For Goodness Sex
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For Goodness Sex
Erectile Inconsistencies: It’s OK To Be Soft Sometimes, With Dr Nic Gilbert
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ATTN: All penis knowers, lovers and growers.
Chances are your penis (and the one(s) you know and love) is normal, but sometimes it can act in unpredictable and undesirable ways.
That’s ok, dolls. We’ve got you. Dr Nic Gilbert is here to reassure us that erectile inconsistencies are very normal and very common.
Join us as we give the penis some love and care - it’s totally ok to be soft sometimes.
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Cam Fraser Men’s Sex coach: https://podcasts.apple.com/au/podcast/men-sex-and-pleasure-with-cam-fraser/id1511646621
Out of your mind and into your body: https://www.dabacosunset.com/embodied-aliveness-lead
We are your co-hosts, Dr Shyamini and Nurse Ellie, and this, is For Goodness Sex xx
Hello, my name is Shamani and I am a co-host of the podcast for Goodness Sex. I am a Fijian Indian woman of immigrant parents and am proud to live, work and play on Wajuknunga Country. This podcast acknowledges the past, present and future traditional custodians of stolen country and the impact this has had on the health and well-being of our Aboriginal and Torres Strait Islander brothers and sisters. Sovereignty was never ceded. Hi team.
SPEAKER_02Now, whilst we are healthcare professionals, this episode is for informational purposes only, and it does not replace personalised healthcare advice. Your health is unique to you. If you have healthcare concerns, please seek out your local health professional. Nailed it. Nailed it. Nailed it. Nailed it. Absolutely nailed it. Sorry, sorry. Thank you, babe. Thank you. Higher mental load, harder to blow your load. Got it. Oh God, you're good.
SPEAKER_03Thank you. I love how you made that connection to this podcast. That's actually a good thing. I've been thinking non-stop about our actions. Oh, that's the podcast. Oh, that's easy.
SPEAKER_02Hello and welcome back. We are your beloved co-hosts, Dr. Charmani and Nurse Ellie. And this is for goodness sex. Today we're actually starting off with a guest. We are starting off with a very special guest. Tell us about our guest, Ellie. So today we have the lovely Dr. Nikki G with us. Hi Nikki G!
SPEAKER_00Hello, hello, thank you for having me.
SPEAKER_02Thank you for being here. Um so Dr. Nikki G is a GP with a special interest in sexual health. He is a S100 HIV prescriber and he's been practicing for over eight years. When he isn't practicing, he can be found cruising at Swanborne, looking after his physical and mental health, or dancing at gigs with his friends. Dr. Nick is a beloved GP within the community, known for his open door, open ear, and open heart policy. But most importantly, he is our friend.
SPEAKER_01Welcome, Nick. Welcome, Nick.
SPEAKER_00Thank you. Thank you so much for having me. It's an honor and privilege to be here today.
SPEAKER_03How are you?
SPEAKER_00I'm good. Very well, thanks. It's good. Long time listener, big fan of the show.
SPEAKER_03Stunning. Love that.
SPEAKER_02Amazing. Long time, long time. First time caller.
SPEAKER_03First time guest.
SPEAKER_00Yeah.
SPEAKER_03Um, I'm so glad you've come on today because I really wanted to talk about erectile dysfunction.
SPEAKER_00Yes, yeah. Fantastic.
SPEAKER_03Great. So shall we get cracking?
SPEAKER_00Let's do it.
SPEAKER_03I would like you to tell us the science of an erection and what is normal erectile function.
SPEAKER_00Yeah, absolutely. And I guess I like to think of erections um in terms of like the nervous system. So in terms of the parasympathetic nervous system versus the sympathetic nervous system. So the parasympathetic nervous system is the rest and digest nervous system that controls relaxation and sexual arousal. So essentially the parasympathetic nervous system gets activated. And this may be most commonly due to some sort of sexual stimulation, such as touch, thoughts, some visual cues. And then the parasympathetic nerves release nitric oxide in the penile tissue, which causes the smooth muscle in the penile arteries to dilate, blood flow to engorge in the penis and the corpus cavernosum, which compresses the veins.
SPEAKER_03Yeah, they're the two muscles at the bottom, hey? So the penis has got three muscles, three long ones. So the two at the bottom are the corpus cavernos and the top is the spongosum. Yeah. Yeah. That's right.
SPEAKER_00Yeah. And so the nitric oxide causes the arteries to relax, blood engorges this area, resulting in the erect penis and compression of the veins, so the blood stays in the penis. And then you have to be a little bit more.
SPEAKER_02Nitric oxide like nos.
SPEAKER_00Absolutely. We can shorten it as nos. Um that's a parasympathetic nervous system that I guess activates the erection. Um and conversely, I think it's good if we're going to talk about dysfunction in erectile function, um, we can talk about the sympathetic nervous system, which I guess does the opposite. So the sympathetic nervous system is the fight or flight nervous system, um, which controls stress, alertness, and survival responses. So if there's any sort of threat, the sympathetic nervous system's activated and blood gets shunted to the skeletal muscles. So away from the penis, away from the genitals. So that all would result in reduction in the in the um in the erection. And I think important to think about in this way because it kind of relates to um how anxiety and stress can um result in reduction in erections.
SPEAKER_03Yeah, and like if you're running away from a bear, which is a sympathetic nervous system, you don't really want to have an erection, do you?
SPEAKER_00No, absolutely not.
SPEAKER_03That's not the ideal. You would make it. Yeah. Resting. Exactly. Relaxing.
SPEAKER_00So if you're in a situation where you don't feel safe and comfortable, perhaps there's not been consent, it's um other issues at play, yeah. Yeah, the unsympathetic system will activate. Yeah. And erections may not be as spontaneous as you'd like.
SPEAKER_03Okay. So I guess leaning into that, is the part of erectile dysfunction predominantly parasympathetic and sympathetic, or is there more to it?
SPEAKER_00I think it's a very complex issue. And I think going back to the initial question about what is normal is probably an important thing to consider. Yeah. Um because what is normal really? I guess I guess yeah, I think that's important language to use is yeah, is to sort of de debunk what is normal. No way of knowing what is normal in terms of erectile function. And it's very normal for erections to come and go during sex. Totally.
SPEAKER_03And I guess that leads into the dysfunction kind of um definition, which is specific to sexual performance, which is variable, right, for everybody. So how would we define erectile dysfunction then?
SPEAKER_00I'll um offer you a definition um of erectile dysfunction as a persistent difficulty getting or maintaining an erection sufficient for penetrative sex.
SPEAKER_03Yeah, yeah, sexual performance, right? Yeah, exactly. So yeah, that's a variable for everyone.
SPEAKER_00Exactly. And I think there's a few key sort of like uses of language there. I think I think persistent is um important to remember because yeah, it's a normal for erections to come and go. So if someone doesn't get an erection once during sex, I would I don't think they should be labelled as having this rectile dysfunction.
SPEAKER_02I guess is it more so defined that it's I don't want to say creating an issue, but like creating a barrier to actually having those sexual experiences at all. Like that what is what would define a problem? You know how it's like is in like it's actually getting in the way of my life. Well, yeah. Do you know what I mean?
SPEAKER_03Well, I guess, you know, if we think about medical things broadly, and we all fall to degrees of problems, right? It's whether that problem is causing dysfunction or not, essentially. Or just distress. Distress, yeah. So I guess that's where the persistent bit comes in. So if it's happening all the time, then that's something that we need to look into. But once off.
unknownYeah.
SPEAKER_00Probably not a problem. Probably not a problem. Probably part of normal life. Yeah. Yeah. Yeah. And I guess, yeah, there's probably historical sort of definitions and narratives around sex being, you know, a hard penis in an orifice. Um and that's what's required for sex. But I really I guess we should yeah, look at that definition, and I guess that can help shift some of the um sort of like problems away from erectile dysfunction.
SPEAKER_03And what do you mean by that exactly? Shifting the the definition. Yeah, I mean um Do you mean outside, like obviously if we think of it in a very heteronormative way, we're looking at it largely from a fertility point of view, right? So we see a lot of patients who struggle with erectile dysfunction or um erectile issues in general, and then that can impact on fertility. But you're saying that maybe we need to look at sexual performance as a broader definition. Yeah, exactly.
SPEAKER_00Yeah, yeah. Rather than sex being a performative thing, yeah, design. Yeah, good point. Reproduction or performative in any other sort of way sex is for pleasure. Yeah, yeah, yeah. And do you need a hard penis, erect penis for pleasure? No.
SPEAKER_01No, no, no.
SPEAKER_00There's many other sources of pleasure throughout the body. Totally. I think, yeah, anything that shifts the focus um from stress and anxiety around maintaining erection is probably good to help people who have issues with erections.
SPEAKER_03Yeah, yeah. Okay. I love that. Right. Yeah, that's really good.
SPEAKER_00So we just just gave a definition of erectile dysfunction, which I guess probably many people wouldn't meet that diagnostic criteria. Um but another term may be erectile inconsistencies, which is kind of a good language to use, perhaps. But you know, like people who maybe have problems with consistently getting an erection, or they see that as a problem.
SPEAKER_03Yeah, oh I like that. That erectile inconsistency.
SPEAKER_02I'm so glad we're having this chat because I have so many calls on the helpline about this, and like I don't this is definitely not one of my strong topics at all. You know, I feel like at our workplace there's not a lot of like focus on um like male sexual health issues. Um so I'm really glad that we're having this chat. Yeah. I feel like it's really helpful.
SPEAKER_00Yeah. And I think for certain I mean, certain populations, perhaps older men with um vascular disease, diabetes, other organic pathology, yes, they may experience erectile dysfunction. But for a lot of young people with no sort of you know organic physical issues in their penis, they're probably experiencing psychogenic erectile inconsistencies.
SPEAKER_03Yeah, and and and what you're saying is changing the language around like the negative words so or or um pressurizing words like performance, dysfunction, you know, that kind of adds to the mental health load of it.
SPEAKER_00100%, yeah, exactly. Yeah, yeah.
SPEAKER_03Stunning, stunning. Um well, because no one else is as obsessed with stats as I am, um I I came up with some earlier. Oh yeah, yeah. So apparently by the age of 40, 40% of men will have a decrease in erectile function or erectile inconsistencies. Which is huge.
SPEAKER_00Yeah, right. That's a lot.
SPEAKER_0340 is not that old. No, it's not. It's not old. But we know that it increases with age. Um, particularly between the ages of 40 and 70, at least half of these men will experience erectile dysfunction or inconsistencies.
SPEAKER_01Right.
SPEAKER_03Which is huge. Yeah. That's a lot. I would hazard a guess and say as to what we'd we've been discussing is that, you know, the older we get, we are more at risk of cardiovascular disease, um, and younger is likely to be more psychogenic. This doesn't include other things like smoking and things like that that you know are varied, and and we will get to the to the risks as well of erectile inconsistencies. I'm just gonna say erectile inconsistencies the entire time. I love it. It's so good.
SPEAKER_02So good. Yeah. I think so. Yeah, exactly. I think so great. I'm just gonna keep saying it over and over again. It's so much nicer.
SPEAKER_03Yeah, yeah. So I guess I just wanted to expand a little bit on how erectile inconsistencies can actually affect um people who are assigned male at birth. I think we've touched.
SPEAKER_02We vetoed it.
SPEAKER_03Sorry, but this we address we are kind of addressed some of these things, but um I guess, you know, we know that perhaps there's feelings of blame, guilt, anger, or bitterness, you know, that kind of thing, feeling like a failure, letting partners down. Is that generally how how people feel with erectile inconsistencies? Are there other things that can impact?
SPEAKER_00Yeah, I think that's pretty spot on in how it can make people feel. I think yeah, the impacts on someone's mental health can be quite significant, um, which can then become a positive sort of cycle, can't it? So um someone might experience erectile inconsistencies during sex and perhaps that wasn't well received by their partner or they inflicted some blame on themselves, which then can cause ongoing anxiety about uh getting erection the next time they have sex.
SPEAKER_02Yeah so you mean like a positive cycle in that like it's almost like a self-fulfilling like prophecy where it just keeps they keep reinforcing to themselves that this is the issue. Yeah.
SPEAKER_00So while having sex, instead of focusing on sensations of pleasure and connection with their partner, they may be focused on thinking about whether they're going to have an erection or not. And then there comes the sympathetic nervous system.
SPEAKER_03Exactly, because anxiety is fight or flight largely, right? Our sympathetic we're outside our window of tolerance, and so we're not able to rest and relax. Yeah, absolutely. Yeah. So what are the causes then or the risk factors?
SPEAKER_00The risk factors for erectile inconsistencies. So I guess, yeah, looking um at the risk factors, we should sort of weigh up, I guess, the organic sort of biological factors. So, you know, advanced age, diabetes, vascular disease, perhaps use of recreational drugs, alcohol, um, stress, poor sleep, all the factors that can result in erectile inconsistencies. Um I think we could also consider medications. Yeah, absolutely.
SPEAKER_03Yep, yep. The ones? The ones, yeah. Medications can be um the medications though. So the medications that are commonly used are like antidepressants.
SPEAKER_00Well, yeah, I was I was cautious to say that because I don't think yeah.
SPEAKER_03It can. And I think it's tricky because we know that it can, but we also know that low mood can impact libido and erectile function. So when we're counselling people, we say, but the moment it's so low, do people actually experience a better in mood and therefore better in erectile function? So you know you always weigh up the risks and benefits and looking at quality of life, but but it certainly can affect antidepressants can. Um also anti-um hypertensive or blood pressure medication. Yeah. Um and just uh touching on so fucking.
SPEAKER_02No, go for it. Just go for it.
SPEAKER_03Um what you said.
SPEAKER_02I don't think anyone else like notices as much as we as I do. So please say touch touch.
SPEAKER_03Yeah. So when you were saying diabetes and and hypertension, so I guess just to help people understand the mechanism of that, right? Is that um so sugar control or high blood pressure or even cholesterol, right? Our blood vessels get smaller the further away they go. So our eyes, fingers, feet, kidneys, heart, and penis, right? So in like a pipe system, as we explain, well, that's as how I explain it, that the end of the pipe is quite small. So if there's lots of pressure or sugar molecules or things going that then that it can actually affect the blood supply. And that's sort of how I explain it.
SPEAKER_00Yeah, I think that's a good explanation. Yeah, yeah, that makes sense. Yeah. So I think some good I mean, as a medical professional, some good questions to ask to sort of delineate whether the erection issues is organic in cause or psychogenic would be to ask about nighttime erection, whether the patient's waking up with spontaneous erections in the morning, um, and in particular if they're having any issues um getting erections when they're by themselves versus with their partner. I think they're a good discriminating question. So if someone's able to get erections by themselves or waking up with erections, it's probably not an organic physical cause, probably more likely psychogenic. But if there's a lack of morning erections and spontaneous erections by themselves, and maybe other risk factors, so advanced age, like you know, risk of diabetes, those sorts of things, we might need to investigate for organic causes. Yeah.
SPEAKER_03Are there any other organic causes that we look out for?
SPEAKER_00In older men there is a condition called pyroneas. Yes. So you know, you can get which is um you get plaque deposition in the penis, which can cause a change in curvature of the penis and pain. That can definitely cause erectile issues.
SPEAKER_03Yeah, and I guess like aside from cardiovascular, we've got some neurological causes as well. So stroke, brain injury, or post-surgery, so after radical prostatectomies, we can have erectile inconsistencies as well. What is your thoughts? I did a little bit of reading before. Um there's some mixed evidence on cycling and erectile inconsistency. Do you know much about this?
SPEAKER_00I don't know much about that, no. I know, I guess, yeah, cycling. I certainly have had a few patients with sort of chronic pelvic pain and maybe pedendal neuralgia from cycling. Yeah. Um, which can be a good thing.
SPEAKER_02So what's pedendal neuralgia? Great question.
SPEAKER_00Great question. So pedendal neuralgia essentially is I mean, I'm not an expert on it by any stretch, but it's it's a pelvic pain syndrome characterized by sort of neuropathic pain, numbness in the pelvic region due to compression of the pedendal nerve. Okay, okay.
SPEAKER_03Which innervates innervates the pelvis. Yeah. And then neuralgia just means painful nerve. Yes. Okay. Yeah. Yeah. Yeah. Sounds awful. Yeah, it is awful. Yeah, but cyclists are getting this. Yeah, well, so so it's it's possible, but it's controversial, apparently. So apparently, prolonged pressure on the nerves and vessels could lead to some form of pelvic floor dysfunction or compression, typically in like elite cyclists. Right. But so everyone calm down. Yeah, if you're a man. Yeah, yeah, yeah. Um but interestingly, pelvic floor dysfunction is also a possible cause as well, um, of erectile inconsistency. So that kind of links. And then the other thing is, I guess, um, pornography. Thoughts on that? Yeah.
SPEAKER_00Yeah. I think um definitely use of porn can shape our sort of attitudes towards sex. So I guess excessive use of porn probably teaches us this narrative that the penis needs to be hard and erect straight away as soon as they see somebody, as soon as they take their clothes off, um, and needs to stay hard for for hours and hours. So I think porn has really created some challenging sort of attitudes around and assumptions around the erection. Absolutely.
SPEAKER_03So so the evidence, well, it's there's limited, we haven't done a lot of studies on this, unsurprisingly, but um, they've said that porn uses not directly correlate with erectile dysfunction, but it's certainly associated with sexual performance, as you've certainly identified, which can include erectile dysfunction. So yeah, I think that's something else to consider.
SPEAKER_00And particularly for for a man who may whose main complaint may be more about maintaining an erection during penetrative sex rather than getting the erection, I probably would ask a lot around the way they masturbate and use porn because you know the grip of a hand around a penis is often quite different to the sensation inside a vagina, mouth, or anus. And so perhaps if they're using porn excessively and maybe conditioned to um maintain erection just with the hard grip of a of a hand, um they may be using porn a bit too much.
SPEAKER_03Yeah, yep. So in terms of the risk factors that we've just discussed, we've talked about cardiovascular disease, diabetes, neurological conditions, medications. You did touch briefly on psychological aspects. Can you expand on that for us?
SPEAKER_00Yeah, absolutely. Um, and I'd like to break it down to, I guess, a few categories of psychological factors that can impact erection um difficulties. One, I guess, is performance anxiety, and this is probably the most common sort of cause of erectile issues. Um, when someone worries about whether they're going to get hard or stay hard, and like we mentioned before, this causes the anxiety loop that um then can um result in a lack of erections. Uh the second sort of psychological factor I'd consider would be unrealistic sexual expectations. So, you know, the sort of cultural ideas around masculinity that men should always be ready for sex, erections should appear instantly, erections should last through the entire encounter, and sex must involve penetration. So we know erections come and go during sex, and I guess um unrealistic expectations again feeds into the anxiety loop.
SPEAKER_02Um honestly for a lot of us it's our least favorite bit.
SPEAKER_03What? Safe. I'm kidding.
SPEAKER_02I mean, for a lot of people, you know, it's yeah, the other stuff is way more important. Yeah, yeah.
SPEAKER_00Yeah, yeah, absolutely. Um, the third category I'd consider would be stress and mental load. So more broadly, thinking about, you know, work stress, financial pressure, sleep deprivation, anxiety depression, and also relationship issues as well.
SPEAKER_02Higher mental load, harder to blow your load. Got it. Oh God, you're good. Thank you.
unknownWow.
SPEAKER_02All right, I'm gonna have it out. You guys could do it. Stunning. Love your work, love your work.
SPEAKER_00Um the fourth sort of category I would sort of mention, which like we alluded to before, was is porn-conditioned arousal patterns. So, you know how repetitive porn-based stimulation can then condition arousal to a very specific environment. So, you know, if you're watching porn all the time, your body's conditioned to only being aroused in that situation. So if you find yourself um having partnered sex and that may not be as exciting and arousing for you as porn, you may find it more difficult to get an erection.
SPEAKER_03So I guess what you're saying largely with the psychological causes is it's largely around. Why am I saying largely? Because I'm thinking about a large erection. I can't be stopped. Um so I guess you've identified that there's like mental health conditions like anxiety, depression, then there's life stresses like relationship, financial work, and then there's performance-related things which can be influenced by porn or societal expectations. It's a miracle anyone gets an erection. I know, right? Like, isn't everyone stressed? What? I know.
SPEAKER_00We must be confident that we can. Yes, of course. Because if we have that predetermined thought that it's hard to get an erection, put that thought on the bid L.
SPEAKER_02Sorry, sorry, sorry, positive, positive, incinerate that thought. Yeah. We can all get hard, but you don't have to.
SPEAKER_00There is an Australian sexologist, Cam Fraser, who's who has some really fantastic podcasts and is very articulate and And has been very helpful for uh for thousands of people, I'm sure. Yeah, so he proposed this model that there is the accelerator, things that increase arousal, and then the break, things that inhibit arousal and erection. So, you know, the accelerator are things that signal to the body that it's safe and um pleasurable to become aroused, and that can include things like, you know, sexual attraction, physical stimulation, so touch, intimacy, feeling relaxed and safe, um, emotional intimacy, erotic thoughts or fantasies, and novelty or excitement. So all of these things increase blood flow to the penis, increase sort of erections. On the other hand, there are the breaks, the things that inhibit erections and tell the body that sex might not be safe or appropriate right now. So these can be things like perfor the, like we mentioned before, performance anxiety, stress, fear of losing the erection, relationship tension, feeling judged or self-conscious, or fatigue or alcohol as well. So when the brakes activated, the body prioritizes survival and the um sympathetic nervous system gets activated. So erections um are reduced. And so it's very normal for there to be breaks and accelerators during sex. Um so rather than thinking that erection going away is a problem, maybe just need to consider perhaps there's a break that's um more in force at the moment than an accelerator. So, you know, rather than trying to force the accelerators, maybe trying to sort of reduce the breaks can can help foster maintenance of the erection.
SPEAKER_03Yeah, and you've you've actually um identified something quite interesting is that a large part of erectile inconsistencies can actually be directly correlated to who you're having sex with.
SPEAKER_01Yeah, 100%. Right?
SPEAKER_03So it's actually like not always a you problem. It's it can be the context and the environment that you're in. So that takes away the onus and the responsibility of you as the person with erectile inconsistencies and largely about the environment that you're in.
SPEAKER_00Yeah, 100%. Yeah. I think you have to feel safe with your partner. Absolutely.
SPEAKER_02Um I guess that's also tricky because there's it's also like I know that it can be the person themselves that has erectile inconsistencies that feels the pressure or feels bad. But then you also know that sometimes it's the partner. And then it's actually the person with the erectile dis inconsistencies that's feeling bad because the partner feels bad about their erectile inconsistency and thinks it's a them problem. You know what I mean? So feeds the yeah, it's hard, but really it's it's it's a no-one problem. It's a no-one problem, it's not a problem. It's just not a problem, it's not a problem.
SPEAKER_03And at the end of the day, it's about safety. True.
SPEAKER_02And I love I like love what you said there about taking breaks and like because I think that like normalizing that, like taking breaks during sex is so good, you know, like checking in and then building it back up and starting again. Like, I just love that idea where it's like if something has occurred rather than like, as you say, forcing the narrative, you know, you stop, pause, pivot, and you know, explore another route.
SPEAKER_03I mean, not like you know, well, I guess erectile function is a metaphor for life, is it not? It ebbs and flows. It's so true. Yes. I just came up with that.
SPEAKER_01Thank you so much.
SPEAKER_02And also that, like, I guess the the accelerator and the and the brakes metaphor also like applies for anyone, regardless of sex or gender.
SPEAKER_03All right, okay. Well, I guess moving on, how can we how can we I mean, sorry, I should rephrase this question. I had written this question originally about fixing it, but we've just established that it's not a dysfunction that needs fixing, it's inconsistencies that need addressing. So what are the options for addressing the inconsistencies?
SPEAKER_00Um there's a range of treatment options available for erectile inconsistencies. Um, but I guess, yeah, again, using language, this is not a problem we need to fix, nothing we need to treat. But um, having said that, there are probably things we can do to help support erections and a healthy sort of relationship with sex, erections and intimacy. Um and I think it really starts with education and reassurance, you know, normalizing the fact that erections come and go, um, normalizing the fact that you don't need a hard erect penis in an orifice to have sex, normalizing the fact that there's um sex is about pleasure. It's not necessarily performative. In fact, it shouldn't be performative, it should be all about pleasure, um, and maybe reproduction if you're that way inclined and want to make a baby. Maybe um but really I think yeah, opening up the communication and um setting expectations or taking away the expectations about what sex is is probably the first start.
SPEAKER_02Um hard to do, right? So hard to do it is it is hard to do though, that to to take away those expectations.
SPEAKER_00But yeah.
SPEAKER_03Sexpectations.
SPEAKER_00Sexpectations I love. And I guess, yeah, difficult, difficult in different situations. So obviously there's this situation of a long-term relationship where perhaps it's easier to have hopefully easy to have open communication around expectations and a sense of safety. But then there's also, you know, more casual sex and particularly in the queer community, maybe the hookup culture where things can become very performative and hard to set those expectations.
SPEAKER_02Yeah, yeah, absolutely. And I guess that's what we're trying to do. We're talking about again. Yeah, yeah. Um, yeah, I feel like we've spoken a lot about how difficult sex is um for anyone. It's terrifying. It's terrifying. And how little people talk about it. And I can only imagine um, like men or people with penises, this also isn't a topic that is discussed much. You know, like like a lot of things, as we say, we like to think that it's getting better, but it's probably something that I I'm sure, I don't know, the guys don't all sit around and be like, how's your how's your how are you erectile? How are you a erectile inconsistencies? Are you consistent? Are you consistent? I mean I wish that they were. I wish they were then just there would be cons you know, people would realise how normal it is. Yeah, I'm glad that we're opening up this channel. Yeah, I think it's a good idea. M2.
SPEAKER_00M2.
SPEAKER_03Yeah, yeah. Um, so after educational reassurance, what are the what are other options that we can offer people?
SPEAKER_00Yeah, so I guess there's psychological treatments and things we can do to support, and there's also medications. Um but maybe we should talk about the psychological some of the other psychological things initially.
SPEAKER_02So you know is that so sorry, is that because like I mean obviously every case is different and therefore every treatment is different, but like would you start with some of these psychological treatments first before move moving to medication, or is it just case by case?
SPEAKER_00I think it's case by case. So if it's an older gentleman with an organic cause for erectile dysfunction, uh I think um use of medications is probably more of a priority. Whereas we want to cut to it. Yeah, but for a younger person with no organic uh sort of physical cause for their erectile inconsistencies, medications really are not required. I guess they can be used as a safety net to re-establish that confidence in the bedroom sexually, but really they shouldn't be required because their body st still works normally to get an erection. Um yeah, I think in terms of psychological things and behavioral things, that should be the the main focus. So once you've established um some education around erectile inconsistencies, um, I think then we need to sort of address things that can help um people activate their parasympathetic nervous system during sex and help them relax around sex. So I guess sometimes that may look like some deep breathing exercises before sex, um, a breathe body scan, um, or really like shifting the focus to focusing on pleasurable sensations.
SPEAKER_03Really taking notes. Deep so deep deep breathing, deep breathing exercise, gas earlier.
SPEAKER_00Yeah, or a body scan. So these things, yeah, they activate the parasympathetic nervous system and help the body calm down, relax, and signal safety to the body to facilitate erections.
SPEAKER_02Totally. Because yeah, and I'm just remembering something that you said before, because I was just thinking, you know, when I'm a bit nervous about a sexual encounter, I have sometimes and we've spoken about this and the issues that that might be involved with having a couple of drinks before. Yeah. Um, but then yeah, I remember what you were saying about how alcohol can also affect yeah, so it's like double-edged sword there a little bit.
SPEAKER_03Yeah, good point, actually. Yeah, because alcohol can r like lead to um erectile increases. But also makes feel more relaxed.
SPEAKER_00Yeah, absolutely. And I guess, yeah. We want to be using non-substances. Yeah, exactly. Yes, yeah. Not relo I wouldn't want uh someone to rely on a substance. Correct, we don't want that. Uh to help facilitate their erection. That may become a perfect.
SPEAKER_02And he used that he tells me every day.
SPEAKER_00So and actually beta blockers are really bad for erections too.
SPEAKER_02Well, thank god I don't have a penis.
SPEAKER_03Okay, so we talked about safety signalling, parasympathetic nervous system. So you you touched a bit on I really need to stop. Uh, deep breathing, body scanning. Is there anything else we can do in that or the main things? I guess there's some of the simple things, but you know, yeah, and I guess if we've got um if we're confident enough to have the conversation with the person, hey, I'm feeling a little bit nervous, uh can we open that up? Yeah, communication.
SPEAKER_02Yeah, even though it's skilly. Sometimes just saying its name. Yeah, it's the best.
SPEAKER_03Totally, totally. And I think certainly historically for me, when I've said to someone I've got, you know, some issues around intimacy and physical touch, if that's not responded to in a safe way, then I'm like dries the Sahara desert, you know? So so you know, if they're not gonna acknowledge that, then that's part of the safety thing, right? Yeah, totally.
SPEAKER_00Absolutely, yeah.
SPEAKER_03Cool. Okay, so aside from that, or do we have any other options?
SPEAKER_00The next thing I would suggest is during intimacy is to really focus on avoiding the genitals initially and pleasurable sensations in other parts of the body. Oh my god.
SPEAKER_02Go back to the episode. Go back to episode nine. Yeah, go back to that episode.
SPEAKER_00So, yeah, focusing on touch of other parts of the body, really taking pressure off the genitals is probably like an could be a helpful thing to do. Um, so lots of foreplay, kissing, touch, really avoiding the genitals and take shifting that mental focus from whether you're gonna get hard or not to just enjoying pleasurable sensations and focusing on those pleasurable sensations. Maybe a helpful thing.
SPEAKER_02Sexy AF. I'm so on board. Yeah, that sounds amazing.
SPEAKER_00Yeah, and the idea is to retrain the brain to associate touch with pleasure rather than evaluation. So, you know, not reaching down to see if I've got checking if my penis is hard or not. And then you can do a graded sort of step up to eventually include genitals, so just soft touch of the genitals initially to stimulate some sensation there, and eventually erections will come.
SPEAKER_02I love that. I love that. And often, you know, sometimes we do just get a bit excited, we go in too fast. True. It's so nice to slow it down. I think slow it down.
SPEAKER_00Slow it down, take your time. Slow it right.
SPEAKER_02Why are we rushing? Do you know what? Because we rush, we rush day to day. So why are we rushing in the bedroom?
SPEAKER_00Slow it down, allows our bodies to relax. That's so nice. I need to take that's focus on what's on enjoying each other's pleasure.
SPEAKER_02Yeah. Yeah. That's hot. Absolutely.
SPEAKER_00And then we really want to reduce spectatoring.
SPEAKER_01Oh, expanding. Expat.
SPEAKER_00So spectatoring is a common problem of mentally observing one's own performance during sex. So it's this idea that um you know, constantly checking, am I doing a good job? Is my partner enjoying this? Is my penis hard and erect? And that's called spectatoring.
SPEAKER_02Yeah. Okay, so if you if you spectate your life like that, how are you meant to not do that in the bedroom? Hard. Not hard. Soft. Both inconsistent. It doesn't matter.
SPEAKER_03That's really difficult though, true.
SPEAKER_02100%. Very difficult.
SPEAKER_03I wonder if it's the same for AFABs. Because like you know, d sometimes you're like, am I going to reach an orgasm? Am I wet enough? Am I performing? I mean, it's probably similar. Yeah, 100%. Yeah, yeah, yeah. Yeah.
SPEAKER_00So practical techniques would be, yeah, focusing on physical sensations, slowing your breathing down, maintaining eye contact with your partner. Um, and maintaining that connection with your partner.
SPEAKER_01Okay, can't wait for that grab.
SPEAKER_02I love eye contact here. Yeah, that's nice. No, I'm actually taking so many notes. Yes, so many. Yeah.
SPEAKER_03Oh, did that thing again? Continue, sorry. Sorry where you're going to be able to do that. That's all that's for our specs. So you've identified what I love about your answer is you've identified the cause and offered solutions. That's just so wonderful. So you've identified that it's largely issues around activation of the sympathetic nervous system, and we want to um activate the parasympathetic nervous system, and you've given us some strategies to do that, which includes deep breathing, body scanning, avoiding spectatoring, um, and you know, focusing on erogenous zones and taking the energy away from our genitals.
SPEAKER_00Absolutely.
SPEAKER_03Great, love that, love that.
SPEAKER_00And I would also say, I mean, I am a GP, so you know, I think it's important to think holistically about someone's health. Um, so it is also important to, you know, encourage regular exercise. 100%. Encourage smoking cessation, limit alcohol. Limit alcohol consumption and recreational drugs, um, reduce pornography. Yeah, encourage um regular sleep, a healthy, balanced, nutritious diet. All those things are important. So important. So important.
SPEAKER_03Yeah. So say we've maximized all those. Yep. Which would be amazing. What are our next options?
SPEAKER_00Our next options, there's a few options. So if it's a persistent problem causing a lot of psychological distress, I would encourage someone to speak to a sexologist.
SPEAKER_01Yep.
SPEAKER_00Because the one thing we haven't mentioned is, you know, sexual trauma and things like that. So that really need to be possibly explored in a very safe environment with a trained professional.
SPEAKER_01Yep. Yep.
SPEAKER_00So I think that would always be an option if the person is up for it and open to it is seeing a sexologist really to explore their issues in more depth. I'm so sorry.
SPEAKER_02What are you laughing at? I'm so sorry. Is it the open? I'm sorry.
SPEAKER_00I'm sorry.
SPEAKER_02If the person is going to be able to do that, how many erection jobs can we make? I I stopped myself when you said um persistent problem. I stopped myself and saying a PP for your PP. So I would have liked that if you said that.
SPEAKER_00Okay, you can noge, yeah. If it's a persistent problem of a psychological basis, perhaps there's a history of trauma, um, then I would encourage someone to explore it in a safe environment with a trained professional psychologist or sexologist. Yeah, and there's two other options that can be helpful to um help maintain erections. So one is a vacuum pump. So this is particularly helpful, I guess, for older, for older gentlemen, and essentially it's a pump that um uses vacuum pressure to um engorge the penis with blood. So that could be helpful some for someone experiencing um inconsistencies with their erections. Um the other thing that could be a very safe and and and quick intervention is a cochring. So a cockering is um a ring that is um put on the shaft of the penis at the base and it helps um keep blood in the penis. So particularly this is good for for guys who might um have issues maintaining their erection.
SPEAKER_02Um can you explain the vacuum pump a little bit more to me? Oh, yes, okay. Yeah, yeah, yeah. Yeah, yeah, yeah. I understand what you're doing.
SPEAKER_03It's like a it's like it's like a cylinder, like a clear cylinder, and you put it over the penis and it's got like a little pump attached to and then it suctions the air out of it so it pressurizes inside, and then it's just engorges the penis over time. Yeah, yeah.
SPEAKER_00And often used in combination with a cockering. I think that's a good thing. Yeah, yeah. Because yeah, the co- the vacuum is to use to help get the erection. I see. And then the cockering can help maintain the maintain it.
SPEAKER_02Okay, that's yeah, that that was gonna be my next question. Is like, so when you stop pumping or take it off, then what happens? Yeah, but I guess, okay. Yeah. Yeah. Yeah.
SPEAKER_00And I guess I mean, while cockerings are, I did mention that they are safe, I guess you do have to make sure that the cockering is on appropriate size, that it um that you'd be able to get it off at the end. Yeah, because you can get, I believe you can get sort of glass cockerings that aren't don't move. Um so I have certainly seen one patient who has some scar tissue from that, um, from not being able to get his cockering off. Um so probably a safer option for cockerings would be, you know, those elastic cockerings that can be cut easily and silicon. Silicon, yeah, silicon and can can move and can get off the penis.
SPEAKER_03Yeah, yeah, yeah. Okay. Okay. So we've got psychosocial stuff, which you've addressed, the vacuum pumps and the cockering, so manual intervention. And now we've got medications. Is that the next thing?
SPEAKER_00Yeah, absolutely. So medications certainly do have a role for some people, um, particularly for uh men where there's an organic biological cause for their erectile inconsistencies, medication can be very helpful. Um and for younger men, there could potentially be a role potenti in breaking that sort of anxiety cycle. Um So I'd always be very cautious about using these medications in younger men, not to develop psychological dependence on them, essentially. Because essentially, for younger men, it's like younger healthy men, right?
SPEAKER_02For young, yeah, exactly.
SPEAKER_00For younger, healthier men, from a pathophysiological point of view, they aren't necessary. But what they provide is a safety blanket, really, essentially. To break the cycle. To break the cycle. Yeah. And so the medications we're talking about are phosphodiesterose type 5 inhibitors. So PDE5 inhibitors. The two most common ones are Tadalophil and Sildenophil. Yeah.
SPEAKER_02You love sildenophil, Nick.
SPEAKER_00I have never used sildenophil in my lab. I have never used sildenophil in my lab.
SPEAKER_03The brand names you might be familiar with are Viagra and Cialis.
SPEAKER_00Absolutely. Yeah. Yeah. And so what these medications do, as um their class name suggests, is that they inhibit phosphodiesterise type 5. And so what does this do? So big sciencey words. Yeah. So phosphodiesterise type 5 breaks down CGMP, another enzyme, which causes smooth muscle to tighten, blood flow to decrease, and the erections to subside. So essentially the medications inhibit the breakdown or the product that causes the breakdown of erections.
SPEAKER_03Yeah, so it's essentially working on the smooth muscles, right, to relax them. So it's like a direct effect on the smooth muscles to relax them rather than the parasympathetic nervous system specifically, I believe.
SPEAKER_00Yeah, that's right. Yeah. And it only works after nitric oxide is released during sexual stimulation.
SPEAKER_03So you have to stimulate for it to work. Absolutely.
SPEAKER_00So yeah, you still have to have healthy libido and sexual stimulation for these medications to work.
SPEAKER_03So it's not a magic pill that suddenly gives you an erection. Oh man. Yeah, I know, sadly. But you do need the good stuff, the sexual stimulation beforehand. That's good. That's right.
SPEAKER_00Absolutely. And so the difference between tadalophyll and sildenophyll is that tadalophyll has a lot longer half-life. So it can last in its half-life, so which is how long it takes for half of the medication to be excreted from the body, essentially. It's somewhere between 36 and 48 hours, I believe.
SPEAKER_01Yeah.
SPEAKER_00Um, versus sildenophyll, which is a lot short, correct. Shorter half-life, so a lot shorter acting.
SPEAKER_03Yeah. What happens can we get complications from these medications?
SPEAKER_00100%. Yeah. Yeah. So they're not benign, these medications. So essentially they're dilating blood vessels, and that can cause dilation of blood vessels throughout the body and can cause overwhelming low blood pressure, fainting dizziness. Particularly if there are other risk factors for that or other substances that might use that, such as amyl nitrate. I was just gonna say poppers. So poppers. So it is absolutely not safe to use poppers and Viagra together.
SPEAKER_01Yeah.
SPEAKER_00The other the other medication to look out for would be sort of older people who are on nitrates for cardiovascular disease.
SPEAKER_03Correct, yeah. So they're completely contraindicated in people who use nitrates. Yeah. Yep. Yeah. Um, okay. What about priopism? What's that?
SPEAKER_00Priepism is a good yeah. So that is another so priprism is another risk of using these medications. So priorprism essentially is a prolonged erection. So where the erection will not go down for, I think by definition, three hours perhaps. So um and this can be very damaging for the health of the penis long term. So the treatment is normally some big needles in the penis to drain, to drain the blood flow. And and that in itself can cause damage and then erectile issues later on.
SPEAKER_03Yeah, yeah. Yeah. I know. Speaking of needles, we do have another treatment option though, don't we?
SPEAKER_00Absolutely. There are injectable treatments available for persistent erectile dysfunction. The injectable treatment, so it's essentially where you inject a medication into the penis itself that causes blood flow to engorge the penis in erection. Yeah. Um, can be it's often a last resort treatment for men with organic pathology that's causing their erectile problems. Perhaps they have vascular disease, um, medications aren't going to work, your psychological treatments aren't going to work, these can be very helpful.
SPEAKER_03Yeah, and just to like de-escalate the stress of needles into your penis. Please I don't even have one. No, they're very small, very, very small, tiny, tiny needles, and they go into the intracavernosal muscles. So the two at the bottom. I don't know why I'm doing this, but they're like it's like a triangle. So there's two muscles at the bottom, and that's where. Where the um blood flow is increased in those areas. But the the needle is very, very small, and you're right, uh Nick, it's a very last-minute resort. Um last minute? Last option. Last line. Yeah. Yeah.
SPEAKER_00And I think I guess important that treatment uh with injectables is supervised by a medical professional training in that area. Correct, yeah. It's not something I wouldn't say just grab your friend's injectable and do that. 100%. It's very dose-dependent and important to get into the right spot. So otherwise can be and I guess there is one last resort.
SPEAKER_03Yeah. Yeah.
SPEAKER_00So the last resort would be a penile implant.
SPEAKER_03Yes, good point. Yes, yes.
SPEAKER_00So perhaps for for men with neurological disease, um a penile implant where the corpus cavinosum is actually replaced with an implant and then can inflate on demand might be helpful.
SPEAKER_03Yeah, yeah, yeah. Very cool. That's actually true.
SPEAKER_00That is absolutely the last resort.
SPEAKER_02We don't want that. Yeah, yeah. Still cool for those with neurological issues. Yeah, but that's still a cool thing.
SPEAKER_03Okay, so I was just hoping we could take a little turn into libido, if you will. Um how are erectile dysfunction and libido linked?
SPEAKER_00Good question, Shamani. So they're very intrinsically linked. We essentially do need a healthy libido to have a healthy erection.
SPEAKER_03What is libido?
SPEAKER_00What is libido? That is a very good question. And I guess depends. Um uh each everyone's definition of libido is different. I guess libido refers to a sense of sexual desire.
SPEAKER_03Like sex drive.
SPEAKER_00Sex drive, yeah. Sex drive. Yeah. I think we can we can label it as a sex drive. Yep. Um, yeah, essentially we need some sense of um libido and sex drive to to initiate the erectile process from a physiological sense. Um and so low libido is is, I guess, quite a controversial air thing to think about because it implies that there's a normal sort of sense of what libido is.
SPEAKER_03It's normal for the person though, right? So somebody will have a degree of libido and then it might change. Yeah, I guess essentially yeah, we want to ask for a change. For that person, yeah.
SPEAKER_00But I guess, yeah, we also we do see a change in libido over someone's life. Correct. Yeah, yeah. And I guess there are a lot of psychosocial factors that can contribute to someone's libido. Yeah, so I like to think of libido as less intrinsic libido and extrinsic libido. Okay. If we can talk about that for a minute. In and out. Yeah. So intrinsic libido refers to this spontaneous sexual desire. So that arises without any external stimulation. And if you think from an evolutionary sense, young people in their 20s need to get out and meet people to find a partner to reproduce. So they're gonna have a high intrinsic, spontaneous libido to facilitate that. As people get older, from an evolutionary sense, we often need to settle down with one partner. So our libido shifts from this intrinsic libido to extrinsic libido. And extrinsic libido refers to sexual desire triggered by some sort of external stimulus. This can be partner stimulation, erotic stimuli, physical touch, or emotional intimacy. So I guess when someone comes in like concerned about their libido, you can sort of explore it from that sense.
SPEAKER_03Yeah, okay.
SPEAKER_00So yeah, and then okay. So we can look at and then we can also frame if we're a lot of people um no, no, but a little, sorry. Um okay.
SPEAKER_03Do you want to ask you a question? No, no, no, no.
SPEAKER_00I just want to I just want to keep I just want to keep talking about it. Keep talking, go for it, go for it. Yeah. Yeah. Um okay. And so when we look at libido someone's libido, it is so multifactorial. There are physical organic causes, psychological causes, and other lifestyle causes for changes in someone's libido. Um, if we're looking at a change in someone's intrinsic libido, it may just be a part of normal aging.
SPEAKER_03Yeah.
SPEAKER_00Um, but it may represent low testosterone.
SPEAKER_03Yeah, yeah. Yeah.
SPEAKER_00So common symptoms of low testosterone may include, yeah, um, reduced spontaneous sexual thoughts, um, fatigue, reduced muscle mass, um other things like that. Yeah. And so then these symptoms, low lib of low libido from low testosterone, can then cause erectile issues. Yeah. Rather than low testosterone on its own causing erectile problems. Yep. Um other things that can cause result in low intrinsic libido would be um chronic medical illnesses such as diabetes, kidney disease, cardiovascular disease, chronic pain.
SPEAKER_03So the same things for erectile inconsistencies. Yeah, exactly.
SPEAKER_00Sleep disorders, sleep apnea, sleep deprivation, and medications, all possible causes of reduced intrinsic libido.
SPEAKER_03So just life. But just life. Yeah, exactly. The stress of modern-day life. Yeah, yeah.
SPEAKER_00Then causes of low extrinsic libido. So these are usually psychological or relationship or situational factors.
SPEAKER_03Yeah, and again, very similar to erectile inconsistency, right?
SPEAKER_00Yeah, so common issues might be conflict with a partner, poor communication, emotional disconnection, unresolved resentment between your partner. And these can markedly reduce stimulus responsive desire.
SPEAKER_02So is extrinsic libido always to do with you and someone else? Like you and a partner. Well, not necessarily. I guess it doesn't matter.
SPEAKER_00Yeah, sexual self-pleasure does require some necessary can involve extrinsic libido, self self-touch, um, use of pornography in a healthy way. Toys, maybe toys. Exactly.
SPEAKER_03Yeah, yeah, yeah. Yeah. Okay, great. Um all right. Can you discuss how erectile inconsistencies and libido can be affected by uh hormones and other substances, particularly anabolic steroids and people who are transitioning with gender-affirming hormone therapy?
SPEAKER_00Yeah. Interesting, excellent. Yeah. Hormones are yeah, very intrinsically related to um libido and sexual desire. So I guess, yeah, use of anabolic steroids can have several effects. So um initially, the use of anabolic steroids, and we also include exogenous testosterone perhaps, can definitely result in increased libido, increased sexual drive.
SPEAKER_03Yeah, it can.
SPEAKER_00Um but conversely, it can also result in reduced libido. I mean, feelings of irritability, anger, frustration are very common with use of anabolic steroids.
SPEAKER_03Yeah, it's also linked to, I think it's also linked to estrogen. So after a while the estrogen will go up and then yeah, we'll we'll lose the lib-wee? I don't have a penis. And you hopefully do not use anabolic steroids. Yeah, so higher doses can lead to estrogen imbalance. And then like after a while, that can that can swing. And then I think commonly once you withdraw the steroids, right, that's when the problems occur.
SPEAKER_00Yeah, 100%. Yeah, it's often that period of withdrawal of the exogenous steroids or testosterone, that, yeah. Because there's huge reduction in um yeah, libido and erectile function as well.
SPEAKER_03And and for those of you who are confused about the words endogenous and exogenous, intrinsic and extrinsic, just to be uh make it a little bit clearer. So endogenous and intrinsic means the system exists within you. Okay, so we have a very sensitive endocrine hormone system that exists within us that cycles regularly, and there's a there's an interplay between all of them. And then exogenous or extrinsic means factors from the outside that can influence that cycle intrinsically, right? Yeah. So sometimes when you add things, it can suppress the cycle. And when you can withdraw them, they it can dysregulate or it can be abnormal. Um because it's such a beautifully complex system, right? We can't just put things in and expect things to be normal. Uh not we don't want to use the word normal, but like there's no such thing as normal, but like um, I guess regulated, right? Yeah. So yeah, that just to clarify, that's what those terms mean.
SPEAKER_00But um and for our gender diverse population, so um, particularly patients using estrogen-based gender-affirming therapies, um the use of testosterone blockers may impact libido and sexual function. So um trans women uh may or may not be on testosterone blockers such as CIPROTORone, which is purely designed to reduce their testosterone level. But also we know estrogen can reduce testosterone level as well. So so um this can reduce libido and sexual function.
SPEAKER_03Yeah, and it can re result in fewer spontaneous erections that reduce testicular volume and testicular atrophy, so it can shrink over three to six months of initiating. So it's a decision I guess we'll we'll talk about it in detail in the future, but it can happen quite quickly after initiation.
SPEAKER_00Yeah, so I think yeah, it's very important to discuss that, I think, before condensing before condensing gender-affirming hormones. Totally, yeah.
SPEAKER_03We I don't yeah, it's something that I guess I mean we both um do gender-affirming hormone therapy. Um and it's certainly something that um people do come in frequently, or it's like a I guess it's like a foresight, right? Um addressing that libido can change should be part of our consulting process, I suppose. Yeah.
SPEAKER_00And I guess really important for the patient about to undergo gender-affirming therapy that they have an awareness of that and that they discuss that with their partner as well. Absolutely. Yeah, absolutely.
SPEAKER_03Um, so I guess we're all very comfortable talking about erectile function, it would seem. Um, but not everyone is. Um how do you in your clinical practice make it more comfortable? Or both of you really make it more comfortable for people to talk about?
SPEAKER_00Yeah, well, I think as a clinician, I think the onus is on us to create a comfortable environment. So I think the first thing is for us to be comfortable talking about it. Correct. I think if we're comfortable talking about it, the patient will hopefully become comfortable talking about it as well. So I think there's yeah, it's important to, you know, establish nice rapport with the patient. It's much easier to have these conversations if you've known the patient for a long time. So I think that's one of the benefits of of having a regular GP is having that long-term relationship.
SPEAKER_03Have a regular GP.
SPEAKER_00Um so you can have these conversations. Um, and I guess, yeah, always have to be like, I guess, um responsive to the patient's um like verbal and non-verbal cues, you know. Absolutely. If if they're feeling really sort of guarded and anxious talking about it, that may show up in their body language and can signal to us as clinicians maybe not to to bring it up and talk about it at the moment. Um, but you know, you can ask a few probing questions to sort of gauge how responsive they are to the discussions and then maybe build on that over subsequent appointments, perhaps.
SPEAKER_03Yeah, and just on the probing questions, I think that's really important. So if I could just speak to the clinicians that are listening, I guess, to this predominantly, is how we how we do it, right? So it's our it's our job to create a safe space and open up the conversation. And so something that I use quite frequently, which may be of use to clinicians listening, is when we go through medical school and when we're um going through training, we're often taught to ask um specific parts of you know social history, right? Alcohol, smoking, exercise, that kind of thing. I actually include sexual history in that always with new patients in particular. And I tend to just approach it in a very um casual, calm way, which is something like, Are you sexually active? It's a very general term. And um if they say I I don't I'm not making inferences on relationship status, how many people they're having sex with, who they're having sex with, I'm just saying sexually active, that automatically makes it safe and neutral. And then if they say yes, I say, Are you having any issues? And then they'll often say no. I said that's fine, we close it. But then always a week later they come back and they said, actually, I really want to talk about that. So in that very small safe questioning, I've opened up the space to create a safe space for that person to talk about their issue. I'm and again, body language probing questions, but these are safe ways to introduce regular questioning about sexual health in your consults frequently because as you've identified, well, we've identified earlier is erectile inconsistencies is often the first sign of cardiovascular disease. So if we're not asking about that, we may not know to screen for it, right? And so being able to I know it's hard as clinicians to talk about sex, we get it, right? Um, but if you could just try and introduce that at the first appointment, uh even with men I don't know, or they're the first time they've come and seen me, they've automatically gone, right? This clinician actually feels comfortable talking to me about sex. Love that. I'm gonna come back to this person. And you've mentioned in a previous episode, Early, the key is I want my patients to come back.
SPEAKER_02Yeah, yeah, absolutely.
SPEAKER_03So that that is like maybe just a little practical tip that you can you can introduce. And if they if they say, Yes, I'm sexually active and you say, Are you having any issues? and they say yes, then you say, Do you want to talk about it? Yeah. And that's it. That's all you need to do. It's just a really gentle opening.
SPEAKER_02Also, it gets easier the more you do it, you know, even though the more you do it, the easier it becomes.
SPEAKER_03Yeah, yeah. So I think that's like a a nice way to incorporate sexual health history taking. Yeah, yeah. What about you, Ellie? Do you have anything specific you sort of do? I mean, you're always so open and lovely.
SPEAKER_01So I'll put it, yeah.
SPEAKER_02I guess, yeah, I was I was yeah, thinking the same with with Nick. I get I feel like mirroring the client and where they're at is so important. Like um, I feel like I will change the way that I consult on how I ask questions depending on how the person presents to me, you know? Um and that always seems to work to work really well. Yeah, I'll and it's it's um not in any way like false or it disingenuous, it's just that I access different ranges of me to to meet that person. Yeah, because I can be on yeah, all of those things. So I think yeah, sometimes yeah, just meeting that person where they're at. Yeah, where they're at.
SPEAKER_00I think using a similar language to what they use to have.
SPEAKER_02Absolutely. Maybe using it. As soon as they start swearing, I start swearing.
SPEAKER_03Same. Same, same, yeah, yeah, yeah.
SPEAKER_02But yeah, that and just like I know we've been saying what is normal, but just like normalizing and reassuring them that what they're going through is is not like then there's well, they're not alone in it.
SPEAKER_03No, yeah. It's common, we've identified 40% in over 40%. Yeah, it's a lot. Exactly.
SPEAKER_02Yeah, just really um reassuring them that they're not alone. There's not something wrong with them, you know. Absolutely. Um unless there is.
SPEAKER_03No, but there's there's usually not well most things are most things are manageable and treatable, is is even if there is something, I guess, wrong in inverted commas. We've identified there's multitude of treatment options, right? There should you know, discomfort in discussing there should not be a barrier to accessing these options. Exactly. Yeah, yeah.
SPEAKER_02Um that and also um like kind of praising them for for being there and talking to me. Absolutely. Yeah.
SPEAKER_03Well done for coming in and talking about how uncomfortable this is with a dranger. Well done. Yes, absolutely. Very important, yeah. Yeah. Okay, so just to just to summarize, you know how much I love summarizing. So uh we've identified that there really is no normal, right? That um erectile dysfunction is largely just inconsistencies that are related to sexual um performance from an arbitrary term, but that performance um is subjective and is different for everyone and should also be put in the bin, right? We want performance to be put in the bin because we want to focus that erectile function, um, healthy erectile function should be focused on pleasure, safety, overall sense of health and well-being, including our lifestyle and our relationships.
SPEAKER_00Beautiful.
SPEAKER_03Sound sound good? Sounds great. Great. Okay. So I guess where if if anybody who's listening and they're like, yeah, okay, that sounds like me. I've got some inconsistencies, where do they go for help?
SPEAKER_00Well, I think the first place would be if if you have a trusting relationship with your GP, probably speaking to your GP if you feel comfortable in that space.
SPEAKER_03Yeah, I think. What's your address again, Nikki? Please do. Yeah. So yeah, absolutely. So any qualified general practitioner should be able to help you with this. Um, and I think I've said this before. If you feel uncomfortable with this person, don't stop there. Find someone else. Try try again. Try again. Try, try again. Okay, one does not represent the many. So certainly that is the best port of call. Um, do you have any resources or um websites that people can use? I did have a quick look. I couldn't find anything specific.
SPEAKER_00Yeah, I know that I don't really need a real.
SPEAKER_03So I guess we've probably identified that there's a dearth or an absence. I like the word dearth. Dearth. Uh, or absence of resources for people with erectile inconsistencies. Yeah, shock horror, right? Like we don't talk about it, so we don't provide any resources for it. So that's a real shame, obviously. Sexologists are the other things. Sexologists, sexologists, GPs who are confident in this space, nurse practitioners, psychologists, psychologists. There are people. So what we're trying to say is whilst it might seem like a lonely space, you're not alone. There are people that can help you. Absolutely, absolutely. It's so complex, isn't it? So complex. You know, it's so complex for something that I feel like society has made so black and white. Oh, you reckon? Like, I feel like we've just been like, this is what you do, this is how it happens, if you don't do it, there's something wrong with you. And like we've literally gone into the nitty-gritty science of it and the complex bipsychosocial model, as we love.
SPEAKER_01Love that word.
SPEAKER_03Um and it's actually so complex.
SPEAKER_02It's so complex, but and yet it's been like, on one hand, it's like, oh, you can't get it up now. Yeah, and then other hand immediately it's like, oh, this kid's got a bone up. Yeah, okay.
SPEAKER_03Where do you fit in? What do you mean? Let the dude have a bone on my god. Exactly.
SPEAKER_00Well, I think we should, yeah, we should practice some um principles of acceptance and commitment therapy here. Absolutely. Like, you know, while we it sounds complex, really it's not. We just need to accept that this is the this is the way it is. Yeah, and focus on pleasure. Focus on what sex is about intimacy, connecting with the uh friend, the lover, enjoying each other's bodies, pleasure.
SPEAKER_03Stunning.
SPEAKER_00And for some people, reproduction. For some people, yeah, for some climate. No judgment. Yeah, yeah, yeah.
SPEAKER_03I feel that way climate. It is important. Um but yeah, I think, yeah, you're right. I guess it's it's complex in the science of it. Um, but I guess when you're thinking about your erectile inconsistencies, that the focus is we don't want you to to blame yourself. You know, this isn't inherently a you problem. If you feel like you can have the conversation, do it. Your sexual function for you is really important. Yeah, it's so important for your social and emotional well-being.
SPEAKER_02And you're really surprised at who you're opening up to, you know. Absolutely. How much more you'll get from sex. Absolutely, yeah. Well, even like Nikki and I were just talking before we even started recording, um, just basically about similar things and expectations and you know, rah-da. And I was talking about one of my first like um sexual encounters with like an A-man, with a male, and like I remember them being like um kind of embarrassed that like when that when they ejaculated or came that their sperm didn't like shoot out of their penis, right? You know, and I was like, oh god, you know, because that's I guess what what's what's shown and porn all the time, you know. But that that's not always the case. It's gonna shoot across the room and like you know, it's like and I'm like, okay. Spray across the wall, you know?
SPEAKER_00And that just highlights how yeah, performative sex can be seen. And so, like a a load shooting across the room doesn't improve pleasure for anyone. It's it just creates mess, yes, exactly.
SPEAKER_02Society, yeah. It was like, and I was like, Oh, I never thought of that. No, but that was obviously something that was upsetting him. Yeah, you know? Wow. Yeah. Wow. Interesting.
SPEAKER_03Okay, well, what a conversation this was.
SPEAKER_02I loved it. I loved it. Thank you so much to both of you. Thanks for having me.
SPEAKER_03Oh, that was amazing.
SPEAKER_02I think we're gonna have to have Dr. Nick back. I think so. I think so. I think so.
SPEAKER_03Oh we love you. Yeah. Love you. Wow, what a lovely conversation. And look, if you're listening and you've got some stories you'd like to share about your erectile inconsistencies or questions you have, you can actually send us a message now. So if you're gonna text line. Yeah, we've got a text line. So if you go to that's all right, it's all right, you're right. Uh so if you go to each of our episodes in the show notes, there'll be a little link that says send us a text. Send us a text, send us a message there, um, and it'll be anonymous and um we'll be able to uh bring up your questions at at future episodes. Yeah, so maybe we'll collect a bunch and then get Nikki G back on. Rapid up.
SPEAKER_00I was gonna say, maybe maybe it'd be nice to hear from people like what worked for them. Absolutely. Because you know, like there's no one size fits all, and um things, yeah. There's I mean, sometimes you have to be creative in what works for you, and it's always good to learn from other people in the same experience. So maybe maybe sharing what worked well for. People could be could help someone else out there.
SPEAKER_03Yeah, and we hope you feel safe enough with us if that's the case. Yeah, absolutely. Okay, well, thank you so much. All right. Well, we'll see you. Not next Tuesday, because we're in Port Early. I'm so sorry. Put in a boundary. Put it a boundary. Yeah, every quarter. Next next Tuesday. We'll see you next next Tuesday. Okay, love you. Bye. For Goodness Sex is produced and edited by me, Dr. Shamani, social media and visuals by Nurse Ellie, with audio assistance by Avesta Zanel. We couldn't do it without our management team, Louisa and Sarah, the Hen House Recording Studio for hosting our recording sessions, and Tapari Sound Safari for our music. Don't forget to check out our show notes for all our recommendations and to send us a text with your questions, queries, stories, or feedback. We love hearing from you. Thanks for listening.