If you've been seeing ads for erectile dysfunction pills everywhere, whether they're targeted ads because you happen to Google the average penis size or you're running into them at every subway stop like I am, you're definitely not alone. Welcome back to beyond the bedroom. I'm Birna. I'm a sex educator and have a degree in Health and the public interest, so this topic is something I've been dying to get into because the uptrend of erectile dysfunction medication marketing, I don't know. It really begs the question, do more people need these drugs than we thought? Is there really an erectile dysfunction problem plaguing young men? And where's the female Viagra? I hear that one a lot, so I'm definitely addressing it in this episode! This whole episode is all about those little blue pills; I'll be answering your questions and sharing some of my hottest takes on them, and yeah, definitely putting my public health hat on for this one. So, I'm recording this episode from my home studio here in Brooklyn, yay, please clap, the move happened. I moved from DC to New York. I'm so happy to be back in New York. I missed the city so much. I actually, in my first month here, I went to an expert meetup, a sexpert meetup, I should say. Shout out to all the lovely people I met there that night. It's been so amazing to kind of get back into the swing of things here in New York. You'll hear from a lot of these people, dearest listeners, I promise, as I invite these super talented, brilliant sex educators, therapists, pleasure aficionados, on the podcast over the next few months. In other personal news, I put a ring on it. Everyone's like, wait, you're already married- what? Yeah, my other true love in this life, Unbound, sent me the ring of my dreams. It is a wearable vibrating ring called Flick. It's super cute. It's so chic. And guess what? You can get flick and anything else on Unbound’s website for a discount when you use my code, B, B, I R, N, A, that's B, Birna and have a ball. I mean, I'm definitely wearing this ring. I'm gonna wear it when I teach up in Massachusetts at the end of this month, and it'll be like a little surprise. “Guess what this is?”, like at the end of the class. I think that's always really fun to do, but yeah, go and put a ring on it for yourself. Speaking of rings, let's talk about pressure, the pressure to perform, the pressure to always be on. And pressure can make diamonds, of course, but it can also lead to feelings of inadequacy, especially for men who may confuse performance anxiety with erectile dysfunction. By the way, in this episode, I'm going to be using a lot of gendered language, and it's on purpose, but I want to make it clear why. So, erectile dysfunction can happen to anybody who has a penis. Not everyone who has penis identifies as a man. For non binary and trans people, sometimes the marketing is not geared towards them, and the gendered scripts for them are different for non binary people, a lot of people are unlearning and relearning what it means to perform their masculinity and femininity and where they fit in in all of that, and I think that it can be a separate topic altogether for trans men. There's a whole other host of issues surrounding erectile dysfunction and validation. A lot of the gendered scripts they learn and they kind of internalize, it can be really difficult. And then for trans women, of course, who still, or, you know, choose to have a penis or still have one, basically, some people kind of choose to avoid being touched in their penis or the when they do have erectile dysfunction, it might be related to a hormonal treatment. So I'm choosing to focus today more on men who identify as men, but are also born male, and the reason for that is that most of the marketing is geared towards them, and I'm really focusing on this specific pharmaceutical marketing, so we can get into all of those issues at a separate time, but I just want to make that really clear. But anyway, the aggressive marketing of erectile dysfunction drugs, is it contributing to a societal shift in what counts as sexual dysfunction? Because here's where I'm coming from, I've noticed over the past year a huge uptick in questions I get from cis men who are asking me, Is this. Is erectile dysfunction? Does this count? Is my dick broken? What's going on with me? Do I need erectile dysfunction medication? Should I be taking it? Is it okay if I take it recreationally? These are things that are popping up all the time, and so sometimes it's that, like chicken and the egg situation. Was there a hole in the market that erectile dysfunction medication and telehealth platforms for it became more popular because there was more of an interest in these medications, because there was more research on them. Maybe, I mean, it's been like 30 years since Viagra came out. But was it that, or did this kind of uptick in pharmaceutical marketing create a larger interest, or maybe it's both. I think for me personally, I think it's a little bit of both. I also want to be clear: I’m so fully supportive of making these treatments accessible to those who need them. And as someone in public health, I think we also need to be careful not to over medicalize sexual performance, because here's where I think we need to be careful. While these medications, they're incredibly effective and safe for most we're seeing a rise in their use, often in situations where erectile dysfunction isn't necessarily a physical issue. I don't have a citation for that right now, but I've, I've seen it in the literature, and so I kind of want to be clear, I'm making a lot of generalizations In this episode, but it leads to a broader conversation about the societal pressure to always be ready for sex. And I've talked about this before, right? This like gendered script that the guy is going to drop everything to get laid, and this kind of masculinity performance that often it comes along with being like, not just the initiator, but like the womanizer, the ladies man, all of that, but also just in one on one in couples, a lot of things I keep seeing is like, well, I just want to always be ready, because I don't know when she's going to be ready, and I want to stay ready, and I'm just like, Oh, like, that's a lot of pressure, and I think there's better ways to frame that. So when medications like this are widely prescribed, especially through telehealth platforms that make it really easy, sometimes they're just like a quick questionnaire, and then you get to talk to a doctor, but there is a risk of labeling normal variations in sexual function as dysfunction. On medical side of things, there are pretty distinct patterns for diagnosing erectile dysfunction, and I'm going to get into that on this episode. What counts? What doesn't count, the two types all of that. But I think it's there is a conversation to be had here about how many people may be treating performance anxiety or temporary stress related issues with a medication that may not be helping as much as it could be, or it's a treatment that is not helping as much as they'd want it to, and that's not inherently harmful, but we need to be mindful about what this says about how we view sexual function in general, because I feel like it's not just about solving a physical problem anymore. I think the conversation about erectile dysfunction has kind of moved on from that, which is very interesting, because I've noticed that the emergence of the quicker, the more accessible, the fast acting, long lasting blue pills are shaping a narrative where people feel like they should be on all the time, and that is what is damaging. There's nothing wrong with using these medications when they're needed, but I think we could do more to create space for the conversations about arousal versus desire and the role that mental health plays in sexual functioning, because sex is complex, it's physical, it's mental and it's emotional. So let me take a step back here. What is erectile dysfunction? You've probably heard that erectile dysfunction is one of the most common sexual issues that men face, and yeah, it's true. An estimate suggests that it's somewhere between 30 to 50 million men in the United States are dealing with this, and that's a huge number, and it just goes to show how common this really is. It really boils down to erectile dysfunction, is a persistent inability to achieve or maintain an erection. This is kind of what we say, sufficient for satisfactory sexual performance. So what does that mean? Though, basically, like In layman terms, it means you can get hard or you're staying hard long enough to feel satisfied during sex. So whether that means that you are able to stay hard until you ejaculate, or you're able to stay hard while you're, you know, engaging in sexual behavior, it's okay if it goes away and then comes back later. Because here's something that I hear, it's like, Oh, I was hard, but then when I was going down on her, I got soft, but then I got hard again later. But is that erectile dysfunction? I mean, technically, no, that's not. But if it's like, I get hard, she's touching me. I'm touching me. Everyone. You know, the focus is on me. And I start getting soft, is that erectile dysfunction? And I'm like, Well, is it a repeat pattern? Talk to your healthcare professional, because it could be. So these are the type of things that count towards being diagnosed with erectile dysfunction. And it could be temporary in somebody's life, and it could be a very long term issue that some people deal with. It can be also caused by variety of factors, and they're kind of broadly categorized into what's called organic, which is a physical cause, and psychological, which is like a mental or emotional cause. So organic erectile dysfunction, this is Ed that's caused by physical or biological factors that interfere with your body's ability to achieve or maintain an erection. So what is this? You may be thinking, you know, vascular issues, yeah, so poor blood flow to the penis. This can be caused by things like high blood pressure, clogged arteries or diabetes, neurological conditions also. So if you have damage to the nerves, either like in the spinal cord or the pelvis, some people even with damage to the nerves directly, obviously on the genitals or also, like the inner thighs. This can also happen when somebody has injury or something like MS or stroke, so these are things that can cause kind of long term erectile dysfunction issues. There's also hormonal imbalances. I want to be clear when I say low testosterone, I mean like clinically significant low testosterone, measured and diagnosed by a healthcare professional. No, I'm not talking about like the bro science low testosterone, which I can do a whole episode on, but also other hormone related issues, like pituitary gland issues, adrenal all that stuff. Then there's medications, substance use. Some medications, like for high blood pressure, some for depression or excessive alcohol or drug use can also contribute to erectile dysfunction, and then aging, I told you I would dive into this one. So as men age, the likelihood of experiencing organic erectile dysfunction increases because the likelihood or kind of risk factors of underlying health conditions also increase. So there's this myth that only older men can get erectile dysfunction, but that's not true. It can happen to anyone, regardless of age. I just want to point out that age is a risk factor, but it isn't like the only or even the most important one. So what are some psychological erectile dysfunction things? So this definition is a little different. It's caused by mental, emotional or psychological factors. So it's related to stress, anxiety, relationship issues, trauma, rather than a physical or organic condition. And I think sometimes it's hard, because people get these confused a little bit. They're like, well, isn't it an organic issue if you can't get blood flow to your penis because of the thoughts you're having? And I'm like, Yes, but the the root of the cause is not poor circulation, so you can't get it up. It's that you aren't becoming aroused. You aren't getting blood flow to the penis. The biological processes of that aren't happening because of things like stress, like freezing up performance anxiety, causing that drop in blood pressure, or other biological things. So performance anxiety is a big one. Worrying about sexual performance, being afraid that you're not going to achieve an erection, can cause erectile dysfunction, which is, like, the worst cycle, like, whoever invented that jail, right? Having this stress of, like, am I going to be able to get it up? Am I going to stay hard? Oh, my God, they're so pretty, I want to XYZ them, like, whatever. And then it's like, Uh oh, like, I'm not getting it up. I'm not getting up. And it's like, panic inducing. That's the horrible cycle, and it's a mental cycle, and it can have a physiological effect. So stress and mental health also. So high stress levels, maybe you work a really intense job, maybe you work a labor intensive job, or you work graveyard shifts, or shift work in general. You're not sleeping while you're not eating enough. This can and does interfere with our sex lives. So depression, also in generalized anxiety, can interfere with sexual arousal, including the ability to maintain an erection. So relationship issues, this can also be a cause of ED so emotional disconnect. We're talking about long term resentment, unresolved conflict. You're having communication issues. You're having issues with your partner where you don't feel respected, you don't feel good about yourself, you feel very insecure around them. Maybe you're with somebody who like ridicules you or point. Out your flaws during sex, or not even during sex, just like in general, in your relationship, maybe you don't want to have sex with them. That's definitely though. If you're feeling in the moment like I want to have sex, but there's just something kind of not connecting. This can be a form of erectile dysfunction, because if you're wanting to be aroused, you're wanting you're desiring sex, and it's not happening, that's that's when it becomes dysfunction. So trauma or past experience, I think it gets its own little category. So this one is very important that people deal with, and it can be really difficult sometimes to treat this type of erectile dysfunction with medication, because the underlying cause can be a little bit more intense psychologically. So here's kind of the what it boils down to, organic Ed is pretty persistent. So even in situations where there is desire relaxation or like a strong emotional connection, you're really turned on by them, you're just your dick is not cooperating. It can also be accompanied by other physical symptoms, so sometimes it also includes reduced sexual desire or changes in physical health, like you notice pins needle sensations, pain, etc. So for psychological erectile dysfunction, this can vary a little bit more. So you might be able to get normal erections during sleep, because everyone gets those nighttime erections if they have healthy erectile function, but maybe you are able to do that, but you can't do it. You can't get an erection during sex, or maybe you are able to masturbate, but struggle when a partner initiates sex, maybe you're able to masturbate, but only to relieve stress, and so you can't connect with your partner. And you don't want to have sex with your partner and connect with them in that way, because it's it's overwhelming, it's stress inducing. So again, before I dive even deeper into this topic, I want to be so clear. So medications like PDE, five inhibitors, that's erectile dysfunction drugs. So Viagra, Cialis and others, they have been revolutionary for a lot of people. They have improved their quality of life. They've helped them regain confidence in themselves and their sexual relationships, and that should be celebrated. And the availability of these medications has made treatment a lot more accessible to those who really needed it, especially people who were previously they were too ashamed to go to the doctor, they were too embarrassed to seek help, or they faced barriers to access or barriers to care, like financial or geographic they couldn't, maybe afford to go to the doctor, etc. But like anything in healthcare, it's important that we balance the benefits with a critical look at how they're being used. Because my concern is not with the drugs themselves or even like the entire erectile dysfunction industry. It's more about how we're using and discussing the medication, so like the context of societal pressure, and how that's impacting, if at all, the way that people think about their sexual health. Because this is kind of my jam, you know, this perceptions of sex, that's my whole thing right? My goal here is not to discourage their use, but to ensure that people are using them for, I won't say, the right reasons, but, you know, using them when appropriate and when it actually helps them. And I want to make it also more accessible to be able to talk about the stress, or, you know, the shame or the negative spirals about sex that people are dealing with that could be interfering with their erectile function too.

This is also really important to note, because it is just like a huge topic right now, the fact that women's health care and medications that are used for abortion, fertility, etc, are being restricted or banned in this country. The double standard is really infuriating. But I, like I promised, I'll cover female Viagra and all of that in a bit. But first, what is a PDE five inhibitor? Like, what does that mean when I say that so a Phosphodiesterase type five inhibitor, so PDE five inhibitor. Most people will know this as Viagra, Cialis or even those, like newer versions, they were actually like accidentally discovered when researchers were looking into treatments for heart conditions and high blood pressure. But it turns out that these medications were even better at improving erectile dysfunction because they increased blood flow to the penis. So these meds are usually the first option when Ed is caused by poor circulation. And like I mentioned. And they now come in, like, really accessible forms. They even come in like mints, like Chews and mints, which is a game changer. It's way less awkward than pulling out like a pill on a date or keeping them in like pill form on vacation, you know, if you're taking them through TSA and stuff, and it takes away some of the stigma and pressure around it. But even though they help, I really want to emphasize that you should never feel like you have to take them if you're not in the mood to have sex. So they don't work like magic. They can't replace desire. So even when people have something called high genital concordance, it's just like a fancy term for feeling the desire to have sex when your genitals are engorged, like a random mourning boner or ovulation. So when you're more likely be aroused because of those things, even if you're like that, it doesn't mean that you're always down for sex. So they won't magically give you an erection. They won't make you want to have more sex, necessarily, like some people, it does, but that's not really the idea behind these drugs. It may make it easier for an erection to happen if it was, you know, if you were aroused, something like Cialis, which you take, and it works. It stays in your system for about a day or two. Like that's something that can make it easier for the erection to happen when you are aroused. So it helps you perform sexually when you're in the mood for it. So here's like the science of how these meds work and how erections work. So when you're aroused, your parasympathetic nervous system kicks in and releases this molecule called nitric oxide, or no for sure, so this triggers another molecule called cyclic GMP, which relaxes the smooth muscles in your penis and allows blood flow to increase by a crazy like 20 to 40 times. But there's an enzyme called PDE five that breaks down cyclic GMP, basically reversing the erection process. So what PDE five inhibitors do is block that enzyme from breaking things down too early, so they keep the blood flowing and the erection lasts longer. So it kind of prevents that biological process from happening that might happen too soon or too much in some people, especially if they have poor circulation. So if you struggle with stress related Ed, PDE, five inhibitors may help short term, but you see it may not be the best option for addressing like the underlying cause, because, yeah, you might have an erection, but what else is going on for you during that and long term if you're not addressing kind of that root of the stress related or the performance anxiety, maybe, like being able to perform, maybe that will help you, and it helps a lot of people, but for some people, it's not helping and they're kind of confused. They're like, wait, I took the Viagra. I'm not sure why it's not helping me. It's because the stress level they have is either blocking their desire to have sex even though they're maintaining an erection, or they're not getting the erection, even though they took the drugs because just they are not in the mood to have sex. So I don't want these drugs to replace open conversations about sex gendered scripts or sexual shame. But really, is anyone actually being harmed by the rise in accessibility, and is over prescription of Ed medications really a thing. So I hear this question come up a lot, because, after all, you know, these drugs are generally safe and they've helped a lot of people, but when we look closer, we can see a few different types of harm. So even if they're not immediately obvious, this is just what I'm noticing so there is, you know, this huge kind of push in in modern American society, especially for men that are, I'm gonna say around, like, late 20s to early 40s, like not the typical demographic that Ed medications have traditionally been marketed towards, which, again, is great, because not everyone who has Ed it's not because of aging, like that's not the only reason, right? But this demographic has kind of been marketed towards in a new way. And so I want to discuss, like the pressure to perform, because there's the mental and emotional toll of feeling like you always need to be ready for sex. And it's like this consistent tagline where it's like you can stay ready you'll be ready, like you'll be ready to go, and the overuse of erectile dysfunction meds, like the people in my DMs that are like, oh, like, is it okay? That I use them recreationally all the time. This can reinforce the idea that your sexual performance should be automatic. It should be on demand, it should be flawless, and that your penis is like the most important part about sex all the time. And this pressure can actually lead to performance anxiety, so that can also create a new problem or make the underlying problem worse in the long run, and for some people, it can really erode their self confidence and their connection to their partner, because instead of learning to understand and manage the natural fluctuations and desire and arousal, people may come to rely on taking these medications as quick fix to their stress induced erectile dysfunction, and their real issue is this deep anxiety or unrealistic expectation about their sex life. Another thing that I'm gonna you know, it's another hot take, but it's a concern I have that we may be medicalizing normal variations of sexual function. So what does that mean? What I'm trying to say here is that not every moment of sexual difficulty, like the occasional trouble getting an erection, needs to be pathologized or treated with medication right away. And I want to make sure that I am not anti pharma in this like, you know, I want to make sure that that's not my position. I am coming from a place basically by framing every hiccup as dysfunction, we risk setting this precedent where normal, healthy sexual experiences get labeled as problems because we're not having enough discussions about what counts as like normal and good, every day I get to hear is this normal? Am I Normal? What's wrong with blah, blah, blah, you know? And this can shift how people view their own sexuality. And again, this can make people more anxious and less confident in their natural sexual responses. Suddenly, just being not in the mood can be dysfunction, and that is a loaded term. Suddenly, when you you know you're in a work sprint, you're working shifts. One of my friends who's a resident right now in med school working like 12 hours on 12 hours off. 36 on 12 off is just really overwhelmed. You know, was telling me that there are some people that they're in residency with, and they're like, oh my god, I just like, don't have any sex drive at all, and I don't know why. And my friend was like, well, we're overworking ourselves and not sleeping, not eating very well. I mean, we're also like, just learning so much and also encountering things that are really intense for the first time in our lives. So obviously, like, sex is not going to be first priority for us right now. Or if taking the medication works for you in that regard, that's great, but it's okay that you're not in the mood to have sex during that time in your life, you know that should be like a conversation that you're having with your partner, but also it's like if you're using sex as your only coping mechanism for de stressing, that's also a conversation you should be having with yourself, right? Another concern of mine is that we're ignoring underlying health or psychological issues. So you know, I think it's just always great to be able to check in with a primary care physician. I know, I know we can't always do that in the United States, but this is just kind of my pipe dream. I guess that people can go to primary care and talk about these things. You know, sometimes erectile dysfunction can be an early warning sign of cardiovascular disease or diabetes. So, you know, I would just want to make sure that people are not missing these important health cues. And you know, really quickly, because I'm going to have to mention this right, there is a financial harm over prescription and high demand can drive up the price of erectile dysfunction medications, which eventually will make them less successful for people who do need them as well. But this is kind of a complex issue, and like the rise of overuse, can really make this problem worse by creating competition for the drugs and increasing their cost. But I think that we're moving in a direction in the United States where erectile dysfunction medication just, it's always going to be more accessible, or, I guess, for now it's, it's, unfortunately, a lot more accessible than so many of the medications that women can access. So kind of, to wrap this up, sexual health is not just about performance. It's about communication. It's about self awareness. It's about overall well being always using these drugs, especially if you're using them just like recreationally, without fully understanding what's maybe driving the issue that you're having, can sometimes lead to consequences, and I think that's something we should be aware of. So when we talk about the pressure, I think there's cultural expectations, because. Is, society often places this unrealistic expectation on men to always be ready for sex. And I love that. Like, you know that meme that's like, who's gonna protect women at night if there's no men, and then the women were like, protect me from who like if there's no men, like, that's kind of how it feels sometimes when I talk about this, where I'm like, oh, there's this unrealistic expectation that I'm like, well, we live in a patriarchy. So it's like, I guess it's just competition and machismo and gendered performance and like, it's just a whole big thing that we can't even, we don't have enough time in the day to discuss on this podcast, but we see it heightened in media. So, you know, obviously I have to mention how porn and media depictions may influence this. And I say also media depictions, because it's so common, like in so many sitcoms I grew up watching, in the movies I see now there's this depiction where constant sexual readiness is happening, and it's really leading to misconceptions about how sexual desire and arousal naturally work. I think it's really great when media just shows like, you know, it's just like that escalator that happens where it's like, we're kissing, and then we're touching, and then, bam, we're having penetrated sex. It’s like, I'm really loving that there's so much media that's like disrupting that escalator, because that's just not how it works for everybody. That's not how it works for everybody all the time. Like that might be the case for a lot of people, but not every single time, right? And also, if it is happening every time. Maybe that's not the best way you know. And of course, this pressure to perform can lead to anxiety, which actually inhibits arousal and erections so so horrible that that's like the cycle, right? Let's kind of tune into your body and your mind. So if you have a penis. If someone you love has a penis, let's go through this little list together. Here are some things you should learn to accept about yourself. So arousal isn't a switch that just turns on instantly. It fluctuates depending on mood and stress, fatigue and other factors, it's okay that you're not on all the time. Let's ask this question, Are you mentally and physically in sync? Are you distracted in bed? Are you too stressed to even think about sex? Are you simply just not in the mood? And when does that become an issue? What is that boundary for you? Are you not in the mood right now? For are we talking six months? Are we talking it's like a new thing. Are we saying, like, actually, like, every fourth time my partner initiates, I'm just not in the mood. What is the boundary for you in terms of, like, when it becomes a problem? Because sometimes people that are in a relationship even it's like, Wait, are we supposed to be having more sex? And it's like, well, if both people are okay with the amount of sex they're having, you don't need to have more. You don't need to have less. You don't you know, it's just do what feels right and works for you. Acknowledge that feeling disconnected from your body's signals is really common, and it's important to be mindful of what you want in the moment, because that's really key to a healthy sexual experience. So let's, you know, I hate this word, but I'm going to use it. Let's normalize sexual timing. It's okay to not be ready immediately or need more time to get the mood. Maybe you need more of something, more stimulation, more attention, less attention, like whatever it could be, normalize that sex doesn't have to be instantaneous. And let's have some honest conversations. Let's openly communicate with their your partners about what it is you need. Maybe you're the one who needs to take a bubble bath before sex. You know, we always see this depiction of like, women have to be so calm and like. It's like, well, not every woman feels that way and like, what about the men who need that? Maybe there are men who need different types of intimacy before sex. They want that slow make out they're not just like, the penis is ready, I'm going in, you know? And for everyone who may be feeling like, Oh, I think my partner has erectile dysfunction because he's not always in the mood. Not being in the mood is not a rejection of you specifically. And I think it's really important to remember that sometimes it's just their body's natural rhythm, and we don't always have to frame it as something else, or take it personally, right? So let's go on to my listener questions. So Kelly from Maryland asks the golden question of the day, why isn't there a female Viagra? I get asked this a lot, and it's a great question, and the short answer, the shortest one I can give you, is that there have been. Medications developed to address female sexual dysfunction. Again, erectile dysfunction is not the same as sexual dysfunction, but it's like a type of sexual dysfunction. But these medications have not worked as well, and the reasons why are actually pretty complicated. So here is my longer answer. It's important to note that female sexual dysfunction is very different from the erectile dysfunction in male genitalia. So for males, erectile dysfunction is often tied to a physical issue like I mentioned, but it can also be, you know, stress related reduced blood flow, for example, can be addressed pretty directly with something like a PDE five inhibitor. So the PDE five inhibitors like Viagra don't work the same way for females. So these medications work by increasing blood flow to the penis, making it easier to get erection. And you're like, Whoa, whoa, we have erectile tissue down there too. Yeah, I know, but this is like a mechanical solution to a mechanical problem, right? And female sexual dysfunction often involves a combination of psychological, emotional, hormonal and relational issues. So it's not just blood flow and it's not just physical readiness, it's also about mental and emotional arousal, which is a lot harder to fix with a medication. As of right now, I'm going to get into that, but let me give you a little, mini, tiny, little history lesson. So there have actually been attempts to create medications like I mentioned, for female sexual dysfunction, so not necessarily just female genital erectile dysfunction, but there's this medication called Addy, which is like a, d, d, y, I believe it was kind of labeled as the female Viagra, and it was approved in 2015 to treat what's called hypoactive sexual desire disorder. So hsdd in specifically premenopausal women, very specific here. Unlike Viagra, Addy works on the brain rather than on just blood flow. So it specifically impacts serotonin and dopamine, which are actually it could be norepinephrine. Someone can fact check me, but these are tied to mood and desire specifically have a really big effect on sex. But the medication didn't work as well as I think the pharmaceutical manufacturer had hoped. It only marginally increased sexual desire for some of the women, and it came with some pretty intense side effects like low blood pressure. Some of the participants fainted. It was like a whole thing. But then there was vileesi, which was another drug approved in 2019 for the same disorder, but it works a little differently, so it activates a receptor in the brain that is involved in sexual arousal, but again, didn't significantly increase sexual desire for many of the women, and this one had the side effect of nausea, which is like, a huge deterrent to sex. So, like, it just didn't, you know, imagine, like, taking something to help you, and like, you faint or you're nauseous, like, just not, not good. No, no bueno.

Why hasn't there been a successful one? So I want to say, like, oh, it's because the issue of sexual desiring women is is less tied to specific biological processes like it is for men. But like, I think I'm doing a disservice by saying something like that, because both men and women's sexual arousal is influenced by emotional intimacy, stress hormones, body image, mental health, relationship dynamics, all of it, right? But I think this is one of those like nature versus nurture things, where I think this one's kind of a bit of both, where, like, biologically, obviously there are differences. But also, you know, addressing sexual dysfunction women isn't just a matter of increasing blood flow or altering a single pathway in the brain. It's kind of a broader issue, and it makes it hard to treat it with like a one size fits all medication. There's this issue also of what we define as dysfunction in women, because in men, erectile dysfunction is is pretty often clearly defined and diagnosed. But what counts as dysfunction in women is really a lot more subjective. There are some women that have a really big fluctuation because they are more responsive to the hormonal changes of their menstrual cycle. Some people will tell you like, oh my god, I definitely notice when I'm ovulating because I'm so horny all the time. Other women are like, I don't feel that way at all, like I kind of just feel the same kind of all the time, just regular levels of horniness. So neither one of them is better than the other. Neither one of them is like, healthier than the other, despite what the Tick Tock health and I. Holistic hormone gurus will want you to believe those are normal kind of ranges for people that have menstrual cycles. So it's trickier to identify a clear kind of treatable problem. Or I guess I should say it's been trickier to do that because is there as much funding for the research. Has there been enough time to research this problem? That's also a big part of it, too. So in terms of treating female sexual dysfunction, I mean, these are more kind of individualized and multifaceted solutions than single pill therapy, hormone treatments, lifestyle changes. We're talking about stuff like that, a female Viagra, in the traditional sense, is is probably not going to be the answer to this. But that doesn't mean that women's sexual health is being ignored. There's a lot of great research going into the future now, because I think people are realizing that it's such an important quality of life metric. But let me break down a little bit. What are some factors for female sexual dysfunction? Because, like some people actually are not just they're just not getting enough blood flow to their erectile tissue, in their vulva, in the in and around the clitoris, the inner labia, parts of the vaginal walls, they kind of engorge with blood, just like the penis. So just like in men, poor circulation, cardiovascular issues, hormonal changes, like post menopausal it can all affect that process. But even when the erectile tissue in the vulva is engorged and physically ready, quote, unquote, that doesn't always translate to sexual desire or arousal. That's because sexual arousal is not just about the genitals or the blood flow. It's also emotional, psychological, relational stuff. Because a lot of people ask me if my body is showing signs of arousal, like I can feel my heartbeat, like in my vagina, like I'm wet, why don't I feel like having sex. This is something called genital non concordance, or genital concordance. So that's the alignment between the physical signs of arousal, like being wet, engorged, you kind of feel like the labia lips are a little more puffy and firm, and the feeling of being turned on, like wanting to have sex, which can be really hard to discern. For people, the difference, and then other people like, it just goes hand in hand. Or, I guess I should say for some people, it's hard to discern because it goes hand in hand. And for other people, they're like, Oh, I definitely feel a difference. For men, genital concordance, on average, is often a lot higher, meaning that if they have an erection, they're more likely to feel desire. But I'm in that in that group of people, that's like, well, if women had been raised with this idea that, like, well, you should always be ready for sex, you're allowed to just initiate. You're allowed to go for it and like all that stuff. Would that have an effect on genital concordance, if you didn't feel like such a dirty, bad girl negative connotation every time you were turned on? Would it be different? You know? But also, there's obviously a lot of biological things happening, and and kind of psychological things happening. You know, a lot of time you might just, like men have, like the random boner. Sometimes you might randomly feel aroused, turned on, like down there, but you're not really in the mud. Upside that's just part of life. There is a lot of research that female sexual desire and an arousal tend to be more context dependent. So this is, like the neuroscience part of it. So feeling safe, relaxed, emotionally connected to your partner, or just having time to focus on pleasure is the key to feeling consistent desires. So not just like in that one moment, but like if you look at the amount of times you're wanting to have sex over the course of, like, six months. But it's like, if you have deep resentment for your partner because you feel like you're doing everything around the house and like they're not doing anything, and like you're the one taking care of everything, like, these are things that's like, yeah, you're not going to want to go down on them. You're not going to want to fuck them. They're not going to want to have sex with them, obviously, because you don't like them very much anymore. Are you still masturbating? Are you still using the shower head when you lock the door, when you have, like, five minutes to yourself? Like, if these are the types of questions where I'm like, is it really a lack of arousal, or is it like desire for that specific partner? That's another thing you know, like we don't always focus on. So next listener question, Trevor from New Orleans, asks, My girlfriend has a lower sex drive and tends to get in the mood only once in a while, when she does, I feel like I'm being put on the spot, and I struggle to perform the way I want to. Is this erectile dysfunction? Is it performance anxiety? What can I do to handle this better? This? This is great. And this is a great question. I mean, not like, oh, Trevor, this is great for you. No, it sounds very difficult, and I'm really sorry that you're going through that, but let me kind of walk you through a couple things, and I hope that you, with this new knowledge, can kind of understand more about yourself. So, like, I just talked about in terms of the reason that, you know, there's, there's not, like, been a great like female Viagra, yet there's that idea that people have different, like desire types. So it's like the dual control theory. So it's like responsive versus spontaneous desire, fancy terms, I know, but hang in there.

Responsive desire means that somebody typically becomes aroused in response to external stimuli, like physical touch, emotional connection, stuff like that, rather than spontaneous desire, like, Oh, I'm really in the mood all of a sudden. So people also can also have different sexual timelines. It's very common for couples to have mismatched levels of this desire. One person's more spontaneous, the other's responsive. And sometimes it can be hard when they're so different to kind of come together, because one person may be like, hey, the windows opening if I have to spend time doing all of this for you or waiting around for you, I might not be in the mood by the end of it. And the other person is like, Oh God, I have to hurry up, otherwise they're gonna not be in the mood when I'm finally in the mood. This is also like adding a lot of baggage, and it's probably getting worse each time this happens. So talk about how feeling pressure to perform on demand is creating anxiety. You know, maybe you're struggling with the fact that, like you as a guy, you're just like, wow. Like, why am I not able to just, like, do it? Like, what's you know, but just talk about it. Be like, Hey, like, I kind of feel put on the spot, and I really love having sex with you. I obviously want to do it, but sometimes in the moment, I need something different. Is the pressure coming from her, or is it coming from you? Often men feel responsible for making sex happen. They're they feel weird when they're not the initiators. So this pressure can definitely trigger performance anxiety, but once the performance anxiety sets in, this fear of failing can make it harder to focus on what's happening in front of you. I think those are good, like little nuggets to think about. But let's differentiate Ed from anxiety so it could be both. Erectile dysfunction, like I mentioned, is this inability to get or maintain an erection, even in situations without pressure. So that's kind of like the organic definition. So it's like the if you're able to get an erection other times, you're probably not experiencing this loss of circulation issue, like high blood pressure, like stuff like that. But if the issue arises only when you're being put on the spot. Yeah, it could definitely be related to anxiety, and it could be an psychological form of erectile dysfunction. So I would talk to a healthcare professional if this happens a lot more. Here's what I want you to do, maybe create a more relaxed initiation of intimacy. You know, is she coming and jumping your bones and being like, oh, like, I just want to do it right now. Maybe what you should tell her is, like, next time you're turned on, you really want to do it. I want to initiate more slowly. I need to get used to it. I want to ease into it. Maybe, if I'm like, in the middle of something else, I can't do it. Maybe I just got off of work and it's been a long day. Maybe I've had a lot going on in my personal life. I just need a moment to relax, and so maybe that means bonding with me. Let's just kiss for a couple minutes and see where it goes. And please don't be disappointed if I don't want to continue. I know it sounds weird, maybe for some listeners, but just being able to address like, oh, like, I'm asking you to not do this, like, it makes it worse, can feel a lot better for a lot of people. So a slower, more gradual approach could help you feel less rushed. And also just pick something to kind of ground yourself in. So shift the focus from achieving an erection or, oh, like, I have to make her come. I have to come myself. Like all of this focus on like, she's coming to you. She's in the mood. What can you do for her, you know, like, maybe shift the attention to her pleasure without your penis. Maybe just take the pressure off the penis. Like, just put it aside for a sec.

What else does she like? What does she enjoy? Make her feel liked and enjoyed, because it sounds like you want to have sex. It's just the pressure is getting to you. So take the pressure off by being like, Oh, I'm gonna enjoy. Produce a toy. I'm gonna go down on her. I'm gonna hold her while she touches herself. We're gonna make out for a long time and just see where it goes and talk to her about that. Be like, I really want to make you feel good. And right now, my penis is not cooperating because I'm a little stressed about that situation. There's a lot of pressure on me, and I want to make you feel good. So let's figure out what else I can do to contribute to that. Because I love being there in that moment with you, and I want to be there. Maybe that kind of conversation can be really helpful. I know it's hard, but you know, trying to stay present in the moment. If you're too present on what's happening in your body. It can be good to just stay present what's happening in her body. Sometimes that can be a great distraction. Next question comes from Taylor from Seattle, what are some drugs, recreational or otherwise, that could have an effect on my erections? There's a bunch of them, so I'm not going to try to give the whole pharma lecture here, but there are a bunch of drugs, both recreational and prescribed, that can interfere with an erection. So this is specifically like what I know for male erections. So obviously a lot of these, most of these, all of these, have an effect on female erectile function as well and female sexual dysfunction. Okay, so let me just run through the list really quick. So sometimes these have sexual side effects. So that's antidepressants, antipsychotics, anti anxiety medications. We know a lot about these, right because they block serotonin or reduce dopamine, etc, etc. We hear a lot about antidepressants, antipsychotics, anti anxiety medications, having potential sexual side effects, for sure. But there's also blood pressure medications, opioids, cancer medications, antihistamines, like Benadryl, for example, that can reduce blood flow and inhibit the central nervous system, and then prostate medications, something like five alpha reductase inhibitors, stuff like that, they can reduce DHT and decrease libido. But Hello, you should not go off of these medications if you're having sexual side effects without discussing it with the person who prescribed them. So I don't want to spend too much time on that, because I'm definitely not here to tell you what to do in terms of your medications. So I'm going to shift gears into recreational drugs, which is probably more of what you were wanting to know. So the big one, obviously, is alcohol. You know, small amounts of alcohol can help with relaxing, but heavy drinking, binge drinking or like chronic alcohol use can depress the central nervous system, which we can guess what that does, impairs the ability to what Say it with me, achieve or maintain an erection. There we go. Everyone gets points. So alcohol can also lower testosterone levels over time. Nicotine, same thing. It constricts the blood vessels, though, so this reduces blood flow to the penis for some people, and with like long term use, it can lead to Ed so that's tobacco and vaping and non tobacco products, it can can contribute to it cannabis. That's a hard one, because there are some studies that suggest that it can decrease sexual desire and impaired erectile function. But like this, impact varies a lot. What it what's really happening, I think, is like it's chronic, intense use that's interfering with, possibly like hormones. So I don't know the jury's out on cannabis for sure, I think that that one is, it's hard to to say, but there is some pretty, pretty good evidence for some other ones. Are we ready cocaine? That one causes constriction of blood vessels, so it can make people really excited to have sex, but especially chronic use, long term damage to sexual function. So if there was a reason to quit cocaine, do it for your penis. All right. So amphetamines, also, we're talking about meth, for example, these can make you really energized and, like, really aroused, but then also can, like, disrupt dopamine regulation and blood flow, and so it's like a double edged sword. Opioids, of course, prescribed and recreational, they can lower libido, not necessarily causing Ed but just can impact your erections. MDMA, another one that's like, it almost is, like, unfair, right, increases sensations of pleasure, increases emotional connection for a lot of people, but then reduces physical sexual performance because it inhibits erections. Like, very funny that that happens. Maybe, maybe something to explore. Obviously. Honestly, I'm not recommending anybody do any of these drugs, but I'm just answering Taylor's question here. Biggest one, I would say. I don't know if this counts as like a recreational drug, but anabolic steroids, the ones like you use to enhance your muscles, they can disrupt hormone production pretty badly. They can lead to testicular shrinkage, little, tiny, tiny balls and lead to Ed so you know you're getting jacked, but at what cost, ma'am, if you are experiencing erectile dysfunction you think is related to any of your recreational drug use, you know what I'm going to say, Right? Talk to your health care provider, because they can talk to you about that. Or if you're on a prescription medication that you think is having a big effect on your erections, talk to the person who prescribed that as well. So here are some questions that get kind of like frequently, little, little lightning round, is it okay to take erectile dysfunction pills recreationally? Listen, I know it's exhausting. I'm covering my bases here. If you're getting them prescribed to you for a reason, that's not my gig, right? But if you're buying them off the streets, because, you know, I say off the street, but you know what I mean? I don't stress that one, because they are one of the most counterfeit medications in the world. No joke, it is, like, a big issue. But two, because, like, you know, just don't do that. But like, I people are gonna be like, Oh, you're so lame. Sorry, I told you. Public Health hat is gonna be on for this one, another lightning round question, supplements that work like Ed drugs. I've discussed this before, but erectile dysfunction, drugs are not stimulants. So if you're taking something that's like, stimulates, you know, and that's like, that's why you're going to get an erection. That's not necessarily how it works. As we just discussed with Taylor from Seattle, there's a lot of drugs that are stimulants, like, we're looking at you, meth that may, you know, actually inhibit erections for some people. So it's similar to, like, how for some people, taking something like maca or caffeine can make them really aroused, give them stronger boners, etc. They feel like they're stronger. I'm not saying that they're clinically stronger. You know, starting to watch my language here. But for other people, caffeine will just like, kill their ability to maintain an erection. Like it really depends what's going on for you chemically, right? So sometimes vasoconstrictors like nicotine backfire and you don't get enough blood to the genitals. So I don't recommend anything taking, taking anything sold in a single pill form from behind the counter at a gas station. Let's just try to avoid that one like hashtag Rhino pills. Let's just not, you know. And so far, there isn't, like, great evidence suggesting that libido supplements do much for people who actually have, like, organic erectile dysfunction issues. So if these supplements are making it easier for you, it could be either like a mix of placebo, which is, like, incredibly powerful. When it comes to sex, it's basically just like permission for pleasure, or maybe there is a boost from the maca or other ingredients that's causing kind of an overall surge in blood flow, and you're sensitive that stimulus. It's similar to, like I mentioned, some people with caffeine makes them super horny. Other people, it just like, kills their drive. Same thing with like, a glass of wine gets some people, like, incredibly horny and aroused, like super aroused genitals. And other people, it's like, I absolutely am not in the mood for sex. Like it's, it's very you know, it depends. But in terms of supplements, remember that the supplement industry is largely unregulated. So also make sure you're not falling for snake oil or harmful ingredients at the sake of this pressure to improve your sexual performance. I think a lot of the marketing from these erectile dysfunction medications is bleeding into a market where people are selling you snake oil. And what I mean by that is like they're going to tell you the supplement will increase your erections and all this stuff. One, there's just no evidence that it does that. Two, it could be harmful for you. Three, you have no idea what's even in that. And four, there's trying to kind of create a problem that they can solve. And it's very ironic that this is what a lot of these, like, super anti pharma people are always saying, like, oh, like, they're creating this issue, like, with every medication to sell you a solution. That's really largely what a lot of like, like supplement industry in general, I've seen, is starting to do where they're taking the context out of medical issues and telling you, oh, well, we have a natural solution, and it's kind of just the same. So that's all for this week. I'll give you that to kind. Of mull over. Next week, we're talking some spooky, spooky stories, so send in your Halloween themed questions and confessions. It's going to be kind of the opposite of this episode. It's going to be very lively and fun. If you want to send me a voice note, please, do I have a voice mailbox that I'm going to link in the Episode Notes. So we're talking role play costumes, ghosting, fear of intimacy, spooky and fun, campy Halloween topics, it will all be covered.

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