Transcript of Sex Scientist: Phone Addiction Is Killing Your Sex Life More Than Porn! New

Is there a way to enlarge the dick?

So you can put your penis in this device. They've actually done research on this. So 30 minutes twice a day, and it does show improvements in length, about 2 centimeters. Ta-da! And that's not all. So they actually did a study on pistachios where guys ate 100 grams of pistachios every day, and they saw a decrease in erectile dysfunction. Because if you're not having erections, now you're no longer getting blood flow to your penis, and it will shrink over time. And the same goes for women with their clitoris because it's the same type of tissue. But also, when you look at people who have sex once a week, they live 49% longer than people who only have sex once a year.

49% longer?

Yeah. And for every 100 orgasms men had, they lived like 13% longer.

Be right back.

Dr. Rena Malik has become the world's most watched urologist.

After sharing everything you need to know about hormones, sexual health, and how to have better sex based on the data.

So how can you have the best sex possible? So there's 4 main pillars of sexual health. So pillar 1 is fuel. So how you nourish your body. And it's a huge part of sexual activity. And then pillar 2 is strength. When people think about strength, they always think about going to the gym and lifting weights, but it's much more than that. So when you look at the data, any sort of cardiovascular exercise is going to improve sexual function. It's gonna improve blood flow to the penis and to the clitoris. And then also, if you do 150 minutes a week, it is the same amount of improvement as you would see when you take a medication like Viagra. And the other part of it is the pelvic floor. It's undervaluated and underdiscussed, and we'll get into that. But pillar 3 is environment. So things like sleep, stress, sleep, and endocrine disrupting chemicals. For example, they looked at data on men sleeping 5 hours a night versus 8 hours a night. Guys who sleep 5 hours a night, their testosterone drops by 15%. Wow. And then the last of the 4 pillars that we don't talk about enough is shit, and that's so important.

Reena, I wanna talk about morning erections, squirting, clitoral stimulation, and certain positions that are going to increase the probability that my partner has an orgasm.

Let's talk about all of that. First of all—

Guys, I've got a favor to ask before this episode begins. The algorithm, if you follow a show, will deliver you the best episodes from that show very prominently in your feed. So when we have our best episodes on this show, the most shared episodes, the most rated episodes, I would love you to know. And the simple way for you to know that is to hit that follow button. But also, it's the simple, easy, free thing that you can do to help us make this show better. And I would be hugely grateful if you could take a minute on the app you're listening to this on right now and hit that follow button. Thank you so, so, so much. Dr. Reena Malik, if somebody was to come up to you in the street having watched your videos online and they were a, a follower of the content you've produced over the last couple of years, if you had to guess the question they would ask you, because it's probably the most frequent popular question you get asked What do you think they would say? They would say, "What can I be doing right now to improve my sex life?" Who would be asking you that question, and why do you think they'd be asking it?

I think everyone can agree that sex is something we enjoy. It's something that's important that we want to have, right? And there is, um, a desire to have good sex or feel like maybe you're missing out on something that could be even better. So how can you have the best sex possible? Because you hear all these people talking about amazing sex in the media, you might see it on pornography, you might feel like this is something amazing. Why am I not having that? I want that, right?

So on that point, you said it's obvious that it's important. I think it appears to be increasingly not obvious that it's important, because when you look at some of these stats— I'll throw this graph that I've found here up on screen— and it shows that people are becoming more sexless, especially young adults between 18 and 30. This graph is pretty stark.

Think about 50 years ago, there was no cell phones. There might be some TV programs, but there was ads. In between TV programs, and there was only certain TV shows you could watch at a certain time that you enjoyed, and then there was nothing to watch. There was no email. So you went to work and you came home, and there was really not a lot of communication between you and your coworkers or your job. They made dinner with their family, they hung out, and then maybe they watched a program or two, and then they lied down in bed. They didn't have a phone to scroll on. They didn't have anything to keep them up. And so then they were like next to their partner, and maybe they're talking, maybe they're cuddling. And so there was more like opportunity and space for sex, right? You— it was a thing that you did for enjoyment. For pleasure, for fun. Now we have all these distractions that keep our mind away from sex. In order to enjoy sex, you need to have space for it, to be able to enjoy your partner and feel like you want that, right?

And now we're sort of— there's not as much room for it. That's one. Two is younger people, how are they dating, right? How are they meeting each other? They're meeting each other through apps, through DMs, and so they're not actually like really having these deep meaningful connections. There's hookup culture. There's a big, like, fling culture. And imagine first-time sex for most people is not great. You don't know your partner, you don't know what they like, and you may not be able to express what you like. You were never taught how to talk about sex, right? So you don't know how to say, like, hey, I like it like this. And you may be self-conscious because it's your first time, so you have, like, mediocre sex or bad sex. And you're like, well, I don't really want that. And there's just no, like, follow-through, right? There's, there's not a lot of education on what sex should look like. The only education people are getting are from often erotic films And so they're seeing sex that's not real, that's curated, and they're trying to emulate that. And that's not pleasurable for most people. And younger people these days are actually having a rise in more what we call rough sex.

So choking has become very, very common, as common as like— they call choking almost like vanilla sex. So young people, if you look at data, like 60% of women and I think it's 20% of men have been choked during sex of that age group, like college age group. And of those people who get choked, 20% have been choked 25 times or more. Now, I think it's fine if you're into that, but I can't imagine that that many people are into choking. And there's data to support that. So when you look at qualitative data, and this is by Debbie Herbenick, she's a sex researcher, and she did qualitative research and she asked people like, what is it like? Do you enjoy being choked? Tell us about it, right? Women were like, yeah, it's okay. Sometimes I'm scared because my partner is big and strong and I'm, you know, smaller. And they have big hands. Sometimes it's fine and sometimes I don't really care for it, but like, it's just a part of sex. It's just as normal as kissing, for example. And so if you're having sex and you're doing things just because you think that's what your partner wants or what it should look like and you're not enjoying it, well, that's not gonna be sex that you wanna have.

00:06:55

That point you said about the lifestyles we lead and how that might be impacting our sex lives, I thought was really interesting 'cause we don't talk enough about this. But when you look at some of the data on this demographic, um, you know, people 30 and below, around that age, the extreme outliers are spending 8 to 10 hours on their phones, on social media, and on the internet. And roughly about 15 to 20% of young people describe their usage as almost constant, effectively scrolling during all waking hours, while they're eating, while they're in the bathroom, and before they go to sleep. So I was wondering, from a dopamine perspective, if there's correlation between these, like, dopaminergic activities that are now like hijacking our lives, whether it's short-form videos on social media, whether it's pornography or food, whether it's having an impact on what then happens in the bedroom and our performance in the bedroom.

If you think about what you need to have good sex is you need to be sort of in the mind space for sex. And if you're constantly like hijacked by all these other things, you're never like really getting in the mood, right? You're just like, oh, I'm gonna be turned on when I see my partner and we're gonna have sex, it's going to be over. And it's just really a mechanical thing at that point, right? You're not actually— you're just trying to get an orgasm. You're not actually like spending the time to enjoy and to experience that fully because you're just so like— you're just— your brain is always doing something else, right? Because people are constantly scrolling, like every 60 seconds there's a new video, there's something else. And so it's really hard to focus. And so that can translate to the bedroom where you're like, you're having sex, but your brain is somewhere else thinking about something else you saw or something you have to do or something you want to see or something you want to look up, whatever it is. But you're not really in there in the moment. You're just going through the motions.

And so I think that's really where the challenge is, is that people are becoming increasingly distractible.

I find it really hard, I'm gonna be honest, to have sex if I've had like a really, really busy day or if I'm really, really thinking about something. Yeah, I almost have to— I have to like intentionally create quite a lot of space.

Exactly.

In order to be able to be in the mood.

Yeah, be aroused, right? It takes like time and energy. I think I appreciate you for saying that because a lot of people think that men are ready to go at any moment. And that's not fair, right? Because everyone needs time to be aroused. It's not just instant for everybody, especially when you have a lot of work stress or life stress or other things going on. It's actually like you have to make time and space for it.

Yeah, because as a man, you've got to get an erection. And I always think that an erection is a consequence, usually, especially when it comes to sex. And I'm not talking about morning glories here, but an erection is a consequence of like a story you use the word aroused. There's like a story in my head which makes me go, oh, that's kind of hot.

Yeah, you need something, you need some stimuli, right? You need to think about something, see something, smell something, feel something, right? You need to just be together and sort of allow yourselves to be intimate before that sort of desire and arousal come together.

And for me as well, it's not just touch. Like, that doesn't necessarily— for me, it really is quite like a psychological thing. I was wondering if this is there's any data around this, or I mean, just even anecdotally, like, people get aroused in very, very different ways, don't they?

Yeah, absolutely. I mean, some people are very, like, visual, so they, you know, they see their partner and they get aroused very quickly. Basically, when you get aroused, you need to be in a parasympathetic nervous system state. So in order to get an erection, you need to be in the state which is like rest and digest. So if you're stressed, if you're thinking about other things, if you're essentially on the go, you are not allowing your nervous system to calm down. And so for some people, that's a whole bunch of different things. Some people can switch more easily into that state, and some people need more of like, uh, you know, to feel either mentally stimulated, or they need to have some associations. Like, it might be like they need a certain scent, they need to like relax their body, they need to like go take a bath, whatever it is. But some people need different things, and knowing what that is for your partner is super important, right? Because then you can incorporate that. Everything is scheduled in our lives, right? And then you're like, oh, but now sex is like the last thing on in the schedule, right?

And like, I don't even think about it. Like, oh, okay, now, yeah, maybe let's have sex. But it's like, if you actually make time to be intimate, allow yourself to be in that brain space, be together, that's when it can actually happen. Especially when you've been in a long-term relationship, it doesn't come as easily, like spontaneously, which we call spontaneous desire. It comes more of as a response to these other cues that allow you to feel desire and to feel aroused.

I also think— I was thinking about a previous relationship I had where on the days where I'd been like working very hard and I was like tired or stressed or I'd been traveling and I was jet-lagged, I think there was also— because I didn't see this person often, there was also an expectation that when I did see them, we were gonna have sex. And, um, that was, that was very hard because actually the expectation of it stressed me out more.

Yeah.

And that can happen, like if it becomes the elephant in the room, it can become a little bit heavy, which then is sort of counterproductive to performance.

And this is, you know, sort of a variation on performance anxiety. So when you feel like you have to perform on demand and maybe you're worried it might not happen, it creates this vicious loop, right? So you may maybe have trouble with an erection, or maybe it's like, I am expected to have sex, but I really can't get there mentally. Whatever it is, now you're thinking about that, right? And then you're with your partner, you're like, oh my God, am I going to have trouble? You're not enjoying the pleasurable sensations or the visuals or like feeling each other, you are literally thinking in your own head about how you're gonna respond. And then that anxiety makes it so that you can't get an erection or you can't be aroused. And so now you're like anxious and you're not focused, you're just almost spectating, you're just watching yourself have sex, you're not actually like in the moment. So then, you know, you have a negative outcome because when you're stressed, your sympathetic nervous system is on, right? You can't really get an erection or you can't really get aroused. And so then you're like, oh man, now I've let my partner down, now I haven't performed performed, which I hate that word, but like performed the way I should, or I'm expected to, and now something's wrong with me.

And now that just keeps going in a vicious cycle.

Have you spoken to people that have experienced this?

Absolutely. It's common, very common. I tell people, anytime you have problems in the bedroom, it stays with you.

So how do you break the cycle?

Yeah, so I tell people, when you're with your partner, take the pressure off, um, penetration. Just explore each other's body. Do what's called like sensate focus, like explore the rest of your body, figure out other erogenous zones, other things that can turn you guys both on that don't involve erections and penetration. And then once you realize you're focused on that, you're really like exploring, enjoying, playing, you're having a good time, and you're not thinking about your erection. Now you'll notice, oh, the erection just comes, right? And then once you get to that point, then you can start even touching genitals, but still hold off on penetration. And then after you've realized like the genitals are, you know, it's always working the way I want it to, and I'm not thinking about it, I'm not stressed, then finally you can then introduce penetrative sex again. So it's just sort of like a graduated, sort of slow advance into, um, you know, having sex again, but now kind of focusing on being more present and mindful and enjoying those sensations.

I think a lot of people will be able to do that, but there's also a big contingent of people that just avoid sex. It's, it's a sore subject in their relationship for whatever reason. Both partners don't know how to communicate. They haven't got the tools to talk about these kind of things openly and honestly. Do you see that a lot as well?

Absolutely.

I mean, what do you hear in this regard?

So I think it's really sad. I see people come in and they're like— I ask every patient, like, are you, are you having sex? Why not, right? Because sometimes they'll say no, and most doctors are like, okay. But I always say, why not, right? Why are you not having sex? Is it because you're having an issue? Is it because you're having pain? What's going on, And oftentimes, I'll hear from people that my partner is just not into it, and I just sort of gave up, and I'm just— we just don't have sex anymore. You know, for me, that's a red flag because sex is a huge important part of our lives. It is a way we connect with another human being. It's also telling that things are working really well. So when you have good sexual function, meaning you get an erection well, or you get aroused well, and you have a good orgasm, and everything feels good, that tells me that, hey, you you've got great blood flow to your genitals, your nerves are working great, your hormones are sending signals. Like, all these things are good, right? But also, sex is more than just the act of sex.

It also helps you live longer. So there's been a few studies looking at sex and longevity, and when you look at people who have sex once a week compared to people who have sex once a year, the difference in all-cause mortality is 49%. They live 49% longer than people who only have sex once a year.

49% longer?

Yeah, yeah.

Be right back. No, I'm joking.

So, and, but even if you're doing like less than once a week but more than once a year, it still improves your longevity. There was actually an interesting study in 1997, I think it was, where they looked at the number of orgasms men had, and they found that men who had, for every 100 orgasms men had, they lived like 13% longer. They had a 13% increase in life expectancy. And so it was really interesting to me to just, just showing you that like, this is not just an act of pleasure and fun. It is obviously, but it's much more than that because people who are having sex clearly have better health. And there, this connection with people, I mean, loneliness is a big issue right now. The WHO made loneliness like an epidemic. So they've said that loneliness is as bad as having like 15 cigarettes. And so So sex is a way to feel connected to another human being.

On that data, we're not saying that it's the sex itself that's causing people to live longer. We're— I guess it's, it's hard to establish causation in terms of—

yeah, it's not necessarily sex, but they've looked at, like, they try to control for other things like age and comorbidities and all these studies. And, um, it's also like sex is a cardiovascular workout, right? For many people, as a cardiovascular workout, you are getting a physical, physical activity with your partner. Um, you are increasing your heart rate, you are doing these things that are also good for your your body. And the fact that you're able to have sex, right, tells me a lot about it, right? You're, you're able to hold a certain position, you're able to maintain this level of activity without getting short of breath, right? Like, these are things that having sex, you know, keeps you healthy to some degree.

If I want to make sure that I have great sex, what are some of the foundational things that I need to be thinking of in terms of my lifestyle?

Yeah, so there's 4 main pillars of sexual health. I like to think of it like your sexual health is your house and these pillars are the foundation. And if you don't have the foundation, it doesn't matter what else you do. You can try to do everything else to patch up your house, but it's always gonna break again because the foundation's not there. So you've got fuel, and fuel is how you nourish your body. A lot of the data I'm gonna talk about is about men because there's just a lot more data on men and sexual health. But that doesn't mean that the same things don't apply to women. There's just less, less robust data on it. So when you talk about fuel, the Mediterranean diet is the most studied diet. So including things like healthy fats like avocados, leafy greens, nuts— and we're going to talk about nuts in a little more detail— these things are super helpful. And obviously having lean proteins, having an abundance of fruits, which we're going to talk about as well. There's a study called the Health Professionals Follow-Up Study. There was a 20,000 men, and they saw that men who adhered to a Mediterranean diet had a 22% lower risk of erectile dysfunction.

So what specific things in that diet, right? People are always like, what are the superfoods I need to have? Almonds are great, but pistachios Pistachios, they actually did a study on pistachios where they looked at 100 grams of pistachios, guys ate 100 grams of pistachios every day, and they saw a decrease in erectile dysfunction.

So pistachio nuts will make my penis harder.

I mean, so I always say, like, I don't love to talk about superfoods because then people are like, "Oh, I just gotta eat pistachios and it's all good," right? It's part of a whole diet, but certainly having nuts because they have great omega-3s, they have healthy fats, these are the reasons that they really sort of improve diet. Fruit, anything that has sort of flavonoids, so like colorful fruit, like blueberries, citrus fruits, lycopene, which is red fruits, all of these things improve antioxidants and also have been shown to reduce the incidence of erectile dysfunction. So having stronger erections, specifically blueberries actually came out to have, I think, something around 20% also improvement in erectile function when you're eating blueberries regularly. So lots of, I think, things in the diet that can be helpful. Also fiber is one that we don't talk about enough. When you eat fiber in your gut, it converts to short-chain fatty acids. These short-chain fatty acids then sort of have these endothelial protective mechanisms. They protect the blood vessels, they make them healthier. And so when your blood vessels are healthy, you get better metabolic health. So you get less diabetes, less high blood pressure, less high cholesterol, and these, all of these things together improve erectile function.

Hmm. So I think making sure that you meet the criteria for fiber, which is 38 grams for men, 25 grams for women, is really, really important. And then obviously managing your calories in a maintenance, right? Because we don't want to gain weight because excess adipose tissue or excess fat also puts you at higher risk for erectile dysfunction and other sexual dysfunctions. Next, we have strength. All right. So there's strength where we think about cardiovascular and resistance exercise, but there's also pelvic floor strength. So we'll start with cardiovascular exercise. The one study that's quoted very often is 150 minutes of exercise, of cardiovascular exercise, moderate intensity. When you look at the improvement in erectile function scores, it is the same amount of improvement as you would see when you take a medication like Viagra. So, literally, if you do 150 minutes a week, you are getting the same improvement as you could get with a medication potentially. And so, I tell people like, look, if you don't wanna take a pill, this is a great way to improve sexual function. Now, you might say, okay, Well, I, you know, maybe you're listening and you have heart issues and you can't really do moderate intensity exercise.

They actually looked at that too. So there was a group where they looked at men who had heart disease and they weren't really able to do moderate intensity exercise. So they did like a 5-minute warmup. They did 20 minutes of walking and 5 minutes of a cool down. And with this supervised protocol, they still improved erectile function by 70%. So it's all relative to where you're starting, but any sort of cardiovascular exercise that's above what you are capable, like what you're doing now, is going to improve sexual function, particularly erectile function, 'cause it's gonna improve blood flow to the genitals, gonna improve blood flow to the penis, it's gonna improve blood flow to the clitoris for women. So that's where cardiovascular exercise is so, so important. In terms of resistance exercise, now these little weights are probably not sufficient for doing much, especially for men, in terms of improving muscular health. But obviously we're not gonna bring like really heavy weights to the table here. So one, we know that resistance training is significantly correlated with testosterone. So when you do heavy resistance training of your large muscle groups, so like your lower extremities, your glutes, you're doing like Olympic deadlifts, squats, that sort of stuff, you actually see improvements in testosterone.

Now, it's not gonna be like you do it once and you get this sustained improvement, but continuous sort of regular resistance exercise improves testosterone. There's also data that shows that when men do resistance exercise to maintain muscle mass, so we know that muscle mass decreases is about 7% every decade of life after around 40. When you maintain it through resistance exercise, they're 3 times less likely to have erectile dysfunction.

Oh really?

Yeah, so they maintain erectile function, they maintain sexual desire, they maintain, um, satisfaction with sex.

I read a quote yesterday that said muscle is medicine, and I thought, hmm, that's really true based on everything I've learned on this podcast around, you know, like glucose control and, and testosterone and now you're telling me about your sex life.

Yeah, it is. I think people push back because they think like, why should I have to go to the gym? But our lives have changed. We sit at a computer, or we sit at podcasts, or we sit all the time. We're not moving, we're not doing manual labor, which is what a lot of our historic history is, right? Doing manual labor, farming, doing things outside, being physical. And we're meant to be physical, we're meant to lift heavy things, we're meant to move our bodies, and we're just doing less and less of it. So I think it's so So that's important. The other thing is we wanna prevent sarcopenia. So sarcopenia is muscle loss. And when you have muscle loss, that also increases your risk of having sexual dysfunction.

What about the pelvic floor? Like, how does that come into this story of the pelvis?

Oh yeah, so we missed that part. So the pelvic floor, here's your pelvis, right? It's this bony structure where all your organs live. This is a female. So I'm taking out the internal structures, which is the uterus, the rectum, and the bladder. And so that's what sits inside the pelvis. And so you can see this bowl of muscles here, right?

Interesting. I've never seen—

And you can see them from the inside and you could see them from the outside. That's your anus. And in this person, there's a vagina. So that's the hole for the vagina. So you can see that your anus and your vagina run through the pelvic floor. And in men, your penis runs through the pelvic floor. And so this, let me see if I can show you on this model. In this model, you can see they kind of show you the muscles here on the side.

Yeah.

So these are your pelvic floor muscles that are around around the penis and the anus.

Okay.

Okay. These structures are very important for a variety of things. They attach to your bony landmarks here, your hips, your sacrum, your pubic symphysis. They attach to all these, and they sort of just work in the background for most people. How they affect your sexual function is when you orgasm, these muscles contract and release at a rhythmic contraction of 0.8 seconds. And so you may feel that, right? There's like this pulsing feeling when you orgasm, and that's these muscles sort of doing that. And when men ejaculate, the pelvic floor muscles are contracting to help shoot the ejaculate out. They squeeze when you need to keep things in, so they'll keep urine in, they'll keep your stool in, and they relax when you need to pee and when you need to defecate.

So when you're trying to hold a wee, you're like tightening your pelvic floor muscles?

Correct, correct. But these are also responsive to stress. So just like people get TMJ, where they get tense in their jaw because they are stressed and they like sleep at night and they clench up their jaw, they don't really know they're doing it. The same thing can happen. These muscles can get very tight or they can get misaligned. So say you have a hip injury or say you have a back injury, the muscles can compensate by tightening up. And so a lot of people unknowingly have tension in these muscles and it can present in multiple different ways. It can present with back pain, it can present with constipation, it can present with urgency frequency, because remember your bladder is sitting right here on top of these muscles. So when the muscles are tense, your bladder is feeling like there's something, something activating it. And so it's like, oh man, I gotta pee. That means I have to pee. This tension is telling my bladder I have to pee. But it's really that your bladder is not that full. It's that these muscles are telling you to do that. You can also have trouble peeing because you can see that your urethra goes through here.

And if the muscles are really tight, sometimes it can be difficult to urinate because it clenches off the pee And then with sex, it can cause pain. If they're really tight, it can prevent blood from getting to the genital organs. So for men, they can have erectile dysfunction. For women, they can have difficulty getting orgasms or difficulty getting arousal because they're not getting blood flow to the clitoris. Sometimes it can also cause premature ejaculation in men. And so these muscles are so important, and all we hear about is Kegels. And Kegels are exercises to strengthen these muscles. Muscles. But Kegels are good when you have a normal pelvic floor, meaning like there's no tension, it's completely normal, it's acting normal, you're not having any symptoms at all. But if you have any of the symptoms I talked about, doing Kegels might make it worse because you're now tightening muscles that are already tight. We also talk about pelvic floor relaxation, doing exercise to specifically relax these muscles. So that can be diaphragmatic breathing, that can be doing like a figure four stretch, that can be doing happy baby pose, which are yoga poses, or child's Child's pose.

All these things can sort of stretch and lengthen these muscles so they can learn to relax again. Now, when it's really bad, you have to go see a pelvic floor physical therapist who can really work with you to identify which of the muscles are maybe more dysfunctional and maybe work specifically on those. But I think it's, it's so important. It's undervalued, underdiscussed when it comes to sexual function. It's a hugely important part of sexual function.

How many people are struggling with these issues, specifically the, like, erectile dysfunction issues, and what age are they?

Yeah, so it starts early. I think there's always been a sort of a disconnect where we think young guys don't have this, or if they have it, it's all in their head. That's not necessarily true. Many young men do develop erectile dysfunction because of biologic factors, but the data is really robust on older guys. So above the age of 50, we see 52% of men having erectile dysfunction, which is— 52%? Yeah, and it goes up 10% every decade. So 60% of 60-year-olds, 70% of 70-year-olds. So erectile dysfunction continues to worsen. This happens because one, you know, our blood vessels get older, they get stiffer, they're not functioning as well as they should. And we're seeing also a rise in all these other comorbid conditions like diabetes, cholesterol, high blood pressure. All these affect how healthy your blood vessels are. And so with these, they see the problem in their penis or in in women's case, in their clitoris before they see heart disease or strokes or brain issues or dementia.

I think this is worth pausing on, which is an erectile dysfunction problem is often a symptom of a cardiovascular issue, right?

Yeah, we call it a canary in a coal mine. So it is like telling you that something bad is coming. So the data would support that when you have erectile dysfunction, if it's because of an organic reason, right? Not psychogenic, but most people I think have a combination of both. That within 3 to 5 years you will start developing issues with your heart. And so it precedes those issues. And if 7 years later, 14% of those guys will have a heart attack. And so it's really an opportunity. Sexual problems are an opportunity to look inside, to figure out what's going on, and to investigate, and to change your life.

And when you say erectile dysfunction, we should probably define what that What does that mean? Because there's going to be a lot of guys at home now thinking, oh my God, like, my penis is a bit softer than usual.

Yeah. So erectile dysfunction is defined as the inability to maintain an erection that's sufficient for intercourse. So you can get an erection, but it goes away before you ejaculate or climax. And so that's typically— I think it's really important to differentiate that from something like premature ejaculation, where you climax too soon. So you ejaculate before you want to, but that doesn't mean that you have a problem maintaining your erection. That's a whole different process.

I've got a friend— people are going to think I'm talking about myself because I use that phrase a lot— I've got a friend, he's, um, he's almost 40 years old, and I've heard him say on several occasions that he's lost his erection during sex. Is that erectile dysfunction? But what if he can keep his erection watching porn?

Well, so that's more multifactorial, right? So I think if you lose it once or twice, right, most guys will have an issue where they lose an erection at some point in their life. I think the important thing is not to catastrophize. It's a problem when it becomes a routine. Now, if someone is telling me, "Hey, I can watch porn and maintain my erection, but I can't with a partner," there's multiple different reasons for that that could be at play. One is that there's no pressure, right? You're by yourself, you're watching porn, there's no pressure of performance, there's no anxiety of performance, so that may be part of it. Other thing may be that that level of arousal that you're getting from porn, if you're watching, like, let's say the same kind of porn every time, you're masturbating the same way every time, be using a firm grip, or some people will masturbate like facing the bed or, you know, against hard objects. And so that—

Against hard objects?

Yeah, like the, their fist or something. And so that can't be replicated by a person, right? You can't replicate those behaviors by a vagina or a mouth. If you become habituated to a certain thing that turns you on, and that's the only thing that really gets you going and that's, that's something that you can't really get with your partner, then it will be difficult to reach the level of arousal that you need to get an erection.

Okay, so two questions then. So that doesn't count as erectile dysfunction if you can get an erection watching porn but can't get it with your partner?

Yeah, it may or may not be. So if you wake up with your morning erection, that's great. That's a sign— that's when there's nothing else at play, right? You are just— that tells me that your body's functioning well. You've got good blood flow, good, good hormones working, got a good amount of testosterone, and your nerves are working well, and you're getting a good morning erection. Now, morning erections or nighttime erections are normal, and they're healthy. So, when you're a young boy, you get actually like erections 3 to 5 times a night, and they can last up to 40 minutes long. So, you can spend a lot of your night with an erection. When you get older, like in your 40s, that drops to about half the time. So, maybe erections are a little shorter, that they may be maxed out at 30 minutes, but sometimes they're shorter. You should still be getting 3 to 5 erections You won't know all of these, but typically you wake up with a morning erection. And so if you're not getting morning erections, that tells me that, hey, there's something going on that we should address.

And on your other point about how you masturbate impacting your sex life, I imagine that applies to men and women.

Absolutely.

And are you saying that if there's a particular way you get yourself off in private that is very hard for the other person to replicate, you might become desensitized —You might just get habituated.

I don't think desensitized, but habituated is like you might just— your body just might respond really well to that particular stimulation. Now, that's not inherently a bad thing, right? If that's what gets you off and you and your partner are okay with you doing that together, right? You may mutually masturbate together and that's fun for you and you guys enjoy it. There's no problem with it. It's just knowing what's going on, right? And sort of deciding like, okay, if this is a problem, let me try to diversify what I do during my solo sex periods. So let me take a little break and kind of try something, you know, just not masturbate for a little while and come back to it later.

The fact that we get an erection in the morning, does that mean that we're supposed to have sex in the morning from like an evolutionary perspective? Not necessarily.

It's just, it's the way your body releases testosterone is one of the reasons this happens, is overnight your body is making more testosterone. That's when your body sort of has nocturnal testosterone production, and so it's highest in the morning, which is why very often you get a morning And, you know, it just means that some people will have more desire also in the morning, 'cause testosterone is a hormone of desire. Is it the same for women? Yeah, so women also have nocturnal clitoral tumescence, same sort of pattern, and they won't necessarily know it, right? 'Cause they can't visualize it. But, you know, you can— some women may, you know, sort of feel that pelvic congestion, or like feeling like there's a bunch of like blood flow in the area, but most will not, and that's okay. But your body protects itself. So you've heard the term, I hate the term use it or lose it, right? People are like, your body's protecting itself. You don't have to have sex. If your body is healthy, it will do this all night to keep your genitals healthy. It will make sure that your genitals are getting blood flow even if you're not having sex.

But if you stop having those nighttime erections, now it becomes more of a problem because over time, say you stop having erections or clitorotumescence for months, years, right? And then there's no blood flow to those areas over time. And actually I can show you here, this is a pelvic model. And here, this purple thing here is called the corpora cavernosa. And this is like a really nice spongy tissue that fills with blood. And when it fills with blood, it expands and lengthens. And then the blood stays there until you're done with your stimulation and then it goes back. And so if there's no healthy, fresh blood getting to the penis on a regular basis, either through nighttime erections through sex with your partner, then you will get fibrosis of these tissues. That means there's a little scar in the tissues, and then over time, you might see some shrinkage of the penis. And so it is really important to maintain also good health of these tissues. And the same goes for women with their clitoris, because it's the same type of tissue. In fact, if you look at the clitoris, it is— this is the part that you see.

We don't really have a clitoris, do we? Is it that one there? This is the uterus.

You're gonna keep that in? Okay, actually, I can show you here.

There we go. Does this come?

Look at that. She told me. Is it crazy?

Okay, yeah, this is good. This is good. Okay, they told me. That's a little— that's, uh, yeah, okay. You're not gonna live that one down.

You asked the team where the clitoris was. Did you ask the team where the clitoris was?

Well, I'm worried about who said that too. Okay, so let's talk about the female anatomy. This is a pelvic model, and here you can see this is the vagina. This is the urethra where you pee from. This is your labia minora, and you can't see the labia majora, but they would be out here, right? So inner lips, outer lips. This up here is your clitoral glands. So it's the same as the glands of the penis. And so this is all you see, right? It also has a little covering, which you can't see here. Just like men have foreskin, women have a clitoral hood that covers the head of the clitoris. And so when you look at the clitoris on the inside, which we can't see perfectly here, but I'm going to just take this up. Um, it actually goes all the way back like this. So if you were to feel from the vagina, from the vaginal side, it would be at the very top of the vagina going all the way back. These are the— these blue things are the clitoral bulbs here. And these are the legs of the clitoris here on the side.

And so this is essentially the homologue of the penis. So if I take the penis, and we don't have a, like, a full model here. What does homologs mean? So homologs means that they're essentially the same structure. They're made from the same cells, but they're in the male and the female. So here you can see this is— if this is your penis, this is what you see up to here. This is the bone, this is your fat up here, and then here it goes deep into the pelvis. And so here's your testicles, right? And so below the testicles, this area of the perineum, you also have penile tissue sort of that you can palpate from this side, um, that's coming all the way down. And if you had sort of a 3D model, you'd see that it forks out just like the clitoris does.

So does clitoral stimulation feel stimulating someone's tip of their penis. Exactly.

And so you could think if someone just stimulated the head of the penis, they, uh, it would be fine, it would be nice, but it's probably better if you stimulate more of the clitoris or more of the penis. That's where you could stimulate, obviously, the external, the clitoris, but you can also stimulate from the inside. And some people are more responsive to that than others. What you hear of is like the G-spot or the G-zone, right? And the G-spot or G-zone is if you were go in the inside of the vagina at the top side, which I can't really stick this in here, but it would be about 2 centimeters in at the top. And that's because that's an area where there's a lot of nerve endings. One, you can palpate the clitoris basically throughout the entire anterior wall, but also there's the Skene's glands, which are these glands that sit underneath the urethra, and they're the homologue of the male prostate. And so they're right there, and then the vagina is there. And so that's an area that can be very enjoyable to stimulate. It's not necessarily always going to lead to orgasm because Some people have different sort of distance between the clitoral body and the vagina.

So some people have less distance, may feel it better than some that don't. But ultimately, that's why that area is so sensitive for many women.

On this point of morning erections, I was thinking, much of the reason why I've always been cautious of having sex in the morning, or even like masturbating in the morning or anything like that, is I'm worried that it will cause a dopamine crash, which will make me feel lazy and lethargic.

Well, so when you think about what happens during an orgasm is you have this release of dopamine and then you, your prolactin goes up and sort of like everything calms down. Now, some people feel a sense of clarity. They call it post-nut clarity, right? They feel clear. They feel like motivated to do stuff. They feel excited to go do something else and they sort of move on from what they're doing. There's some people who feel post-coital dysphoria. They actually feel sad or they feel depressed after they orgasm. And we don't know exactly why this happens, but it is because of this dramatic change in sort of neurochemical signaling in the brain. And for those people who have it, it can be days where they sort of like feel bad. It can be hours where they feel sad. And so it can be really traumatic.

So Pillar 2— what's Pillar 2 of the 4 pillars of men's sexual health?

We talked about strength.

Okay, so we did strength, we did fuel.

What's Pillar 3? Pillar 3 is environment. So we can start with the easy stuff, and that's stress, right? Everyone knows stress is bad, but I think the thing is people just think like, ah, I'll just— I'll deal with it. Everyone's stressed. Like, what's— it's normal to be stressed. If you are chronically stressed, that means your cortisol is raised all the time, which is dampening your testosterone, which is also keeping you in the sympathetic state, and you just cannot get in your mind space and in the nervous system place to actually have sex. So that's super important. And I think, you know, there's lots of different ways to alleviate stress. You got to figure out what works for some people using a stress ball even just at work. And I think part of it, you can actually incorporate some intimacy. There's some evidence, you know, the Gottmans have been on your podcast, doing a 20-second hug. So standing with your partner or loved one and hugging for 20 seconds on your own, like independent gravity, actually helps alleviate stress and break sort of a stress loop. Doing a 6-second kiss with your partner. And so it seems like 6 seconds, no big deal, but actually if you time it, it's like, hmm, if I'm just doing a kiss and I'm not like actually, It's a little bit longer than normal.

And so these sort of small things can help alleviate stress. Any type of movement can be really beneficial. Going to the gym is great.

Breathwork as well.

The other thing is just having interactions with people. And so that's where we're becoming more isolated, but even just talking to the barista or talking to someone at the grocery store, this again tells your brain that you're in a safe space, like you're talking to someone, you're having a normal social interaction. And then being creative. And we've been trying to work on this with our kids because there's so much external stimuli all the time, right? They wanna play video games, they wanna watch TV, they wanna play sports, but we want them to be bored and be creative, like come up with creative ideas to keep themselves interested and engaged in a different way. So I think that's so, so important. And outside of stress, sleep. Sleep is, there's just so much abundance of data on how sleep affects hormonal health. They looked at data on men sleeping 5 hours a night 8 hours a night. So you take the same guy and he sleeps 8 hours, then you do 5 hours for a few days, his test for a week, his testosterone drops by 15%. Damn. That's like as much testosterone drop as would happen with 10 years of life.

And do you know how long they did that for? How long?

It was short, it was like a week. So a week of sleep deprivation will tank your testosterone. Damn. And sleep apnea is another one that I think people, one, don't realize they have, and two, don't realize that fixing it could actually improve their hormonal health.

Wait, so does this mean that people who have chronically bad sleep probably have low testosterone? Probably, yeah. And what is the symptoms of low testosterone?

So low testosterone is— they're sometimes very vague. So it can be fatigue, it can feel brain fog, it can be depression, it can be low desire, it can be erectile dysfunction. That's what people always think, it's just erectile dysfunction, but it's this whole constellation of symptoms. It can also be increased fat mass, decreased muscle mass. So all of these things can happen because we have testosterone receptors all over our body. We have them in our brain, we have them in our muscle, we have them in our bone, and these can all have really serious consequences when it's low. When you have sleep apnea, and how you know you have sleep apnea is your partner might tell you that you're like waking up in the middle of the night gasping for air. If you have— one really easy way to check is take a measuring tape and measure your neck circumference. If it's more than 17 inches for a guy or 16 inches for a female, it means it's very likely that you may have sleep apnea. And that's because when you have excess mass, basically, here, it's compressing your airway and can make it difficult to get air into your body.

When you improve sleep apnea, we've seen improvements in testosterone as high as 200 nanograms per deciliter. So huge jumps in testosterone after fixing sleep apnea. And the same goes for other sleep disorders, although the data is not as abundant. But sleep is so important. Then we talk about what's in your environment. So, let's grab this. Okay, so you get a bottle of water. So many of my patients actually, they only buy like cases of plastic bottled water. Once in a while, a plastic bottle of water, like don't stress yourself out. This goes back to stress. People get really stressed, like what's in my environment? What am I drinking? What am I eating? Like do what you can control. So plastic water bottles have things like phthalates and BPAs, which can affect hormonal health. They can mimic estrogen, they can reduce the production of testosterone based on these mechanisms. Also things like plastics in the environment, PFAS, so the things like nonstick cookware, all those things can affect hormone health. Now, how do you sort of protect yourself, right? I tell people, again, don't stress. There's only so much you can control. So like, I love that we are not drinking out of plastic.

If you have to drink out of plastic because you're at an event or whatever, whatever, try to make sure it's not a warm bottle. So it hasn't been like sitting in the sun for hours and hours and hours, because as it gets warm, it releases more microplastics and more chemicals into the water. When you're eating food, if you are eating out of, say you get takeout, put it on a plate and warm it up. Don't ever warm up that plastic. And when you store food in the fridge, put it in a glass container or a metal container, but don't ever leave the food in the plastic and put it in the fridge. Simple things you can control. You could also limit sort of your exposure to dust because dust has microplastics. You can try to wear more cotton fabrics, less synthetic fabrics, because they shed less microplastics. But again, I think do what you can do, but don't let the stress of these chemicals like derail you, because stress is not helping either.

And how much of a difference does, you know, microplastics make on my hormonal health? Is Is it really a big, big deal?

Well, I think it depends. It's all dose-dependent, right? So we're all exposed. Like, if you look at the data, like, people are, you know, consuming quite a bit of microplastics, and we're seeing them actually even in testicles and penis tissue samples. Like, they're in our bodies. And so I think that it's definitely playing a role. How much, we don't know yet. We just know there are mechanisms, and we know that they do affect hormonal health. And so do the best you can.

Do you and your family drink out of plastic bottles? No, we drink—

we have like metal water bottles for the kids and myself. And what about nonstick pans? We buy ceramic. We do our best to like avoid those as much as possible. So the other thing is the company you keep. I think we don't talk about this enough, and we talk about it in terms of business. Like you want to keep people who are successful around you. You want to keep people who can help you, but it also plays a role in your sexual environment, right? So my husband is in these groups with a bunch of other male physicians, and there's a lot of discussion about how they never have sex. I don't want to have sex anymore. And they're all just like, oh yeah, this is just like normal. Like, we're getting older, our partners don't want to have sex, it's so frustrating. And there's a discussion about this, and, and it's, it's almost like, oh, that's okay, like, that's just normal, right? They're normalizing this experience where that sex has not become a priority because life is so stressful, things are so crazy, maybe you're having relationship discord. So it absolutely plays a role, and there's actually some evidence that it may help you make better choices.

So there's one study where they looked at, I think it was like 50,000 people, and they they did an intervention where they tried to encourage these people to surround themselves with positive influences that were like, have safe sex and avoid negative influences. And they saw that for— that these people had an increase in like sexual positive behavior, so like safe sex practices, by 46%. So just by changing who they spent their time with, they saw this major difference in how they approached their sex lives.

Okay, so if your friends are very pessimistic about sex and they're not having and they're about it, that's going to become sort of contagious. Yeah.

And I think it extrapolates to everything. What kind of relationships you're in? How do they view their relationship with their partner? Is it a priority? Do they make it a priority, right? Or are they just busy doing their own thing and they're just like living in parallel lives? They're doing their own thing, you're doing your own thing, you never really spend time with your partner. And then when you go hang out with your friends, you're like, oh God, I'm so glad to get away. And you're not like talking about how much you enjoy your partner. People tend to talk negatively, right? They want to like to sort of like vent. And so when you have people who don't make that a part of their lives, it also affects you. They value their partner and they talk about them in a positive way. That's a great thing to say, like, okay, this is the right kind of person I want because I want to value my partner too. And I don't want that to rub off on me because it absolutely does.

And the other thing you said in this category of environmental stuff is things like pornography consumption. Is it possible to consume too much porn?

So it's not the amount of porn that you watch, it is the sort of the way you feel about it. Many people watch porn for a variety of different reasons. Most often it's for pleasure and enjoyment, but there's some people who watch porn because they wanna get away from negative feelings, right? This is giving them dopamine and they're using it as a way to just feel better in the moment. And so that become, that can become a compulsion where they're watching porn and it's like giving them these positive feelings and they feel negative in life and they're going back to porn to sort of again, have that compulsion to watch porn again. But that's a small subset people. The other thing is that there's a lot of negative discussion around porn, right? People are like, porn is bad, it's dangerous, it's evil. And I think, you know, it's more nuanced than that. But if you feel that porn is bad, every time you watch porn, you feel negative, you feel bad about yourself, that's where we see people having the most dysfunction associated with it because they feel guilty. They could watch it once a year and they could feel super guilty about it and it could affect their sexual function.

They could see themselves as a bad person. They could see themselves as wrong or immoral. And that's really when it becomes an issue. If you are finding yourself either compulsively watching pornography and using it as a scapegoat, maybe time to reevaluate. Say, why am I doing this? How can I switch this out for something else that makes me feel better that might be healthy, like exercise or going for walks or whatever that may be? And then if it's something that's really making you feel bad or guilty because maybe that's how you were raised, maybe that's what you feel about morality, then yeah, maybe like you either need to work through that because porn is maybe something that you still want to watch at times, or you need to abstain. But usually those are— it's very difficult to abstain for most people, to abstain for prolonged periods of time. So I think it's something you have to work through if you find yourself having these sort of feelings about pornography or you're compulsively watching it. But for most people, it's adults, for most adults, it is fantasy. It's a place where you can experience, see things that you may never do in real life that may be enjoyable, that are fun to watch, that allow you to feel arousal.

We see that when couples watch porn together, they are more likely to be more satisfied in their relationship. And when there's a discord, like one person really doesn't like it or doesn't use it, and the other one uses it a lot, that's where we see the problem.

Is porn consumption going to impact my intimacy with my partner?

So it depends. I think a lot of people watch it without an issue, right?

They watch it and masturbate and I ejaculate. I'm not going to then be able to ejaculate very quickly necessarily with my partner.

Yeah, so that obviously, that is, you know, there's a refractory period after you ejaculate. Now when you're younger, that refractory period could be minutes, and when you're older, that can be a day in half. And so we see that some people may struggle, especially if they're watching a lot of porn every single day and their refractory period is maybe a day, then they may actually really have trouble ejaculating with their partner because they've not given themselves that time.

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The last of the 4 pillars, we talked a little bit about, it's called confidence. And confidence is not like strutting around like a peacock, like I know what I'm doing. It's confidence in knowledge and curiosity. So knowledge, we talked about a little bit, understanding female anatomy, like how do female bodies get aroused, right? What makes them aroused? Where is the clitoris? Knowing some anatomy. And 2, actually talking to your partner or paying attention to their cues. We, for some reason with sex, it's the only time that we just expect people to be mind readers. We just want you to know what I like and just go for it, right? And, and then when it's not good, you're like, well, you just don't know what you're doing. And it's like, it's, it's wild to me that we actually never got taught how to talk about sex, how to bring it up with a partner, how to, you know, just explore and have fun with sex. Maybe add a toy to the bedroom. So there's lots of different types of toys. This is a vulva stimulator. So you put this on the outside, so you can see that would, in theory, if this was smaller, would stimulate the clitoris on the outside.

It also can change in shape. It'll vibrate, right? It'll have different stimulations that you can play around with and decide what you enjoy.

So this one's run out of battery.

They're brand new. They've not been used.

I didn't say they had been. Very defensive there. So if my pinky finger— if my finger here is the clitoris, Yeah, I put it on like that. Yep. And then it vibrates. Correct. And then the penis goes through the hole.

And there's another version of that. This is basically— oh, sorry, this is basically like the hole goes around the penis and that goes in, and that can go in and stimulate and vibrate. So you both feel the vibration and you both feel the stimulation.

I remember I was with, um, I had a partner and she, she felt that sex toys were for older people, old people, specifically what she said. And she, she was kind of against the use of them. I've always been down. I think it adds novelty and it's exciting and it just adds something new. But she felt like it was almost like giving up. Well, I mean, look, I think—

I wonder why. I would, I would— if I— she was here, I'd ask her, why do you think that? What belief system do you have that's making you think that this is like not a good thing to use, right? We use technology in in so many places in our lives, right? So why not introduce it in our sex lives?

Are you gonna become reliant on it though? Because it doesn't make it easier to get off with a sex toy.

So they've actually looked at vibration and can you get desensitized to it? And the way they've looked at is actually like construction workers where they're using those like vibration tools, right, to— and seeing if like their hands get desensitized. And what they've seen is yes, for a short period of time, they do lose a little bit of sensation at their fingertips, but then it restores back to normal. And so it's not that you're going to become desensitized forever, right? I think you brought up a great point, which is adding novelty. Now, I think when I say novelty, people are like, oh my God, I need to roleplay in a different way or bring like some sort of BDSM or whatever into my sex life. And that's not exactly true. So when you think about sex, right, it's just like eating your favorite ice cream. Maybe you have vanilla ice cream, you know, 3 times a week and you enjoy it. But if you start having vanilla ice cream every single day, you're kind of bored with it, right? And the same goes for sex. Now, having routine in sex, knowing what you like, Knowing what your partner likes, it can be very helpful, but it also is nice to add novelty.

So if you think about, we could extrapolate from the flow state. So when you are in a flow state for work, right, things feel really almost effortless and you're just like in a zone. You can also get into a sexual flow state. When you look at the flow state, yeah, you need things to be slightly challenging to get into the flow state. They can't be easy and they can't be so hard that you're gonna get frustrated, right? And so you need to add a slight challenge challenge to your sexual encounter to get into that flow state. And that's when you start having really great sex, because you're like in— you're so totally immersed, you're feeling great, and it's, it's super fun, right? So I think that's another part of being confident, is being able to and confident to try new things and explore new things. And it can be as simple as like doing it in a different room, or maybe getting a pillow, or switching where your head position is. Like, it can be so small, but it can just add little bit of uniqueness and novelty and challenge.

Are there certain positions that are going to increase the probability that my partner has an orgasm?

Yeah, so, uh, typically when the female partner is on top, she has more control over where she's getting stimulation, um, to the clitoris, because, right, she can angle her body in such a way. So oftentimes that shows, uh, that has, uh, higher orgasm rates. There's actually like this this technique called the coital alignment technique, where you sort of move in a rocking, sort of a rocking motion so that your pubic symphysis, so this bone right here, is sort of like rubbing against their clitoris, like this area, the skin here is rubbing against the clitoris while you're penetrating. And that has been shown to increase orgasm rate and pleasure index. So really, it's about figuring out and trying different things and realizing like, that, for example, that coital alignment technique is sort of difficult. Like, it's not that easy and intuitive. And so you have to sort of play around with it and figure out like, what is going to work best. And yeah, realizing it might not work, you might be like super awkward and be like, okay, like, that's okay. Like, it's not the end of the world if sex is not perfect every time, because we're learning and we're playing and we're having fun.

And so I think that's really the key is like not letting yourself get so frustrated if something doesn't go exactly the way you envision it in your head.

I used to think that a woman orgasming was when— this is I was younger, was when she squirted. So that's what I thought it was. I thought an orgasm was squirting.

Yeah, well, you're probably not the only one to think that. And so squirting— not every woman squirts. So about 40% of women squirt. Squirting is the emission of fluid at the time of orgasm. Usually it's clear, colorless, and it can be quite voluminous. It's coming from the urethra, which is the pee hole, essentially. And remember I talked about those Skene's glands? Those Skene's glands are the homologue of the male prostate, and they have a little bit of fluid in them too. Typically, when you have stimulation and squirting, they will release fluid from the bladder as well as the Skene's glands that combines together and it's emitted through that.

So it's not pee.

The way they describe it, and there's been a lot of research on this, so there's people who say it's pee, there's people who say it's not. There's a couple studies. So one is they put dye into the bladder and they took women who said they were squirters and they had them orgasm and they saw, is there dye in the, in the fluid. And yeah, there was dye in fluid. So it's coming— it has to come from the bladder. The Steens glands only hold a small amount, but it's chemically different. It's usually clear, odorless. It doesn't smell like pee. And so there's some theories as to why that might be. It may be that, um, when you're having sex, there's different hormonal signals that change the concentration of what's filtering through your kidneys so that it is a little bit different in composition. There's some theories that when there's more estrogen around, that it may change. There may be some, like, um, fluid filling in the actual interstitia of the organs. Again, it's hard to say, but it's absolutely coming from the urethra, which is connected to the bladder, as well as the Steens glands. But I think, like, this, this whole discussion about what it is, it doesn't matter.

Like, is it pleasurable? Are you enjoying it? Great. If you squirt and you enjoy it, great. If you don't, that doesn't mean that there's something wrong and that your partner hasn't orgasmed. The way to figure out if your partner orgasm is you ask her, right? Either she tells you or you ask her. And sometimes it's obvious and sometimes it's not, but, you know, you, you sort of figure it out.

There's 3 theories that emerged in my research about why women squirt from an evolutionary perspective. The first was that— and these are just theories, they're not proven, um, of course— the first is that squirting contains PSA and zinc, which are naturally antibacterial, and ejaculating these fluids during or after sex may have evolved to flush the urethra and prevent UTIs, the logic being in a pre-antibiotic world, a woman who could flush bacteria out of her system after mating was more likely to stay healthy and reproduce. That's one theory. The other reason—

Well, before you go, I wanna talk about that really quickly. So that's a really interesting theory. So one, the reason they emit PSA is because Skene's glands are the homolog of the prostate. So the prostate makes PSA, which is prostate-specific antigen.

So this point, this word homolog again.

Yeah, it's a, so basically the prostate in the male, the same tissue when they're an embryo becomes the prostate in the male and becomes the Skene's glands in the female. So that's why it's emitting PSA. That is an interesting theory because there are a subset of women who get UTIs after sex. Not everybody, but some do. And it's, it's not because of the ejaculate or because of the male harboring some bacteria. It's because of the actual thrusting of the penis. It's taking bacteria from the outside and making it more easy for it to go through the urethra into the bladder. And women have a short urethra. And so I want just to debunk that myth that it's like you're getting it from your partner or there's something wrong with you. It is literally just anatomy. And so some women do get more UTIs after sex. And so that is an interesting theory because maybe that's true, I don't know.

The second theory was in ancient ancestors, the hormonal surge during orgasm and ejaculation actually triggered the release of an egg. Humans evolved to ovulate on a cycle now, but we kept the plumbing and the neurohormonal reflex. It's a happy accident a biological vestige that no longer serves its original reproductive purpose but remains because it isn't harmful for survival.

Interesting. I mean, there is some thought that maybe orgasming, um, orgasms help with fertility, but it's not really, uh, robust.

And the last one kind of matches what you just said there, which is the mate selection theory. The intense pleasure and psychological response of squirting or orgasm act as a reward system. It incentivizes women to seek out specific partners who provide high levels of stimulation, potentially signaling a better genetic compatibility or a more attentive male, which would help with the survival of offspring. Maybe that makes sense. 40% of women squirt.

Yeah. So the other thing is, obviously, a lot of sex is focused on genitals, but there's a whole body of erogenous zones, right? Almost, almost your entire body can be an erogenous zone. We talked a little bit about it when we talked about sensate focus, right? You can explore, you can find areas that people people find, uh, erogenous. So when you've looked at data— necks, nipples, lips, buttocks, inner thighs— all these areas are considered erogenous by most, most people, regardless of their sexual orientation, regardless of their cultural upbringing. It seems to be pretty universal. There's actually a famous paper about non-genital orgasms and like how people orgasm without any genital stimulation. So lip orgasms, anal sex orgasms, it's Is that possible? Yeah, it's been documented, absolutely. And so it's— nipple orgasms, there's a whole variety of ways, even like women have had orgasms during childbirth. Like there have been these documented ways to orgasm, and it's because these areas can be very erogenous. And sometimes stimulating multiple areas can like add more erogenous interest. And that's why you see people like maybe in the BDSM community, they'll be using nipple clamps while they're doing other things, right?

So there's a whole bunch of areas are erogenous. And most of the times, people are not really spending much time on foreplay or stimulating these erogenous zones as much as they should, right? You have a whole body to play with. And how do you stimulate them? There's actually evidence behind that. So on your skin, we have these special fibers called C-tactile afferents. So when you stimulate these fibers, they help you feel pleasure, enjoyment, those sorts of things. And so there was a study where they took 19 couples, a small study, it was out of London, and they basically told them to stimulate an erogenous zone and a non-erogenous zone, the non-erogenous zone being the forehead. And so they had the couple stimulate, and they told them stimulate at levels of 18 centimeters per second in terms of how fast you're caressing the arm or, or, or body part, and at 3 centimeters per second. And what they found was those who stimulate at 3 centimeters per second had more sexual arousal, had more pleasant stimulation compared to those who were stimulating at 18 centimeters per second. Now, this And this makes sense because those C tactile afferent fibers respond very well to that slow, gentle caress.

The other interesting thing is that these fibers are only responsive to human touch. So if I take a glove and I put it on my hand and I touch you, it still doesn't work. Oh, that's interesting.

That's so interesting because in Los Angeles, where we are now, we were viewing an office and we were walking down the street to see what the neighborhood was like. And we walked past one place, and it is a robot massage parlor. Hmm. And I always thought, great, like, well, part of me thought, maybe my prefrontal cortex thought, oh, great idea, because, you know, you can get massages whenever you want, right? It's going to be cheap. You maybe can have one in your home. Yeah. But then the other part of me, as I saw it, thought, actually, I don't actually think that's like why I get massages. Yeah, I think there's something about human touch which makes a big difference.

Absolutely, there is. Um, and so I think that's, uh, we're evolutionarily evolutionary built to seek out human touch and human behavior.

I wonder if I would want a robot to massage me. It wouldn't be as good.

No, I mean, think about sitting in a massage chair. Is it ever as good? It's never as good, right? And so I don't think a robot's going to be that different from a— maybe a little better than a massage chair, but like, massage chairs are never good. No, they're just like, they're okay, they're mediocre.

Let's talk about, um, testosterone, how that links to sexual function, but also just overall health. Because I was reading that there's been a 300% increase in the United States in the last 10 years of testosterone prescriptions. And my friends are increasingly having conversation about testosterone, which we weren't having even 5 years ago. It wasn't a conversation. And now the conversation I'm having amongst my friends is like, is our testosterone high enough? Do we need to go get supplements to increase our testosterone?

Testosterone is declining. So when you look at testosterone levels from the 1990s, like late 1990s, the average level was around 600, and if you look at data around 2015, it was 450. So there's been like a 25% decline in testosterone. Now you're gonna ask me why. One, we talked about some of the endocrine disrupting chemicals. That's part of it, certainly. Two, there's a significant rise in obesity. Testosterone has aromatase, and testosterone converts to estrogen using this enzyme called aromatase. And so when you have more fat mass, you have more aromatase, and more testosterone is being converted to estrogen. And so now you have less testosterone testosterone.

Sorry, how do we— how do you have less testosterone?

So because there's more fat mass, there's more aromatase. So that aromatase sees all this testosterone and it converts it to estrogen. Ah, okay. Okay.

Or estrogen. This is where they say—

they talk about man boobs. Yeah. So when you have a lot of estradiol around, you can get, uh, man boobs. Okay. You can get gynecomastia, so term for it. So that's one. Two is we see a rise in diabetes and insulin resistance, which also causes a decrease in testosterone. We're seeing a rise in ultra-processed food intake, and that doesn't have the optimal nutrition that you need to optimize testosterone. So we're getting, you know, highly caloric, which then leads to obesity. We're getting lack of healthy fats. We're, you know, all these things are super important for testosterone. And the Mediterranean diet is what has been the most studied, basically an anti-inflammatory diet is what they found for testosterone. So trying to just eat like whole foods, unprocessed foods as much as possible, and minimizing the inflammatory foods.

Does testosterone— having high testosterone make me more fertile?

No, not necessarily. So I think people inherently think that the higher your testosterone level is when you check your blood work, that that's better, and that's not necessarily true. Now, everyone is different, and what I can't tell you is what your receptors look like, what your testosterone or androgen what their receptors look like, how sensitive are they to testosterone. And everyone's a little bit different. When you look at the same guy, or you look at two different guys, their variability can be so much that a guy who's 900 can be normal and a guy who's 500 can be normal because everyone has individual genetic variations. It's how their cells, how sensitive their cells are, how many cells they have, you know, how many Leydig cells do they have in their testicles, um, the CAG repeats, which are these DNA repeats on the receptor themselves. People who have more are less sensitive to the testosterone that's around, so they need more testosterone to get the same result, whereas people who have less repeats have more sensitivity, so they, they don't need as much testosterone. And so everyone is individual, and so that's why it's really important to understand how are you feeling, right?

It's not about chasing a number. And so absolutely, we know that when your testosterone is low, but below 214 nanograms per deciliter, that your risk of mortality goes up by 2. So you are going to double your risk of dying if you have low testosterone. But when you go super high, super physiologic, meaning like 1,900 or higher, now you're putting yourself at risk for other things. You can have blood thickening, which is a known side effect of testosterone replacement, and that puts you at risk for stroke, heart attack, heart disease. Over long periods of time, it can affect your heart because it can— there's also heart muscle cells that get exposed to this high level of testosterone, and when that happens, these, they sort of change over time and they become more collagen deposition, they get more fibrosis, and this makes them stiffer, and so that you're not pumping blood as effectively as you would otherwise. And so there are real consequences to going too high. There's also the side effects of having acne, of changes in mood in terms of aggression and things when you get really high. So really, it's about finding what you feel good at.

More is not necessarily better. Once your testosterone receptors are saturated, meaning they're all bound to testosterone, more doesn't help help you. It might help you get more muscles, which is why people abuse anabolic steroids and testosterone, because it will continue to help you get bigger muscles. But that's it. It's not going to help you with your brain health, your bone health, your sexual health, your—

any of that. Is there a way to visually spot a person with low testosterone? Are there visual clues?

Usually it's someone who feels very fatigued, like they can't get out of bed. They feel just like so Usually they are a little bit more overweight. Skinny fat? Visceral adiposity. I mean, you can't always tell if they're skinny fat. It could be because they could have visceral adiposity, which is meaning that the fat is around the organs, right? And so you don't see like a big pot belly necessarily. They may have really low sexual desire. They may have decrease in mood.

What about skin and bones? Does it impact skin and bones?

Yeah, so if you get high testosterone, you can get acne 'cause it affects the sebum in the skin. Bone health, so testosterone converts to estradiol, and estradiol is really important for bone metabolism. And so when you have low testosterone, you can also have low estrogen. And when your estrogen gets very low, you get a higher risk for fractures, higher risk for osteoporosis. And so that's where your bone health can be in danger. And so that's why testosterone can help protect your bones because of its conversion to estradiol.

If you do have low testosterone, should you be considering taking anabolic steroids? Like, and who is testosterone replacement therapy good for? So I'm going to ask you a question.

Why, why are you saying anabolic steroids?

I don't know, because I hear that people, big bodybuilders, take anabolic steroids.

The reason I asked you that is because people think anabolic steroids and testosterone replacement therapy are the same thing, and they're not. And so testosterone replacement therapy is what is given to guys who have low testosterone. If you have truly low testosterone, there's a few things you can obviously improve testosterone naturally by going back to those pillars of health that we talked about. Improve your sleep, do resistance training, avoid endocrine disrupting chemicals. But if you are still low despite doing all those things, or you're like so fatigued that you can't move your body and like you really need to do it, then I think testosterone replacement is very valuable. And so testosterone replacement is getting you to a level of testosterone that is, within normal. We're not trying to get you super high. We're not trying to get you to become a bodybuilder. We're trying to get you to normal, what you should be. And so anabolic steroids are different. Anabolic steroids are like all these different oral pills and injectables and things that work on muscle as well as work on your, uh, androgen receptors. And so those are typically things that people are taking on their own.

They're kind of self-directing their care, and they're not really monitoring monitoring their testosterone, or they don't really care how high they go. They just want the end product of looking muscular. And so they are getting really high testosterone, and that has its own host of concerns in addition to the ones we talked about, like blood clots and, and heart attack. But there's a 15 times higher risk of having premature heart failure and 122 times more risk of cardiac death when you're taking anabolic steroids for the purposes of increasing muscle mass and not— and getting really high in your testosterone. So it is a real serious issue when you take anabolic steroids because it can have real serious health consequences.

I've always imagined that once I have kids— so I'm— I think I'm scared that if I have testosterone replacement therapy at this age, at 33, it might impact my fertility. It absolutely will. Okay, good. So I'm not going to do that until I've had all 4 of the kids. Yeah, as many as can. And then I figured when I hit like 45, then I'll go on testosterone replacement therapy. Is this a good strategy?

Well, first of all, I would want to know why you want to be on testosterone. Is your testosterone low? I have no idea, right? Are you having any symptoms? I mean, you live a very high-powered, busy life, and so I can guarantee your stress is probably not under control. Like, probably you're not sleeping great. And not to say that those are things that, you know, you can't do in addition to taking testosterone if your testosterone is indeed low. But I think the important thing is realizing, like, it's only going to help you if your testosterone receptors are not fully saturated, and giving you more testosterone is going to saturate them.

Doesn't it just drop anyway with age? It does.

So it drops about, uh, 1% a year on average. Some people drop less, some people drop more. So if you look at someone who is healthy and they have a normal testosterone, they usually won't become what we call hypogonadal, or have low testosterone, even as they age, because the drop is so low, it's only 1% a year. But if you add on these comorbid conditions, if you add on a high stress life, if you add on poor sleep, if you add on exposure to endocrine disrupting chemicals, you're gonna see that number come down much higher.

It's actually, I was just, I pulled up a graph here that shows testosterone decline with age, and it's actually not that steep.

It's not, it is gonna decline, but it may not decline to the point where you need testosterone. So not everyone needs it depending on depending on the data you look at, 20 to 40% of guys have low testosterone. And when you look at the number that get treated, it's like 2%. And it starts declining from about 20 years old. Yeah, it depends on the person, 20 to 40 years old to start. It's probably more around 30 to 40. And the reason we came up with these numbers, right, these guidelines to guide us on what's normal and what's not, is because you look at population-based data and you look at when these symptoms arise, and there are like clear number that you may start having bone loss around 300. You might start having, you know, decreased sexual frequency of thoughts at 215. You might start having— feeling less physical vigor around 290, right? And so there are numbers that we know based on population-based data that we're seeing these numbers decline. Now, the other thing to think about when you're looking at testosterone is free testosterone. So testosterone comes in different forms in body. It comes bound and unbound.

So 45% of testosterone is bound to SHBG, which is a molecule of protein that really tightly binds to testosterone, doesn't let it go for your body to use. Then there's some that's bound to albumin, which is sort of loosely bound. And then there's 2% that's free, 1 to 2% that's free. And that's what we say is like the most available to your body for use. And there's actually, you know, good data that looks at free testosterone and the levels of free testosterone testosterone are correlated with these symptoms as well. And so you do have to look at the big picture. So I always check the total testosterone as well as an SHBG, because some people can have elevated SHBG due to thyroid dysfunction, due to aging, just genetic variability, right? In women, SHBG goes up when you take oral contraceptives, and it stays up for life if you take oral contraceptives. So it can affect their free testosterone. Well, the other thing to think about testosterone is it's for life. Once you take it, your body stops making its own testosterone. Many people over years will notice that their testicles get smaller because their body stops making its own testosterone.

So it's not something to take lightly. Now, if you want, say you were low right now and you wanted to conceive, there are ways where you can take other pharmaceuticals that will naturally boost your own production, like HCG or Clomid or Enclomiphene. These work basically in different ways to either tell your brain that, hey, we need more testosterone, or they mimic the signals that tell your testicles to make more testosterone. And so, there are ways to do it, and you definitely need someone who's well-versed in managing hormone management. But, there are things that you can do if you're low. But again, I don't think it's— once you start these things, you can't go— I mean, you can get off of it, but it's sort of a process, and it's not something that everyone will do because you're going to feel good on testosterone if you're taking it, and then when you get off stop it because your body is like no longer making its own, you're going to feel horrible.

So do you think most 50-plus-year-old men should be taking testosterone replacement therapies?

Only if they're symptomatic and they're low, right? So would it make them—

the average man, the average 50-year-old man, if this is the average— feel better on a daily basis?

Not necessarily, because if they are normal, like I said, if their testosterone receptors are already fully saturated, it's not going to change, right? It's not going to change the— it, like I said, it may make their muscles look bigger, but it's going to change their, their cognition. It's not going to change their mood. It's not going to change their sex drive. It's not going to change their erections when their testosterone receptors are fully saturated.

And, you know, in this graph, what is showing the decline here, has that got anything to do with whether their testosterone levels are fully saturated? Because no, you can't tell from that. You can't tell from that. So you could have low testosterone but still be fully—

that's why we talk about symptoms, right? Because that's how I can tell. I think, you know, that's part of what being a doctor is, right? Talking to your patients and figuring out what's going on with them and what their symptoms are and making sure it's nothing else, right? You can have low thyroid, and that can mimic what, what, uh, what low testosterone feels like. You can have a high prolactin because you might have a benign tumor in your brain that's secreting prolactin, and that can reduce your testosterone. So that's the reason to get a full evaluation, to make sure there's nothing else that we're missing that's causing you to have these symptoms if your other levels are normal.

Okay, that makes sense. So just because my testosterone testosterone levels would be low doesn't mean I necessarily— if I don't, if I'm not symptomatic, doesn't mean that I should necessarily just assume that I need testosterone replacement therapy. Exactly. Okay. Yeah, I think, I think most of my male friends are just assuming that once we hit 50, we're all on the testosterone.

I mean, look, I think when— if you need it, it's a great drug, it's a great option to improve your quality of life. It's obviously preventing, uh, bone loss, it's improving your longevity, it's, uh, preventing— hopefully having some benefit in terms of cardiometabolic health. And so yeah, absolutely, if you need it, but it's not something that like everyone should just take because why not, right? Like, it's just when you play with hormones, it's serious business, you know.

I guess a lot of men are self-conscious in a way that they don't often admit, and they want to have big muscles and they want to feel strong.

And this is the, the problem I'm seeing with younger guys right now is that there's a lot young kids taking anabolics because there's so much pressure to look a certain way, right? Because nowadays, when— how do you meet people? On social media, through like swiping. And, and all you see is what they look like. And so there's this pressure. And like, I'll see it at the gym. Like, I'm like at the gym and there's these young kids who I'm like, there is no way you are naturally that built at that age, right? Like, unless you've been lifting since you were like 7 years old. And so, and Of course there are some, but it is serious because one, it causes infertility, right? When you're on testosterone replacement, after about 18 months, 70% of people on testosterone replacement will be infertile. 17. 70, 70%. 70? And even as soon as like 10 weeks, we see some people having drops in their sperm count. So it's variable with how quickly you're gonna see impacts on your fertility, but it absolutely absolutely happens, and it can, it can come back for the large majority of people. But how long it takes depends on your age and how long you were on testosterone replacement therapy.

And in some cases, it can take as long as 2 years to come back. I really need to get my testosterone levels checked.

Yeah, you should.

But also, you should get your semen analysis checked. And I've done that. Good, good, because that's also a biomarker of health. We've seen that people who have poor semen parameters they have higher rates of mortality and they actually live— when you look at age, like what age people die, they die younger compared to people, and it's dose dependent. So if you have like normal concentration of sperm and then it keeps going down and down and down, if you look at the age, it's like they live to 78, 77, 76. Like you can actually see it come down except for people who have no sperm, 'cause those are usually genetic disorders. Those live a little longer because it's not necessarily due to cardiometabolic disease metabolic issues, but it's basically a reflection of your overall health. Steve, what are you doing?

Uh, just making myself a delicious coffee. From the freezer? From the freezer. Have you not heard about Contia? No. Oh my gosh, this is going to change your life. A couple of months ago, the founder of this business called Matt sent a big shipment of this coffee to our office in London. What most people don't know is that the processing of coffee takes out a lot of the taste. So what they do is they flash freeze it at the optimal moment when it's most tasty, and they send you in the post the coffee in these little frozen ice cubes. Now Matt sent a big shipment to my office, I moved it to the kitchen, I said to the team, knock yourselves out. And then I saw so many messages in our Slack channel of people going, oh my God, what the hell is that? It's so delicious. All I have to do is pop it out in the morning using the little button on the back of this I pour my hot water in and I mix it and that is done. You can get $30 off your first order of Cometeer coffee if you go to cometeer.com/stephen. Try it and please Instagram DM me, LinkedIn me, and let me know if you love it as much as I do.

Make sure you keep what I'm about to say to yourself. I'm inviting 10,000 of you to come even deeper into the Diary of a CEO. To my inner circle. This is a brand new private community that I'm launching to the world. We have so many incredible things that happen that you are never shown. We have the briefs that are on my iPad when I'm recording the conversation. We have clips we've never released. We have behind the scenes conversations with the guests and also the episodes that we've never ever released and so much more. In the circle, you'll have direct access to me. You can tell us what you want this show to be, who you want us to interview, and the types of conversations you would love us to have. But remember, for now we're only inviting the first 10,000 people that join before it closes. So if you want to join our private closed community, head to the link in the description below or go to doaccircle.com. I will speak to you there. One of the things I was quite surprised by, I'll be honest, is when I went on your YouTube channel, one of your very high-performing videos— I think it had 31 million views— was about enlarging your penis.

Yes. I didn't know that so many men were interested in ways to enlarge their penis.

Well, it's interesting because when you look at the data, more men want to— so let's say most guys would love to be taller, right? If you're an average height man, most guys would love to be taller, right? Yeah, true. Um, more men want to have a longer penis they want to be taller.

Really? Wow. Wow. Why is this?

Well, I think, you know, a lot of people— it starts at a young age. I have sons, right? And so I see it, like, they talk about their penis in such a way, like, very early in life, like, oh my God, my penis is so big, or it should be so big, or whatever. And, and there's— and it's like this, it becomes this, like, this society thing about who's got a bigger penis. Like, it's very interesting, but there's a lot of pressure to feel like— and a lot of discussion around bigger is better, right? It's, it's talked about in media, it's subtly joked about, it is everywhere you look. People are talking about, like, being well-endowed as being better. But initially, on my podcast, we interviewed the, the guy who has the largest medically verified penis. It's— I think it's like 13 or 14 inches in length. And he actually has a lot of trouble because it's so large that people don't want to have sex with him, and it's uncomfortable for them. And so, like, it's not all roses and sunshine on the other side. But the reality is that many people feel what's called small penis anxiety, and they— they, even if they have a normal-sized penis, they feel consumed with how the size of their penis is.

And so that's why this this video did so well. I naively had no idea how many people would resonate with because I'm not a guy, right? And I see patients all the time, but at that time in my career, people weren't coming to me to talk about it. And so I, um, I realized like there's so many people quietly feeling insecure. And we talk a lot about women having body image issues. Men do too, right? They feel insecure about the size of their penis because also they're seeing guys on pornography who have very well-endowed phalluses. And, you know, they chose to be porn actors for a reason, right? Because they are naturally well-endowed. And so you're comparing yourself to the outliers, and the average penis is about 5.3 to 5.5 inches erect. But when you look at, like, what do women want, they will say on average they want a 6-inch penis. But when you look at, like, the kind of sex toys they buy— and they did this study because they were looking at people people who— they were trying to decide what kind of— when they were developing phalluses for trans people, like they, they reconstruct phalluses for— they want to— they were making them too girthy, and they're like, well, we need to figure out what girth women want.

And so they looked at like what women buy online, like what are the most purchased sex toys, and it's actually pretty close to average. Do you say 5.2 inches? 5.2 to 5.5, depending on the study you're looking Yeah. Erect.

Mm-hmm. Hmm. And what size do men think the average is?

Oh, they think it's like 6 or 7 inches.

Oh, okay. So they think the average is bigger. And also, how does age come into this? Because I'm presuming that when I get older, my penis is going to shrink or something.

If you have good blood flow to your penis, it shouldn't shrink. So like I said earlier, if you stop having nighttime erections or you're not having erections, now you're no longer getting blood flow to your penis and it will shrink over time. Also, if you're gaining weight, it will appear that it's shrinking because you're getting more fat over here. So, if you think about your penis here, this is the fat right above this bone. And as this fat gets more and more, you're seeing less and less of the penis.

And is there a way to enlarge the penis?

So, there are many ways that have been tried, discussed, attempted. So, there's definitely surgeries that you can get, but they— there's not a lot of surgeons who do a lot of penile lengthening surgeries, and they have lots of complications, like very high rates of complications, because the penis is a very vascular organ. And the thing is that when you have the tiniest difference on your penis, you notice it, right? Like, I have guys coming up with the tiniest little thing on their penis and like, is this okay? Like, this is new. And like, luckily it's nothing, right? But I'm like, they notice it. You notice it when something's wrong. So imagine you have a surgery and now something changes, right? So it is, it is really difficult to sort of replicate exactly a normal penis when you're lengthening it through surgery. So I don't recommend surgery for lengthening penis. There is a safer way, and that has been shown to help, and that's using a traction device. So a traction device, we have one here. This is one brand. You can get many of these online, and you can put your penis in this device.

It really— I like, I feel like, um, I get like shivers when I watch you do this to this penis.

So you would wrap it, it would be more more comfortable than just putting this like directly on your penis.

For you guys that can't see, she's clamping the end of the penis into this—

into this device. And then you sort of lengthen it, extend it with this, 30 minutes twice a day for this particular device. They've actually done some research on this one, 30 minutes twice a day. And you— there's like a whole protocol on their website, and it does show improvements in length, about 2 centimeters. But it is a commitment to increasing length and to doing this process.

So just on those numbers, 2 centimeter increase over what period of time? And does that—

we're 3 to 6 months, depending. Yeah. And is it permanent? So that's what we don't know. I mean, most of the studies stop at, you know, once they get the result. And we don't know that if you stop, will it just revert back to normal? I don't know. And so the other thing about this particular traction device that's nice is if you have a curvature in the penis, like you developed something called Peyronie's disease, this device can actually curve a little bit away from— if you have, like, let's say you have an indentation on the top of the penis, it can actually bend away from that. And it can help straighten out the penis. So that's actually a really nice utilization for it because for some people that can be really traumatic and devastating to have a change in the way your penis appears because it starts curving all of a sudden. And this is safe and effective, and you can have bruising, it can be slightly uncomfortable, but it's— you're not gonna really hurt yourself too much by doing something like this. I thought a curved penis would hit the G-spot better. Yeah, sometimes a slight curve can be beneficial for some people, but again, I think like when you notice like there's a dramatic change.

You do that more calm. It's okay. Um, I'm just trying to figure out how this works. So I get the penis, I put it through, yeah, clamp it down, and you want to put it at your normal, and then you'll just slightly advance the, the length. You're not going to pull crazy, you're going to do a little bit of traction so it's not uncomfortable. It's slight, like just a slight tension. It shouldn't be like, like that. It should be much less tension. But it is, I mean, they can vary in price from $100 to $500. So it's a one-time cost. It is not, like I said, not dangerous. What is dangerous is when people try to do something that became popular on TikTok called jelqing. And jelqing is where you use your hands and you make like an okay sign with your fingers and you're like stretching the penis with your hands. And this can be dangerous because you can create micro tears in the penis. And we in the urology community have seen plenty of patients who have now developed erectile dysfunction after doing jelqing because they've now created damage to their penis. And so I really caution people because this— there is so much despair around sexual function, around penile health, that people are are willing to try things and they might really hurt themselves.

No joke, I had a patient the other day ask me if he should drink hydrogen peroxide because he saw some ad that said hydrogen peroxide will fix your erections. And I said, please don't. This is, you know, but he really was like seriously earnestly asking me this question. And I, you know, I didn't want to shame him by any means. And I was like, no, you know, this is actually not safe and it's not going to help you. And there's no pill, there's no drink, there's no anything that's going to give give you a longer penis. What are the cases that you see that break your heart? You know, I, I've seen— so there, I've seen patients who've had surgery to lengthen their penis, and they are above average when they— at baseline, and they have these surgeries to lengthen their penis, and they have a bad outcome, and now their penis is disfigured forever. And that's what really, um, you never forget that, because that person, knowing the risks and benefits, perhaps made a choice, and that choice didn't go the way they wanted, and now they have to live with that for rest of their life.

And that's really sad. Gosh, imagine that.

Christ. Yeah. Well, and it just— it doesn't work anymore.

Well, like, the one patient I'm thinking of, um, he, uh, had it— like, it, it basically developed a scar all at the top of the penis, so it was like disfigured, essentially. Um, and so it was, it was really sad.

Before I hit puberty, I definitely had penis anxiety because I was the youngest in my year at school, and I, I was this— I was short, very, very short, very small. I remember what it felt like to like hide my, hide my dick when I was around like guys in the changing room and stuff like that. Um, you know, after puberty, things changed.

And what I want people to understand, I think more than anything, is that you don't need a long penis to pleasure a partner. We just talked about how the clitoris is the most reliable route to orgasm, right? And so you don't need a penis to stimulate the clitoris. You can use your mouth, your fingers, you can use a toy. There's so many ways to help your partner achieve pleasure. And yes, of course, there are a small subset of women who really appreciate a large phallus, but the large majority of women, if you look at survey data, are very happy with the size of their partner. Are very content with average or slightly above average or slightly below average, as long as they are feeling intimate and they're feeling pleasure. And so I think that there's a misnomer that, that people think if I have a longer penis, I'm going to be able to pleasure my partner more.

As it relates to women, is there different size vaginas? Yeah, so the average—

so like, just like there's averages, there's averages in females. And so average vaginal length is about 3.5 inches. So when we women get aroused, it expands and widens and lengthens to about double. So, the average woman can easily accommodate the average penis, maybe slightly larger than average. And so, I think generally speaking, knowing that like you will be able to fit in the average woman and you will be able to please her with the size of your phallus. And like I said, penetration is, is not as important. In fact, only about 85% of women orgasm through penetration alone. They need clitoral stimulation to achieve climax. And so again, penetration feels good. I tell guys it's like somebody rubbing your testicles or your perineum. That feels good, but it's not going to make you orgasm. And so penetrating, yeah, if you're getting a lot of clitoral stimulation because maybe she has a thinner, you know, her clitoral shaft is closer to the vaginal canal, maybe, you know, the size of the penis matters more. But for a lot of women, it's not going to be sufficient, and they're going to need need some directed clitoral stimulation.

Why do different vaginas feel different to— and I guess the inverse is also the case where like different penises will feel remarkably different even if they're the same size roughly. And people, you can have sex with somebody and go, it feels really good.

I mean, I think again, it's how you— it's like the motion in the ocean, right? Like how you use your— so let's talk about the vaginas first. So when a vagina vagina is, um, has more pelvic floor strength, they may be able to, like, tense around the penis better. Like, they may be able to sort of grab the penis with their pelvic floor a little stronger versus someone who doesn't. And that's where I think some people get worried when I say, oh, you need to relax your pelvic floor. They're like, oh, I don't want to be looser, right? And that's not going to happen if you have a normally functioning pelvic floor. If you're—

so the penis is going in here, right? Correct. So if I— if you're a woman and you do pelvic floor exercises, you're strengthening, feel tighter.

Well, you're, you're able to contract and squeeze those muscles during sex better, right? The penis. Yes, but we don't want you to be tighter. We want you to be able to squeeze the muscles and relax the muscles. Use them like a normal muscle, like your bicep. You squeeze and relax, squeeze and relax. We don't want it to be constantly squeezed, but to the man, it will feel tighter. You will perceive it as tighter, but it will not be that she's actually tighter. It just means that maybe her pelvic floor muscles are doing a better job. So that's for the female. For the male, it's, it's generally like how the penis moves and how the positioning is and where it's, uh, it may be girth that's different, it may be the way that you're moving in the vaginal canal, and that may be why it feels different.

They often say that if you've got big feet or big hands, you know, like people think you have a big penis. Not necessarily.

That's not entirely true. So there's, there's actually no evidence that big hands, big feet correlate to penis size. There's one study in Japan where they looked at nose length. And so the longer your nose is from the bridge down to the tip, that is potential, at least the Japanese population that they studied was correlated with the length of the penis.

People also think tall people have big penises.

Not necessarily.

But nose length, there's some correlation in a study in Japan. Yes. Okay. Let's just check my nose. Okay. The last thing I want to talk to you about is Ozempic and how this relates to everything we've talked about today. Desire, attraction, sex. Is there any early data emerging that shows any correlations?

Yeah, so Ozempic, there's sort of benefits and there's potential downsides. So the benefits are that when you're on Ozempic, we see improvements in metabolic disease. They have improvements in diabetes, improvements in heart disease, improvements in overall health, right? And so that is going to mean that your blood vessels are healthier. You're more able to get blood flow to your genitals. You're gonna have stronger sexual function and arousal, right? So that's great. The other thing is that you are losing weight, so you feel better. You feel more like your body image is, is feeling good about yourself. Also for men, remember I talked about this fat pad, right? Fat above your penis, that's getting smaller. And so now you can see more of your penis. So you may have heard of Ozempic penis where people are saying, "Oh, my penis is getting longer." It's not actually that your penis is getting longer, it's that this fat is going down. So now you're seeing more of your penis. Which makes it look longer. Yes, exactly. It makes it look— Science is reality. Yes, exactly. Well, it is reality to the person looking, right? So those are all great things.

And I think that's wonderful. Now, the other part of it is, Olympic works on the brain and it works on the reward pathway. So you now see food, you don't feel like it's that much of a reward, so you don't chase after. You have less desire for food. There's emerging data that we're seeing people on these medications, these GLP-1s, have less desire for, let's say, gambling, let's say shopping, let's say, you know, alcohol, smoking, whatever it is, right? And so there's a theoretical— because it works on the same pathways, that it could also decrease desire for sex. And I think the thing that, you know, there's so many people on these medications, there's so many metabolic benefits that I worry that people may not even realize that their sexual desire is changing, right? They might just be like, oh, you know, I'm, I'm eating less, I look great, everything's wonderful. But like, slowly in the background, they're like, oh, maybe my desire is less, and maybe it's creating discord in the relationship. Hard to say because we don't have data yet. So yeah, I think it's just something that you should be aware of, that if you start feeling like you have less desire for sex, or maybe you're like, "Man, I just really don't feel into anything," talk to your doctor, 'cause maybe your dose is just too high, and maybe it just needs to come down a little bit.

And again, we don't know yet, but I do worry about this, because I feel like we're gonna start seeing it.

Is it possible to do studies on this type of thing?

Absolutely, so you can take people starting Ozempic, and you can say, "Hey, here is," or any GLP-1, you know, there's questionnaires. So like, for women, there's the Female Sexual Function Index, for men, There's ADAM, which is a questionnaire about testosterone, but you could— there's sexual desire questionnaires that you can use, um, and you can take it at the beginning, and then you can take it as they increase their dose and see if there's a change, right, in terms of their sexual desire.

You said at the start about knowing how to talk to your partner. I think, like, intimacy, desire, maybe the conversations, like, with your partner, how to have that conversation when there's a problem.

Yeah, I wish I could say there's, like, a script that you can follow and it's gonna work, but everyone's so different. But I think the important thing is not giving up. Because what happens is, because we don't ever talk about sex, when you bring it up, it's immediately like, oh my God, is something wrong? Like, did I do something wrong? Um, do you not like me? Am I not attractive? Right? You're automatically going down the rabbit hole of worry and concern, and instead of dealing with it, you're just gonna shut it down. No, I don't want to talk about it, right? Um, especially if like maybe you haven't connected intimately in a while and like you just don't want to deal with that, or you're— you have other stressors in life. Maybe you're feeling like very good about yourself. And so you're like, well, I don't really feel sexy, so I don't want to have sex. And so I think really understanding that whatever reaction you get from your partner when you do talk to them, it's not about you, it's just usually about how they're feeling. And so don't stress about that. And two, like, it's— anything that is worth having requires work.

So having a good sex life, having intimacy over the long haul with someone, if you are committed to that relationship It is worth working for. It is worth dealing with a little bit of discord to get there. And so I tell people, when you want to talk about sex, first of all, don't do it in the bedroom. Don't do it right before or after sex. Do it at a time where you are both calm, relaxed. Maybe you're out for a walk, maybe you're in the car, so you're not looking directly at each other, you know, kind of parallel. And always start with a positive thing like, I, you know, I really enjoy this about our relationship, and I would love if we could talk about this. And, and maybe they're gonna and be like, "Uh, I'm not ready for that." And you say, "Maybe we could come up with a time where we can talk about this that works for you," right? Let them feel like they're coming to the conversation with like, they're not being ambushed or like talking about something. And then be curious. I think the big thing is like being curious, like what's going on with you?

Like, I wanna be there for you, I love you. You know, I miss what we used to have or I miss this about us. And I think that there's always these misconceptions. I hear it all the time, right? It'll be like, this partner only wants sex, and this partner never wants sex. And, you know, and that's it. Like, that's the end of the conversation. But the reality is that there— it's, it's somewhere in between. So typically, women tend to view sex as like added stress sometimes when they're already stressed. Like, they're like, oh, it's just one more thing to do, whereas men look at it as a stress relief. So one, you're coming at it from two different angles. The other thing is men aren't really taught how to be intimate. And so for a a lot of men, sex is their version of intimacy. Like, that's how they connect, that's how they feel connected with a partner. And so oftentimes when they're doing these initiations or attempts at sex, it feels like they're being greedy, or it feels like they're— they just want sex. And I think we have to reframe how we look at that.

Like, sex is not just sex, it is intimacy, it is being together, connecting with another human being. So how do we do that, right? And like, How do we make that sex worth having? We get into this frame where we have sex as like in a hurried, quick, like, just got to get this done way. I just need to get an orgasm. I just need to get a release. But sex is supposed to be something we look forward to. It's supposed to be something that we're excited about. And so we have to build that in. We have to sort of like build the environment where sex can happen. So it may mean like, hey, we are affectionate during the day. Maybe we send a lovey text message. Maybe, you know, I give you a hug, I caress your back, I tell you you look beautiful. I, I'm, I'm just showing you gratitude for how much I care about you in other ways. I think just really taking the time to understand why your partner feels the way they do.

I'm curious about, on that communication point, about how different genders in heterosexual couples have different sort of taboos and things that are just a bit sensitive. Um, and I was looking at the, the variance between men and women, and the, the top one for men was around performance anxiety. So like admitting to things like erectile dysfunction because it feels like it's so intrinsically connected to masculinity, and you feel like a failure as a man if you can't get an erection and pleasure your partner, right? And then for women, it was talking about, um, prioritizing pleasure and asking for more foreplay or, um, you know, specific, specific stimulation around the clitoris or something like that, um, because they don't want to be labeled as high maintenance or too much hard work, etc. And it's interesting that on that with your partner, there are different things that will trigger each of you. Um, other ones for women were pain and discomfort, bringing that up, um, body image and the mental load, explaining why you aren't in the mood. And other ones for men are expressing non-sexual needs because it might be seen as unmanly, boundaries and rejection, communicating when they don't want sex.

And lastly, the script, which is discussing fantasies that deviate from the norm.

So I want to talk about fantasy, but before that, I would just say that You know, because of social media, we're in a place, and I get text messages from my husband 24 hours a day with like, not 24 hours a day, but like all waking hours with reels and videos. Oh, I think you'd like this. I think you'd like this. You should check this out. And it's like his way of like connecting and like, hey, let's talk about this later. Like, this is fun. And so I tell my patients like, send your partner a video that you saw on social media that might help them understand like why this is important to you. Maybe send them a video, send them this video podcast, right? Say like, "Hey, I watched this, it was great." That's a good idea. You know, and I learned so much. And honestly, so many patients bring their partners to me, whether it's women bringing male partners or men bringing female partners, they come to me and they say, "Look, like, I want you to meet this doctor and I want you to talk to them." And like, it's beautiful to see that.

Like, I love it because it's so deeply caring that they like brought their partner and they want them to feel good and they just want to figure out what's going on. And like, I think it's so lovely to find someone who's so invested in making sure that sex this is good for you, right?

As men though, we're just not good at talking about this stuff, right?

But you know, I think you can't use that as a crutch. Yeah, do you know what I mean? Like, yeah, I do.

Yeah, like, it's not good at it though.

But no one's good at it. It's not men. Women are not good at it either.

I think men are worse at it.

I think in general no one is good at talking about sex. Like, I, you know, I think it's interesting because I talk about it all the time, but I have seen very good communicators struggle with talking about sex. And so I think it's just It's just, it's uncomfortable. And it's like, if you and I can have this conversation and we can talk about sex openly, like, there's no reason that you can't learn how to talk about sex. And it's a learning process and it's worth investing in. Do people bring you their fantasies? Yeah, I've had— well, not as many fantasies as, like, real sort of diverse interests in sex. What do you mean by that? So I had a patient who came to me and said, you know, after some time, this was not like their first visit, like, we built a rapport and he told me, you know, the— I really struggle with arousal and the only time I get aroused is I have a medical kink. And so I go to this person who will put a Foley catheter in me and that's what turns me on. And I was like, that's really interesting.

And I was like, okay, like, that's, that's great. But like, it took a long time for us to get there, for him to feel comfortable. But it also then was like, well, if that's what turns you on, you know, then you've got to sort of explore other ways to incorporate that with a partner. Or maybe not. So like, a catheter is, is, um, is a tube that you put in the bladder for to drain urine.

What hole does that go in? The urethra.

It goes in the penis? Correct. And so there's actually a lot of people who enjoy urethral play. So they will take sounds— they're called sounds— like little, um, uh, rods with a flared base, and they will insert them in the urethra. And what people do find that pleasurable. And so because there is some, you know, there's some nerve endings there that can be pleasurable. And so again, it is totally fine to have interests that are, you know, outside what we call conventional. But of course, I think you need to, if that's something that you're really into, you have to sort of bring your partner into the fold if that's what really gets you turned on. Now in terms of fantasies, almost everyone fantasizes, right? Almost everyone does. And the interesting thing when you we look at fantasies is there's a lot of fantasies that you would think are not common, but are. So for example, being sexually submissive is very common. So women fantasize about it, like around 60%. Men are like 20% having this desire of sexual, this fantasy of sexual submission. It may not mean that they want to be submissive in real life, but that's the fantasy they're having.

Men often have voyeurism fantasies, So like watching sex. They also have sex with multiple partners. Women tend to have a lot of like sexual dominance, but also romance in their fantasies. So like in exotic places or with, and a lot of times, like 90% of the time, people fantasize about strangers or it could be someone they know, but outside of their relationship. And so that's completely normal and nothing to be worried about. It doesn't mean that like you want that person. It's just a fantasy. It's a safe place in your head to think about fantasy. And I think one realizing that someone fantasizes about something, it means nothing about how they feel about you. It's just where their brain goes to explore. I tell my patients sometimes, write down your fantasies for yourself, just like write them down, don't share that with anybody, and have your partner do the same. And then if you guys decide you feel comfortable at some point to each share one fantasy, and you can start talking, maybe one that you would want to try. And like, it allows you to sort of explore and think about different things. It could be a negative outcome, like you could just be serious.

Like, we can experiment, we can play, we can have fun. And if you bring that back into your life, you are going to be happier, less lonely, live longer. Like, everyone should just be having more sex.

It's, um, yeah, it's interesting that we're getting more and more sexless because I think the world is stealing our attention, and that's causing a big loss in connection. But then everyone's lives are more stressful than ever before. If if a bomb goes off 10,000 miles that way, I see it when I open my phone. Um, so it's an interesting time to sort of almost try and reclaim sex and to work on one's sexual health, the overall, the full picture of one's sexual health. Um, you're working on a book which is, I guess, endeavoring to do much of that, which is coming out in September called The Hard Truth: Everything Men Need to Know About Good Health, Great Sex, and Long Life. So if you're watching this after the 1st of September, 2026, or around that time, then the book is probably available for pre-order or already out. It's not available for pre-order yet, is it?

Uh, will be soon, but not yet.

Okay, when the book is out, I'm going to link it below in the comments section. When it's available for pre-order, The Hard Truth: Everything Men Need to Know About Good Health, Great Sex, and Long Life. So if the subjects we talked about today have piqued your interest, the book, I imagine, is going to go into greater detail on all of these subjects.

Absolutely. I think it's a book that really I, I wish was a part of sexual education. I I think all men need to know this. You know, as women, we end up taking care of our male partners. I make all the doctor's appointments. I, you know, I organize all of that. I make sure that my kids get all their vaccines, all that sort of stuff. And, you know, it becomes on us to take care of our fathers too. And so, as women, we hold that role. And I think it is so valuable to understand what men go through and also to be able to support them along the way. And I think it's a great gift gift for, you know, men in your life or for, you know, older sons even to like help people understand their bodies. And honestly, it's a huge motivator. I tell people like, if for nothing else, people care about sex. And I have seen patients turn around their lives because they want to have better sex. They'll literally improve their blood sugars, they'll improve their blood pressure because they just want to protect their sexual health.

Freena, thank you. We have a closing tradition on this podcast where the last guest leaves a question for the next guest. Not knowing who they're leaving it for. This is the first time in Diary of a CEO history where the guest has actually stamped it with a stamp that says certified 100% human. Okay. So you can see there's a little stamp.

So it's not AI. So it's not AI.

And it actually says that in the middle. It says Gen AI free. Sign of things to come. But that question, I guess, is somewhat linked to that. The question they've asked for you is so much of the world feels hopeless about this moment, what would you tell someone to help them reclaim their agency?

[SPEAKING CHINESE] I think that we as humans are meant to be with other humans. We are meant to connect. And I think making that a priority will allow people to feel to feel a part of something again. You know, I think there is, like, an emergence of people starting to look back at religious constructs and go to community and be a part of things and enjoy live events again, like we weren't doing before. And I think if we prioritize that, there is still hope that we can come together as a society. And I think, you know, the pendulum is swinging Islam always swings, right? In every way, like, it's gonna go far right or far left, and people are gonna hate each other, and then they're gonna love each other, and they're gonna come back. And I think if you just look at history, time and time again it repeats itself, and we will find unity and we will find togetherness. We are obviously feeling pain from a variety of different sources, and we may feel pain, right, like, in terms of other things to come. But ultimately, I, I'm an optimist, and I think that we'll come together and, and we will find, um, happiness and joy in human connection.

And I hope you're right. I think we're seeing the early signs of that now. For anyone that's listening that wants to learn more from Rina, um, I highly recommend they go to your YouTube channel. I will collab if we can, um, and if we do collab on YouTube, you'll see a little smiling Rina, um, next to the Diary of a CEO logo where you can click through to her YouTube channel. She's got almost 3 million subscribers and she goes through all of the questions which no one has ever answered for us. And I was looking at some of the questions that you answer for people, everything from why you dribble after you pee and how to stop it, porn director reveals what scenes are faked in almost every scene of movies, but then also a lot of the stuff we've talked about today around, um, penile health, erectile dysfunction, um, sex positions, and so much more. So It's a wonderful repository of information that is constantly being updated. That is a great place to subscribe, so I highly recommend you do. Dr. Reena, thank you so much for your time. You're so welcome.

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