can significantly improve erectile function. And one study, the Medida trial, actually showed that it improves sexual function in men and women. So I'm a big believer in using the Mediterranean diet. When Esposito did her first trial, it was a prospective trial. 110 obese men, 55 men get Mediterranean diet. 55 men don't get any intervention at all. She follows them prospectively for two years. What does she find? Not only a significant improvement in endothelial function, remember that lining of the blood vessel? But a significant improvement in erectile function in these men. No Viagra, no pills, nothing. Simply changing the diet improved the erectile function. And the same with sexual function in women. So that's an important one. The second is sleep. Let's talk about sleep. So studies show that if you're getting less than six hours of sleep a night is significant, increases your risk for sexual dysfunction in men and women. Right? Your ideal amount of sleep should be seven to eight hours. Now, let's say you say, well, that makes sense. Maybe I'm going to get sleep for nine to 10 hours because the more sleep I get, the better my sexual function. But that's not true. It plateaus. So if above nine hours, it does not increase your ability or sexual function. So seven to eight hours of sleep a night I need you to get. Third is I really need you to focus on exercise. So I published a very nice study. Looking at it was a meta analysis on how much exercise one needs and what type of exercise to actually improve erectile function. In this study, typically you need 160 minutes a week, so 40 minutes, four times a week for a course of six months of moderate to severe exercise, vigorous exercise. And so most people can get 160 minutes in a week of exercise, but that's getting your heart rate up. And doing the exercise significantly improved erectile function in men. If you did that, and the more severe your ED was, the greater improvement you saw in erectile function. Strictly by exercise alone, no other intervention, Stephen, Just exercise. So here you have a patient that now starts doing some exercise, starts sleeping better, starts changing the diet. It's all additive. You are now significantly improving erectile function just by lifestyle modification alone.
- [58:48]
A
Pretty profound that exercise can have such a big impact, isn't it? Is that the same for women?
- [58:52]
B
It is true because many of the things. So unfortunately, once again, the research we have in women is not close to what we have in men. But the Medida trial was also in women. The sleep studies were also in women. And so these studies also show that Sexual function can be improved with sleep and with diet. I think that men and women are not that different. I mean, if you see a significant improvement in a male sexual function with diet, exercise and sleep, you can also see it in women as well. Actually, there was a great study this looked at 110 women and they had coronary artery stenosis. They did angiograms on 110 women and they showed that the greater her stenosis she had, the worse her sexual function. So the greater the blockage in her heart, the worse her sexual function. They put those women on a cardiac rehab program to actually improve their cardiac function. So a diet and exercise program. And those women that actually put through the program four fold increase almost in their sexual function.
- [59:49]
A
400%.
- [59:50]
B
Fourfold. Yes, sir. Because we use a questionnaire called the fsfi, which is a questionnaire. So a significant improvement in sexual function just on improving cardiac function. So remember, cardiac function and sexual function are related and it's bi directional. You improve one, you improve the other. It's very important. We talked about this earlier. 40% of men in the world at 40 will suffer from erectile dysfunction.
- [60:13]
A
40%.
- [60:14]
B
40%.
- [60:15]
A
Jesus.
- [60:15]
B
50% at 50. 60% at 60. 70 at 70. 80. 80. You do the math. It essentially is a very prevalent condition. This condition is associated with increased cardiovascular events. It's the first sign of a heart attack. We talked about that. This condition is associated with two and a half times more likely to be anxious, three and a half times more likely to suffer from depression. And this condition is also associated with diabetes. In other words, men with ed, two times more likely to have undiagnosed diabetes. And yet only 50% of men even talk about it because they're so embarrassed. So you show me another condition in the world that affects more men's lives, that's associated with more adverse conditions. And they're too embarrassed to speak about it. They suffer in silence. There's not another condition. There's not another condition, but yet we're embarrassed to discuss it. I used to give these lectures and I would look out to the audience. I'd say, please raise your hand if you suffer from hypertension. And many people raise their hand. They have high blood pressure and say, okay, please raise your hand if you suffer from sexual dysfunction. No hands go up. But statistically you know that over 50% of those people had sexual dysfunction. So why is it okay to raise your hand if you have hypertension, but not okay to raise your hand if you have sexual dysfunction? It's gotta stop. We have to destigmatize. It's okay to have sexual dysfunction. It's a common condition. It's curable.
- [61:35]
A
Why don't men raise their hands from a psychological standpoint? Why is that?
- [61:38]
B
I think they're embarrassed. I think that historically, sexual dysfunction looks as like a weakness. I'm not a man, less of a man. You know, you have hypertension. It doesn't mean you're less of a man. But they have this assumption that it's a weakness, less of a man. And I think that it's okay. You have to be comfortable saying that you have sexual dysfunction. There are amazing treatment options for sexual dysfunction. Amazing. That work very, very well. You just have to raise your hand and let me know that you have it. I just want to make one other comment about diabetes. There was a study that came out of St. Louis looking at young men 18 to 40 years old, and they were screening them for erectile dysfunction. And what they found was when those men came in for erectile dysfunction, 30% of those men had prediabetes or diabetes on that day, on the day they were being diagnosed, 30%. And I thought to myself, young men do not go get screened. I remember when I was 30 years old, I didn't go in for my annual blood pressure check and my annual sugar check. There's no way I'd get my glucose check. But if a young man gets erectile dysfunction, he is at my front door first thing tomorrow morning. They show up. That's the first thing they're going to do, because it's a very big condition to them, and they want to get treated. And that is the opportunity to treat these young men and treat the condition. If you see a young man or someone who outcomes for ED and you screen them for diabetes, and I catch the diabetes at 30, as opposed to 40, that is 10 years of damage on the vessels that you're saving because you catch the disease early. So ED is the gateway to men's health and to treating men early before it's too late. So I really use sexual health as a tool, a vehicle to improve overall health, because men take sexual health much more seriously, particularly young men.
- [63:27]
A
Have you ever had sexual dysfunction?
- [63:29]
B
I have not.
- [63:30]
A
Never in your life?
- [63:31]
B
I have not.
- [63:32]
A
I have.
- [63:33]
B
I have not. But it doesn't mean that it's not. But it's okay if I did. There's nothing wrong with it, right? There's nothing. It's normal, it's okay. And it's transient. It can be temporary and come back, right? It's Nothing wrong with having sexual dysfunction. We must destigmatize it. It's completely okay.
- [63:49]
A
The reason I'm sharing this is because if anyone else has been in the situations. The situations I've been in are generally my sex life has been good my whole life. But there's been certain times with certain partners, or, you know, you might be drunk a little bit, or in the day when I was single, there was like the odd person who, for some reason, it just wasn't working for me. And. Or there was other instances in a previous relationship where near the end of the relationship, I'd, like, lose my erection during sex. And that became a little bit bothersome for me. Cause I was like, oh, my God. Like, it almost made me not want to have sleep with this person. Or it convinced me that maybe I don't like them anymore or something else was going on. And for me, it has always been. What's the word used? Psychogenic.
- [64:36]
B
Yes.
- [64:36]
A
It's always been in my head that the problems have arose. And the other part of the thing that I've experienced a lot is in terms of libido. I have, like, no libido. When actually it's slightly different when I'm. When work is very, very busy and I'm very, very tired and I come home very, very late. It's not that I'm not horny, but I just. The act of sex is just really unappealing.
- [65:04]
B
But you're just like everyone else. You're not unique when it comes to that.
- [65:07]
A
Yeah, but that much of my life is like that. Like, I come home late a lot, so I'm, like, tired and stressed quite a lot.
- [65:15]
B
Right. But what if I took you and your partner and put you on a beautiful island in Hawaii for two years?
- [65:19]
A
Oh, we have great sex.
- [65:20]
B
Okay.
- [65:20]
A
Yeah. So that's what we kind of like how we orientate our life. Honestly, that's genuinely how we've oriented our life. Because I just don't think the way. I obviously want to make lifestyle changes to make sure that I'm not always coming home tired and stressed at 11pm but one of the things that's really helped us is, you know, going away on the weekends and going away maybe on Friday and coming back on Monday and getting out of the same context. So, like, getting out of the house and going to a. Even like going to a hotel room, it's actually a bit of a game changer that you can just like go to a hotel room in the same city. Like a book, a staycation.
- [65:49]
B
Yes.
- [65:49]
A
And that seems to have a big impact because it just removes you from the context.
- [65:52]
B
Right.
- [65:53]
A
And then like, yeah, going away for the weekends, holidays and stuff. A lot of my friends say to me, they go. When they're struggling with their sex life, they just like, book a book a local. A local sort of staycation.
- [66:03]
B
Yeah.
- [66:03]
A
And I wonder why. I'm also. I don't have kids, so I've not experienced the impact that kids can have.
- [66:08]
B
On kids, which can have a significant impact, really. Right. Because it increases your stress.
- [66:12]
A
Right.
- [66:12]
B
Particularly for your. Many times for the partner as well. So if you both are stressed because of the children, sex goes lower and lower on the totem pole and underslept as well. Right.
- [66:21]
A
If you're not sleeping, if you have to wake up and be like, oh, gosh, isn't there stats that say, like, when someone has a kid, their sex life, like, vanishes for 18 months or something?
- [66:28]
B
I don't know. I'm not familiar with that stat, but I believe it, I believe it, I believe it.
- [66:32]
A
I read something about post having a kid, libido, but also just like sexual function.
- [66:37]
B
It makes sense. I see it in couples, and particularly, you know, many times it can take years for them to start engaging sexually because the stress is so high, particularly when they originally have the child.
- [66:47]
A
There was a British study done that found over 80% of women experience sexual problems three months postpartum, with nearly two thirds still affected at six months.
- [66:55]
B
Yes.
- [66:56]
A
Which. Which is a lot of.
- [66:57]
B
It's a lot of women.
- [66:58]
A
A lot of women. And that's a significant amount of time. So what about premature ejaculation?
- [67:03]
B
Let's talk about it. Very important. 30. So, sexual dysfunction. We've been talking about ED today. Right. But there are many different types of sexual dysfunction. There's premature ejaculation, there's Peyronie's disease, there's delayed ejaculation. We're just focusing on one aspect. Premature ejaculation affects 30% of men globally. 30% of men.
- [67:22]
A
How'd you define that?
- [67:23]
B
There's two ways to think about it. When they come in, you have to figure out, is this lifelong going their whole life or is this acquired? It's very important because it takes me down two different roads. If you say, look, I've never had premature ejaculation and yesterday it started. That's very different than if you come to me and say, my whole life I had premature ejaculation. And we now define premature ejaculation as having an ejaculation Less than two minutes. Used to be one minute. Less than two minutes. You have to have a loss of control, like I couldn't control it. And you have to be bothered by it. So if you tell me, stephen, look, I ejaculate in 30 seconds and I'm happy, I say, great, then we're done. You know, you are content. You have to be bothered by the condition. The average ejaculatory time in the United States is 5.4 minutes on average. Right. The average time for a woman to achieve orgasm is typically 13.4 minutes. So there's a big discrepancy here, as you can see, right? So 30% of men suffer, but we know that only a small percentage, these men, 9% of these men will ever seek therapy. And it can be a significant problem in a relationship. And that needs to be addressed.
- [68:24]
A
Okay, so there's not like a time limit. It's not like, okay, if you're coming within two minutes, then you've got a problem.
- [68:29]
B
Well, let's say you're not bothered by it. Let's say you and your partner are completely satisfied with it. What's the problem? Okay, what's the problem? And sometimes, if you think about acquired means, that typically we define it as 50% less than your normal time. So if you say, look, I typically used to ejaculate in eight minutes, and now it's four minutes, and it's bothering me, I'd say, okay, that's an issue. You know, so we talk, it's relative, what's comfortable for you? And some men will say, you know, so I think that's very important to look at the definition. The treatment options are actually, actually quite simple. One of the best treatment options is sex therapy, because we can train your mind, we can train you to delay that ejaculation. There's techniques, the start, stop technique, the squeeze technique, how we can delay it? No, but there is. But most men say, just give me a pill. I don't have the time for this. Just give me a pill. But there are ways to do it with sex therapy, which I think are fantastic. Sex therapy is a cure. The pill is just a band aid, right? Sex therapy is a cure. But the pills that we use. The most commonly used pills are antidepressants because they increase serotonin and make it harder to ejaculate. Well, that's what we want in this situation. We want to delay the ejaculation so we can use antidepressants. They sometimes have to be taken daily, which work better or you May have to take it on demand, but if you take it on demand six to eight hours ahead of time, so you need some notice.
- [69:48]
A
But there's gonna be significant side effects of taking antidepressants.
- [69:52]
B
Yeah, there are side effects of antidepressants, so I try to stay away from them. And the other ones I try to use are topical lidocaine sprays, because if I decrease the sensitivity of the penis, you're more likely to be able to engage in sexual activity for a longer period of time. So those are commonly used. So sex therapy and sprays are very easy to use. You don't need a prescription for sprays, and they're commonly used. One thing that we have to talk about that's really important is the Traverse trial. It's really big. Everyone historically has always said that testosterone is dangerous. It causes prostate cancer, and it causes a heart attack and a stroke. And in 2015, there were some studies that suggested testosterone may cause a heart attack. Before 2015, all the studies suggested that there was no increased risk. So in the United States, they mandated that there be a large trial, 5,200 patients, six years long, strictly to decide, does testosterone increase the risk of a heart attack? So myself and eight others designed the study, ran the study for six years, and we published it last year. It finally came out, and it showed that there was no significant increase in cardiovascular events. Finally. But until that time, until that came out, many people said, I still believe that testosterone causes a heart attack. But when the Traverse trial came out, the largest randomized placebo controlled trial ever published, we finally showed that giving testosterone did not increase the risk of a heart attack. In fact, the study also showed it did not increase the risk of prostate cancer. Many people are worried that testosterone causes prostate cancer and no negative effect on urinary symptoms. So many people have thought that if I give testosterone, the urinary symptoms become worse. The study showed no worsening of urinary symptoms. So very important study, the Traverse trial, finally came out. It's the largest trial in men ever published on testosterone.
- [71:38]
A
Will it reduce my lifespan?
- [71:40]
B
Will low testosterone, I believe, will reduce your lifespan.
- [71:44]
A
I mean, taking, like, testosterone injections and stuff. Sometimes I think about, like. Like, again, I don't really know what I'm talking about here, but I think about athletes taking steroids different.
- [71:55]
B
Those athletes are taking supraphysiologic steroids. So the normal range is typically 300 to 1000 is a normal range, and they will take testosterone levels to much higher. 2,000, 2,500. There's a reason for that? There's something called a plateau effect. So if you take testosterone and you have better libido, you intuitively would think, if I take more testosterone, I'll feel even better libido. But that's not true. There's a certain point at which it plateaus. So the more you take, you've already hit an on off button. You've hit it, you're done. The exception is muscle. The more testosterone your body sees, the more it upregulates androgen receptors in the muscle and you put on more muscle. So bodybuilders are addicted to higher levels of testosterone, but they're also taking other off label medications. Anavar Deco, Winstrol. They're taking other medications. And those testosterone formulations have a lower androgenic ratio. Androgenic means facial hair, acne. They're more anabolic. So it's very different than what you're taking. You're simply. Or what you would be taking. It's just all you're trying to do is take a medication that you had before and put yourself back into the normal range. Nothing fancy.
- [73:06]
A
So the more I've learned about testosterone, the more I've started to think that maybe when I've had my kids and I'm done having kids and maybe I'm 45, I should consider it, providing that.
- [73:19]
B
My levels are low and you're symptomatic. If you're 45 and you say, I feel great, I'm gonna say, steven, you're not getting it right. I feel great. So if you say, look, I'm 45, my levels are low and I'm starting to have symptoms, I say, okay, now's the time to consider taking the medication.
- [73:36]
A
Those symptoms you said were like tiredness, energy levels.
- [73:39]
B
Well, the most specific are my libido's gone down, my erections are worse, my energy has gone down, increased fat deposition, decreased muscle mass, poor sleep, and depression. And we have to talk about depression. So early on in my career, I conducted a very large trial looking at depression and testosterone. And we had almost 850 patients. And we showed that men with low testosterone levels were much more likely to suffer from depression. Almost 92% of those men with low testosterone had some degree of depression. And when we treated, 17% of those men actually had severe depression. We treated these men for one year with testosterone supplementation, and that 17% dropped down to 2%. Now, I'm not advocating to treat major depressive disorder with testosterone, but what I am advocating for is to at least check a testosterone level in men who are depressed because it can help them. In fact, in our study, even the men who are on an antidepressant, like, say, Prozac, we put them on testosterone. Those men also saw significant improvement in depression. So may there be some synergy between testosterone and what we call SSRIs? So again, it's very important to check a testosterone level in men who suffer from depression.
- [74:47]
A
You wrote a book called Recoupling.
- [74:50]
B
Yes.
- [74:51]
A
A Couple's Four Step Guide to Greater Intimacy and Better Sex.
- [74:55]
B
Yes.
- [74:56]
A
What are the four steps in this book? And you wrote this alongside it over 10 years ago?
- [75:00]
B
Yes. So I wrote it with a sex therapist. She's an amazing sex therapist. Her name is Mary Jo Rapini. And we decided to write a book together to really help couples get through. So the four steps really are, number one, foremost, communication. You got to communicate. You got to at least be able to tell each other. Did you know that only 44% of men who start developing ED even tell their partners? Now? Think about that. You say, what do you mean they don't tell their partner? You know what they do? They just start avoiding sex. They just start avoiding sex. So they got to communicate, number one.
- [75:29]
A
And making excuses, right? I mean, if I lost my erection, I'd. I'd probably say, oh, so I'm just tired or, you know, because I want to just. On this point, there's much of the reason why it's hard to communicate is because it can sound a lot like blame, and it also can make someone feel like you're not into them.
- [75:49]
B
Right.
- [75:49]
A
So if I said, and maybe you're not that into them, and also maybe you're not like that attracted to them. So, like, that could be.
- [75:56]
B
That's a problem. Yeah, that's an issue. And that's why the sex therapist is amazing, right? That's what they do, right? That's what they do. They work through these issues with couples, and they're fantastic. But the number one step we put in the book was communication. You have to communicate. The second chapter was my main chapter, what I wrote about. What can we do to improve sexual dysfunction in men and women? Testosterone replacement therapy using Viagra, vaginal lubrications, local vaginal estrogen therapy. We didn't talk about that. It's critical for postmenopausal women. Local vaginal estrogen therapy is. Is very important. Decreases this risk of UTIs, decreases pain with intercourse. So very important. The third chapter, really, sir, what is that?
- [76:38]
A
Vaginal.
- [76:38]
B
So younger women have estrogen in the vagina that estrogen is so important, it keeps all the bad bacteria away and keeps the good bacteria within the vagina. It keeps the lining of the wall thick. It allows for the vaginal wall to function with arousal properly. And as she gets older and she goes through menopause, the estrogen goes away, the bad bacteria come in, the risk of urinary tract infections go up, the wall starts to atrophy, means it gets thinner, it's more susceptible to injury and tear. It hurts. Right? So you can't ask a woman to enjoy sex if it hurts every time she has sex.
- [77:21]
A
A lot of women, I've had a lot of women talking about that, about this idea that the reason they don't like to have sex is because it hurts.
- [77:26]
B
It hurts because when they lose the estrogen, the wall gets very thin and it can tear. It hurts.
- [77:33]
A
But even young women, young women, but.
- [77:35]
B
It'S usually typically a different reason. They could suffer from vaginismus. There's other things that could cause vestibulitis, but in older women, the most common cause is atrophy of the vaginal wall because of the lack of estrogen. So what do you do? You give back local estrogen therapy. It can be in the form of a suppository, form of a cream. It doesn't happen overnight. I tell my patients it can take up to three months, but after three months they notice a difference and the urinary tract infections go away, the pain goes down. Right. So these are simple things that women can do to help because again, if someone's having pain with intercourse, man or woman, they will tend to avoid it. Right. It's an important concept. So the second chapter is really important on what are the many different things that you can do to improve your sexual function. The third chapter is really about intimacy. It's really the intimacy. And the fourth chapter really is ways to improve your sexual experience. It was written by my sex therapist. She talks about vibrators, masturbation. So there's a four step guide that I think is very helpful. And I think what's unique about this book is that really, it's really two perspectives. It's one, who is the medical care that I provide and the psychological care that she provides.
- [78:44]
A
Now she's obviously handling the psychological side of things and she's not here, but just on this point of improving communication. What is the best advice you give to people that are currently in a situation where they're both kind of suffering in silence because they're just not communicating with each other?
- [79:00]
B
Number one, Most important is time. We don't spend enough time. It's basically the shadows in the night. You coming in, I'm going out. And you have to make time. That's extremely important. And the second one is open dialogue. You have to be able to express to your partner what you're suffering from. Otherwise you can't get treated. You just have to be able to express it. But time, I think, is important and open communication and dialogue. There's nothing embarrassing about this. It really is something that needs to be destigmatized and the consequences of addressing it. So couples who engage in regular sexual activity have a significant improvement in their quality of their relationship. They tend to be happier and suffer from less depression. I mean, there are physical and emotional benefits from regular sexual activity.
- [79:47]
A
In the opener of the book, where you start talking about communication, there's a sentence that says, when sex isn't going well, it can become 90% of the relationship. And couples seldom know how to communicate about any of these problems. And that is true. You know, we've done a couple of conversations now on the Diarrhea Sea about sex and intimacy in these subjects. And the amount of messages that I get from couples saying that everything else in their relationship is great. Yeah, everything is great. Love this person so much. But there's this massive elephant in the room, no pun intended, which is the lack of sexual intimacy. Now, when we talk about sexual intimacy, does it mean penetration?
- [80:25]
B
Yeah, it doesn't, because the definition of sex span is the ability and the desire to engage in satisfying sexual activity. I have patients that come to me and say, we do not have penetrative sex, but we have a wonderful sex life. I say, great. If this is working for you because it's satisfying sexual activity, you're set right. It's. If you want penetrative sex and you cannot have it, then we will address it and we can fix it. But you get to define, Stephen, you define what is satisfying sexual activity on.
- [80:56]
A
Chapter four, where you talk about things like vibrators and stuff like that. I know that was a chapter handled by your sex therapist. According to what you said, is there any risk that using vibrators or other toys and tools will impact normal intimacy without vibrators? Like, is there any studies that say, okay, you get desensitized to the real thing if you start using a vibrator?
- [81:18]
B
Yeah, I've seen the opposite. I've seen that the studies showing that vibrators and these kinds of toys can actually enhance the ability of the relationship so that you could because you're communicating as you're doing it, right? So you're communicating with your partner. What. What is giving me pleasure? What is not giving me pleasure? You're learning about each other. It's a great tool to use to learn about each other. So when you're engaging in sexual activity, you're more aware.
- [81:39]
A
I think it was a game changer for me.
- [81:41]
B
I'm gonna be honest.
- [81:42]
A
I think, like, just having other things, you know, why? Do you know why? It's a game changer? And I'm not just talking about vibrators. I'm talking about all toys in the bedroom, whether it's like, dice or handcuffs or whether it's something else. A blindfold is just because novelty. Doing new things for me is so critical as it relates to being excited sexually. And there's only so many things you can do. There's kind of. There's a relatively limited list of things you could do if you're not bringing in other tools and toys and stuff, you know? So I think that for me, it actually has helped me to prolong the novelty of my sexual relationship in a way that nobody told me about before. Cause I think as a guy especially, I think you kind of think that toys are something your partner buys for herself, maybe something she uses for herself. And now I think, if anything, I'm the instigator of using other things.
- [82:37]
B
Yeah, that's chapter four. I mean, and we prescribe vibrators for men. We use something called Vibrect. It helps with men with delayed orgasmia. These toys can be very helpful in a relationship.
- [82:48]
A
I think she prefers the toys to me personally. That's another conversation for another time. In terms of energy, there are so many reasons why I'm a big Matcha fan, if you don't already know by now. And so much so that I actually invested in the UK's leading matcha company called Perfect Ted. And one of my favorite Perfect Ted products is these delicious Matcha pouches that come in every flavor from salted caramel to peach flavor to mint flavor to berry flavor. One of my favorites is this vanilla flavor, which I'm going to make in just two seconds. You just take this mixer here, get a little bit of the powder, pop it on top of the shaker like that. Put the lid on shake, shake, shake. Delicious. If you haven't tried this yet, you can find Perfect Ted at Tesco and Holland Barrett stores or online, where you can get 40% off with my code diary. 40 head to perfecthead.com and put in code diary 40 to try this delicious multi flavored matcha now. Highly recommend. And if you do it, please tag me, send me a message online. What's the most important thing we haven't talked about that we should have?
- [83:54]
B
Well, there's a couple things I want to talk about. One is we didn't talk about Peyronie's disease. It's an important disease. 9% of men in the world suffer from Peyronie's disease. 9% of men in the world. Peyronie's disease is an abnormal curvature of the penis when it's erect. So I want you to think about this. The way I can describe it is if I have a balloon, I put a piece of tape on the balloon. Balloon. I blow the balloon up. What's going to happen? It's going to curve in the direction of the tape, right? So if a penis curves greater than 60 degrees, it's prohibitive for intercourse. These men are suffered. Many of these men suffer from severe depression. It's disfigurement. It's disfigurement of the penis, Right? So think about it. 9% of men in the world suffer from this condition. And most men have never even heard what Peyronie's disease is. And essentially in the US we have now one, one FDA approved treatment for this. It's an injection called collagenase, where we can put an injection into the rock plaque and break it up. There are surgeries that we can do to make the penis straight again. But again, it's very important to realize that patients who have Peyronie's disease are also suffering in silence. They don't know where to get the treatment. And there are many good treatment options, whether it be surgical or medical, to solve this condition. So, you know, my whole takeaway from this is this, is that I know that millions of people right now, men and women, are suffering from sexual dysfunction. I know they're silent and they're not saying a word because they don't know where to go. They don't know what to do. But they have to realize that there are excellent treatment options available and they should seek therapy. They're not suffering alone.
- [85:20]
A
What else?
- [85:22]
B
I want you to think about sexual dysfunction as no longer a band aid. We are not looking for Viagra. We are looking for a cure. We want a cure for ed. And a cure for ED could be based on many things, as I mentioned earlier, diet, exercise, sleep, stress. We've also moved into a new generation of regenerative, therapies in my field, stem cells, prp, shockwave therapy. Now we're starting to look at radio frequency in our laboratory. We're looking at hyperbaric oxygen. Men are looking for ways to cure this condition. They no longer want to take a pill to solve the problem. And so I think that's very important. And many of these new therapies are promising. I think shockwave therapy is very promising where we have a device that delivers shocks to the penile tissue. When doing this, it's like, well, but I'll tell you, we've been doing it now for five years and it was invented in 2010. It's actually quite brilliant. If I take your finger and I take a hammer and I hit your finger multiple times, what do you think your finger's gonna do? Your finger is going to start bringing in new blood vessels and new ways to heal your finger. So before urology, the cardiologists have been doing it for the heart for many years, and they would shock the heart many times and you would see new blood vessels form. It's called neo angiogenesis. Orthopedic surgeons have been doing it for a long period of time. In terms of injury, in terms of healing injury, they use shockwave therapy. We are new to the game, but what we see is when you give these shocks, it can potentially improve the blood flow and sexual function in men. And I think the new era could potentially be hyperbaric oxygen therapy and also radio frequency. Radiofrequency is a way to increase heat within the tissue and improve sexual function as well. So again, I think what you're gonna see five to 10 years as we move forward is new ways to cure erectile dysfunction. Stem cells potentially have some promise as well, but patients don't want a pill anymore.
- [87:12]
A
One thing we haven't talked directly about, but we've talked about it indirectly, is the role that trauma plays in sexual dysfunction and trauma in all of its forms. I think I had a partner who was very public again about the fact that the reason why they had sexual dysfunction was because in their view, because they'd been through a sort of traumatic experience. How often do you see that in your office? How often do you see a patient come to man or woman with some kind of trauma?
- [87:37]
B
We query all men and women if they've had any kind of trauma, sexual or just physical trauma. It doesn't have to be sexual trauma. It could be any kind of physical trauma. I will tell you that most patients don't disclose or not very commonly described to have Having it, but they will many times disclose it to the sex therapist. And I'll find out on the back end, to be honest with you. But I think when someone discloses sexual trauma or trauma, it takes more of a relationship and time on the first visit. Sometimes they're not forthcoming.
- [88:09]
A
What's that that you have in front of you on the desk? I've been hesitating talking about it.
- [88:14]
B
This is a penile implant.
- [88:16]
A
Oh, gosh.
- [88:16]
B
And this. Yes, that's exactly what it is. And this is a device that was invented in 1973 by a very famous urologist named Dr. Brantley Scott. Brantley Scott, I will have to brag a little bit, was from my institution at Baylor College of Medicine. And it's been around for 51 years. And the penis actually has two bodies sitting on top of and it has the urethra sitting on the bottom. And those two bodies have muscle inside them or casing. And what this device is, the surgery that I form quite often where we put these balloons or cylinders into those two bodies and fill them up. There's a small pump that goes into the scrotum, and there's a small reservoir that just holds water, normal saline that goes behind the pubic bone. Typically when a man squeezes this, he starts filling up these cylinders with water, and it gives him a very rigid, very good erection. When he finishes engaging in sexual activity, he'll press this button here and it will actually release and all the fluid will come out of the penile bodies and go back into that reservoir. So theoretically, anyone who's willing to have this surgery, we can cure Ed, but it's a surgery.
- [89:27]
A
And what's the consequence and cost of that in terms of sexual experience?
- [89:31]
B
Monetary costs. I would say that in the U.S. medicare covers as this product. So that's actually quite good in terms of pleasure. And men report no significant decline in pleasure. If you look at overall satisfaction, it's greater than 92% for patient and partner with the penile prosthesis. So it is a very. It's a game changer. It really is a game changer. Most patients have never heard of it, or most people have never heard of this penile prosthesis. But, you know, let's be honest. You know, if you had a bad shoulder, you'd get a prosthetic. If you had a bad hip, you get a prosthetic. It's a prosthetic that fixes an organ. And, Stephen, the satisfaction rate is extremely high. But I'll tell you something, you owe me something because When I brought this on the plane and I went through security, they maybe pulled us out and explained what this was and nobody had heard of it. No one had seen this. They didn't believe you. Yeah, well, I had to explain it and I had to pump it up and show them, but I had a little bit of an audience. But yes, but I will tell you this. This is something that really has revolutionized the way we treat men for erectile dysfunction.
- [90:37]
A
But this is surely like a last ditch attempt.
- [90:39]
B
It is, because it is a last ditch attempt. Because if I take it out, no other treatments will ever work again.
- [90:46]
A
Oh, really?
- [90:47]
B
It's the end, right? So if I take it out, no other treatments will work again. So I want you to try every single option before we come to this.
- [90:59]
A
What situation does someone have to be in for you to insert this into their penis?
- [91:03]
B
So remember when I told you that 40% of men at 40, 50% at 50, and most patients will take Viagra, but I told you Viagra is not a cure, it's a band aid. So what's going to happen that Viagra is just like that pain pill. And that pain pill eventually is going to happen is you can't walk. Well, the same thing happens with ed. Eventually the meds stop working. So once the meds stop working and then the second level, we use something called penile injections. Some men will use penile injections. Once you've tried everything and nothing works, what are you going to do?
- [91:28]
A
Okay, so this is like a last.
- [91:30]
B
What are you going to do if you still want to get. But if I look at satisfaction rates, if I give men questionnaires for the pill, for the injections, vacuum reduction device for the implant, Highest satisfaction with the implant.
- [91:44]
A
At what point? What do you mean?
- [91:46]
B
How satisfied?
- [91:47]
A
From a starting point to.
- [91:50]
B
Right. If I.
- [91:50]
A
Because if I'm starting at a point where I'm completely unable to get an erection, right. If anyone helps me get that thing up, my satisfaction is going to be really high.
- [91:58]
B
Right. But let's say you have an erection with a pill, you get an erection with an injection, you get an erection with a vacuum, and you get an erection with this. All four, you know, over time, gave you an erection, which gave you the best erection and which one were you most satisfied with? This will win.
- [92:13]
A
That's crazy. And can you still ejaculate with this?
- [92:15]
B
Yes. No issues? Gosh, no.
- [92:23]
A
I mean, again, I have tremendous sympathy because it ruins people's lives.
- [92:27]
B
It does.
- [92:28]
A
If you, if you can't perform in that way, and it destroys your relationships. And relationships are like the essence of life. So.
- [92:33]
B
But essentially, you're taking someone who can't have sex, who can now have sex again. And some would argue that they can have sex whenever they want, as long as they want with this device. Right. It only goes down when you tell it to go down.
- [92:44]
A
Dr. Mo, we have a closing tradition on this podcast where the last guest leaves a question for the next guest, not knowing who they're going to be leaving it for.
- [92:49]
B
Yeah.
- [92:50]
A
And the question that has been left for you is, have you ever experienced anything that you cannot explain from a position of rational materialism?
- [93:03]
B
I mean, I think so many things in science that we can't explain, so many things that are idiopathic that I have no explanation for. For example, for fertility, which is something we talked about. 40% of men who come to me, our explanation is no explanation. We don't know why you're infertile. Right. So obviously that's very uncomfortable for many patients to hear that. But many things in science I have no explanation for, and many things that I do have an explanation for, we find out 10 years later were wrong. So I think that's what comes to mind.
- [93:33]
A
What about any personal experiences at all in your life? Spiritual? Religious?
- [93:39]
B
Yeah, I'm very spiritual. I'm very religious. Sometimes death, hard to explain, hard to understand why it's real. I see it every day. You know, we see it what we do at work. My. I see it personally in my own life. My father passed away at an early age from idiopathic pulmonary fibrosis. It's a very. It's a condition where your lungs start to scar. It's probably the worst condition you could ask for. And. And he had to have a lung transplant at 70. So it's pretty young. And he retired at 69 and said, you know, one. And he worked very hard. He was a general surgeon, single, you know, solo practice. And he said, one day I'll enjoy. One day I'll enjoy. And then at 69, he retires, he's ready to enjoy at 70, gets idiopathic pulmonary fibrosis at 70, gets a lung transplant and lives for five years with someone else's lungs, which is pretty tough. And his one message was, you know, don't wait till the end. Enjoy the ride. I wish I'd enjoyed the ride because waiting to the end, sometimes there may be no end.
- [94:53]
A
And by that, I interpreted that to mean that he'd worked. Worked his whole life, very, very hard, extremely hard. And he sort of delayed the gratification to a point that.
- [95:02]
B
Right.
- [95:02]
A
It didn't really come necessarily.
- [95:04]
B
He thought it would come at 70 and he'd enjoy the last 15 years and enjoy. But at 69, he got idiopathic pulmonary fibrosis. At 70, we got a lung transplant. And at 75, he passed away. And I think that if anything I learned was, don't wait to the end, Enjoy the ride.
- [95:24]
A
Are you doing that?
- [95:25]
B
I am, every second I can.
- [95:28]
A
And how do you do that, sort of practically, when you're so busy?
- [95:31]
B
So I make time. I meditate every morning. I work out every morning. I have my own time to myself. I pray. I'm very religious. I think those are very important things that keep me going. I spend. It's God, family, work, patience. I mean, it's an order. My family is extremely important to me, and I make time for them as well. And I think that keeps me grounded.
- [95:52]
A
Dr. Mo, thank you. Thank you for the work you're doing. Because as you say in your work, there's a huge proportion of people, couples, men, women, that are suffering in silence, and they are in search of answers. And there's not a lot of people in your friendship group that are necessarily going to know this stuff or even talk about their own experiences with this. So I think it's important to have these kinds of conversations that anyone in the private or comfort of their own home or with their AirPods on can tune into to get a better understanding. If there was a closing message for those people that are suffering in silence in some way, whether they're couples, individuals, what is that closing message to them?
- [96:26]
B
It's okay to suffer from sexual dysfunction. It's normal as we age. And there are many treatment options, good treatment options that can help you today. And I ask you to seek therapy, raise your hand, tell your doctor you suffer from sexual dysfunction because they're excellent treatment options.
- [96:44]
A
And if people want to learn more about you and your work, where's the best place for them to find you?
- [96:48]
B
Well, it's my website, drmohitkhaira.com and sexspanhealth.com I have sexspanhealth.com where you can learn all the different ways to improve lifestyle modification. I started a nonprofit, I just want you to know, called the Testosterone Project, Just so you know, that it's really geared at education, advocacy for testosterone. We're trying to get testosterone approved for women in the United States. I think that's important. We're trying to get testing done as well. We want everyone to be tested for testosterone. It should be norm as well, and we're trying to get it deregulated. So thetestosteroneproject.com is a great way to get information as well.
- [97:22]
A
I'll put all of those links below. Dr. Mo, thank you so much for doing and please do keep doing it because it's so incredibly important.
- [97:28]
B
Stephen, pleasure to talk to you. Thank you.
- [97:30]
A
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