November 6, 2020
All About Your Penis: Pleasure, Curves, Diet, Erection & More!
How’s your penis doing? How’s your diet and how does it relate to the pleasure you experience? And how can you have better anal sex? Sexual Medicine fellow & LGBTQ advocate, Dr. Josh Gonzalez, MD, joins us to discuss arousal, orgasm, ejaculation, erection, pain and more. He shares his expertise and answers your questions including:
- What’s the best diet for your penis?
- How can you deal with painful ejaculation?
- What is a muted orgasm?
- How can you deal with delayed ejaculation?
- What are excitatory neurotransmitters?
- What is soft glans and what are your treatment options?
- What is Peyronie’s and how can it be treated?
- How do some antidepressants inhibit and help and harm sexual pleasure including orgasm and desire?
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This is a computer-generated rough transcript, so please excuse any typos. This podcast is an informational conversation and is not a substitute for medical, health or other professional advice, diagnosis or treatment. Always seek the services of an appropriate professional should you have individual questions or concerns.
All About Your Penis: Pleasure, Curves, Diet, Erection & More!
00:00:05 – 00:05:07
You’re listening to the sacs with dr jess podcast sacks and relationship advice you can use tonight Welcome to the sex with dr podcast. I’m your co host brandon. Wear here with my lovely other. Half dr jess how you doing. I’m all right man. It’s a weird week. We got the election results dragging out. We’ve got good weather here in toronto to the point that it almost felt normal yesterday to sit on patio and which is unusual to because we don’t normally get t shirt weather in november now but i’ll take it on. I guess i probably shouldn’t if it’s bad for the environment. But i did enjoy a moment of normalcy yesterday sitting on the patio. Feeling as though i don’t know we weren’t in the middle of covid for just a moment. Yeah felt really good. First time for me. About seven months where. I felt relaxed for a moment and i remember looking around and the sun was shut. Maybe everything was rosy. Because the sun was shining. I was into t-shirt the weather was comfortable. We were on a patio. Doing what we normally have have done in the past which we haven’t been able to do you mean daydream. that too. yes yeah it’s it’s a strange time but it was nice to have that moment where you kinda forgot that the world is imploding. Your mixed me look very much look forward to the normal see that will once again be upon us. Yes the new normal before we dive into today’s topic which is the pinas and sexual health and sexual medicine and managing sexual dysfunction with our guest. Dr joshua gonzalez. I wanna say thank you to cleveland for their ongoing support of this program. Folks be sure to check out. Cleo von dot com this is sound way of technology that enhances orgasms cellular level by treating the clitoris directly. And it’s a totally noninvasive. No downtime no scalpels no needles. Nothing like that. So follow along at cleveland and check them out. At cleo von dot com now today we are going to be talking about iraq shins and ejaculation and delayed ejaculation and muted orgasm. And all of that. Fun stuff centering on the penis. So how’s your penis doing today filming. Thank you for asking. What do you think about your penis. Much i don’t normally think of my penis much ado at least one of us guys. I tend to over. Think things when we’re having relations what you mean what he thought when we’re having sex all sometimes i get in my own head. I start thinking about work. I start thinking about other things and then my mind goes down this path occasionally where start thinking am i aroused enough my hard enough and my this or am i that and it’s just ridiculous so we’re gonna talk about that But tell me how do you bring yourself back while question. I bring myself back lately by remembering that. What i’m thinking is relevant to what’s happening. So if for instance. I’m not hard enough if you finish too soon. None of that is a problem. If i finished his own or youth and we both know that if that were to happen we would just be looking for it to continue finishing again and again right you but you said if i finished you soon. Oh yeah no. I’m sorry. I was making reference to myself like if i were to finish too soon in the past. I’d be concerned that okay okay. Well it’s like sex’s done. But i know how that that’s not at all the case like you don’t need a penis to have incredible sex or orgasms or any of those things short until i say we’re done but that but that really is a part of it it’s just re framing what i thought sex was so if somebody were to you know finish or not be able to start in in terms of like getting an erection or whatever. It’s like what you’ve got hands you’ve got knees elbows tongues noses you’ve got all these other things that you can use. But how did you get over that. And that’s that’s kind of what we’re going to be talking about. How did you get over the pervasive belief. That sex is about a harvard penis lasting x number of minutes. And then jackie leading experiencing and having these conversations here. And i’m not just saying listen to this podcast but for me having the opportunity to have so many incredible in like so incite such insightful for guests here just reminding you that sex’s not we’ve been taught sex is like sex.
00:05:07 – 00:10:00
Is your elbows the backs of your knees. Your tongue your nose yet. it’s a penis. it’s a it’s a volva. It’s all of these things. Have to be what i was taught growing up which is penis vagina vulva. You know what. I mean like that you are not taught vulva growing up wall. Because i’m trying to use the correct terminology now. I’m not talking about what i was growing up. When did you first even hear the word volva working working with you or you know. I remember your days. Twenty years ago at the sexual education center You of tea and your group of friends and the educators that worked there and even at that point being presented with different terminology. And i remember not knowing what it is so it gave me an opportunity to learn now. Google wasn’t the thing as much then. So i got to ask questions. It was against going to download on napster or something right but you know now. You don’t know something before you even need to ask somebody you can google it. Yeah google doesn’t always bring up accurate responses or inclusive information. And that’s that’s why we have these conversations so joining us. Today is dr joshua gonzalez. Md fellowship trained in sexual medicine specializing in the management of sexual dysfunctions throughout his career. Dr gonzales focused on advocating for sexual health and providing improved health. Care to the lgbtq plus community. Thank you so much for joining us. Dr josh how you doing today on things from me are happy to chat with you now. We have been working in tandem but from afar with clyde and you are astra glides sexual health advisor. What do you do in that role So i Provide written blogs every every month for the websites mostly focusing on male sexual health. So we’ve written some stuff about kind of how to enhance your male sexual performance just submitted one on jackie literary dysfunction which should be published. Pretty soon We had one focusing on anal sex so each month is kind of a different topic depending on what what we want to bring light to From from the brand perspective so when you talk about sexual performance what are you talking about. Took the question It’s it’s sort of all encompassing the the blog that i’m referring to kind of specifically focused a lot on kind of maximizing erections And the piece. I just finished yesterday was actually supposed to be about erection ejaculation. I kind of skewed it. More towards the jackie because we covered a lot of the erection stuff In that mail you know enhancing mail performance blog but it was. It was sort of all encompassing it. Kind of talked about the importance of diet lifestyle behaviors and You know different supplements that have been used in exercise and all kinds of things so On how to kind of just holistically approach Enhancing performance. Dr josh refunding right now in the midst of everything that’s happening in the world is maintaining actions. Something that is more common these days like is that something. You’re seeing more of challenges. I’m sorry yes yes so. I’m definitely seeing a spike in a variety of different sexual health issues. libido is a big one but yeah erections as well. I mean people are kind of quarantined with their partners and hopefully they have good relationships with their partners but not everybody does and so you’re starting to see You know people struggle in their relationships sexually in ways that they hadn’t before and then if you know you’re talking about people who are single there are feeling very isolated and alone and so in dating in this environment can be very challenging. So there’s a lot of things -iety about everything going on in the world and then that often is carried into romantic and sexual relationship so i definitely seeing an increase. I’ve been just as busy. You know in the past few months. I have been ever so that makes sense and now i in in this article because i read the article. You’re talking about you talk about eating like your penis depends on it. Because often think about erection we think about touching it or fantasizing or watching something to get it hard but your erection is dependent on your day. Your lifestyle your exercise your diet. Your interactions as much as the technique you use to develop that direction so when you say eat like your peanuts depends on it. What should these penises gobbling up. So as a general rule.
00:10:00 – 00:15:03
I like that by the way gobbling I would say as a general rule. We kind of say what what is good for. Your heart is good for your peanuts and it’s good for your erection so okay And there’s actually a medical literature to support this. There’s it’s come out in the last ten to twenty years An abundance of literature showing that men are much more likely to present with erectile dysfunction as the symptom of undiagnosed cardiovascular disease years before they would necessarily present with something like a heart attack or a stroke. So everything that your doctor is always told you that you should do to maintain a healthy cardiovascular system is true for your penis as well. So that’s you know eating a well-balanced diet in there some data showing More specific diets that can be helpful like the mediterranean based diet getting you know Regular physical activity watching. How much fat you consume watching your intake of animal proteins. All those sorts of things that that your doctor says you should do to to keep your blood pressure. Healthy in prevent diabetes and keep your cholesterol in check are all going to benefit your s. So that’s you know as a general rule we say what you’re doing for your heart is going to be good for your penis. Say you’re talking whole grains fruits vegetables lagoons nuts. nuts are good for your nets olive oil. Got all the one liners. Today calling penises and the nuns good for your nets and so so it’s your diet. You also say that coffee may play a role you talk about Two thousand fifteen study. That found that consumption of caffeine reduces erectile dysfunction or the likelihood of erectile dysfunction on. Do you know why the the theory that underlies this connection I actually don’t know what the The specific mechanism is for that. I mean coffees an interesting thing that we all you know generally consume And historically it’s really been thought to be detrimental to our health and there’s been a lot of literature that have come out. Probably i would say since the year. Two thousand that have shown the benefits when drinking in moderate amounts of messages one of them So interestingly enough. I just came to mind because i just wrote about coffee in the piece that i just finished this week in about ejaculation and coffee can kind of be bad for generation. Where talking about taste so You know everything in balance. If you’re a big coffee drinker in that in the newest piece i wrote i recommend that you try to leave it to one to two cups a day okay which would also sort of maximize the benefits from interaction standpoint. So you’ve gotta find that that nice balance where you get the benefit for your erections put you. Don’t want your partner tasting. He spoke now. We got we got on the language today. And so when we talk about you know stronger erections what are people’s other options we’ve got lifestyle factors like reducing stress and sleeping better and eating better. What about in clinic. What what are some of the medical interventions when there are issues with with erections you know people come often right in and say hey. My erection isn’t as strong as it used to be right right. So i think one thing that makes my practice unique is that i approach erectile dysfunction and really any sexual health issue from a diagnostic perspective right so we know that that anxiety and psychological factors can contribute to a man’s inability to perform but we also know that there’s a certain number of organic reasons that tall problem so when someone comes to see me for an erection issue doesn’t matter if he’s twenty five or sixty five. He’s getting the same workup. And it’s kind of going through the list of organic causes of edna and those include hormonal issues. So we do a warm testing. We do blood flow assessments with something called a penile doppler where we actually do a vascular study of a man’s penis while he’s erect the office To figure out if there’s a blood flow issue there and then once we understand more about which organic causes maybe president than we can kind of come up with solutions for those And i do my best to kind of. Try to normalize These issues for my patients. The from the first moment i need them. Because the truth is if you look at the ed literature only fifteen percent of men who present with d. have strictly psychological problem. But that’s not what they come in thinking. So i i would say it’s closer to fifty percent of men that icy coming thinking. Well i think it’s all in my head But that’s really not the truth if you look at the literature so And i tell them you know it’s if you’re a man who enjoys sex is in a relationship that you know it were they. They love their partner. They wanna have sex or if they’re single on their warning and wanted to have sex with multiple people but they’re incapable of performing that can be incredibly frustrating and create anxieties.
00:15:03 – 00:20:03
That ben can compound whatever physical issues we find so i work closely with providers such as yourself to kind of help address those anxieties so it kind of takes a village to treat these issues. Sometimes that makes sense and you work in lgbtq health. So do you see differences in terms of sexual orientation and expectations or needs or the way they present or the way they describe issues related to erection absolutely so i another thing that i tried to Figure out when i’m meeting with a patient for sign is what their goals are right. So you’re talking about a man who identifies as heterosexual and he’s primarily going to be having pino vaginal sex. Then we know we have to get him to what we call a great four erection. Which is you know. A perfectly rigid erection and this is based on The erection hardness scale which was developed during viagra. Trials is great one. Two three four four being sort of the perfect direction but that was based on a vaginal model And based on the pressures that are exerted on the erect penis during vaginal sex. If you’re talking about someone who identifies as gay. And maybe engaging in other types of sexual activity say anal sex. The pressure exerted on an erect penis from During anal sex is incredibly higher than than from battle sex. So you know while there are not while there’s not an exact metric that applies to Men who were having sex who are having sex is sort of modified that direction artist. Gail and i tell guys who are primarily interested in penetrating their partners that we’ve got to get you to afford plus because the amount of pressure that’s going to be exerted on your peanuts during sexes is higher than what we even associate with being a great for direction that makes so much sense and it’s interesting and of course not surprising that gay men are left out of the equation and the research. They don’t even register on the scale now. Of course gay men can have lots of different set types of sex besides trated anal but there is that piece that exists and of course people of all sexual orientations and genders are a little bit interested in anal. You’ve been writing about anal and one of one of the pieces. You begin with is a reminder that anal sex does not have to be about penetration right. There’s all this other stuff we can do. So can you give us some ideas. I know that’s not exactly what you do. But you have expertise in the area. I think i wrote that piece. From the perspective of just you know exploration And trying to sort of normalize in all sex as you as you mentioned you know people incorrectly associated with Men who have sex essentially but they’re all different types of people that engage in play and so this blog was really meant to try to normal as that and give some tips on how to engage in that maybe for the first time. And you’re absolutely right. It doesn’t necessarily involve immediately penetrating So you know one could engage in in what’s called winning where you’re performing a linguist essentially using your tongue. You can certainly use fingers ways. I mean there’s other there’s other types of activities that you can use. You don’t necessarily have to insert your penis into someone’s anus right off the bat. So yeah and i’ve got a rule that you really shouldn’t insert your penis into someone else’s amos until you’ve gotten to know your own anus right like you should be able to. You can’t go on your own unless you’re some sort of. I don’t know some sort a puppet mastery going on with the penis but to be able to even put your finger in your own but to get to know what it feels like to have those fingers around it to relax to breathe into it. I think I wonder if it’s less so among gay men than than street people this expectation that anal sex will inevitably be painful is something you run into absolutely i think less so in the gay world but you know i mean there are still game in that complain a bit about her and i think one of the things that he tried to convey in that piece that i wrote was there are things that you can do to become better at play if that’s something that you want to do Often involves patients sit involves A lot of lubrication involves Knowledge of your anatomy it involves Just kind of relaxing and doing what feels good and stopping if it doesn’t feel good In having a partner if you’re engaging in this kind of stuff with a partner that is understanding. And it’s going to go slowly with you if something that you’re trying for the first time So yeah i absolutely would say it does not have to hurt and it shouldn’t her. You don’t want to necessarily engage in in sex if it’s painful just because you think you have to You can there’s other ways to have sex That the don’t necessarily involve pain right.
00:20:03 – 00:25:11
And if we could just see sex as at an exploration of pleasure and not falling into these expectations of how. I have to check this box or i must do this. Because it aligns with what i’ve been told you know fits my gender identity or sexual orientation but what feels good right like if it feels that to suck to suck on an lower than do it if it feels good to suck on a toe then do it feels good to put a penis in the anus. Then then do it as long as as long as everyone’s enjoying the process. So i do some questions from listeners that i’d love to help out with if you don’t mind so the first one this person asks about a penis that curves to the right when erect. They say it has been this way as long as i can remember. I’m a bit self conscious about this. And i researched it. I’m wondering what i can do to fix this. I know there is surgery but that seems a little extreme. Are there any other procedures or therapies. That you know may help. And they don’t They’re not showing any symptoms or pain or anything like that So without examining is this Prison it would be hard for me to necessarily diagnosed him with what i’m going to talk about. But it sounds to me like he has he may have a condition called pai rone’s disease And this is where the examine history become important because there are men who have a certain degree of curvature that is non pathological. They’ve had their whole life. It’s never interfered with their ability to penetrate it. It may be distressing to them. Psychologically or they may have encountered a partner. Who made some offhand comment that kind of insecure about it but it’s not necessarily pathological meaning doesn’t necessarily require intervention On the other hand there’s a condition called perez disease which we mostly think of as acquired. There is a congenital form but a majority of patients develop at some point later in life and it is thought of primarily as an accumulation of traumas to erectile tissue or time. so sometimes that is a very clear events you were having sex. Your partner was on top. They came down. And your penis buckled and you may have heard a cracker snapper pa and then you know it’s crispy And then yeah it’s it’s it’s it sounds in is painful from whatever from vicious but shortly thereafter men start to report a change in the appearance of their erect penis. It bends one way I see a little bit when when iraq’s my penis seems like it’s shorter than it used to be so you start to see a change in the way that european looks when you’re erect and sometimes associated with pain And in those patients There are treatments for their their condition. But it it it matters what the severity of the issue. So generally speaking we think of curves greater than thirty degrees to be something that warrants intervention because once you get beyond thirty degrees it can be difficult to penetrate your partner if that’s the kind of sexy interested in having so that’s where a objective measurements in the office. Become important because there’s only one fda approved if you’re talking about you know Treatment in the us Only one fda approved treatment for this condition is called zay. Affleck’s senate an injection that you In minister directly into the area of scarring. But before you can do that you’d have to make sure that you to a formal measurement in the office and the person is greater than thirty degrees and that they have an area of scarring that you can feel so that you can administer the injection properly. Their surgery was the mainstay of therapy. Prior to the advent of zion flex flex has been around for probably tenure. Ten years now So that is really replaced surgery as sort of a first line therapy for men with with payroll disease There’s other things that had been used off label for years prior to the afflicts That also involve injecting the penis But that’s that’s really the only fda approved treatment at this time and so are some people just concerned about the curve from the aesthetic perspective. Because maybe penises in porn the penises. They see don’t curve as much and so we get all of us. Were so conscious about our bodies. And you know there’s you know mark exist in order to sell us things to fix problems that don’t exist So i imagine it’s the same thing with penises. Do you find that people come in and nothing is wrong. Sometimes they’re just a little bit self conscious. Yes absolutely and so. That’s where this particular person who wrote in i would be interested to see is his curvature truly something that we would consider congenital rone’s or is it just curvature within normal limits that he’s been you know someone insecure about for whatever reason for most of his life And that’s the really interesting thing about peroni diseases that it’s a disease a to functional problem but there’s a certain degree of distress that is associated with it so there are some men who developed an have troop payrolls disease.
00:25:12 – 00:30:14
They may have a curve. This twenty five degrees. Maybe they don’t quite meet. That cutoff are incredibly bothered by it. There other men who i’ve seen you have forty five fifty degree bends. Maybe they’re not having sex with her partner. Or maybe or maybe they’re doing other Non penetrative sex. Maybe they’re having other types of of of Sexual intimacy and it’s not a big deal for them and so It’s it’s when considering treatments you have to consider both the severity of the deformity and also the degree of distress. And those are not always. You can’t look at a curve and predict this amount of anxiety because they’re not always correlated that makes sense you know another person asked about ponies disease they say I had pene. I had a p now. I don’t know what the says. I think it means surgery. I had penile surgery because a peronist disease. My penis lost him girth and length after surgery. My wife and i still have intercourse. But the head of the penis is soft. The sensitivity is not the same Do you know if there’s a procedure that we can do to make the head of the penis hard so there isn’t a a procedure that i’m aware of can Make a penis hard it. There is a condition called soft glance. Which is what it sounds like. This person may have Interestingly wanting that people don’t appreciate is the blood flow to the head of the penis is actually separate from the blood flow to shaft so a man can have a normal erection like a rigid shaft but the head of his penis can be soft. And that’s because the blood flow from to the head of the penis comes from the eureka. So there are Some medications that we can prescribe Usually have to be compounded that you can insert into your three opening That are visa active. So they dilate the blood vessels so some of my patients who have soft glands. I’ve tried those medications with them. In essentially just gels that they insert into aretha opening prior to sexual activity dilates the blood flow to the head of their penis and that can help increase sensitivity and rigidity of pet are rigidity sensitivity correlated. So the harder you are the more sensitive you are or not necessarily generally speaking the more engorge and rigid europeana says The more sensitive however there are a variety of different things that can affect sensitivity so With this particular person’s surgery. I don’t know what what exactly occurred during the surgery but The nerve the nerves that innovates the penis run along tile alongside alongside the top and sometimes those nerves have to be moved out of the way to do these kinds of peroni surgeries. So it may have interfered with normal Nerve input to the head of the penis That may be possibly why he has been experiencing this post surgery And there are other conditions things like Diabetes for instance which is known cause peripheral neuropathy so A diabetic may have completely healthy blood flow to the penis. He may be able to get erect but his sensitivity can be completely abnormal if he has Uncontrolled long standing diabetes. Okay and i have another question that relates to sensitivity sear leading into all of these. This person says my boyfriend has very little feeling in his penis when we engage in sacks vaginal and oral he has the most sensitivity in his penis when we first start but as we continue the feeling in his penis begins to fade. Until eventually he doesn’t really feel anything at all It doesn’t affect his erection but his as his penis loses feeling. Obviously in this happens when he masturbate says. Well he generally can’t have an orgasm or jackie leads so so they say if he finishes kind of quickly than we can do it. But over time as it becomes more numb. They can’t orgasm. Is this something you’ve seen. Yes so i think there’s a couple of things to draw out of that number one. I think it would be important to figure at the age of this person. They’re young. they’re college student. Oh okay ’cause i was gonna say just on that on that note As men get older this the their the sensitivity in their peanuts tends to decrease They’re accurate tori time to their time to Also tends to increase so I got. I have plenty of older. Men who who reported takes a lot longer and they require a lot more stimulation to jackie gaza. But if we’re if we’re talking about a college age student with out any kind of history of trauma or low back pathology. That could perhaps interfere with nerve put from spinal cord I’ve seen a lot of patients develop these report or report these issues with sensitivity and sometimes it’s actually like behavioral And this.
00:30:15 – 00:35:09
I don’t know if you can speak to this. But i’ve referred patients who have trouble ejaculate eating because of reported decreased sensitivity and a lot of times it can be related to how they’re masturbating on and or How that is different from when they’re having sex with department because as i’m sure you know men generally grip their penis a lot harder when they’re masturbating and move their hands a lot quicker than can be reproduced with a partner on. So i have a a handful of patients who i’ve referred to therapists and sex therapists to work on on what they can do through masturbation to kind of set them up for success during sex right. Yeah actually i received that question this morning from someone who said that they can orgasm masturbating porn and they can’t with a partner and they said is porn. The problem and i said i doubt it’s porn. It’s probably how you grip your penis right like you hold onto that thing for dear life like it’s the only one you got which is true but i mean you know there are really simple. Physical approaches like for example. So this person was having intercourse with a vagina. Reach down while you’re having that penile vaginal intercourse and grab hold of the base rate stroke fat lower third with your hand or have your partner do it or where a cock ring. That’s a little bit tighter you can slide along with some caucus with lube a little bit of vibration and then of course as you said training yourself to orgasm in different ways because if your body only knows how to respond to one type of touch you’re creating that association In terms of this other case is do some penises experience numbness and like is this may be related to hormones or medication or stress. Even absolutely yes. So i mean i think all of those are important factors to consider one thing that that i find a lot in my practice. Is that the young men like this person often get dismissed right. So let’s say he has the courage to bring this up to a provider. They’re going to tell you know likely would. would that would be met with dismissal. Essentially oh it’s all in your head you now just You know it’s it’s your partner you know. Maybe you’re bored with this person or whatever and we would still kind of go through the same process right. We would still do A hormonal evaluation consider medications that they may be on or other commodities may be contributing to decrease in sensitivity And the truth is i’ve i’ve found hormonal problems. In twenty year olds that one would never expect to find so everybody kinda still gets that same workup. I don’t think age should be a determining factor. That’s so important. I mean talking about people being dismissed and we talk about this all the time on the podcast you know. Women being dismissed further concerns people of color being dismissed their symptoms especially related to pain. But we don’t tend to talk about young men being dismissed as well. You are supposed to be the pinnacle of health. Therefore i’m going to look at you through that one lens and perhaps not consider all of these other factors absolutely and i think that happens a lot law too young men such an important point that we have to kind of be our own advocates and find healthcare practitioners who have a background in sexual health rate. Is you know you may be willing to talk about sex and really open to talking about it. Like even the fact that you’re talking about different needs of erections for anal versus vaginal versus your own hand so many physicians. Md’s shy away from that. Because you know obviously you don’t exist in in a vacuum you exist in this era phobic world and it’s hard to find comprehensive training and sexual health. I don’t imagine you received it all in med school. You’ve had to do your own learning absolutely. Yeah i I wouldn’t even say i received. I didn’t receive much of it even in residency training Urology and you know the focus in urology General urological cancer. A little bit of paediatrics. In and that’s about it then they leave a little bit for sexual health And so i had to do a fellowship specifically in an area called sexual medicine to kind of learn all that stuff but i. I think you’re absolutely right. I mean i can speak to the american medical education system. And i know in our system. Here there is absolutely not an emphasis put on sexual health and that’s just like man woman sexual health so when you’re talking about anybody who identifies as queer or a person of color or any these sort of Minority groups like the we get nothing no exposure to any of that. So you really do have to kind of continue your education to kind of get that that the knowledge And i think you know.
00:35:09 – 00:40:03
I think i’m thankful that patients can now using the internet To find providers like yourself in an and myself because they are being our own advocates in its it’s born out of necessity because a lot of them either. Don’t feel comfortable talking to a doctor or they already have been dismissed and so it’s still. This problem isn’t going away and now they’re like what do i do. I’ve got to find help so right and doing a fellowship in sexual medicine a wizard training in how to address. Trans patients needs a to a to a certain degree. Yeah i mean. I did some sexual medicine When i did it was like five years ago and it was. The focus was a lot on Specifically male and female sexual health I’m a game end myself. So i have a particular interest in lgbt q. topics within sexual health. So i definitely like made that effort to To learn more about sort of queer sexual health and Check for other people Gender non conforming nonbinary people And so in a lot of that is just like learning language and being comfortable with talking about types of sexual behavior and you know Genitalia and not necessarily associated with specific gender or specific sexual orientation. But that’s that that does require to a certain degree a re education because it’s it’s really not something that we are taught in in medical education so even if are taught at we live in a world that is you know all cysts normative hetero normative. So it’s a lot of. It’s a lot of unpacking professionally and personally So i have a few more questions that i really wanna get you if you don’t mind vegas because you talked about charge about the fact that with time people with penises generally take longer to evacuate so you know when you’re it’s going to be different than when you’re sixty and of course there are exceptions to that But i am hearing from more. Young folks with penises. Who are saying that. It’s taking them too long to jackie late so it takes them a so. We’ve already talked about the fact that it could be training from gripping yourself you know really really tightly and there’s two ways to kind of deal with that you can learn to grip yourself more gently or you can just grip yourself more tightly when you’re engaging and partnered saxon for those who take ten fifteen even plus minutes Have you studied delayed ejaculation. Or do you deal with this in your practice. And what can they do about it. So i would say. I would start with the behavioral stuff right so i would definitely refer to their of sex therapists on. There are some medications that we Do try You know they’re they’re all off label there’s no. Fda approved strategy for delay jackie relation or even premature ejaculation for that matter so There’s there’s a lot more data looking at a medical therapy for premature ejaculation very little for delayed ejaculation. So something’s The the way. I was to think about it during my sexual medicine. Fellowship is Most sexual problems are balanced between expectation and mission so using delayed ejaculation as an example. That is something that is overly inhibitory right so you wanna do something that is excited tori to counterbalance that so one of the things that we use First off you know. You don’t wanna make sure that their actions are normal If they’re not you could consider using something like a pd. Five inhibitor Examples of that would be viagra cialis. Those kinds of pills improve blood flow. Because maybe it’s blood flow issue a lot of men have delayed ejaculation because their erection normal. So you can kind of treat both conditions with one medication if that’s the case Other men have totally normal erect erectile function and still have delayed ejaculation and so we consider other strategies that are excited tori right so there are. There are medicines that work on excited. excited tori neurotransmitters primarily nor epinephrine and dopamine And so we use dopamine agonists sometimes to increase circulating levels of dopamine in the brain One is commonly used as a medication called wellbutrin That is an antidepressant but we use it off label because we know that its effect on dopamine levels and then a medicine that people are probably familiar with. This is adderall which increases It’s a increase nora. So it isn’t excited tori Treatment and you know these can all be very hit or miss. Because as i mentioned there’s not a data looking at the the the use of these medications so it is a little bit of trial and error and i explain that to patients at the beginning. I say if you’re willing to try different things we can.
00:40:03 – 00:45:00
We have lots of options. But there’s no one-size-fits-all there’s not a medicine. That’s absolutely always gonna work for everybody because our brains are all different so as long as they’re sort of willing to go down that journey with me then then i try whatever i can to to try to help them. And i’m really thankful that you include discussions of the relational or psychological or lifestyle elements. Like we think about. We’ve seen this all the time. Something happens one time. That’s unfavorable whether it’s the loss of erection or premature ejaculation or delayed jocular or no orgasm and then we get in our heads that this is going to happen again. And then we create that feedback loop via amp right under performance pressure and then of course the body works against itself because we get stressed out and we can no longer an act that relaxation response to this. This all makes sense. I imagine you also run into people taking medication that can inhibit orgasm. I’m wondering if you can speak to that. Absolutely so i would say probably the biggest one would be antidepressants so Sri’s which are probably the most prescribed titled anti-depressant Are notorious for causing delays to jack. They can sometimes interfere with Erectile function as well and can can even mute orgasm. Sometimes like the the. If you’re able to jackie late at the sensation the pleasure will sensation that you get from work sometime sometimes to be muted so that is a. Yeah that’s definitely something a battle that we’re constantly fighting there are some you know Antidepressants that we would consider sex friendly that are newer. So wellbutrin i already mentioned is one of them so if patients i i usually give my patients a list of sex friendly antidepressants to discuss with their prescribing doctor to either transition them onto those or two discussed possibly adding them to their regimen to see if we can counteract the the effects of their sri So again that can be thought of as sort of a excited tori. Inhibitory kind of thing as well. Because as as result in an increase in serotonin and serotonin is generally thought to be an inhibitory neurotransmitter from sexual respective so We actually used off label for premature ejaculation. Which is an overly excited tori state that we want to inhibit a little. So we put people on that. And that’s while that’s not. Fda approved it’s been well studied and is one of the first line therapies for premature ejaculation. This all makes sense and deal with pain during or after jackie latian all the time. I don’t know how this happened. But somehow it become like the pelvic pain specialist in los angeles Yes so Many times when men. Experience Pain after generation. Actually in the same could be true for women Who experienced pain with orgasm. If you about the act of jackie relation or gossiping involves a dramatic increase in tension in our pelvic floor muscles. Right that part of the pleasure that we get from the orgasm generally speaking is that you build up all this muscle tension and there’s a release well for a number of reasons men and women Can walk around with a lot of tension in their pelvis may because they’re doing squats all the time or really hardcore pilates or they got into a car accident so they had a baby vaginal. -i lots of different things that we do in our daily life can affect Defunct pelvic floor muscles and so patients who start out with dysfunction at area can often as the tension in their their poets increases as they approach orgasm can actually cross a threshold where it actually impinges on nerves and can cause pain sort of like if you sort of getting a charley horse in your pellets. Right like when you get a really when that calf muscle so tight that even after it releases its painful like you still feel the pain there. Even though the the not has kind of worn out That’s kind of what happens. And so a lot of patients who we see who have pain with generation orgasm one of the first things i do is refer them to pelvic floor physical therapy to have an evaluation because a lot of times they have dysfunction. There needs to be addressed. Yes and we work often with pelvic floor therapists here. We recently had uc logic on the program. Who’s also a sex counselor and happy down there and at brand. You’re really drawn in by the discussions around pelvic floor. It’s it’s your turn to go to a pelvic floor therapist. apparently i’m up. I volunteered myself to go in the report back.
00:45:00 – 00:50:01
Because you know my my first impression is that is if i go to see a public four therapists. They’re going to insert their fingers into my rectum and start poking around. And that just doesn’t sound like something. I want to do the very first time. I see somebody but by them flowers. Yeah exactly so before. Yeah before you know it was. It was something that i it made me less inclined to want to go but after the conversation that we had on this podcast. I felt comfortable. That i would go and see how how it felt so that people are waiting but i think you might be postcode. The i’m not that’s screamingly probably wise. I would say listen. I think that everybody at some point in their life Earlier rather than later should go to a therapist and should go to it. Up a pelvic floor physical therapists and both can be painful experiences but both are often very very very helpful I generally shy away from telling my my Male patients that They’re going to have a finger. Inserting in the rectum. Because i think fifty percent of them wouldn’t go If i did tell them that in it’s hard to convince them to go even if you know that I kind of I have a handful of physical therapists that i referred to in la that i absolutely love And they’re really great with patients and they you know they end up developing these incredibly intimate relationships That you know start out a little awkward. And then you know by the time i see them. They’ve gone a six treatments. They’re talking about their dogs in their kids. Do after school while having someone’s finger up there but so you know it’s it’s it may not be the most enjoyable experience at the beginning but once people see the The benefits they’re just you know they. They keep that appointment more than they do to see like a brazilian wax. Only even better right now. Really i mean to to have that capacity these pelvic floor therapists who are so skilled to have that capacity to be talking about your pets your animals while you’re in this most well. This person is feeling so physically vulnerable. There’s such amazing skill. I i hold them in with such reverence. So i’m glad that i’m glad that you brought them up and it would. It reminds us is that it takes village right. It’s a community you know. No single person has all of the answers. And i think we need that. Reminder kind of in an instagram world world of gurus where everybody sharing their knowledge and insights. But we can’t just draw from one source. So i i’ve learned so much from you i’ve just been taking notes here Certainly i another time. I wanna talk a little bit more about muted orgasms. But i love that. You’re working with the framework of the s. e. s. s. i. s. the sexual exploitation exi- tation system. It’s always so hard to say. And the sexual inhibition system. And i think that’s a great model for people to walk away with to think about. Okay so what are all the things that could potentially excite me anything from something physical to something mental to something emotional to something spiritual Anything at all right. Is it that. I you know i’m excited when i know my house is clean or i’m excited. When you call me dirty whore in my ear at the dinner table like what whatever it may be all the things that potentially excite you and then of course what are the all the things that inhibit us. And how can we make. How can we make lifestyle. Behavioral attitudinal and relational changes to address. These i’m so happy to hear. Because i don’t think i’ve heard another md talking about that model so again. I know that comes from your your background in sexual health. So what where can people learn more about you. I know you write your blog on astro glide dot com and i’ll be sharing those links I know that you’re also on twitter instagram. And you’re you have a website as well. Yeah so my website. Just joshua gonzalez. Md dot com Yeah so We have lots of information at every blog. That right for our guard ends up going on the website. And i you know. I do blogs and other media content As often as i can so all that goes up on the website. And you know i focus. We focused a lot. I think today on on the side of things but do treat all types of people With sexual dysfunction. So there’s a lot of information on the website on the place to start and then as you mentioned. I’m active on twitter and instagram. That they can lead to from the website awesome. And yeah you know what. I had a questions about menopause. Because i know you also do a lot of work with people who are postmenopausal. We’ll save that for another time because we ran out of time but really appreciate you being here today. Folks make sure you follow along on facebook and instagram joshua gonzalez link to him and on twitter sex med l. a. Thank you so much for being with us closer to see you.
00:50:01 – 00:51:32
U2 take care has your penis cobbler. phelan wish had. I’m feeling spunky. Funky did you ever name your penis. No i didn’t really did any partner every name your penis that you know not not to my knowledge. No no franken beans. That’s an awesome name. Franken beans that’s what you’d name it. Yeah yeah i could get a weiner dog or to weiner dogs. I’d name them franken beans the name and it would be frank and being smart lake. My balls would be franken beans talking about the dog or your penis. Now you’re talking about your venus. So we went from dr josh teaching us all these important naming european so i like the way hebrew highbrow on my on my end. I like the way it goes. Thanks for the discussion. Babe no problem thank you. Thank you to clear von. Ah for their ongoing support. Reminder that cleo vonda enhances arousal and the potential for orgasm at the cellular level by stimulating the clitoris to do more of what it naturally does so it can address vaginal dryness painful sex and of course increase your capacity to have an orgasm. Check them out. At cleo von a- dot com wherever you’re at i hope you’re having a great one great week ahead and we’ll be back next week with a brand new episode. You’re listening to the sex with dr jazz podcast. Improve your sex life improve your life.