Why Older Couples Stop Wanting Sex — And How To Fix It

0:00 We need to like deconstruct all these shameful perceptions of oh,

0:04 now I ruined my sexual life because I had I've masturbated,

0:08 I watched pornography.

0:09 People becomes very anxious and they're very anxious about do I do it right?

0:13 And we always think that what's happening in the neighbor's house is much

0:17 more good or nice or more exciting that that what we are experiencing.

0:22 With newer generations of 70 years old people,

0:25 they had higher expectations of being sexually active and meaning

0:29 that sex would be something that's important when you get older.

0:31 Needs more stimulation to have an erection.

0:34 Mhm.

0:34 They need more stimulation to have [music] an ejaculation

0:37 and maybe it takes longer time before they can function again.

0:41 [music] Yeah.

0:40 So, when they were used to when they were 18,

0:43 it only took 1 minute and then they were ready again.

0:45 Now sometimes it takes a week.

0:47 Yeah.

0:47 Because the whole system is like slowed down.

0:49 So, it needs more stimulation, it takes longer to recover.

0:52 And it's the same with women that women can

0:54 still lubricate it when they go into the menopause,

0:56 but it [music] takes more stimulation.

0:58 And I think that's where some of the problem starts with people

1:01 that get older that they are doing what they used to do.

1:04 And suddenly what they used to do is not good enough.

1:08 Sex can get a little bit more challenging as you age.

1:11 And recently I had an elderly patient ask me, "Things aren't working that great.

1:14 Should I just let it go?" And I told him

1:16 that really everyone deserves a life filled with pleasure and intimacy.

1:21 I'm Dr.

1:21 Rena Malik, urologist and pelvic surgeon,

1:23 and welcome back to the Rena Malik MD podcast,

1:26 your trusted guide for leveling up your health,

1:28 relationships, and sex life with evidence-based tools.

1:31 Today, I'm bringing you a masterclass

1:33 in sexual medicine across the lifespan with Dr.

1:37 Anna Maria Giraldi, a psychiatrist at the University

1:40 of Copenhagen and a researcher who's published extensively on hormones,

1:45 depression, and sexual function.

1:47 She's an editor of the Sexual Medicine Reviews and a key contributor

1:51 of the International Consultation of Sexual Medicine's

1:53 first-ever guidelines on sexual health in older people.

1:57 In this episode, we're covering the biological changes that happen with aging,

2:02 decreased nerve sensitivity, hormonal shifts, vascular changes,

2:06 and the psychological barriers like internalized ageism and body image concerns,

2:11 and the double pause phenomenon where both partners are undergoing changes,

2:16 but oftentimes only one partner gets treatment,

2:18 sexual rehabilitation for cardiac patients,

2:22 and the complex relationship between SSRIs to depression and sexual desire.

2:26 We also cover many of her research studies,

2:29 including those on looking at androgen receptors in women

2:33 using EEG to predict SSRI sexual side effects,

2:36 and sexual health in populations with dementia,

2:39 bladder cancer, and psychiatric illness.

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3:02 Dr.

3:03 Giraldi, thank you so much for being here.

3:05 Thank you for having me.

3:06 All the way from Denmark.

3:07 Yeah, it's a long trip, but it's so nice to be here.

3:10 We have a snowstorm in Denmark,

3:11 so It's so [laughter] nice waking up this morning with sunshine.

3:15 That's wonderful.

3:16 Well, you are so prolific in our field, and I'm so excited to talk with you.

3:21 And I think what I want to start with is that our culture tends

3:24 to sex to treat sexuality as something

3:27 that is really just belonging to young people.

3:30 But from your research and clinical experience,

3:32 what's the truth about desire, sexual activity, and satisfaction as people age?

3:37 My experience, and I think it's supported by research, is that it's changing,

3:43 and I should say culture has a very high impact

3:46 on how we see older people and and and sexuality.

3:50 And so that's some kind becomes internalized in in older people too.

3:56 But I think that what we are seeing right now and what we

3:58 also see is that many factors

4:00 that somehow determine sexual life of older people.

4:04 So there's no doubt that when you become older function

4:08 decreases and maybe also your wishes for a sexual life is

4:13 changing and then also life circumstances are changing and then

4:17 we have like the perception of how older people should behave.

4:21 Mhm.

4:21 So having said that there's a lot

4:23 of research showing that with newer generations

4:26 of older people older people have more

4:29 expectation of having an active sexual life.

4:32 Mhm.

4:32 I usually refer to now it's a little bit old but there

4:35 was a very very nice study from Sweden where they interviewed older people.

4:41 So they were all 70 years of age but they were born in different times.

4:47 So some of them were born in the 1910s and 20s and 30s.

4:51 And they talked to them about sexual health.

4:54 That must have taken a long time to get that study together.

4:57 Yeah, I think I think it did but it's it's really a nice study.

5:00 That's great.

5:00 And there so it was a study that you I really like because

5:04 they actually it took a long time

5:05 because they have to find different generations.

5:08 But what they looked at was what do did these 70

5:12 years old people expect about sexual life when they became older?

5:16 And two things that are interesting in this study and there

5:20 are many interesting things but two things are really interesting.

5:22 The one is that with newer generations

5:25 of 70 years old people they had higher expectations

5:28 of being sexually active and meaning that sex

5:31 would be something that's important when you get older.

5:33 Mhm.

5:34 And the other thing is that in the younger generations of women they had

5:38 lower expectations than men but in the end

5:42 men and women had the same expectations.

5:44 So in the first generation of the oldest of 70 years old,

5:48 men about 2/3 of the men had an expectation of sexuality

5:52 as a part of being older and only about 1/4 of the women.

5:56 But it with the newer generation of 70 years old,

5:59 they had almost all of them had an expectation of being

6:03 sexually active and sex being important when you get older.

6:06 So I think it tells us that with newer generations,

6:09 we will have other expectations for old people.

6:11 And then we also as health care providers need to recognize that.

6:15 And the other thing is that now we have

6:17 at least where I come from, we we talk about that.

6:20 We have all the boomer generations, we have the 60s,

6:24 the people from the 60s that were part of the liberation in the 60s,

6:28 they they have other perceptions and the culture in in their you know,

6:33 the way they have been brought up,

6:34 their lives is different from maybe the people that were,

6:37 you know, before the Second World War.

6:39 So I think that times are changing,

6:41 culture is changing, so we have more aspects, more positive.

6:45 I'm involved in the International Consultation of Sexual Medicine.

6:49 And for the first time we actually

6:50 had a committee coming out with recommendation

6:53 about sexual health in older people because we also have more older people now.

6:57 Yeah.

6:57 The world's demographic is changing,

7:00 so we have more older people and we're going to people live longer.

7:04 So I think that all in all, we need to recognize that older people

7:09 are changing and they are also more healthy.

7:12 Yeah.

7:13 We know that sexual health and mental

7:15 health and physical health goes hand in hand.

7:18 And people live longer, they're more healthy,

7:20 and a healthy sexual life is part of that.

7:23 Absolutely.

7:24 So this consultation that you guys are organizing, are they guidelines?

7:29 What What are you looking at specifically in sexual health in older people?

7:32 They came up with It's just to explain what the consultation is.

7:35 It was the fifth consultation.

7:37 It was in 2024 and it was organized

7:40 by the International uh Society for Sexual Medicine, also the European Society,

7:45 and then the North American Society for Sexual Medicine,

7:47 and what we call ISWISH,

7:48 which is the International Society for the Study of Women's Sexual Health.

7:51 It's a expert groups gather.

7:54 Uh this time it was in Madrid.

7:56 So, experts from all over the world gather,

7:58 and then we have committees on different topics.

8:00 There were about 25 different committees.

8:03 And what they focus on in this committee, they have a lot of recommendations.

8:08 I think more than 50 recommendations.

8:10 But they have specific focus on that we as healthcare

8:13 professionals need to focus on sexual health in older people.

8:17 Mhm.

8:17 That we need to ask the questions.

8:19 We need to be sensitive to how do

8:21 we talk about sex with older people because they

8:23 have might have been brought up with other

8:26 values and other ways of looking at sexual health.

8:30 Uh we need to inform them about the effect of age.

8:34 I mean, what are the changes?

8:35 What are the physical changes?

8:36 What are the hormonal changes?

8:38 What are the psychological changes?

8:40 Relationship changes, maybe.

8:42 And we need to be sensitive to different

8:45 cultures and religious groups and ethnic groups.

8:49 I think that goes for all sexual medicine,

8:50 but that is one of the things that they emphasize is.

8:54 Then they also say that age should not be a barrier for treatment.

8:59 Absolutely.

9:00 So, the fact that you are old uh shouldn't be oh, then we can't treat you.

9:04 Then it's not relevant because I think younger people tend

9:07 to think it's not relevant for, you know, older people.

9:11 It's only relevant, as you say, for younger people.

9:13 Yeah.

9:14 And then they have a focus on um special groups like people with dementia,

9:20 saying there might be diffi- culties or uh certain problems that arise

9:25 when maybe in a couple when one uh person has dementia,

9:29 one of the partners has dementia, how how do we manage that?

9:33 Because you still have the right to a sexual life,

9:36 but maybe how can you give consent if you have dementia?

9:40 I think that's a very very important and very

9:43 fascinating and very something that we really need to have

9:46 a focus on because there have been cases where it

9:49 has been discussed can people with dementia can they give consent?

9:54 So how do we deal with that?

9:55 They also discussed that if people with dementia

9:59 have sexual lives or want to have it,

10:02 it shouldn't be the children or the caregiving people where they live

10:07 that but you should need to include the partner and you need

10:11 to really try to to protect the person and also protect

10:15 the the right to having a sexual life but also protect the person.

10:19 I think that's uh looking into the future

10:22 about older people being sexually active, we also need to look at maybe the more

10:26 negative uh sides and how do we deal with that?

10:30 And then they also discussed that there are different like Parkinson medication

10:34 that might increase sexual desire and have

10:37 suddenly persons with Parkinson having the treatment,

10:41 they might have like change their sexual behavior and be

10:45 more sexually active and how do we deal with that?

10:47 Yeah.

10:48 So they actually try to focus on the responsibility

10:51 of the health care takers of introducing,

10:54 talking about, treating sexual problems,

10:56 but also like introducing new things that we might face

11:01 in in in the future with a growing older population.

11:05 I mean, this is such an important discussion not only

11:08 for the health care providers but the patients as well.

11:10 So I had a patient this morning who was like,

11:12 "Oh, I'm 65, things are not working that great.

11:15 Should I just let it go?" And I said,

11:17 "You You deserve pleasure and intimacy, you know?

11:20 And I don't think you should just let it

11:22 go." It doesn't mean that you have to have,

11:24 you know, if you're struggling with erections,

11:26 you have to have an erection to have intimacy, but I don't think you should say,

11:29 "Oh, I can't have an erection and so I should just stop trying to be intimate.

11:33 And I think that's, you know, a big misnomer in our aging population.

11:36 Like, oh, maybe I'm just too old for sex.

11:39 Yeah, and I think that's I agree with you.

11:40 It's It's very very important and one

11:42 of the recommendation from this uh committee is also

11:46 that we need to open the discussion because

11:48 a lot of older people might say, "Oh, this is something that I need to accept,

11:51 so I won't even open the discussion." Your patient is

11:54 open and actually went to you to to get some help,

11:58 but a lot of people won't do that.

11:59 But and and so they also have a focus

12:02 on how are we as healthcare providers ages?

12:05 I mean, how do we look at older people and and how

12:08 do we open the conversation in the best possible way?

12:11 Absolutely.

12:12 Um you know, it's interesting.

12:13 I did a study when I was a a resident

12:16 and the study was what do we as urology residents think,

12:20 like, how how sexually active are elderly patients?

12:23 And it was remarkable how many people under under valued

12:28 the percentage of people who were sexually active in older age.

12:30 And I was like, "Look, we're residents.

12:32 We should We know a little bit more than

12:34 the average medical practitioner because we are training in urology,

12:37 but it's still so low." And so I

12:39 think it's so interesting because we we are ages.

12:42 Like, we can't be uh digging our heads in the sand

12:45 and think that doctors are not ages or we're not doing these things.

12:48 We absolutely are.

12:49 of the culture.

12:50 Yeah.

12:50 I I think it's such an important aspect.

12:52 And the other aspect I've been a little bit

12:53 involved in is what we call the double pause.

12:56 Mhm.

12:57 That very often our healthcare system is built up the way it It's a little

13:01 bit different depending on which country you

13:03 are in, but but usually as a gynecologist, you'll see the female partner.

13:08 Um if you're a urologist, you'll see the male partner.

13:11 If you're a GP, you might only see one of them

13:14 in your practice and the other one is in another practice,

13:16 no matter whether it's a male or female partner you have.

13:19 So, what we talk about with the with the double pause is

13:23 that very often if you have an older person presenting with problems.

13:27 A man with erectile dysfunction,

13:29 you need to be aware that there's a partner at home.

13:32 So, it might be a female or male partner,

13:35 but that partner also maybe has the same age.

13:38 So, there's a risk that this partner also has problems.

13:40 So, if we only treat one of them,

13:43 we're really not doing a good enough job because

13:45 we need to think about and involve the partner.

13:47 And that's one of the recommendations, too,

13:49 that we really need to involve the partner both in the assessment

13:52 because if I give a PDE5 inhibitor to a man with erectile dysfunction,

13:57 and he has a wife who is in the menopause,

13:59 she has problems with pain and lubrication,

14:01 and she actually doesn't want to have sex,

14:04 then we didn't really solve anything because

14:06 Yeah, we've actually created more problems.

14:07 Yeah, because they were probably blissfully not having sex.

14:10 And and I think that's also so important,

14:12 and I think we need to think about not only treating one person,

14:15 but really include the partner.

14:17 And here we see barriers.

14:19 We we have health care system where I'm working in a place where we

14:23 are able to to invite the partner to come as a part of the treatment,

14:27 but that's very rare.

14:28 Yeah.

14:28 And we need to create a system if we

14:30 want to take care of older people's sexual health,

14:32 where we can actually have both of them and also discuss what you are saying.

14:36 What is sexual health?

14:37 What is sexual intimacy?

14:39 Because maybe they don't have an intercourse,

14:41 but maybe they have a lot of kissing and intimacy and bodily contact,

14:45 and maybe they have other goals than just having an erection or an orgasm.

14:49 So, it's also about involving both of them,

14:52 and sometimes they don't have the same goal when we we treat them.

14:55 One of them might have one goal and the other one says, "Oh,

14:58 that's not my goal." Or maybe a problem, typically a erectile problem for a man,

15:03 it doesn't matter a lot for the partner, and the partner would say,

15:06 "Oh, we can do something else." But for this guy, it's it's very important.

15:10 Yeah, it's a huge opportunity when you have a couple in the office with you.

15:13 And I I do see some couples, and I think that it's so valuable because you

15:17 can then sit like figure out what the problems are.

15:20 They're probably not even talking to each other about it, right?

15:23 And so, when they're finally with you,

15:24 they open up and you can actually see like,

15:27 well, where do we need to work on things for both partners?

15:30 you're like the mediator of the communication because I think it it

15:33 it can be very very difficult for people to talk about sex.

15:36 And and it's even though you have known each other for years.

15:39 And when it works, you don't talk a lot about it.

15:42 And when it doesn't work,

15:43 it it might be very difficult because you also people are very vulnerable,

15:47 but they also care about the other one.

15:49 So, very often it can be very difficult to say,

15:52 I really think we need to do something different or this doesn't

15:54 work for me or I never liked that or whatever it can be.

15:58 And and then it's good that you have a third person that can like some

16:01 kind mediate that conversation because it's people

16:04 really want to protect each other and themselves.

16:06 So, it can be very difficult to talk about sex.

16:09 Yeah, and everyone I think everyone to some degree wants intimacy.

16:12 They may not want sexual intercourse as they see it or as they believe it to be,

16:17 but they I think everyone wants closeness with another human being.

16:21 I I very often when when I see couples,

16:24 I ask them, what is the goal of your treatment here?

16:28 So, we need to set a treatment goal.

16:30 Most of the time people say, I want us to have more intimacy and communication.

16:34 I mean, some of them say, I want to have more intercourses,

16:37 but that's actually intimacy and communication are the first

16:40 choices because that's what really matters to people.

16:42 That's the intimacy.

16:44 And and sex is where we really get close

16:46 to to each other and that's where we have intimacy.

16:49 Yeah.

16:49 That's why it's so important.

16:51 So, sometimes if you can get the intimacy,

16:53 the intercourse or or the orgasm or erectile the erection isn't

16:59 that important because it's intimacy that they really say, I miss that.

17:02 I miss that we depa- we depart from each other.

17:06 We we move diff- different directions.

17:08 We we don't think to each other.

17:09 And for a lot of relationships, I say this often,

17:12 but that sex is the only form of intimacy that they know, right?

17:15 They may not be very physically affectionate,

17:17 and so sex is a time that they feel physically close,

17:20 and when that's gone, it feels like a huge rift in the relationship.

17:25 Yeah.

17:26 And you know, you mentioned something interesting.

17:27 You said the way we talk to older people may

17:30 be different than the way we talk to younger people, right?

17:32 Because there's a big generational difference.

17:33 Like I can talk to my son about something in a very different way.

17:37 I'll I'll share a funny story.

17:38 I made a little short video, and the video said,

17:41 "Someone cooked here." And cooked is a slang term

17:44 for you the younger generation that means something good happened.

17:47 Like I did something really good.

17:49 Whereas in the older generation, cooked means,

17:51 "Oh, you're cooked." That's a bad thing.

17:53 And so when I posted this piece of content,

17:55 it was showing something good happened,

17:57 and then oh, someone cooked here in a positive way.

17:59 And people were like,

18:01 "Why are you saying this is negative?" Like there was so many comments,

18:04 and I realized like there's such a divide

18:05 here in how we talk to the older generation.

18:09 But I also find that when I bring up things like

18:13 maybe you should try this or do this, or you know,

18:17 try maybe a toy in the bedroom.

18:19 And that's very foreign to patients who are older.

18:22 A lot of them are like, "Well,

18:23 no one's ever talked to me about this, and I'm kind of excited

18:26 about it." And there's others that will shut down and be like, "Oh, no,

18:28 no, no, we don't do that." And I think

18:30 it's it's it's okay to broach it, but being,

18:33 you know, cognizant that you might not get

18:34 a response the way you expect it to be.

18:36 Yeah, and I think that's also it it

18:38 says a lot about our role as healthcare professionals.

18:41 And And just also I think that if you sit there,

18:45 I'm a little bit older than you are, so it's like how would I feel

18:49 if Sometimes when I meet a healthcare professional,

18:51 I think, "Oh, did they even finish high school?

18:53 They're so young.

18:54 So how can they talk to me about this?" So

18:56 we also need to think about the barrier between generations.

18:59 As you said, we have different languages.

19:01 And And sometimes when I talk to younger people, I think,

19:04 "I'm just too old for this because I don't

19:06 know the language." I wouldn't know that about cooking.

19:08 right?

19:10 [laughter]

19:09 So it's it's really interesting but I have kids.

19:13 That's [laughter] You know, I wonder is it I think of Denmark

19:20 as a very like sexually positive country and do you find

19:24 that you travel a lot you see doctors and and people

19:27 from all over the world so what what is your experience?

19:29 My experience is that that Denmark is a sex positive

19:32 it's it was the first country that had pornography allowed.

19:35 I mean I don't know if that's positive or negative but I

19:38 think it has a very positive attitude towards sexual life and sex

19:43 we accept that people have sex without being married we accept

19:46 that teenagers have sex we have very low rate of of teenage pregnancies

19:53 we have high information about you know contraception and things like

19:58 that but still I think that sexual life is still difficult so even

20:03 though you have a positive attitude and even you have an open

20:06 society where you're not like moralizing and say this is not allowed.

20:11 It's still difficult it's still difficult to talk

20:13 about still difficult to find your way.

20:15 I think that that's quite interesting so we think it should be

20:18 so easy but it isn't but what I see in our clinic

20:21 is that we see younger people see coming for help and I

20:25 was in the beginning I was like oh why do we have

20:28 all these young people shouldn't they just find another partner or something

20:31 like that but I think in the other hand maybe it's a positive

20:33 thing that they actually say okay now something isn't working so we

20:37 need some help we need to to get some help from someone.

20:40 So and then we have a health care system where you know it's

20:43 free and and you can actually go to a GP and get a referral.

20:46 But I I think that also especially for women

20:49 when you ask about traveling especially for women there's

20:53 a huge difference in how we look at sexuality

20:56 in in women depending on the culture you live

20:59 in because in a lot of countries we have

21:01 absolutely no information to women about sexual health they

21:06 everyone thinks something that hurts is something that you

21:09 you don't do it before you you get married, you do not masturbate.

21:14 We also have cultures where it's not allowed for men to masturbate.

21:17 And I think that it has a negative impact.

21:20 It might have a negative impact because if you don't learn anything about it,

21:24 if you don't know how your body works, if you don't know what do I like,

21:28 what don't I like, then you're very inexperienced and then and we also

21:32 know that from research then it increases the risk of of having problems.

21:36 Of course, a lot of people will find out and how they do.

21:38 But I think that's really the impact of the culture when we talk about what

21:42 has an impact because I think the bodies are the same all over the world.

21:46 But the impact of the culture and the shame that's connected to sex,

21:49 especially for women, is not very good for a healthy sexual life.

21:53 The shame is really the problem.

21:54 And so that you know,

21:55 was it so interesting for me when I started making content on YouTube,

21:59 I would get a lot of comments and one of the comments

22:01 I would get was how do I stop my nightfall?

22:04 And this blew my mind that people thought that having

22:07 nocturnal emissions or ejaculating at night was a bad thing.

22:11 And like I had never, you know, I just knew it was normal.

22:14 And granted, obviously I'm a urologist,

22:15 but I think I knew that from a young age because

22:17 it's not a it's not a not really taboo in the US.

22:21 And it shocked me and I was like, why are people are so stressed?

22:24 How do I stop this?

22:25 What's wrong with me?

22:26 I'm broken.

22:27 How do I stop this?

22:28 And it was just a normal function.

22:29 Also, when you go on the internet,

22:31 you'll find a lot of different stories about you know,

22:34 if you get into the like the the wrong line in on internet,

22:38 you you can have a lot of things.

22:39 Also, we see a lot of people now,

22:41 young men that are referred with erectile problems

22:44 and then they go on the internet and they find,

22:46 "Oh, it's because I watch pornography." And really, I really disagree with that.

22:49 Then they have all this shame about, "Oh,

22:51 I watch pornography." And we know that, you know,

22:53 99.9% of of men and a lot of women have watched pornography.

22:58 Mhm.

22:59 And then they get this impression, "Oh,

23:00 I have to stop that." And then there's a lot of shame and a lot of anxiety.

23:04 So, we need to like deconstruct all these shameful perceptions of oh,

23:09 now I ruined my sexual life because I

23:11 had I've masturbated or watched pornography and Yeah.

23:14 So, it it people becomes very anxious and they're

23:17 very anxious about do I do it right?

23:20 And we always think that what's happening in the neighbor's house is much

23:24 more good or nice or more exciting that that what we are experiencing.

23:29 Yeah.

23:30 You know, well, there's science that shows

23:31 that pornography is not the problem, right?

23:33 I don't think it's just your personal opinion.

23:35 I think there's there's real science behind the fact that it's

23:37 not the actual visual aid that you're using that's creating dysfunction.

23:42 It's the moral incongruence.

23:43 If you feel that pornography is bad,

23:46 that's when the shame spiral creates this problem where you feel

23:50 negative after doing the act of masturbating while you're watching pornography

23:55 and then you continue to do it to feel that little

23:57 bit of dopamine and then it just become becomes a vicious cycle.

24:00 Yeah, and I I I I completely agree and and I think there was a very nice study.

24:04 I I don't remember the the authors,

24:05 but they showed that young men that were anxious, they were anxious.

24:10 So, they were the one that, you know,

24:12 when they had watched pornography and masturbated,

24:14 then they felt a lot of guilt and shame and anxiety,

24:17 but the one that weren't anxious and had no problems or anxiety,

24:20 they used it and they they felt good.

24:23 And and then we know there's a lot of research.

24:25 We have one researcher, Dr.

24:27 Hall in Denmark, that did a lot of research on pornography.

24:30 Actually, there might be a small group that like watch too much

24:34 and have a vicious circle and watch more and more violent pornography,

24:37 but they are it's not the only pornography.

24:39 They they have a lot of other alarming signals.

24:42 So, it's it's it's not the pornography alone,

24:44 but they they are the one that you should be a little bit concerned about,

24:47 but that's really a minority.

24:49 Yeah, there's often a lot of concomitant

24:51 depression and and psychological factors, right?

24:54 And there's sort of maybe there's a theory that there might

24:56 be some untreated psychological factors

24:58 that they're self-medicating almost with the pornography.

25:02 Yeah.

25:02 Um and I think the other thing is there's so much information on online, right?

25:06 Oh, quit pornography.

25:07 How do I quit?

25:08 Like there's coaches who are like, you know,

25:10 take my 10-step program to quit pornography

25:12 for good and those don't even work, right?

25:14 There's science that that actually there's evidence that doing these sort

25:17 of very drastic interventions of complete abstinence don't actually work.

25:22 Yeah, and and that's uh Yeah,

25:24 it's talking against research actually and it's talking against

25:27 what we like also would like to, you know, be sex-positive and it becomes a very

25:32 negative thing and you have like this 12-steps

25:34 or 10-steps programs like if you have been

25:37 drinking or taking drugs or something like that.

25:39 Yeah, yeah.

25:40 And and it's easy it's easy to I mean it sounds good, right?

25:44 Oh, you're this like morally righteous person saying porn is bad,

25:47 it's ruining your life.

25:48 If you quit this, you're going to have a much better life.

25:50 And I tell people, look, if you cut back and you feel better, great.

25:53 Like by all means, you don't have to watch pornography,

25:56 but you shouldn't feel shame about it.

25:58 the shame is really bad for sexual health.

26:00 You did mention that there are changes that happen

26:02 in sexuality as we age from a biological standpoint.

26:06 So, can we go over some of those?

26:08 We know that changes in hormones.

26:10 We know that in women we have the the the decrease

26:14 or or the lack of estrogens after the menopause,

26:17 which has an impact on especially lubrication, but also somehow on on desire.

26:23 We know something happens with desire when when

26:25 people go in when women go into the menopause,

26:27 but especially it has an effect on on lubrication and pain and feeling dry.

26:32 We know that testosterone is declining both in men and women.

26:35 We know that has an impact on desire.

26:38 So, we have like the hormonal changes.

26:40 We have uh just the fact that you may need

26:43 more stimulation and that goes for both men and women.

26:45 We need the men needs more stimulation to have an erection.

26:49 They need more stimulation to have an ejaculation and maybe

26:52 it takes longer time before they can function again.

26:56 Yeah.

26:56 So, when they were used to when they were 18,

26:59 it only took 1 minute, and then they were ready again.

27:01 Now, sometimes it takes a week because the whole system is like slowed down.

27:05 So, it needs more stimulation.

27:06 It takes longer to recover.

27:08 And it's the same with women that uh women

27:10 can still lubricate when they go into the menopause,

27:13 but it takes more stimulation.

27:15 And I think that's where some of the problems starts with uh

27:18 people that get older that they are doing what they used to do.

27:21 Suddenly, what they used to do is not good enough.

27:24 Yeah.

27:24 And then it's very, very difficult to say I actually need more stimulation.

27:28 I I'm not just turned on by you saying, "Oh,

27:30 should we do something?" And and then then uh it's very

27:34 difficult to to find out how do we do that stimulation?

27:37 And how do we talk about it?

27:38 How do we help each other in finding out what do we like now?

27:42 And it takes longer time.

27:43 So, I think that's the the major changes.

27:46 I mean, we have the hormonal changes

27:47 and more physiological changes with with the genitals.

27:50 And then we also have the more psychological changes.

27:52 Maybe people have known each other for a very

27:54 long time if they're still in the same relationship.

27:57 We're always doing the same things.

27:59 You might feel older.

28:00 Your body image might change.

28:02 Mhm.

28:02 Yeah, you only asked about the physical ones.

28:04 Now, I'm going to the other ones.

28:06 So, so and also the the the internalized ages that I mean,

28:10 do you do I think I can have sex when I'm older?

28:12 I Do I like my body?

28:13 Do I like my my partner's body?

28:15 So, also Oh, now I'm getting old.

28:18 You're a little depressed.

28:19 What if I don't have a long time.

28:21 I'm getting older and and all the more psychological things.

28:24 So, I think And also the change in roles that the children are leaving home.

28:28 What is my role now?

28:30 Um how do I have a value?

28:32 I stopped working.

28:33 So, it's really like the whole bio-psycho- psychosocial approach is

28:37 like a lot of things happens when you get older.

28:40 But there's a physical thing which is can be quite dramatic.

28:44 And then you have all the other aspects that's also are are very important.

28:49 Uh there was a very nice study by Lorraine Dennerstein, who she's still there,

28:55 but she did a study long time ago looking

28:57 at estrogens and women's sexual health when going into the menopause,

29:02 and she found out that the psychological factors are just

29:05 as important for desire and pain as the decrease in estrogens,

29:10 meaning that the transition of becoming an old

29:13 woman now I go into the menopause.

29:15 It's as important as as the more physical factors.

29:19 I think that's so important to emphasize because I think we I mean, of course,

29:22 as physicians we focus on the things that we can,

29:26 you know, we can fix with a with a treatment, right?

29:29 But I think the other things,

29:31 the psychological factors, and the stressors are different, right?

29:34 As you mentioned, you go through retirement, perhaps.

29:36 You don't feel as much purpose,

29:38 and I think that's a big thing that we don't talk about enough, right?

29:41 That when you go through retirement, if you don't have a plan,

29:44 you can only golf so many days, you can only travel so much.

29:47 Like, you need to feel like you have a purpose,

29:50 and and I think a lot I have a lot of my patients

29:53 come in, and I feel like they really don't have one,

29:56 and that's really a big struggle.

29:58 Yeah, so it's both about mental and and physical health.

30:01 And and then we of course know that when you age,

30:03 the risk of having cardiovascular diseases, rheumatoid arthritis,

30:08 and you know, a lot of diabetes, I mean,

30:11 they also have a negative impact on sexual health.

30:13 So, we know that that physical health declines with age for for a lot of people,

30:17 and there's some very nice study by um her name is Lindau,

30:22 where she looked at how long can you expect to be sexually active,

30:26 and and she can like show that it's

30:28 correlated to how physically healthy are you.

30:32 So, so if you have a good physical health,

30:34 then you are in a higher have a higher chance

30:37 of of being sexually active a longer time when you get older.

30:39 So, they go hand in hand, and just the feeling of not being physically fit like

30:45 you used to be also have like a psychological impact.

30:48 So, it goes hand in hand.

30:50 Yeah, there's so many things.

30:51 I did want to point point out the the stimulation thing

30:53 because I think people feel like there's something wrong with them.

30:56 But just like you're aging, your nerve cells are aging, right?

30:59 So, they don't respond the same as they used to.

31:02 And that's kind of I don't think that we get have anything that can combat that.

31:06 Right?

31:07 Like I don't think you can you can't

31:08 exercise out your nerve cells to work better.

31:10 You know, you can I mean those things will help potentially,

31:12 but they're not going to completely eliminate aging of the nerve cells.

31:17 No, but but we know that that there is a little bit you can combat,

31:20 but I agree with you.

31:21 I mean, we we have to recognize we're getting older, and it works differently.

31:25 I mean, it does in many other levels,

31:27 but and and then you need to change your sexual script.

31:30 You need to change that.

31:32 Uh we need to do something differently.

31:35 And and I think it's um as we discussed,

31:37 it's it's difficult to communicate about.

31:39 I think I see a lot of women

31:41 that if the man starting having erectile dysfunction,

31:44 they think, "Oh, something is wrong with me.

31:45 He is in love with someone else.

31:47 He does he's not attracted to me anymore." And she

31:49 might have like body image concerns because she's getting older,

31:53 she might have gained weight,

31:54 and then he's not able to have an erection and she because he

31:57 needs more stimulation or he's just have

31:59 a decreased function of his erectile function.

32:02 And then she thinks, "Oh my god, now I'm not attractive anymore." And you know,

32:07 he becomes very nervous because he knows

32:08 that he's going to confirm her, you know, well-being by having this erection.

32:13 So, there's so much pressure on on it functioning.

32:15 So, they really need to to uh You can help people if

32:19 you tell them actually that's what happens when you get old, right?

32:22 It has nothing to do with you as a partner.

32:24 It has nothing to do with you.

32:26 It has to do with becoming older.

32:28 Yeah.

32:29 I think nowadays we're talking a lot about testosterone declining.

32:33 And and while we know estrogen declines to zero basically for women,

32:36 Te- declines um at a sort of expected rate per year,

32:42 but there are things So, in general,

32:44 most people should not need testosterone replacement if they are healthy,

32:49 functioning, normal individuals.

32:51 Is Would you agree with that?

32:52 Yeah, I I would.

32:53 And we know that, especially if you're overweight, that testosterone is lower.

32:58 So, so we might be able to to help

33:00 ourselves by staying fit and staying not too overweight.

33:04 But it it declines with age.

33:06 Yeah.

33:07 And I'm a psychiatrist, so I'm not really an endocrinologist, andrologist.

33:11 We But I I think that for most people, we don't need to to supplement anything,

33:16 and I think we we need to see another factors

33:19 because it's also I think we all want the quick fix,

33:22 but sometimes you give testosterone to people and nothing changes.

33:25 So, you need to focus on, okay, then what's What was it then?

33:29 And for some people, it's very, very good,

33:31 and for some people, you need to do look at something else.

33:34 Yeah.

33:34 to look at what's happening in their relationship.

33:36 Do they have depression?

33:37 Are there other factors that are more important than the testosterone?

33:40 I mean, I think we know that low testosterone is

33:43 is becoming more common because of all the comorbid conditions, right?

33:46 Because people have more high cholesterol,

33:47 more diabetes, more being more overweight.

33:50 And so, getting to that level where testosterone

33:52 becomes low enough to create problems is more common.

33:55 Uh but I just want to reassure people.

33:57 I think my point is to say that yes, we know that there is a hormonal decline,

34:00 but if you remain healthy in your body and you're exercising

34:04 and and you're moving your body and doing all the things that you need,

34:07 eating correctly, that you should be able

34:10 to maintain a a reasonable amount of testosterone.

34:13 Yeah.

34:13 And sometimes it's a little bit easier if uh if I mean,

34:17 sometimes people come into the clinic and say they

34:19 just wish it's the testosterone because that's the easy thing.

34:23 Yeah.

34:24 That that you Okay, then you can have a supplemental testosterone.

34:27 And and then everything is fixed.

34:29 And then when we say, "No,

34:30 your testosterone is normal," or we don't think it's that.

34:33 Oh, then it's really difficult because then then what?

34:36 Yeah.

34:37 Yeah, absolutely.

34:39 What do you think in terms of a psychological standpoint?

34:41 What helps older adults sort of reclaim their sexuality

34:44 the most in terms of people who are struggling?

34:46 I think that communication is a good thing.

34:49 Both communication in the couple,

34:51 but also communication with health care providers.

34:54 That you are assured that it's okay

34:57 to have the desire for being sexually active, that it's something that's normal.

35:02 I think normalizing and communication is that's very

35:05 very important because then people can start helping themselves.

35:09 A lot of people they really, if you speak to them,

35:12 they're very capable of of thinking about what's the problem.

35:16 And if you give them like a safe space where they can discuss it together,

35:20 or or or they can discuss it with you, I think it's a lot of people can see,

35:25 okay, I can see that maybe we should do a little bit more

35:29 of this and a little bit less of that and and and put more focus on intimacy.

35:33 And I think that that can help a lot.

35:34 So So basically, I think sometimes it's not very drastic what you

35:38 have to do because you can help people with with education and information.

35:43 Yeah.

35:43 Yeah, that's great.

35:45 You um were part of this trial, the Copenhagen SF trial,

35:49 where you looked at testing sexual rehabilitation programs on cardiac patients.

35:54 So let's talk about how that trial sort of started

35:56 and what was the what was the impetus for doing that?

35:59 I I have to say I was only a small part of the trial

36:01 because I had a at the primary investigator was a a nurse called Pernille Palm.

36:05 She was like the main investigator.

36:09 Um it was partly based on another study

36:12 that was done in in the Heart Association in Denmark,

36:16 where I was also part of that, where they looked at people with heart problems.

36:22 So they actually looked at all people that had

36:24 their first time event related to heart disease.

36:27 So, it could be many different types of heart diseases.

36:31 And then they looked at whether they had been uh asked about or counseled

36:37 about sexual life and the impact of of heart disease on sexual health.

36:41 Mhm.

36:42 And not surprisingly, we would say, we found out that the older people were,

36:46 the less information did they receive about heart disease.

36:50 And the other thing was that women,

36:52 older women were the one that received almost

36:54 no information about heart disease and sexual health.

36:57 So, it again talks into we think about older people,

37:00 they're not so sexually active,

37:02 but if we think of someone being sexually active, it's the men.

37:05 We we all recognize, oh, men, they want to have sex,

37:07 but the women, they were like forgotten.

37:09 So, that put a focus on on sexual health in in people with heart diseases.

37:14 And Pernilla had this was very interested in how do ex- can

37:18 we use exercise to help people with with the men with erectile dysfunction.

37:23 Mhm.

37:23 So, um she created like an intervention where they had

37:28 quite a um good support in exercising three times a week.

37:33 Mhm.

37:33 They could either have a they could come

37:35 to the hospital and and be part of an exercising program.

37:39 Or they could have a personal trainer in in a fitness center.

37:43 And they were instructed to do both

37:45 um cardiovascular and and um lifting weights, strength.

37:49 Yes.

37:50 Resistance training.

37:50 Yeah.

37:51 Yeah.

37:51 And it was combined with also with physiotherapy.

37:54 Mhm.

37:54 So, it was also a something about if we do pelvic floor um exercises,

38:01 if you give that to men, can that also improve erectile function?

38:04 Mhm.

38:05 And then they also had a counseling with a sexologist.

38:09 They had two uh counseling um sessions.

38:12 So, I think that it was more than exercise.

38:15 It was like a package of an intervention with men with ischemic

38:18 heart disease and uh men that had uhm, uh a pacemaker.

38:23 Mhm.

38:24 And what she showed was that they all had better shape,

38:29 they had a higher oxygen,

38:31 you know, yeah, VO2 max, and and they actually had a better erectile function.

38:36 So, that was like the very, uh, quantitative measures

38:39 That was the outcome of the That was the outcome.

38:41 So, the primary outcome was to look at how how was the erectile function.

38:45 So, it improved the erectile function.

38:47 I think it was a 12-weeks intervention.

38:49 I mean, it it was positive.

38:51 But the other thing was that she

38:52 also did some qualitative interviews with the men.

38:56 And this again emphasizing that it's more than

39:00 just erectile function that they, uh, said that, uh,

39:04 the three there were like three themes

39:06 that that came out when she did the qualitative interviews.

39:08 The first one was that it was so nice to have

39:11 a place of understanding at somewhere where you could uh,

39:15 actually discuss it with other men,

39:17 and uh, that there was like a professional environment that actually took it

39:21 seriously and and and guided you and gave you something about sexual health.

39:26 She said, the other one was that there was a very supportive atmosphere,

39:29 so it was very nice for the men that some

39:31 of the things they said they gained from the study.

39:33 The fact that they trained together motivated them.

39:36 I think we know that from a lot

39:37 of research about motivating people to do exercise.

39:40 And they also developed friendships with with the other people,

39:43 and they also said they felt sexually empowered.

39:46 That they it was nice to have more information about it,

39:49 and uh, uh, speaking to someone about it,

39:52 and that itself would create more desire because

39:55 they now were more empowered in their sexual lives.

39:58 So, I think that all like the more soft benefits are very valuable, too.

40:03 So, it's not only about how do you

40:05 measure your erectile function and how is the scale.

40:07 So, it had a lot of of of good impact on on the men.

40:10 And when these people joined the study,

40:12 like was their goal to return to sexual activity?

40:14 Were they not like was that kind of the premise of it,

40:17 or were these just people who had heart disease

40:19 and were sort of interested in I think they were recruited

40:21 because they had a heart disease and they were asked

40:23 whether they would like to be a part of the study.

40:26 I don't think she really discussed what what were their goals,

40:28 but but um they they reported a lot of benefits from the study.

40:33 Well, that's you know, I love this idea of sexual rehabilitation because I

40:36 think that there's so many people where we don't realize

40:38 that their goal is actually like it not maybe not

40:41 you or I cuz we talk about sex all the time,

40:43 but I think when you see a primary care doctor or surge you know,

40:46 surge orthopedic surgeon or you know,

40:48 somebody for your back pain or your heart disease that really

40:52 your goal is to be able to have sex again.

40:55 Yeah.

40:55 And there's so many patients where that's a big

40:57 goal and I think if you're like, "Hey,

40:58 we have a sexual rehabilitation program for you

41:00 with the goal of you being able to improve

41:03 your sexual function." And for men it's

41:05 a little bit easier to measure with erectile dysfunction,

41:08 but I think even for women you could measure that.

41:10 I think that would be really valuable.

41:12 Yeah.

41:12 And also what was nice about that study

41:15 because they also had to talk with a sexologist,

41:17 they could also discuss alternative solutions if

41:20 if you don't get your erectile dysfunction,

41:23 you know, good enough for having an intercourse, what do you then do?

41:25 And there was some kind of information about, you know,

41:29 other ways to do it and and how what is sex?

41:31 Sex is not only intercourse.

41:33 And I think that's where we should go and and we see

41:36 the same with a lot of programs for men with prostate cancer.

41:39 Yeah.

41:39 Uh a very large group and um and I I think it's the same that we

41:44 should not only focus on on the erectile

41:46 function because sometimes it won't come back.

41:49 Yeah.

41:50 And then we need to have an alternative because else you're going to just like,

41:53 "Wow, then what are we going to do

41:55 if we can't give people an alternative?" Yeah.

41:57 Do In Denmark is sexual rehabilitation like available

42:00 readily or is that just for that study?

42:02 No, I think we we have more focus on it.

42:05 We we have a quite good health care system,

42:09 so I think that I mean, we we we can be better.

42:13 Yeah, I think everyone can be better,

42:14 but it's not that we have a sexual rehabilitation program for all people,

42:18 but we have a lot more focus on it.

42:20 We have in all we have like five regions in Denmark,

42:23 health care regions in the country, and I think most of the centers have

42:29 what we call rehabilitation centers when people have cancer.

42:32 Mhm.

42:32 And I and I think in most study

42:35 centers now there's a focus on sexual health, too.

42:38 It's not only about rehabilitation regarding sexual health.

42:41 It's about rehabilitation living with having had a cancer diagnosis,

42:44 having been treated.

42:46 So, there's more focus on the impact of diseases and getting older.

42:51 And then we have a system where you can be

42:53 referred to a clinic with special interest in sexual health.

42:56 Yeah.

42:57 I think that's the way it works.

42:58 So, it's not that all people have a sexual rehabilitation,

43:01 but there's a possibility of having it,

43:03 especially if if people recognize you have a problem.

43:06 So, we need to take the discussion.

43:08 We need to ask people about it.

43:10 Well, I love this idea.

43:11 I think that you know, it would be so wonderful if just like people

43:14 get cardiac rehab after they have a heart attack,

43:16 that people got sexual rehabilitation at some point after some

43:21 sort of intervention that was just available to them and accessible.

43:25 You know, don't you think that would be so helpful?

43:26 we and and I think we have a focus on it.

43:28 So, at least people with diabetes, especially men,

43:32 because it's it's a little bit easier with men because

43:34 it's very measurable and we have treatment for erectile dysfunction.

43:37 So, Yeah.

43:38 It's easier to prove that it's easier to prove that it's easier.

43:40 it's also easier because you have something you can offer them.

43:43 But especially with men with cardiac problems, diabetes,

43:47 prostate cancer, we we have programs many places.

43:51 And and a lot of nurses are very interested in it.

43:54 So, it's it's very often something that the nurses,

43:57 because they know the patients a little bit better.

43:59 They see them more often.

44:00 So, And they could have more time to do education with them.

44:03 have a focus on them asking about [clears throat] how is it going?

44:06 And and and we also have focus on I've just participated in a program for women

44:12 with breast cancer where some of my I'm only

44:15 like a part of it of the psychological part,

44:17 but there's a the we have cancer rehabilitation in in Copenhagen.

44:21 They have a focus on women with breast cancer about living

44:25 with breast cancer and being treated and after you've been treated.

44:29 And there's like they made an intervention with like an app

44:32 with modules and one of them is about sexual rehabilitation and intimacy.

44:37 So not only about having intercourse,

44:38 [cough] but about intimacy and how do you get back to intimacy?

44:42 What are the barriers?

44:43 What are the problems?

44:44 I mean I think we can extrapolate from the cancer

44:47 rehabilitation programs cuz as you mentioned prostate cancer has it widely.

44:50 Like it's become a very common thing.

44:53 Uh post prostatectomy, you know, sexual rehabilitation programs.

44:56 So yeah, I think that's great.

44:57 So we're going to switch gears a little bit.

44:58 So you published work uh predicting what type of person might be

45:03 more likely to have sexual side effects from medication based on EEG findings.

45:08 And this was so fascinating to me because we know that um some subset of people,

45:13 a small subset, but some do have

45:15 severe sexual dysfunction after medications like SSRIs, antidepressants.

45:20 And so what did you find in this study?

45:22 Again, I have to say it's not I'm not really the the main person in this study.

45:26 I was just so lucky to be a part of a group

45:29 that's looking at the serotonergic system and depression and treatment.

45:35 Yeah.

45:35 And it talks into a a larger focus that we're trying to build up.

45:40 I'm I'm a part of psychiatric center

45:42 Copenhagen and we have quite many professors.

45:45 We have a lot of research in depression and treatment of depression.

45:49 And the colleague that did start the study, Christian Røder,

45:51 is like the the main author of the study.

45:54 He's looking at can we predict the effect of of treatment of depression,

45:59 people with major depressive or moderate depression.

46:02 And then there's another arm in it which I have a very good colleague,

46:06 Wiebke Foekens, who's a professor looking at hormones and depression.

46:10 And and the good thing about our center

46:12 is that we somehow try to combine research.

46:16 So, we have been talking about, I mean,

46:18 what about sexual health in these people with depression?

46:21 And we know that when it's a long story now, so I'm going to unfold it,

46:25 but we know that people who are depressed, they have less desire.

46:28 We know that antidepressants, as you say,

46:31 especially SSRIs, have a lot of sexual side effects.

46:34 We were just thinking, "Wow,

46:35 how do we can we get can we combine our knowledge about this?" So,

46:40 the whole the overall idea is that when we look

46:43 at sexual desire and sexual uh sexual desire and depression,

46:48 I I think maybe it's the the two sides of the same coin.

46:52 Because if you're uh depressed, you don't have desire for eating,

46:54 [clears throat] you have don't have desire for doing anything,

46:56 you don't have desire for living, you don't have desire for sex.

47:00 So, we wanted to see are there some mechanisms that uh are

47:04 common when we look at depression and and sexuality and sexual desire.

47:08 That brings me then down to where that they are looking

47:10 at uh what is the impact of serotonergic system on depression,

47:15 and then we wanted to add sexual desire.

47:18 So, that was a long story to come to Christians'

47:20 uh very nice study where they looked at EEG.

47:23 So, they stimulated electrical responses in the brain by uh audio stimuli.

47:31 And then they got these EEGs, and then they looked at can we look

47:35 at how's the effect of of our antidepressant medication.

47:39 But then they also looked at sexual health.

47:41 What they looked at was that, depending on the pattern of the EEG,

47:47 you might say that some people are more the serotonergic

47:50 system is like having an impact on your sexual desire.

47:55 They found that the lower signaling Mhm.

47:58 that might predict if you would have sexual side effects.

48:03 So, it's not that we now think that now we can just make an EEG on people

48:07 with with the depression and then we're going

48:11 to find out you're going to have sexual side effects,

48:13 but it tells us that some people might be more

48:16 vulnerable because they have a different serotonergic level than other people.

48:20 So, some people might be more vulnerable to sexual side effects.

48:24 Yeah.

48:24 So, it's it's in a it's in a bigger picture

48:26 where we think about how is the serotonergic system modulating depression?

48:31 How is it modulating sexual desire?

48:33 And how do we respond when we get treated with with the SSRIs?

48:38 Yeah.

48:39 And and then Dr.

48:40 Frøkjær and I did another study where we

48:42 looked at people that had a moderate depression

48:45 and we measured sexual desire before they were

48:48 treated and then we measured sexual desire after treatment.

48:51 In that study we found that overall if

48:54 you treat depression the better the depression is treated, the better desire is.

48:59 So, there was like no So,

49:01 we shouldn't be that afraid of giving SSRIs and say, "Oh,

49:03 we can't give that for depression because then you'll have sexual

49:06 side effects." But we know that if you treat the depression,

49:10 desire becomes better.

49:11 But the other study with the EEG might

49:13 say that there might be people that are more

49:17 vulnerable to treatment with SSRIs and they might have

49:20 higher levels of sexual side effects than other people.

49:23 Yeah.

49:24 So, it's it's a little bit like basic

49:26 trying to find out what are the mechanisms?

49:29 What are How do we see sexual desire?

49:31 And and what's so nice about my two colleagues here are they actually have

49:35 a kind of picture into the brain because Christian Rabel is measuring the EEG,

49:40 the electrical output from the brain saying

49:42 something about how what's happening in the brain.

49:45 And and Dr.

49:46 Frøkjær is is measuring the the serotonergic receptor activity.

49:50 So, we also can see how is that relating to anhedonia

49:54 and and sexual desire and they go hand in hand.

49:57 And how is the measuring the serotonergic receptors?

50:01 So, they do that by PET scan.

50:02 So, yes.

50:03 So, they actually have seen the activity of the receptor.

50:07 And and it's quite exciting.

50:09 So, it's now we're just like looking into it

50:11 and trying to see what what can we see?

50:14 So, I I'm quite um excited about can we use it in the future

50:18 because I mean you can do a PET scan on all people,

50:21 but we can get have some information a lot about some basic

50:25 structures and basic mechanisms that goes hand in hand when you have depression.

50:30 And anhedonia is a part of being depressed and and we see that goes

50:34 hand in hand with low desire and it seems like you have course it does,

50:37 but no one else have actually looked at looked at it together.

50:43 And I think that's the beauty of being in a center

50:46 where you are able to combine research from different groups.

50:49 Yeah.

50:50 We're going to That's fascinating.

50:52 I mean I think that's really like

50:53 a window into personalized medicine eventually, right?

50:56 Because it is so important.

50:57 There are you know, even if it's 3% or 1%

51:00 of people taking SSRIs who have debilitating sexual side effects,

51:04 you know, we would love to be able to recognize those people in advance.

51:07 And so, I think that's so exciting and so

51:09 needed and I really think that, you know, this work is going to change the game.

51:14 Like I mean obviously this is early,

51:16 but I really feel like as you move forward and do more testing,

51:19 I think hopefully there'll be an easy

51:21 cost-effective way to screen people and say,

51:23 "Hey, before I put you on this, you're at high risk.

51:26 You can still make the choice, but you know."

51:28 And that is that is actually a part of of the overall project from my colleagues

51:32 is to do the more personalized medicine that they we need to we need to be

51:37 better to predict when we treat depression

51:40 who will benefit from the treatment and who

51:42 are more resistant and maybe need some other

51:44 treatments or so it's it's yeah, it's fascinating.

51:48 Um it's also a nice illustration of if you

51:52 combine research areas that sometimes we can do something new.

51:56 Yeah, it's it's great.

51:58 How is how just this is my personal curiosity,

52:00 how is research funded in Denmark?

52:02 Like how does that work?

52:03 I mean you need to to I guess it's like in in in in the states.

52:07 You need to have grants.

52:09 And we have like national grants that you can

52:12 apply for and you have a lot of private grants.

52:16 So it's yeah, so it's it's funding like you have to raise money.

52:20 So another study you looked at is

52:23 looking at the androgen receptor specifically and female

52:27 sexual function because we know that low

52:29 testosterone is related to low desire in women,

52:33 but I don't think we talk enough about how the receptor which you know,

52:37 basically attaches to testosterone,

52:40 how variations in that affect people differently.

52:43 So can you tell me a little bit about what you found in that paper?

52:46 Yeah, and again remember my psychiatrist because but we

52:49 we were so interested in the whole discussion.

52:52 For for the audience it's like it's important to say that for many years

52:56 it was discussed a lot whether testosterone

52:59 has an impact on women's desire or not.

53:01 So it's it's very interesting because I think of course it helps,

53:04 but but the problem was that in a lot of studies you weren't able

53:09 to show that there's a real correlation

53:12 between testosterone and and sexual desire in women.

53:15 So we have a much clearer picture in men that if you and now you're the expert,

53:19 but if we come below a certain level,

53:22 there's a very very high risk that first sexual desire is going to be decreased

53:26 and then you in the end when it

53:28 becomes very low you'll have problems with erectile function.

53:31 Yeah.

53:31 So there was a lot of discussion about

53:33 what is the impact of testosterone in women.

53:37 So many years ago I had we had a PhD project

53:39 with with the researcher Sarah Valin who wanted to look into that.

53:44 The discussion was that how do we find

53:47 out if testosterone has an effect on desire?

53:50 Because if we measure desire and we measure testosterone,

53:53 a lot of studies weren't able to show a real

53:56 convincing effect of the level of testosterone and desire.

54:00 Mhm.

54:01 So, then it was discussed that maybe you're not measuring the right thing.

54:05 Maybe the way you measure it is not good enough.

54:08 Then there was a lot of discussion about how do we measure?

54:11 This is more a methodological thing because maybe all

54:13 the assays you had to measure testosterone weren't good enough.

54:16 So, the first thing we wanted to do was to measure it the right way.

54:20 So, we were sure that we had a good way of measuring it.

54:23 Then the next discussion was that when you measure what's in the blood,

54:27 maybe that's not what's active in the cells.

54:29 Mhm.

54:30 So, then we had like an end product of testosterone.

54:33 So, if we measured that, we would say that instead

54:36 of measuring how much testosterone is in the blood,

54:39 we would measure what is the end product of testosterone because

54:42 then you would know that it has been kind of used.

54:45 So, it has been active.

54:46 And she did some very nice studies.

54:48 We had women with the just like a random size sample of women.

54:53 And we could see that there is some

54:55 kind of influence on desire by testosterone levels.

54:58 So, if you have lower levels,

55:00 there was a higher risk that your desire was lower.

55:04 But we also showed that if you had depressive symptoms,

55:07 if you had relationship problems, that's also had an impact on desire.

55:10 So, it it didn't rule out I mean,

55:12 it didn't really say desire is it's not only um influenced by testosterone,

55:18 but testosterone has an effect.

55:20 The next step was we couldn't see any effect if we measured the end product.

55:24 We we we had hope that oh well,

55:26 the end product is real measure because that tells us

55:29 how much testosterone has been active in in the cells, but there was nothing.

55:33 So, so total testosterone was better than than the end product.

55:38 So, to come to the receptor,

55:39 in the end we found out that when the testosterone is in the cell,

55:43 it has to bind to the receptor to become

55:45 act to give the effect of the testosterone.

55:48 And we know from studies in men that receptors are different.

55:52 Mhm.

55:53 Because they have like different lengths of their you

55:56 could call them the arm of of of the receptor,

55:58 so they have different structures.

56:00 So, some of them are more active than others.

56:02 So, that was like the last key we wanted to look

56:04 at that maybe it's not because what is the level of testosterone,

56:10 but it's about how does it bind to the receptor and does

56:13 that have an impact on whether it's more active or not active.

56:17 Mhm.

56:18 And there have been some studies in men showing that there

56:21 are some men who have more active receptors than others.

56:25 Yeah.

56:26 So, we tried to do the same in women and we didn't really show a lot.

56:30 We showed that the structure of the receptor

56:33 might have an impact on their orgasmic capability,

56:37 but we didn't have any impact on desire.

56:40 So, I think it left us with the picture

56:42 that we know testosterone has an effect on women's sexual desire,

56:46 but it's not the only thing determining sexual desire.

56:49 I mean, we we became a little bit wiser

56:52 and we know a little bit more and there were

56:54 some kind of um complications in how do we measure

56:58 the receptor structure because it's related to the X chromosome.

57:03 So, it means that men only have one.

57:05 Yeah, so it's a little easier to measure.

57:07 it's easier because they only have one.

57:09 So, women can have like two because they have two X chromosomes.

57:12 So, they have like two components of a receptor.

57:14 So, one can be it's about the length.

57:16 It can be long or short and and then it was

57:18 a little bit more difficult because how do we calculate it?

57:21 So, we had needed to find something in between.

57:23 But that was more technical thing,

57:24 but I think that it's really What was so nice about

57:28 the studies are like it it took us like on a journey

57:32 that we wanted to see what is it about testosterone

57:35 in women and then we just measured testosterone and we said,

57:37 "Okay, maybe we don't get the full answer here

57:39 because something more is happening in the body." So,

57:42 we found out then we look at the end product.

57:45 Then we looked at where it binds in the body, where it actually has its action.

57:49 And and it was like a puzzle and I think that what we

57:51 concluded was that of course testosterone

57:54 has an impact on women's sexual desire.

57:57 But there are also other aspects, especially relationship and depression.

58:01 Uh so, that was the the long story about this study, but they were quite nice.

58:04 Well, I think it's so important to hear, right?

58:06 Because I think what people are hearing now are like these short

58:09 snippets of conversations [clears throat] about

58:11 testosterone in women, even in men, right?

58:14 And like it is much more complicated than that, right?

58:16 The way a hormone functions in the body is so

58:19 and the way it functions in different tissues is so different, right?

58:22 The same testosterone functions differently in your genitals than

58:25 it does in your brain or your, you know, um or your cardiac tissues.

58:29 Like it's just it's different in every tissue and so

58:31 And I I think it's um it's the beauty about research,

58:34 it's the beauty about medicine that that we can I mean,

58:37 you don't have one black and white answer.

58:40 Um it's it's it's more complicated and we if we can gain knowledge

58:45 and and that do research together and and other specialties and also know,

58:49 yeah, the receptor is important and but it's not the whole picture.

58:52 We also need to look at the relationship and we

58:55 need to look at your physical and psychological well-being, but it Yeah.

58:59 has an impact.

59:00 Absolutely.

59:01 You are you've done so much work in the field and and I

59:05 was What are you working on now that you're really excited about?

59:08 a little bit older, so I'm I'm decreasing a little bit the activities,

59:12 but we have the projects that I'm

59:14 My my special interest is actually disease and sexual health.

59:17 Mhm.

59:18 So, uh I did a lot of studies and we

59:20 did the one with testosterone and we we have done something

59:23 about prostate cancer and other cancers and and sexual health

59:26 and So right now we we have some projects about bladder cancer.

59:32 I think that's related to our discussion.

59:34 It's very interesting.

59:36 I'm supervising a brilliant young PhD student who is

59:40 looking at bladder cancer and here people are older.

59:45 Mhm.

59:46 So they are older than people that have prostate cancer

59:49 and so we are really facing both the the taboo

59:53 about older people having sex and and also looking

59:56 into what happens when you have a bladder cancer.

59:59 I just got a message from her this morning

1:00:01 and she's doing both she's doing a mixed message study.

1:00:04 So she's doing some qualitative interviews and some quantitative measures.

1:00:09 And she just texted me this morning and said why I had my first

1:00:11 qualitative interview and I was so touched

1:00:14 by the responses I got from the patients.

1:00:17 So this saying this is something that really means something.

1:00:20 I didn't talk to her.

1:00:20 It was 4:00 in the morning so but she was really I mean she she

1:00:23 she she texted me and and she said I was so So this is the project.

1:00:27 We have a project on pulmonary

1:00:30 disease obstructive diseases that are almost finished.

1:00:34 Uh we have I have a few projects on on cancer still going on and sexual health.

1:00:40 And then my focus now is a lot of psychiatric

1:00:44 disease and and sexual health because that's also an overseen field.

1:00:49 We know that people with depression as we discussed have a higher

1:00:52 risk of sexual problems but a lot of people with psychiatric

1:00:55 problems have an increased risk of having a sexual problems

1:00:58 but they also receive medication that impair their sexual health a lot.

1:01:02 So we just finished a study on bipolar disease and sexual health

1:01:06 and find that they have challenges

1:01:10 especially when they're in a depressive phase.

1:01:12 We have the the what we discussed the the people that do depression

1:01:16 and the all the studies on depression

1:01:18 we try to include some sexual health measures.

1:01:22 And then we have something completely different going on.

1:01:24 We uh our center uh when we started

1:01:28 having a program about transgender adolescents and children.

1:01:32 Our and we're the only center in in Denmark,

1:01:34 so we have like the whole populations of all

1:01:36 children and adolescents that were referred for assessment and treatment.

1:01:41 So we're doing a follow-up and see how did it go?

1:01:43 Mhm.

1:01:44 Uh how many went through treatment,

1:01:46 how many weren't offered any hormonal treatment, and how do they do?

1:01:51 Uh so that's a huge project, so so it's completely different.

1:01:54 Yeah.

1:01:55 Yeah, that's I mean, you're busy.

1:01:58 [laughter] You know, bladder cancer is interesting.

1:01:59 So I treated a lot of bladder cancer in residency,

1:02:02 um and it is a very different disease than prostate cancer.

1:02:06 And I think that that part of it is it's so intense,

1:02:09 it's requires so much recovery if you have surgery, for example,

1:02:13 and it can really change the way you sort

1:02:16 of function in the world because if you have surgery, you become more frail,

1:02:20 you become nutritionally maybe not as robust as you used to be.

1:02:24 And so I think it's it's often very much not thought about

1:02:27 because the cancer takes so much front and center for these patients.

1:02:31 Um and I think it's so important for what you're And and that's what

1:02:34 we hear about a lot of cancers is that people are just you know,

1:02:37 they think I have to be happy I'm alive.

1:02:40 Yeah.

1:02:40 But then we still need to recognize

1:02:42 that you also need to live when you're alive, and and and sex is a part of it.

1:02:46 Absolutely.

1:02:46 Uh so we uh the PhD students are also like uncovering what do

1:02:52 you actually offer people with uh bladder cancer in in the Nordic countries?

1:02:56 So she's trying to doing a survey trying to find out because

1:02:59 we have an idea that there's not a lot of focus on it.

1:03:02 So that's a part of the program, too.

1:03:03 And for women, it it obviously they don't always do vaginal sparing surgery,

1:03:07 and so that can really affect um their sexual function afterwards.

1:03:12 So we're trying to I mean, she just started a program,

1:03:14 but I think in 3 years we'll know more.

1:03:16 Yeah.

1:03:17 In terms of other psychiatric conditions, what about things like ADHD?

1:03:21 Do you look at that at all?

1:03:23 We uh I just had a graduate student or a master student Mhm.

1:03:27 uh that did a scoping review on it.

1:03:29 And actually, there's not a lot of of data on it,

1:03:32 but it's something that we need to to know more

1:03:34 about because we have like a clinical impression that for example,

1:03:38 like premature ejaculation, that very often if you have ADHD,

1:03:41 that I mean, it's so difficult to be like present in the moment.

1:03:44 Focus.

1:03:45 And and some So So she looked into it, and it's a little bit inconclusive,

1:03:49 but but I think that we we can say that there might be some challenges,

1:03:55 but but it's difficult to know exactly what they

1:03:57 are because there's not a lot of studies on it.

1:03:59 So we we have had a focus on it.

1:04:01 Yeah, I think it's really important, right?

1:04:03 Because people are definitely from what I've talked to from other experts,

1:04:06 it seems that um there's a very difficult with focus,

1:04:10 which makes it difficult to be in the moment,

1:04:11 be present, and actually achieve orgasm, or potentially maintain your erection,

1:04:16 or you know, whatever the situation may be.

1:04:18 And it is a clinical feeling.

1:04:20 We we have the same,

1:04:21 but and sometimes we treat the ADHD, and then sexuality becomes easier.

1:04:25 But but I think we need to have more focus on it,

1:04:27 and do more studies, and actually see if that's how it is.

1:04:30 Yeah, and the stimulants that they use to treat

1:04:32 ADHD also have sometimes positive and sometimes negative effects, right?

1:04:37 and I that's a huge problem with with psychopharmacological treatment,

1:04:42 that that they are the the treatments that have most sexual side effects.

1:04:46 Uh I mean, we know that if you treat breast cancer and prostate cancer,

1:04:50 it has a huge effect because the effect on the hormones,

1:04:54 but but beside of that, I think that the treatments we use in psychiatry,

1:04:59 they really have a lot of side effects because they have an effect on the brain,

1:05:02 and they have an effect on the same regions of the brain

1:05:05 where where we uh where we have the sexuality happening.

1:05:09 Yeah, it's really interesting.

1:05:11 What um I think just for the audience listening,

1:05:13 what are some of the treatments for, let's say,

1:05:15 depression that have the least sexual side effects?

1:05:18 I think that I would start to like to turn it

1:05:20 around and say that the one that have most side effects, that's the the SSRIs.

1:05:27 So, if you go outside the SSRIs,

1:05:29 I think it's antidepressants with other effects like having

1:05:34 an effect on the noradrenergic system or the melan- system.

1:05:38 I think these are the one that are the one with least side effects.

1:05:43 But, having said that, we also need to see

1:05:46 that maybe they don't have the same effect on depression.

1:05:49 Mhm.

1:05:50 It's a balance.

1:05:51 Yeah, it's a balance because depression is a very, very dangerous disease.

1:05:55 A lot of people die from it if we don't treat it.

1:05:57 So, we should always treat it,

1:05:58 but we also should recognize that there are side effects

1:06:01 and maybe at least when people are treated and become better,

1:06:06 as I told in the beginning,

1:06:07 some of them actually have better sexuality when you treat the depression.

1:06:11 So, it's about following up and say, "Okay,

1:06:13 if you still have side effects or if you have side effects,

1:06:15 maybe we can switch you." So, Yeah.

1:06:17 I think it's important that we treat people with depression the right way

1:06:21 and SSRIs are the first choice for many people and in many countries.

1:06:26 But, but we need to talk to people about the side effects.

1:06:29 And very often they will say,

1:06:30 "I don't care right now." because they are depressed.

1:06:33 depressed.

1:06:33 Yeah.

1:06:33 But, when they're not depressed anymore, we need to, uh, to, uh, Reevaluate.

1:06:38 Yeah, reevaluate.

1:06:38 And we also use SSRIs for many other conditions like OCD and anxiety.

1:06:43 And a lot of people get them and we

1:06:44 need to be aware they have sexual side effects.

1:06:47 Do you think there's going to be newer medications in this space

1:06:50 for depression that maybe don't affect the serotonergic system the same way?

1:06:53 Yeah, maybe they, um, my colleague Vibeke Frøkjær,

1:06:56 which I did some of the studies with, she looked at the, um,

1:07:00 another receptor, the 5-HT4 receptor,

1:07:03 which has an impact on the reward system and maybe that might be a new target

1:07:07 for antidepressant treatment and I think that's why we

1:07:11 also were quite interested in looking at sexual desire.

1:07:14 So, I I think there's a lot of research going on because we

1:07:17 we can be better and uh we want something with less side effects.

1:07:21 Absolutely.

1:07:23 Yeah.

1:07:23 Well, there's no free lunches is what I always say to my patients.

1:07:25 You can't Unfortunately, there's nothing that you're going to take

1:07:29 as a pill that's going to be without side effects.

1:07:32 And that goes for all medication.

1:07:33 And sometimes people forget Yeah.

1:07:35 Even a supplement, right?

1:07:36 Everything.

1:07:38 [laughter] But I it's about and that's why personalized medicine is so important

1:07:41 that we need to discuss it with the individual patient and I

1:07:44 think that practicing medicine has changed a lot over the years

1:07:48 because people go on the internet and they know something about it.

1:07:51 It's a It's really a challenge for us as as doctors because they know something.

1:07:57 We can't just say, "Oh,

1:07:58 you do this because the doctor says it." And and I think that's a good thing.

1:08:02 It's It's more difficult but and it's challenge you as an expert,

1:08:06 but I think that's we need to discuss with the individual patient

1:08:10 what How many side effects can you tolerate if you get this effect?

1:08:15 And that goes with like with the PDE5 inhibitors.

1:08:17 We Some people say, "Just give it to me and I don't care about

1:08:20 the side effects." And other people are very

1:08:22 vulnerable to the side effects and they say,

1:08:23 "No, it's it's not worth it." And and that goes for all medication.

1:08:28 Absolutely.

1:08:28 I mean, we I do a lot of bladder

1:08:29 medication treatment and there's a lot of serious side effects,

1:08:32 you know, that affect people's quality of life.

1:08:34 And and I talk about it all the time and I think it's it's so important.

1:08:37 Yeah, we need to be open.

1:08:39 And I think that uh some people don't have side effects.

1:08:42 And that's why I tell my patients too.

1:08:44 And I mean, these are possible.

1:08:45 Yeah.

1:08:45 Hopefully, you know, in in the next 50 25 years,

1:08:49 we'll have some more personalized medicine.

1:08:51 We'll be able to see who's more more vulnerable to side effects.

1:08:54 But it will be for each medication, you know, it'll take time.

1:08:57 You know, in your many decades of work,

1:08:59 what's something that you changed your mind on?

1:09:01 Something that you thought very held strongly when you were

1:09:04 younger perhaps and now you realize it's not not true.

1:09:07 Maybe a a little bit another perspective is that I

1:09:10 started out in I'm just going to start again.

1:09:13 Maybe another way to see it is that I started out in in basic

1:09:17 research where I was looking like I have a PhD on on cells,

1:09:21 how they communicate with cells from the penis, how they communicate.

1:09:24 I really moved into becoming a psychiatrist.

1:09:27 So it's it's a big move from being like

1:09:29 looking in a a small plate with with cells

1:09:32 and how do they communicate and how is

1:09:34 the calcium running from one cell to the other?

1:09:37 To me looking more at the whole person and I

1:09:39 think where really changed my my view is that we

1:09:43 really need to be more holistic in in in the way

1:09:46 we see it and it's also reflected in my research.

1:09:48 A little bit like then we do this and we do some study on mindfulness,

1:09:51 we do something on a PET scan and but it's it's it's

1:09:54 to get a more broad picture and I think that's where I have moved.

1:09:59 Maybe I would have said when I was young that we need

1:10:02 to do the same but it has really become very evident for me

1:10:05 that it's so important that we see we have a more holistic

1:10:09 approach to to to to sexual health because it's also about pleasure,

1:10:13 it's not about only about function.

1:10:15 So maybe the cells can communicate in a way

1:10:17 but if the person is not functioning well

1:10:20 and do not have the right you know circumstances

1:10:23 for having a good sexual health then it doesn't matter.

1:10:26 Yeah, I think that's where that has been my journey I would say.

1:10:29 What would you say if you had one message that everyone needs

1:10:32 to learn from today's talk or or about sexual medicine, what would that be?

1:10:37 One message is that sex is very important

1:10:41 for most people because it brings you closer to other

1:10:44 people but you also need if you don't

1:10:47 feel like having a sexual life, that's okay too.

1:10:50 Yeah.

1:10:51 I I don't think we should like put It's it's it's

1:10:54 a it's a balance because we need to recognize it's important,

1:10:57 we need to put focus on it, but we also need to let people decide their own way.

1:11:03 Yeah.

1:11:04 Uh because if they don't want to have sex,

1:11:06 then we should put the pressure on them saying,

1:11:08 "Oh, then you don't have a good life." So,

1:11:10 I think it's is an the the take home message

1:11:13 is that sexuality is individual and it changes during your lifetime.

1:11:18 Yeah, absolutely.

1:11:19 What do you think is the most exciting

1:11:21 development that's coming in sexual medicine right now?

1:11:24 Yeah, you you gave me you sent the question before

1:11:27 and I felt a little bit bad because I couldn't say,

1:11:30 "Wow, this is really happening now." Yeah.

1:11:33 Uh being a psychiatrist,

1:11:35 to me the most exciting thing is that we have much more focus on integrating

1:11:41 the partner and also have much more focus on the whole person and not only,

1:11:46 you know, a genital function or my very small aspects of sexual health,

1:11:51 but it's not like we have one invention that that we have now.

1:11:55 So, that I think that's it's more trend.

1:11:58 Mhm.

1:11:59 And also I think that we have over the years, it's very exciting,

1:12:02 we start talking about medication for women that was a taboo for a long time.

1:12:06 It was a struggle to to get them on the market.

1:12:10 Yeah.

1:12:10 They're not going to solve everything, but I think that the way we see women's

1:12:14 sexual health is better because we say it's also biology.

1:12:18 Mhm.

1:12:19 And on the other hand, I think at least I think most places we

1:12:22 also see men's sexuality being other things than biology.

1:12:26 So, I think we're getting a more full picture of what

1:12:29 is important of sexual health for both men and women.

1:12:32 Yeah.

1:12:33 And the other thing So, this is you know,

1:12:35 a psychiatrist speaking because I think also that we

1:12:37 have more focus on pleasure, not only function.

1:12:40 Mhm.

1:12:41 That is also about having pleasurable sex.

1:12:43 Yeah.

1:12:43 For both men and women.

1:12:44 Absolutely.

1:12:45 I think we have minorities, we have Now,

1:12:47 we have more focus on minorities because other things might apply for them.

1:12:52 Absolutely.

1:12:52 Different cultures, different Yeah.

1:12:54 different factors.

1:12:55 orientations and and yeah.

1:12:57 Where can people find more about your work,

1:13:00 your research, everything you're doing?

1:13:02 Yeah, I'm a very old-fashioned person.

1:13:04 I don't even have an Instagram account.

1:13:06 I'm not on Facebook,

1:13:07 but I think that people can go into the University of Copenhagen.

1:13:11 That's where they can find link to me.

1:13:14 Uh and then I would say if you're a little bit more professional,

1:13:17 depending on who you are,

1:13:18 you can always go and pop med where you can find research.

1:13:22 But I'm also the editor of a journal called Sexual Medicine Review Journal.

1:13:26 And for example, we have all the recommendations

1:13:29 from the consultation where it's not basically it's not my work,

1:13:34 but it's a lot of updates on what's

1:13:36 happening in sexual medicine for both men and women.

1:13:39 Mhm.

1:13:39 I think that's where you can find a lot about what we have been talking about.

1:13:43 Yeah.

1:13:44 That's wonderful.

1:13:45 Oh, I forgot to ask you this question.

1:13:46 Maybe we'll delete it, but there's a cartoon, I think it was from Denmark,

1:13:50 where there was a a cartoon with a boy with a very long penis.

1:13:54 Was that in Denmark?

1:13:56 the the the like the for children's television, yeah.

1:13:59 Um what is it with a stripe, the white and red stripe, yeah.

1:14:03 the name of the show.

1:14:04 Yeah, it's um what do you call I I John Dillermand.

1:14:08 Yes.

1:14:09 Diller is like a slang for for the penis.

1:14:11 Yeah.

1:14:12 Yeah.

1:14:12 So he's called John Dillermand and uh yeah,

1:14:14 he's from Denmark and he's actually reflecting that is a national TV,

1:14:18 you know, it's a Danish national TV that created him.

1:14:21 Yeah.

1:14:21 And um it it says a little bit about the environment

1:14:26 in Denmark that you can have a person like him

1:14:28 in in children's television about having this long penis that gets him

1:14:34 in trouble all the time because it's it's acting in the way.

1:14:37 Yeah, it's getting in the way and actually um we

1:14:40 had an employed in our clinic when he had birthday,

1:14:44 you could actually buy a John Dillermand cake.

1:14:46 So you would like buy this long cake with red and white stripes.

1:14:51 So, he was always, you know,

1:14:53 treating us with this cake when it was his birthday.

1:14:55 It It doesn't have this the shape of a penis, just like a a long thing.

1:14:59 Yeah, yeah.

1:15:00 So, um yeah, that's that's from Denmark.

1:15:02 That's crazy.

1:15:03 So, do kids like watch it?

1:15:04 Is it like very popular?

1:15:05 I think I uh my children are grown-ups, so I but I think they did.

1:15:09 It but it created more fuss than it actually, you know,

1:15:12 it was just one program and and it it created

1:15:15 more fuss than it was actually um enjoyable or funny.

1:15:19 Yeah, I mean that that people actually watched it, I think.

1:15:21 Yeah, it created a lot more discussion.

1:15:24 it it did.

1:15:24 But was it positive discussion or were

1:15:26 people like learning about sexual anatomy from it?

1:15:28 Um I think that was the intention, right?

1:15:30 think that um there was a lot of positive discussion and there was

1:15:34 a lot of positive response to all

1:15:36 the negative moralistic responses from outside Denmark.

1:15:40 And and the other thing was that there were few negative responses about, well,

1:15:44 children we teach children that men have this penis and they

1:15:47 don't know what it's doing and it creates all all these problems,

1:15:50 but I think that most of the the discussions were actually that this is funny,

1:15:55 this is something naive, this is something like for children.

1:15:59 It's It's not It's nothing more than that.

1:16:01 Yeah.

1:16:02 Yeah.

1:16:02 That's so interesting.

1:16:03 I think people would lose their minds in the US if there was Yeah.

1:16:06 a cartoon like that.

1:16:07 Actually, maybe not can put this, but I saw yesterday they

1:16:11 were discussing about a German book about animals kissing each other

1:16:15 and and showing and I mean cartoons of animals um

1:16:18 in the states there was one state where someone were I don't know.

1:16:22 Yeah, so it's it's um it's always creating a lot of discussions.

1:16:26 It's interesting.

1:16:27 I I so long ago I did a reaction video to John Dillermand

1:16:31 and on YouTube and I don't I really can't remember like the comments,

1:16:35 but I think people were shocked.

1:16:36 Like they were like this is offensive.

1:16:38 Like how could this be?

1:16:39 Um and I just I thought it was so interesting.

1:16:42 But I think we actually forgot about John Dillermand in Denmark.

1:16:45 I mean it's not a big deal.

1:16:46 He might still be there but it's not like he's everything in the television.

1:16:50 Yeah, it might be there on you can find it but it it it's It's just there.

1:16:55 No big deal.

1:16:55 No big deal.

1:16:58 [laughter] So we end our podcast with four questions that we ask everyone.

1:17:00 They don't have to be about sexual medicine or your work.

1:17:02 They can be about anything.

1:17:04 So what is something you know now that you wish you knew earlier?

1:17:07 Something I know now that I would have liked to know

1:17:11 when I was younger was that everything's going to be all right.

1:17:14 I think that when you're young you're sometimes so serious about oh

1:17:18 what is going to happen and I think that's um everything goes okay.

1:17:24 I think.

1:17:25 Yeah.

1:17:25 Well eventually it has to.

1:17:27 It has to.

1:17:28 Yeah, but I think actually it's right that that you can manage most of it.

1:17:32 That's good.

1:17:33 We're we're more resilient than we give ourselves credit for.

1:17:36 What's a non-negotiable?

1:17:38 Something you have to do every day.

1:17:40 I think about my family.

1:17:41 I'm a family person.

1:17:42 So I'm not in contact with my family every day but almost.

1:17:46 I with some part of my family.

1:17:48 Yeah, I have to think a little bit about my family.

1:17:51 Yeah, that's lovely.

1:17:52 What's a life hack or health hack?

1:17:54 Something that you think really improves people's

1:17:57 lives that that they don't know about necessarily.

1:18:00 Being a family person.

1:18:02 I think family is very can be very negative but it's very very positive.

1:18:07 It's like the foundation of of of my life.

1:18:09 It's family.

1:18:10 it's positive it's great.

1:18:11 Yeah, it's great and I say that something I would have

1:18:14 liked to have known is I would like have more children.

1:18:17 I have one I have two children.

1:18:19 Yeah.

1:18:19 Me too.

1:18:20 And it's I should have had more.

1:18:22 Now I have grandchildren.

1:18:23 That's wonderful and uh So a life hack if I

1:18:26 understand it right then anything is life hack is really family.

1:18:31 And if your family is not great make the family that you want.

1:18:34 You know, that's the one beauty when

1:18:36 you're an adult you can choose those things.

1:18:38 And then another thing is that I'm so fortunate to have been working

1:18:43 with something that has been very very

1:18:45 interesting all my life since medical school.

1:18:47 I started in the sexual medicine in medical school.

1:18:49 And I I think something like makes your life really enjoyable is to have a work

1:18:55 where you feel you make a difference and where

1:18:58 you can develop yourself and and the field.

1:19:02 I think I've been very fortunate being the right place at the right time.

1:19:05 Yeah.

1:19:06 Uh so that's also very important.

1:19:08 Sometimes I tend to forget that because a lot

1:19:10 of people don't have a work that's very interesting or Yeah.

1:19:14 they would like to do something else.

1:19:15 I think having a a job that's interesting is is really really Absolutely.

1:19:21 We spend a lot of time at work.

1:19:23 We spend so much time at work and uh Yeah.

1:19:26 You want it to be something you like.

1:19:27 Yeah.

1:19:28 If you couldn't be a physician or researcher, what would you be?

1:19:32 An archeologist?

1:19:34 Was that what you call it?

1:19:35 Archaeologist?

1:19:36 Archaeologist.

1:19:37 Okay.

1:19:38 Yeah.

1:19:38 That's what I wanted when I was a child.

1:19:39 I wanted to be an archeologist and travel to Egypt and find all the mummies.

1:19:43 Yeah.

1:19:44 Oh, that's so cool.

1:19:45 I've never thought about that, but that that would be fun.

1:19:47 That would be fun.

1:19:48 Uh you know, when you retire in Denmark,

1:19:50 a lot of people start studying in the universities.

1:19:54 So I I was thinking of studying archaeology or maybe theology, um religion.

1:20:00 So I think religion is so interesting, too,

1:20:03 because it really shapes the culture you're living in.

1:20:05 It does.

1:20:06 It absolutely does.

1:20:07 It's interesting.

1:20:07 I feel like um we go through waves

1:20:10 in history where people are very attached to religion,

1:20:13 then people become less attached, but ultimately it always comes and goes.

1:20:18 Yeah.

1:20:18 And and a country like Denmark, I mean,

1:20:20 people if you ask them, they say they're not religious,

1:20:23 but every moral thing, all the ethics,

1:20:26 everything we we think have value in the society is based on on religion.

1:20:31 So So maybe people don't feel they're religious,

1:20:33 but but the way we think is really influenced by religion.

1:20:37 Absolutely.

1:20:37 [clears throat] Well, thank you so much.

1:20:39 You're welcome.

1:20:40 Thank you for having me.

1:20:41 Wasn't that a great conversation?

1:20:42 If you guys thought so, too, you got to do one thing that's going

1:20:45 to take only a second and it's completely free.

1:20:47 You got to subscribe to the podcast.

1:20:49 Look on whatever platform you're listening or watching

1:20:51 on and subscribe because this tells podcast platforms that, "Hey,

1:20:54 this is a podcast worth listening to." and it shares it with more people.

1:20:58 And we need to get the message of education

1:21:01 and sexual health being important to more people.

1:21:04 And as always, I'm going to take care of yourself because you're worth it.