Host: Is there a way to enlarge the...

Dr. Reena Malik: 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 cm.

Host: Tada.

Dr. Reena Malik: And that's not all. So, they actually did a study on pistachios where guys at 100 g 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.

Host: 49% longer.

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

Host: Be right back.

Host: Dr. Reena 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?

Dr. Reena Malik: So, there's four main pillars of sexual health. So, pillar one is fuel. So, how you nourish your body, and it's a huge part of sexual activity. And then pillar two 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 going to 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 under evaluated, under discussed, and we'll get into that. But pillar three is environment. So things like 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%. Yeah.

Host: And then the last of the four pillars that we don't talk about enough is, and that's still important, I want to talk about morning erections, squirting, clitorol stimulation, and certain positions that are going to increase the probability that my partner has an orgasm.

Dr. Reena Malik: Let's talk about all of that. First of all,

Host: 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?

Dr. Reena Malik: They would say, "What can I be doing right now to improve my sex life?"

Host: Who would be asking you that question? And why do you think they'd be asking it?

Dr. Reena Malik: 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.

Host: 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 and I'll throw this graph that I've I 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.

Dr. Reena Malik: Mhm. 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 co-workers 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 um DMs. And so they're not actually like really having these deep meaningful connections. there have there's a big 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're 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 cuz it's your first time. So you have like mediocre sex or bad sex. And they'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 um education on what sex should look like. 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 um 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 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 uh Debbie Herbick, 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 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 going to be sex that you want to have.

Host: that point you said about the the lifestyles we lead and how that might be impacting our sex lives I thought was really interesting because 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, and I was wondering from a dopamine perspective if there's correlation between these like dopamogenic 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.

Dr. Reena Malik: 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 going to be turned on when I see my partner and we're going to have sex and 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 distractable.

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

Dr. Reena Malik: Exactly.

Host: In order to be able to be in the mood.

Dr. Reena Malik: 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 just 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.

Host: Yeah. Because as a man, you got to get an erection. And I 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.

Host: There's like a story in my head which makes me go, "Oh, that's kind of hot."

Dr. Reena Malik: 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 and sort of allow yourselves to be intimate before that sort of desire and arousal come together.

Host: 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?

Dr. Reena Malik: Yeah, absolutely. I mean some people um 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 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 in 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 it comes more as a response to these other cues that allow you to feel desire and to feel aroused.

Host: H 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've been traveling and I was jetlagged. 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 going to have sex and um that was that was very hard because actually the expectation of it stressed me out more.

Dr. Reena Malik: 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 I'm 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 going to 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 almost spectatoring. 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," which I hate that word, but like performed the way I should or or I'm expected to. And now something's wrong with me. And now that just keeps going in a vicious cycle.

Host: Have you spoken to people that have experienced this?

Dr. Reena Malik: Absolutely.

Host: It's common.

Dr. Reena Malik: Very common. I tell people anytime you have problems in the bedroom, it stays with you.

Host: So, how do you break the cycle?

Dr. Reena Malik: 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 arogynous 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. 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 gradiated 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.

Host: 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?

Dr. Reena Malik: 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 will be 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? Right? And often times 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'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?

Dr. Reena Malik: 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.

Host: 49% longer.

Dr. Reena Malik: Yeah. Yeah.

Host: Be right back. No, I'm joking.

Dr. Reena Malik: 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 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 hundred orgasms men had, they lived like 13% longer. They had a 13% increase in life expectancy. And so, it was really interesting to me 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 the WHO made loneliness like an epidemic. So, they've said that loneliness is as bad as having like 15 cigarettes. And so, sex is a way to feel connected to another human being.

Host: 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

Dr. Reena Malik: Yeah. It's not necessarily sex, but they've looked at like they try to control for other things like age and coorbidities and all these studies and um it's also like sex is a cardiovascular workout, right? For many people is a cardiovascular workout. You are getting a phys physical physical activity with your partner. Um you are increasing your heart rate. You are doing these things that are also good for 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 u 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.

Host: 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?

Dr. Reena Malik: Yeah. So, there's four 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. Um, you can try to do everything else to patch up your house, but it's always going to 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 going to 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. They look at 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 always like, "What are the superfoods I need to have?" Almonds are great, but 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.

Host: So pistachio nuts will make my penis harder.

Dr. Reena Malik: I mean, so I always say like I don't love to talk about superfoods because then people like, "Oh, I just got to eat pistachios and it's all good, right?" It's 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 they really sort of improve diet. Fruit um anything that has sort of flavonoids, so like colorful fruit like blueberries, citrus fruits, um lycopine, 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 endothelop protective mechanisms. They protect the blood vessels. They make them healthier. And so when your blood vessels are healthier, 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. So I think making sure that you meet the criteria for fiber, which is 38 grams for men, 25 grams for women, um, is really really important. And then obviously managing your calories and a maintenance, right? because we don't want to gain weight because excess atapost tissue or excess fat also puts you at higher risk for erectile dysfunction and other sexual dysfunctions.

Dr. Reena Malik: Next we have uh 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 want to 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 5minute warm-up. They did 20 minutes of walking and 5 minutes of a cool down. And with this supervised protocol, they still improve 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 cuz it's going to improve blood flow to the genitals going to improve blood flow to the penis. It's going to improve blood flow to the clitoris for women. So that's where cardiovascular exercise is so so important in terms of resistance exercise. I know these little weights are probably not sufficient for doing much, especially for men, in terms of improving um muscular health, but obviously we're not going to 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 going to 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 about 7% every decade of life after around 40. When you maintain it through resistance exercise, they're three times less likely to have erectile dysfunction.

Host: Oh, really?

Dr. Reena Malik: Yeah. So, they maintain erectile function, they maintain sexual desire, they maintain um satisfaction with sex.

Host: I read a quote yesterday that said muscle is medicine. And I thought, 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.

Dr. Reena Malik: 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 important. Um, the other thing is we want to prevent sarcopenia. So, sarcopenia is muscle loss. And when you have muscle loss, um, that also increases your risk of having sexual dysfunction.

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

Dr. Reena Malik: Oh, yeah. So, we missed that part. So, um, 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, uh, 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. So these are your pelvic floor muscles that are around the penis and the anus. Okay. These structures are very important for a variety of things. um 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 at a rhythmic contraction of8 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 um your stool in, and they relax when you need to pee in, when you need to defecate.

Host: So when you're trying to hold a wee, you're like tightening your pelvic floor.

Dr. Reena Malik: Correct. Correct. But these are also responsive to stress. So, just like people get TMJ where they get tense in their jaw cuz 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 a 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 got to 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 they can also cause premature ejaculation in men. And so these muscles are so important and all we hear about is keigull and keigull are exercises to strengthen these muscles. But keigull 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 keles might make it worse because you're now tightening muscles that are already tight. We also talked about pelvic floor relaxation. Doing exercises 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 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. Um but I think it's it's so important. that's under evvaluated, underd discussed when it comes to sexual function. It's a hugely important part of sexual function.

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

Dr. Reena Malik: 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

Host: 52%.

Dr. Reena Malik: And it goes up 10% every decade. So 60% of 60-y 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. And I think this is worth pausing on which is a erectile dysfunction problem is a often a symptom of a cardiovascular issue. Right.

Dr. Reena Malik: 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 psychoggenic 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

Dr. Reena Malik: Pillar three 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 h 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 you. Um, 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 six-second kiss with your partner. And so it seems like six seconds, no big deal, but actually if you time it, it's like hm 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.

Host: The gym is great as well.

Dr. Reena Malik: The other thing is just having like interactions with people. And so that's where we're becoming more isolated. But even just like 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. They're having a normal social interaction. So, and then being creative. And we've been trying to work with this work on this with our kids because there's so much external stimuli all the time, right? They want to play video games, they want to watch TV, they want to 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. Um, 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 versus eight hours a night. So you take the same guy and he sleeps eight hours, then you, you know, do five five hours for a few days. His test for a week, his testosterone drops by 15%.

Host: Wow.

Dr. Reena Malik: That's like as much testosterone drop as would happen with 10 years of life.

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

Dr. Reena Malik: It was short. It was like a week. So, a week of sleep deprivation will will tank your testosterone. And sleep apnnea 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.

Host: Wait, so does this mean that people who have chronically bad sleep probably have low testosterone?

Dr. Reena Malik: Probably. Yeah.

Host: And what is the symptoms of low testosterone?

Dr. Reena Malik: So, low testosterone, 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 apnnea. And how you know you have sleep apnea is uh your partner might tell you that you're like waking up in the middle of like gasping for air. If you have one really easy way to check is take a a measuring tape and measure your neck circumference. If it's more than 17 in 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 um into your body. When you improve sleep apnea, we've seen improvements in testosterone as high as 200 nanogs 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. Uh 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 phalates 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, PAS, so the things like non-stick 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're not drinking out of plastic. If you have to drink out of plastic because you're at an event or whatever, try to make sure it's not a um 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 microlastics 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. These are 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.

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

Dr. Reena Malik: 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, in 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.

Host: Do you and your family drink out of plastic bottles?

Dr. Reena Malik: No, we drink we we have like metal water bottles for the kids and myself. And

Host: what about non-stick pans?

Dr. Reena Malik: We buy ceramic. We 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 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 lot of 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 um 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.

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

Dr. Reena Malik: Yeah. And I think it it extrapolates to everything. what kind of of relationships you 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 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 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.

Host: 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?

Dr. Reena Malik: 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 want to 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 of people. The other thing is that there's a lot of negative discussion around porn, right? People 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. and 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 like 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 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 uh see things that you may never do in real life that may be enjoyable, that are fun to watch, that have 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.

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

Dr. Reena Malik: So, it depends. I think a lot of people watch it without an issue, right? They watch

Host: if I masturbate and I ejaculate, I'm not going to then be able to ejaculate very quickly necessarily with my partner.

Dr. Reena Malik: 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 and a 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.

Host: And the last one, the last of the four pillars,

Dr. Reena Malik: the last of the four pillars we talked a little bit about, it's called confidence. And confidence is not like stringing 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 two, actually talking to your partner or paying attention to their cues. We that, 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 uh vulva stimulator. So, you put this on the outside. So, you can see that it would in theory, if this was smaller, would stimulate the um 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.

Host: I remember I was with um 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.

Dr. Reena Malik: I think it adds novelty and it's exciting and it just adds something new.

Host: But she felt like it was almost like giving up.

Dr. Reena Malik: 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 so many places in our lives, right? So why not introduce it in our sex lives?

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

Dr. Reena Malik: 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 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 role play 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, three 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, um knowing what your partner likes, it can be very helpful, but it also is nice to add novelty. So if you think about you can 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 going to get frustrated, right? And so you need to add a slight challenge to your sexual encounter to get into that flow state. And that's when you start having really great sex cuz 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 a little bit of uniqueness and novelty and challenge.

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

Dr. Reena Malik: 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, often time that shows uh, that has, uh, higher orgasm rates. There's actually like this uh this technique called the cooidal alignment technique where you sort of move in a rocking uh a sort of a rocking motion so that um your pubic symphysis. So this bone right here um 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 in sex. But really it's about figuring out and trying different things and realizing like that for example that coil 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 uh best and yeah realizing it might not work. You might be like super awkward and 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.

Host: I used to think that a woman orgasming was when this was when I was younger. Um was when she squirted.

Dr. Reena Malik: Mhm.

Host: So like that's what I thought it thought an orgasm was squirting.

Dr. Reena Malik: 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. Um usually it's clear, colorless, and it can be quite voluminous. um it's coming from the urethra which is the pee hole essentially and remember I talked about those skins glands those skins glands are the homalogue of the male prostate and they have a little bit of fluid in them too typically when you have stimulation um and squirting they will release fluid from the bladder as well as the skins glands that combines together and and it's emitted through through that

Host: so it's not pee

Dr. Reena Malik: 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 uh in the fluid and yeah, there was dy in fluid. So, it's coming, it has to come from the bladder. The skins 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 interstissia 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 steam 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.