Transcript of Dr Mohit Khera on The Diary Of A CEO

We, most men, most women, want their sex span and their health span to last as long as their lifespan. So I think it’s important.

The Four Pillars of Sexual Health

STEVEN BARTLETT: And there’s things that I can do to make my sex span last as long as my lifespan.

DR MOHIT KHERA: There’s many things you can do, and I call it the four pillars. The first is diet, exercise, sleep, and stress reduction. I don’t have a pill on the planet stronger than diet, exercise, sleep, and stress reduction. Each one of those can significantly improve a man and a woman’s sex span, but also their health span and their lifespan.

The other is hormones. Testosterone, extremely important. Testosterone supplementation can significantly improve a man and a woman’s sexual function. And unfortunately, for women in the United States, we don’t have very many options. Actually, globally, for women, there’s not many options. But I think it’s important, hormone replacement therapy.

And one more thing. I think about the couple. Think about sex span as a couple’s disease. Let me give you an example. Tomorrow, Steven, are you married or in a long-term relationship? Let’s say your partner tomorrow says to you, “I am no longer going to have sex with you.” Unless you cheat on her or you leave her, you’re not going to have sex again.

Think about the importance of the couple. So I talk about this quite often. Keep your partner engaged. Keep your partner healthy if you want to prolong your sex span.

Professional Background

STEVEN BARTLETT: So I’ve got two questions here. The first of which is who have you worked with in your career? And the second question is what is your CV? Give me a rundown of your professional experience.

DR MOHIT KHERA: I started my residency in 2000, and I did one year of general surgery. I did five years of urology training, and then I did one year of a fellowship in men’s health. Soon as I finished my training, I joined the university at Baylor College of Medicine, and I started a basic science laboratory where we do basic science research in sexual medicine and testosterone for the past seventeen years. And I just started a clinical trial, so I have a clinical arm where we do clinical research.

I see approximately one hundred and fifty patients a week every week. I do approximately six to eight surgeries every week. And I still work at the VA hospital. It’s a veteran government hospital, one half day a week working with the veterans. So it’s quite busy.

But my passion really is education, research, and clinical care. And that’s what we do. And how I really got into this was when I finished my training, I was so proud of myself. I was able to get these men these amazing erections, these great libidos. And I realized one day this woman called me and she was frantic.

She said, “Look, you’re treating my husband. You’re able to get him these great erections, great libido, but I don’t want to have sex with him. And he wants to have sex with me all the time, and now we have a terrible relationship. You’ve ruined our relationship.” And I thought to myself, wait a minute. This doesn’t make sense. But she was right.

In sexual medicine, either leave both libidos low or raise them both, but don’t raise one or the other. It’s a setup for disaster. So very quickly that year, I went out and flew out to meet with Dr. Erwin Goldstein, who’s considered one of the godfathers of female sexual dysfunction. Spent some time with him, went to his courses. And for the past sixteen years, I’ve been treating women as well. You can’t just treat one patient without addressing the other. And so therefore, it’s a couple’s disease.

Common Patient Concerns

STEVEN BARTLETT: And give me a flavor of the types of conversations you have on day one when they walk into your practice when they come to see you. What is the issue that they say they have, and how do they express it? Like, what are the words that they use? And if you could just give me, like, five of the most popular things people say to you when they come to see you.

DR MOHIT KHERA: First of all, men and women are very different in how they express it. Most men and women do not get any kind of medical care when they see their primary GP. In fact, most GPs don’t address sexual dysfunction. There was a study looking at medical students. Only sixty-five percent of US medical students get training in sexual medicine. And of those sixty-five, fifty percent of those students said that the training was terrible.

So we don’t get the sexual medicine training to address the problem for patients. So the majority of patients are never discussed about their sexual problems. But when men come in, most of them are coming in because they already have tried some medications that haven’t worked and they’re looking for other solutions.

Now there are two simple questions you can ask a man. They’re very straightforward. Are you able to get an erection sufficient for penetration? It’s either yes or no. Now are you able to maintain that erection till orgasm or pleasure? It’s either yes or no. The answer is no to either one of those questions, he suffers from erectile dysfunction.

And so it’s very important to get a detailed history. You want to ask particularly, are you able to get an erection on your own? Are you able to get an erection with masturbation? Do you wake up with morning erections? He says, “Look, doc. I get great morning erections. Or with masturbation, I have great erections. This has to be psychogenic. With my partner, I cannot get an erection. But when I’m by myself, everything works fine.” Psychogenic. Psychogenic ED. It’s a big component.

Understanding Psychogenic ED

STEVEN BARTLETT: What is psychogenic?

DR MOHIT KHERA: Meaning something in the mind that’s bothering you or prohibiting you from engaging in sexual activity. And that’s where the sex therapist comes in. Because if someone tells you, “I get great erections by myself, but with my partner, I’m not able to get good erections,” psychologically, when they’re with their partner, they’re not able to achieve a good erection. Sex for men and women has a huge psychogenic component, a huge psychogenic component.

So I think it’s very important to get detailed history about are they able to get erection? What did they try? What medications have they tried? You have to query about depression. Sixty-six percent of men who come in with ED have some degree of depression. Anxiety, thirty-five percent is very important.

ED as a Warning Sign

And more importantly, ED is the first sign of other major adverse medical problems. For example, if a man comes into my office today, fifteen percent of them will have a heart attack or a stroke within seven years. The day they get ED, fifteen percent will have a heart attack or a stroke within seven years. It’s the first sign.

Other studies, Dr. Montorsi showed that if a man presents to the emergency room with a heart attack, on average, thirty-nine months earlier, that’s when the ED started. So it is the first sign.

Now there are many reasons for this. One theory is called the arterial diameter theory. The penile arteries are the smallest arteries, one to two millimeters. The coronary arteries are three to four millimeters. The carotid, six to seven millimeters. So if you remember from physiology, if you’re going to block an artery, fifty percent occlusion of an artery causes damage. So if you’re going to block an artery, you’re going to block the penile arteries before the coronary arteries. You’re going to block the coronary arteries before you block the carotid. So men will get ED before they get a heart attack, more likely to get a heart attack before they get a stroke. That’s a theory. But it makes sense.

So I worry when a man comes into my office, could this man have occult cardiovascular disease? In fact, there was a wonderful study that came out of Greece. They looked at fifty men that walked in, and they gave them an echocardiogram or stress test. If it was positive, they went on to a coronary angiogram. What they found is that roughly twenty percent of men, one in five, actually had some occlusion in their heart, whether it was one vessel, two vessel, or three vessel disease. So I think to myself every time I’m writing that prescription, is this one of the five that could have some occlusion? And is there an opportunity to intervene at this point? So it’s really important to think about cardiovascular disease as well.

Understanding Libido Issues

STEVEN BARTLETT: One of the big subjects that I hear a lot about, even in my friendship groups, is about libido. I’ve got so many stories in my friendship group of either one or both partners losing their libido. So on this subject matter of libido, it’s kind of where I wanted to start this conversation. What is the most frequent and popular reason why men and women struggle with libido problems? And how much of that is about compatibility?

DR MOHIT KHERA: Good question. Libido is multifactorial. There’s many pieces of libido. It’s very complex, and I’ll give you some important components.

First, it could be hormonal. And the mnemonic I teach the residents is PET. The four hormones that can affect someone’s libido are prolactin, estrogen, thyroid, and testosterone. So you have to check the PET. If the prolactin is elevated, the libido goes down. If the testosterone is low, the libido goes down. So maybe it’s a hormonal issue, which could be it. Particularly, many women who go through menopause suffer from hormonal issues.

The second is something called neurotransmitters. So in other words, serotonin, norepinephrine, dopamine. Dopamine goes up, libido goes up. Serotonin goes up, libido goes down. So these all regulate how someone’s libido will function. One of the biggest culprits for low libido are antidepressants. What do antidepressants do? They increase serotonin, and they decrease libido. So sometimes it’s a medication or something that a patient’s taking that will shut down their libido. For example, a medication that men take for urinary function called finasteride shuts down their libido.

The other components are lifestyle, diet, exercise, sleep, and stress reduction, particularly fatigue and stress. If a woman is tired and she’s exhausted and she has to choose between sex and sleeping at night, many times she may choose sleep.

STEVEN BARTLETT: Me as well.

DR MOHIT KHERA: Right? I’m just saying. Yeah.

So fatigue is important. Stress. And there’s this cliche, this mnemonic, this saying that with stress, it’s kind of interesting. Typically, if a man has a very stressful day, he will want to have sex to relieve his stress. Women have to relieve their stress to engage in sexual activity. It’s kind of the opposite. So I tell men, if you really want to have sex with your wife, do the dishes, take out the trash, do everything you can to tuck the kids in bed early, relieve her stress because that will significantly increase her desire to engage in sexual activity.

But the other one is psychogenic. And so, we talked about that earlier. Sex has a huge mental component, your relationship with your partner, how close you feel with your partner. So sometimes patients come to me and they’re in an abusive relationship and they say, “Give me the pill that improves my libido.” I say, “It’s not going to work. The essence, the core, the foundation is not working.” And therefore, it’s really important for them to see a sex therapist.

One thing for men that actually shuts down their libido is when they start developing erectile dysfunction. So if a man starts getting erectile dysfunction, let’s say he gets a good erection fifty percent of the time, and he’s starting to have some problems. And it’s ten o’clock at night, he says, “Look. I can try to engage in sexual activity, but it may or not work, and it may be frustrating and embarrassing, or I can just go to sleep.” He’s probably just going to go to sleep. Right? And it becomes a vicious cycle because the less sex he has, the more difficult it is to engage in sexual activity later on. And so you may interpret this as a low libido, but he’s really just avoiding it because he doesn’t want to deal with it.

The Connection Between Erectile Dysfunction and Libido

DR MOHIT KHERA: But the partner also looks at this as maybe I’m not attractive anymore. Maybe there’s something about me that’s not appealing, and it becomes a vicious cycle. So one thing you can do is significantly improve the quality of the erections in a man, and that actually helps improve his libido. For example, if I tell a man, if every night you have a great erection and every morning you wake up with a great erection, what are you going to probably do? Probably going to use it.

Right? So libido inherently goes up. I think ED and libido are tied very closely.

STEVEN BARTLETT: How do you define the term libido?

DR MOHIT KHERA: A desire to engage in sexual activity, right, for men and women. And you have to know, when it’s a true problem, they have to be bothered by the condition. So I just want to be very clear. There are women who have low libido and say, “I really don’t care. I’m happy that I have a low libido.”

Well, then it’s not an issue. You have to be bothered by the issue.

The Vicious Cycle of Performance Anxiety

STEVEN BARTLETT: So on this psychogenic element where it becomes a vicious cycle, I’ve seen this in my own life, several times, well, at least once. And I’ve seen it in some of my friends where because there’s a bedroom issue, when you go to the bedroom, you’re both a little bit anxious, and then one of you can’t perform. And if you can’t perform, it exacerbates the issue, and it creates this sort of vicious downward spiral of, like it makes the bedroom like a really awkward place to be, and this is how I think about when you’re talking about psychogenic component. So in the case of erectile dysfunction, if you’re thinking as a man, god, if I go to the bedroom, I’m not going to be able to get it hard. I’m not going to keep it up.

It’s going to be embarrassing. She’s then going to ask me questions. She’s going to think I’m not into her, which all just makes it even harder because as a man, like, I perform best when I’m really not thinking about it, and I’m just, like, not anxious or and when I’m stress free. Right. And it seems to me that the, like, antithesis, the opposite of great sex is, like, overthinking.

DR MOHIT KHERA: You’re a hundred percent correct, and this is what happens. Let’s say a man gets ED just one time. Just one time. Young man. He says that was really odd, and I what’s wrong?

You know what he does next time he has sex? As he’s having sex, he says to himself, “I hope I don’t lose my erection. I hope I don’t lose my erection.” The second he says that to himself as he’s having sex, he’s going to lose his erection. Right?

Because he’s so worried that he’s going to lose the erection and not enjoying the experience. So now it’s happened twice. So now he engages in sex with a third time, and now he’s even more freaked out because it’s happened twice, and it happens again. We call this the vicious cycle.

Because now sex has become an anxiety-provoking event. And so you really have to work on decreasing that anxiety and not thinking about it. That’s where sex therapy comes in hand, and that’s where a medication called daily Cialis has become unbelievably helpful for my young patients because daily Cialis is a medication that men take daily. You’ve heard of Cialis.

STEVEN BARTLETT: It’s like the Viagra.

DR MOHIT KHERA: Yeah. It’s like Viagra. Right? So there’s Viagra. There’s Cialis, Levitra. There’s Stendra. There’s four different brands. But one of the four is meant to be given daily. It’s a lower dose, five milligrams every day, and the larger dose is twenty milligrams. When you give a man Cialis five milligrams every day, what it does is essentially is having that medication on board all the time.

When he engages in sexual activity, he doesn’t have to take a pill. He just has sex whenever he wants to. And I found that to be unbelievably helpful in breaking psychogenic ED.

STEVEN BARTLETT: On the table.

DR MOHIT KHERA: Yeah. That’s exactly what it is. And so these are pills that are in the US, but what’s nice is they used to be very expensive. Now if you look at Mark Cuban and a lot of the GoodRx companies, men can get ninety pills for fifteen or twenty dollars, which is very cheap.

Medication for Young Men with ED

STEVEN BARTLETT: You used the word young men.

DR MOHIT KHERA: Yes.

STEVEN BARTLETT: Young men presumably shouldn’t be taking pills.

DR MOHIT KHERA: They shouldn’t, but what happens when they have psychogenic ED because they think about it the most is they need to break the cycle.

STEVEN BARTLETT: What’s the cost? Because I’m going to be honest. I’m a pill skeptic.

DR MOHIT KHERA: Yes.

STEVEN BARTLETT: I try and avoid taking pills to solve my problems if I can. Right. Obviously, there’s going to be situations where I can’t. And I accept that.

But my bias is towards figuring out if there’s another way before I take a pill. Because everything in life comes with a cost, all things. So there must be a cost to taking a pill to solve this problem.

DR MOHIT KHERA: Well, the actual monetary cost is unbelievably cheap.

STEVEN BARTLETT: Monetary cost is I’m thinking about, like, do I get dependent on this? Do I have to take this for the rest of my life?

DR MOHIT KHERA: So there’s no dependency. Let me tell you why I think that drug is so important. That daily Cialis has one of the only things in my opinion that actually reverses erectile dysfunction. So let’s backtrack.

I’ll give you an example. Let’s say today you break your leg. Okay? I have two options, Steven. I can fix your leg, or I can give you Vicodin, a narcotic.

And if I give you the Vicodin or the narcotic, you’ll still be able to walk until the Vicodin no longer works, and we’re in trouble. Viagra is a Vicodin. It is not a cure for your erectile dysfunction. It’s just masking the problem. Daily Cialis, in my opinion, is one of the few things that helps cure ED.

If you look at studies and you look at a penile tissue and we biopsy the tissue and then you biopsy three months later on daily Cialis, it physically gets stronger. So let’s say you go to the gym today and ask you to lift dumbbells, what’s going to happen to your arm? It will hypertrophy. With daily Cialis, we see hypertrophy of the smooth muscle, meaning it gets physically stronger. So in my opinion, it’s one of the best things to prevent ED in the future, help reverse the ED process.

More importantly, daily Cialis protects the endothelium, and we have to spend some time talking about that. That is the lining of the blood vessels. It’s the brains. And the lining of the blood vessels is very important because once that gets injured, you start getting caught or plaque, which will get a heart attack, a stroke, and erectile dysfunction. So it protects the lining of the blood vessels.

Two other indications. It’s FDA approved to help a man urinate better. FDA approved. It’s FDA approved to protect the heart in terms of something called pulmonary hypertension. So in my opinion, it’s an excellent medication.

Patients say, do I get dependent on it? I say, you do not get dependent on it. And I feel like you’re better had you taken it than had you not. You take it for three months, you get strengthening of the penile tissue.

STEVEN BARTLETT: What happens if I stop taking it?

DR MOHIT KHERA: If you stop taking it? There’s a wonderful study by Aversa. And what he showed was that those patients that stopped taking it after three months versus placebo still had benefit in terms of endothelial function protection and erectile function protection than those people that took placebo. So thinking about saying, hey, if I go to the gym and I work out for three months, what happens if I stop? I said, well, Steven, you’re better off had you gone to the gym for three months.

That’s my opinion.

Side Effects and Benefits of ED Medication

STEVEN BARTLETT: What is the downside?

DR MOHIT KHERA: There’s side effects. So every drug has side effects, right? But they’re low with five milligrams. Back pain, stuffy nose, headache can occur in these, but it’s quite small. But I do think that this is one of the medications that really can make an impact in men’s health.

Think about it. If I told you it’s a medication that protects your heart, helps your prostate, and helps men with erections, and it’s affordable, I think that most men would say, “I’m in.”

STEVEN BARTLETT: What are the big side effects that people report when they’re on Cialis?

DR MOHIT KHERA: So on a larger dose, headache, stuffiness, back pain is more common with Cialis than other medications, but it can be reported. Remember, you shouldn’t take these medications if you’re taking a nitrate because it can drop your blood pressure. But other than that, these are very commonly used medications throughout the world.

STEVEN BARTLETT: They’re not suitable for certain people that have some cardiac disorders, I’m guessing?

DR MOHIT KHERA: Well, the way this was invented, it came out first one, Viagra came out in 1998. Viagra was in the clinical trial designed to be a blood pressure medication. And accidentally, men were getting erections in the trial. So these medications are, in my opinion, cardioprotective. A very famous physician named Doctor Kloner published an article recently showing that those men who took daily Cialis had a thirteen percent reduction in cardiac events and a twenty five percent reduction in mortality that just came out because of the potential effects of protecting the endothelial lining of the blood vessels.

STEVEN BARTLETT: How does this work to solve for this sort of psychogenic component that we talked about that vicious cycle? I’m guessing you’re telling me that it increases your probability of having a good erection. Right? But this still isn’t really working on a libido, is it?

DR MOHIT KHERA: So let’s say, you started falling through the vicious cycle, and you started having ED, and it was two times, three times. And now I put you on this medication. And every time you have sex, you have the most amazing erection of your life. And thirty times, forty times, three, six months go by, and you’re having these amazing erections.

You’re relaxed, and you’re calm. Then I start going to every other day. You still get amazing erections. Then I go to once a week. You still get amazing erections.

Then I stop. You still get amazing erections. Right? I just need to show you that everything is perfect again. And that has a huge value.

Female Sexual Dysfunction

STEVEN BARTLETT: What about for women?

DR MOHIT KHERA: This is the unfortunate part. We don’t have a lot of treatment options for women. And if you look about it I want to give you an example. In 2015, if you and I went into the drugstore in the US, Walgreens, and said, give me all the drugs to treat women, to treat men for sexual dysfunction, they would put thirty drugs on the counter. These are all the wonderful treatments for men.

In 2015, there was not a single FDA approved drug to treat women for any sexual dysfunction. Very sad. In 2015, the first drug to treat women for female sexual dysfunction came out, and it was called Addyi or flibanserin. Flibanserin basically is a drug that a woman takes every day and increases her desire for sex. That’s it.

That’s the FDA indication. Increases her desire for sex. Several years later, the second drug for women came out. This was called Vyleesi or bremelanotide. Essentially, it’s an injection that she takes forty five minutes prior to intercourse, and it increases her desire for sex.

But, again, we have only two drugs. The reason being is because the research, the funding that we have for female sexual dysfunction is far less than we have for male sexual dysfunction. And it’s unfortunate because as I mentioned earlier, this is a couple’s disease. And so many times, I have to use drugs that I use for men to help treat women.

So I do use Viagra for women, but Viagra for women helps arousal. So let me explain. Female sexual dysfunction has four components. One is decreased libido. The second is decreased arousal. Third is orgasmic dysfunction, and the fourth is pain with intercourse. These are the four. If a woman has any one of these four and she’s bothered by it, she suffers from female sexual dysfunction.

In the US, roughly forty-three to forty-eight percent of women suffer from female sexual dysfunction, significant number. Only nineteen percent seek therapy, will get therapy.

So there’s a huge number of women that I say are suffering in silence. They suffer from the condition. They don’t know where to get help. And unfortunately, there are not many treatment options available. So it’s a big problem and a big unmet need.

Hormones and Arousal

STEVEN BARTLETT: And on the hormonal component, you talked about how if dopamine is up, we’re much more likely to be aroused, And if serotonin is up, then we’re much less likely to be aroused. That’s correct. So this kind of ties into something I was thinking when you’re talking about stress and tiredness. When I’m stressed and tired, is my dopamine down?

DR MOHIT KHERA: It can be. Your cortisol goes up. Right? Your cortisol goes up. So your ability to get excited will go down.

Your fatigue goes up, so it makes it much more difficult. These there’s more than just dopamine and serotonin. There’s norepinephrine. There’s melanocortin. There’s many other neurosteroids.

And it’s really just what we call a plus minus game. If I have more positives than negatives, I’m going to have desire, and I’m also going to have orgasm. Right? That’s important also. So if you give someone too much serotonin and it goes this way, not only does the libido go down, but it’s difficult to achieve climax on orgasm.

Treating Premature Ejaculation and Libido Issues

DR MOHIT KHERA: So one of the ways I treat premature ejaculation is I give them an antidepressant because it delays the orgasm. So we have to be very careful on these neurotransmitters, how we use them. But if you talk about ADI, the drug I mentioned, all it does is it increases dopamine and norepinephrine, which increases libido. So they increase neurosteroids. Many women, particularly with the history of breast cancer, like this because they don’t want to use testosterone or estrogen hormones.

This is non hormonal. Right? It’s just neurosteroids increasing the desire for sex.

STEVEN BARTLETT: Can I think about dopamine and serotonin as like a scales? Where if I put weight on one end, the other one goes up. And if I put weight on the other end, the other one goes up?

DR MOHIT KHERA: Yes. There is a very famous Michael Perlman came up with a tipping point, and it’s basically a scale looking at the pluses and the minuses. And if you have more pluses than minuses, libido goes up, orgasmic function goes up. If you have more minuses, essentially, your ability to orgasm and your libido will go down.

STEVEN BARTLETT: So if I want to be around and have a desire for sex and have good sex, then I want my dopamine levels to be high?

DR MOHIT KHERA: Dopamine high, oxytocin high, norepinephrine high, serotonin low.

Natural Ways to Boost Dopamine

STEVEN BARTLETT: What are the types of activities that make my dopamine high?

DR MOHIT KHERA: Exercise can be a really high dopamine. Other things increase dopamine as well. Right? So, gambling. There’s certain things that are high. It’s like gambling. Anything that gives you a high. Certain foods will cause a dopamine rush, but they’re temporary.

STEVEN BARTLETT: And that’s the problem. Right? Because if it goes up…

DR MOHIT KHERA: And it goes back down. It crash. So you want your dopamine to go up in men and women. So we use medications like Wellbutrin. Have you heard of Wellbutrin? It’s an antidepressant, but that antidepressant increases dopamine. So I use that to help men increase their libido or women to increase their libido or sexual function. I use ADD in men and off label in men and in women to increase dopamine.

STEVEN BARTLETT: I don’t want to do drugs, though. I don’t want to take any pills.

DR MOHIT KHERA: So then I would say, I need you to exercise. And you do, but exercise is critical. I need you to sleep. I need you to reduce your stress. Right? Those things will significantly improve your libido.

STEVEN BARTLETT: So what things then lower dopamine? Because I’ve spoken to a few dopamine experts on the show before, they talked to me about this sort of meaning. Andrew Huberman was telling me that when you do an exercise, like, let’s say gambling or go on TikTok, your dopamine’s going to go up, but then it’s going to crash below the base point. And some of us live in this kind of dopamine roller coaster where we’re doing these dopamine inducing activities. Our dopamine goes up, it then crashes below.

DR MOHIT KHERA: Yes.

STEVEN BARTLETT: When it gets low, we have cravings for dopamine inducing activities. We go out and want to gamble or go on TikTok again or eat something, and then it goes up again and then we kind of live in this kind of roller coaster of dopamine. One of the things that I was told by a dopamine expert on the show recently that does that as well, that links to some things I found in your work is pornography.

DR MOHIT KHERA: Yes.

Pornography and Sexual Dysfunction

STEVEN BARTLETT: And when we talk about this psychogenic component, we talk about dopamine levels. How much is pornography causing this libido crisis?

DR MOHIT KHERA: Pornography and ED and libido is somewhat controversial. There’s some data to suggest that it does not cause an issue, and there’s some data to suggest that it does. The first question I ask a patient when I ask a man, I say, is your ED present with pornography also? So if he says, look, I have erectile dysfunction with my partner, and I have erectile dysfunction with pornography, that’s very different than when he says, I have erectile dysfunction with my partner, and I have amazing erections with pornography. Right? Because then I know that there’s a psychogenic component as well.

This is what I believe. I believe that when a man watches excessive amounts of pornography, what his expectation is becomes here, and his reality becomes here. And that delta causes them to have erectile dysfunction and low libido. They’re not getting what they’re expecting to get. So many times, I question men when they come in. All when all men who come in for ED, I ask how much pornography are you watching. In men who watch excessive pornography, if I ask them to stop watching pornography for a while, many will report improvements in their erectile function and libido.

So again, I do think that pornography in excess can have a negative impact only because of your expectation and your reality. The delta can be an issue.

The Decline in Sexual Activity

STEVEN BARTLETT: Reading some stats here from JAMA Network that says the percentage of men between eighteen and twenty-four reporting no sexual activity in the past year increased from roughly eighteen percent to roughly thirty percent in the space of what looks like just a few years. And similarly, the average number of times American adults engage in sexual activity per year has decreased from sixty between 1989 and 1994 to roughly fifty between 2010 and 2024. These shifts suggest a notable shift in sexual behavior over recent decades. Why do you think this is happening?

DR MOHIT KHERA: I think it’s multifactorial. So I think one is I think that ED and sexual dysfunction is on the rise. And if you look at the causes for ED, it’s very simple. You look at obesity, diabetes, metabolic syndrome. It’s a pandemic. It’s an epidemic throughout.

If you look at just diabetes from 1990 to 2022, a hundred percent increase – seven percent to fourteen percent of the population. One out of eight people globally are obese. One out of eight people. So these can make it very difficult. As obesity and diabetes go on the rise, what happens? Testosterone levels go down. Right? So testosterone levels go down. So the ability to engage in sexual activity, the desire to engage in sexual activity will be impaired by these conditions.

STEVEN BARTLETT: I’ve got some graphs here, which show global obesity trends, global diabetes trends. I’ll put them on the screen for anyone that’s watching on video. Also, there’s been an increase in pornography consumption from what I was able to tell from doing some research. A 2020 study by the University of Antwerp found that forty percent of people aged thirty-five to forty-five who watched three hundred minutes of porn a week had erectile dysfunction. In a 2021 study by German public health and surveillance in three thousand four hundred men between eighteen and thirty-five years old, twenty percent of the participants suffered from erectile dysfunction, and researchers found that the greater the viewing frequency of pornography, the greater the development of this dysfunction.

DR MOHIT KHERA: And that’s three hundred minutes is quite a bit of time a week. It’s five hours. Five hours a week. Right? So that’s quite a bit.

The Impact of Technology and Health on Relationships

STEVEN BARTLETT: How important do you think that is as a component to this sort of fracturing relationships? We think about people having sex with each other less. We’re heading towards a world of virtual reality and AI. What role do you think that’s genuinely playing? And you must have private conversations with men who are really suffering with these.

DR MOHIT KHERA: I definitely think it’s a role, and definitely it plays a factor, but not as much as the epidemic of diabetes, obesity, metabolic syndrome. We are, as a population, becoming more and more unhealthy as time goes on. And I look at it again as a pie, it’s multifactorial, right? Most of us now are not our socialization is virtual. And so we are not engaging and going into seeing each other. Everything is done virtually. And so I think that’s an issue. And so I really believe that pornography is a component, but the decline in overall health is a major component. The decline in testosterone levels decade by decade is also another component as well.

STEVEN BARTLETT: It’s pretty terrifying that young kids at the age of like twelve, thirteen, fourteen, when they open their phones these days will be exposed to sexually graphic images. Whether they chose to seek them out or not. And I’ve always wondered what that’s doing to a developing brain. You know, how it’s adjusting your expectations, how it’s creating some of those psychogenic factors that are making you less aroused.

And, and it’s difficult. Right? It’s difficult to go out and find a partner. You have to, like, put on the aftershave, shave, take care of yourself. You have to risk rejection, spend the money, be interesting.

DR MOHIT KHERA: Right.

STEVEN BARTLETT: So it seems like if from a evolutionary perspective, if I was just trying to get my nut off or ejaculate. I’ve got this really easy way now. Like, it’s so easy. Three clicks on a computer. We’re off to the races versus all the effort and rejection and pain of trying to find an actual human being to have sex with. And then when I do approach number one, when I log on to some website and click a couple of times, I’m getting no headache. I’m getting whatever I want. I can order from an endless list of menus, and I’m sure in the near future, I’ll even be able to make my own. I’m in not so distant future. I’ll have it in my house, and it’ll talk to me.

DR MOHIT KHERA: That’s the problem. And you think about it, it’s making it more difficult for people to socialize. Right? So in other words, now when patients or people engage in sexual activity, and they’re usually having sex on the Internet or with pornography, when you actually engage in sexual activity with another person, it can cause anxiety. Right? You get anxious. It’s not something that you’re doing regularly. And so I think that it can become an issue.

STEVEN BARTLETT: I saw an article this week from an OnlyFans creator who posted that one customer of hers had given her four million dollars this year.

DR MOHIT KHERA: Oh my god.

STEVEN BARTLETT: And you think about what it would take for you to spend four million dollars on a parasocial relationship with an OnlyFans creator sending you explicit pictures. And I don’t quite believe we fully understand what’s around the corner.

DR MOHIT KHERA: I agree.

STEVEN BARTLETT: These stats, I think, are nothing compared to what’s around the corner. And I think about it a lot because when I read these stats about erectile dysfunction being on the rise, and I read that we’re having sex less and less, and then I see this rise in these parasocial relationships. I go for now. I think we’re just at the start of an exponential curve.

Obesity and Sexual Health

STEVEN BARTLETT: Let’s talk about obesity then. Because these stats here are pretty shocking. This one shows the global obesity trends, which just shows them going straight up.

DR MOHIT KHERA: Yes.

STEVEN BARTLETT: This one shows global diabetes trends, which is pretty much straight up as well.

DR MOHIT KHERA: Yes.

STEVEN BARTLETT: Has there been any studies done that show the link between being overweight and your probability of having low libido and some kind of sexual dysfunction issues?

DR MOHIT KHERA: Numerous. And so let’s start with this. So obesity, it’s not surprising that diabetes is going up because as obesity goes up, it causes insulin resistance. So obesity and diabetes typically go hand in hand. The problem with obesity is the following.

Obesity significantly drops testosterone levels. So fat cells contain something called aromatase. Aromatase eats up the testosterone and converts it into estrogen. So the more fat you have, the less testosterone you’ll have because you’ll convert it into estrogen. Fat cells also secrete something called cortisol and leptin, which shut down your own natural testosterone production.

So it’s not surprising that decade by decade as you see an increase in obesity, you see a decline in testosterone levels in men because the testosterone levels will come down as people become more obese.

STEVEN BARTLETT: And low testosterone equals low libido?

DR MOHIT KHERA: Low testosterone increases low libido. The number one driver, the number one hormone for libido in men and women is testosterone. It’s a strong driver. Men and women.

And don’t forget that testosterone is also really important in erectile function. Men need testosterone for sexual function, so do women. Right? It’s extremely important. So now I have a hormone that’s going down that’s going to make it more difficult to get an erection.

I have a hormone that’s going down that’s going to decrease my libido, and it’s mainly due to this obesity that’s occurring, one of the biggest factors. Obesity also, if you look at the risk factors for ED, obesity, diabetes, cardiovascular disease, these are all risk factors. And so as obesity goes up, erectile dysfunction goes up. And the number one condition is diabetes.

Diabetics are four times more likely to have ED than any other population. Four times. So I get worried when we see this obesity diabetes pandemic going up because it’s increasing only the erectile dysfunction. Steven, if you look at the obesity, the group that’s having the greatest rise in obesity is adolescents obesity, not adult obesity. The kids, younger and younger ages are having that age group has the greatest rise of obesity.

So what does that turn into? The younger population are starting out at lower T levels and has an implication on fertility because you need testosterone to produce sperm. That’s very important.

STEVEN BARTLETT: So if I just lose a little bit of weight, that’ll have a big impact on my testosterone levels?

Testosterone and Weight Loss

DR MOHIT KHERA: Let’s talk about that. It’s not a little bit. So the best study was at the European male aging study, Fred Wu. And what he showed was this. It’s a bidirectional relationship.

If you lose ten percent of your body weight, you can actually gain eighty-five nanogram per deciliter in serum testosterone. If you lose fifteen percent of your body weight, you can actually gain two hundred and fifty nanogram per deciliter in serum. So it’s actually significant if you can lose weight, but it also goes the other way. You gain weight, you drop the testosterone proportionally as well. The only issue is I can get the patients to lose the weight, but I can’t get them to sustain it.

Many times they gain it back. But if they can keep the weight off, it significantly increases the testosterone levels. The best data we’ve seen is in the bariatric surgery data. If I do bariatric surgery on a patient—

STEVEN BARTLETT: Which is—

DR MOHIT KHERA: —to help them lose weight, you can shrink the stomach. We do surgery to help them lose weight. They lose quite a bit of weight. Their testosterone levels go quite up. So again, there is a strong correlation between weight and testosterone.

Testosterone Treatment Options

STEVEN BARTLETT: Have you got any examples of patients where you’ve given them testosterone treatment in some form? You’ve done something to increase their testosterone, and you’ve seen a remarkable reported difference in their sex life?

DR MOHIT KHERA: All the time. Yeah. So first, let’s backtrack. There’s two ways to give a person testosterone. If I give a young man testosterone, remember, it causes infertility.

So you would never give someone testosterone if they’re planning to have children. That’s very important. So I have two ways to raise their testosterone.

I can give you medications to raise your natural testosterone. There’s several. There’s a pill called clomiphene citrate. There’s HCG. I can use medications to raise your own natural testosterone, and they preserve your fertility.

The second option is I can give you medications like testosterone. There’s seven of them, but they will shut your natural production down. Not only will they shut your natural testosterone production down, but they will shut down your sperm production. Now if you’ve already had your kids, you’re sixty years old, your testosterone level is already low in the first place, what are you preserving? Okay.

It makes a lot of sense. And there’s seven ways to do it. My favorite way are the injectables and the oral testosterone. They are fantastic. Oral testosterone is quite interesting.

You know, first of all, testosterone was invented in nineteen thirty-five. This is not a new drug. Nineteen thirty-five. And oral testosterone initially was feared because it would actually cause liver toxicity and liver cancer. And it wasn’t till the nineteen seventies when they were able to make oral testosterone undecanoate.

And what’s nice about undecanoate, it bypasses the liver. No cancer, but it had to be taken three to four times a day. It was available in the UK as a drug called Andriol all over the world, but not the US. The US, we did not get our first oral testosterone till two thousand nineteen. And then two thousand twenty-two, we received two more.

And now we have Tolando, Jatenzo, and Kizatrex as our oral. They’re taken twice a day with a meal. What’s nice about Kizotrex, it’s actually available in the UK. So in the UK now, they can actually get Kizotrex as well. But oral testosterone, most patients don’t mind taking a pill, and it seems very easy to do.

Who Should Take Testosterone?

STEVEN BARTLETT: So should someone like me be taking testosterone?

DR MOHIT KHERA: If your levels are low—

STEVEN BARTLETT: Yeah.

DR MOHIT KHERA: —and you’re symptomatic, and I think that’s very important. If a man comes in with low levels of testosterone and says, I feel great. I have no symptoms. I said, I’m not giving it to you. These are the symptoms.

Low energy—

STEVEN BARTLETT: Yeah.

DR MOHIT KHERA: —low libido, erectile dysfunction, decreased muscle mass, increased fat deposition, poor sleep, and depression. These are some of the common symptoms you’ll see. Most sensitive symptoms are the sexual symptoms, erectile dysfunction and low libido. So if he says, I have these symptoms and my levels are low, and I recheck it and confirm that it’s low, that man is a candidate for testosterone therapy. But if he’s young, hasn’t had children yet, I’m going to say, look.

Let’s hold off on giving you testosterone and use medications to make you make testosterone. And if you don’t want to take medications, actually, there are many things you can do on lifestyle modification to raise your testosterone. We talked about weight loss as well. So let’s live in this area here. You are too young to take testosterone now.

But conversely, let’s say a patient comes in and has every single sign and symptom of low testosterone, but if testosterone levels are normal, I’m not giving him testosterone because it could be something else. Maybe he’s depressed. Maybe he has a low thyroid. Something else is going on. So you must have signs and symptoms and a low testosterone level to be a candidate.

And if you fit that, then you may benefit.

Testosterone for Women

STEVEN BARTLETT: What about women?

DR MOHIT KHERA: So this is important. In nineteen thirty-five when testosterone was invented, it wasn’t many years later till they actually started using testosterone in women. And early reports of testosterone in women were actually quite remarkable. The earlier manuscripts describe improved quality of life, improved libido. And if you and I walked into the drugstore today and said, give me the testosterone for women, it does not exist.

There’s not a single FDA approved testosterone for women in the United States, but we have well over a dozen for men.

STEVEN BARTLETT: Can you explain this to me just because I want to make sure I’m—why would a woman take testosterone? Because when I think of testosterone, I think of men.

DR MOHIT KHERA: Yes. So women make more testosterone than any other hormone in their body. Right? And when women have higher levels of testosterone, they tend to see a greater improvement in libido, muscle mass, bone mineral density, sense of well-being.

Some have reported improvements in cognition. As the testosterone level goes down, we start seeing these symptoms, particularly low libido. If you give a woman back her testosterone, she will—many of these women see a significant improvement in their libido. But the issue is that we don’t have an FDA approved product for testosterone in the United States. I think in the UK, you call it off license.

We call it off label. Now in the UK, they did have one. They had a wonderful patch called Intrinsa. And then the women in the UK could get the patch for testosterone going to the drugstore. NHS covered it, and it was fine.

Then they had Androfem. And Androfem was actually approved and now no longer is approved. So now in the UK, you also don’t have an unlicensed medication. You can still get Androfem from Australia. But, unfortunately, it’s very difficult to get.

So what do we do? We use the drugs for men, and we give it to the women in one tenth the dose. That’s all we do. So if we have a packet that a man puts on a day, we say use one tenth of the packet every day for the women, and they can see significant improvements. It is not illegal to give a woman testosterone. It’s just considered off label or off license, but they see significant improvements. In what? Sexual function by far the most. Libido goes up. No question.

I see that many women report that. Muscle mass. If you think about testosterone, bodybuilders take testosterone for a reason. Why? It significantly improves muscle mass. It can decrease fat deposition. Many patients will report improvements in cognition. It can help with bone mineral density as well in men and women. And I also believe in depression. So I think testosterone does help with depression.

Testosterone’s Broader Health Benefits

I just want to make a very important point. Testosterone is not just about sex. There are five other things that you need to think about in men and women, and I want to talk about those. Men with low testosterone levels are much more likely to have a heart attack. Nonnegotiable.

Men with low testosterone levels are much more likely to have diabetes, obesity. Men with low testosterone levels are much more likely to suffer from depression. Men with low testosterone levels are much more likely to have a bone fracture. So it’s not just about sex. It’s about their overall health.

And if you were to check one blood test to assess a man’s overall health, it’s his testosterone level. One blood test to check his overall health, because it affects heart, diabetes, obesity, bone mineral density, energy, muscle mass, erections, libido—one blood test. I can’t think of another blood test that is a better barometer of overall health.

HRT vs Testosterone Therapy

STEVEN BARTLETT: I want to get clear on something because I’ve heard people talking on my podcast before about HRT and women taking HRT because of menopause and things like that. Should they be—does HRT have testosterone in it?

DR MOHIT KHERA: No. So typically when we say HRT, we’re talking about estrogen and progesterone, typically. And typically when we talk about TRT, testosterone replacement therapy, it’s a little bit different. In a woman, there’s something I call the triangle, and it’s just basically estrogen, progesterone, and testosterone.

Just simple. And if you have a woman who’s depleted in estrogen, testosterone, and progesterone, and replace it, many of those women feel better. Right? So many of them do. There are other hormones that are also important.

I call it the outside circle, cortisol, thyroid, growth hormone. We look at those as well. And so I think those are also very important. And I tell them, we’re going to optimize your hormones, but what we’re going to do—we’re going to optimize your medical condition, but that is only fifty percent of the story. The other fifty percent, again, is diet, exercise, sleep, and stress reduction.

And if you do your part and I do my part, we’re on fire. We’re absolutely on fire, but you have to do your part. Same with men. I put you on the testosterone. I optimize your medical conditions. But you gotta exercise. You gotta eat right.

STEVEN BARTLETT: Why aren’t women being prescribed testosterone then?

DR MOHIT KHERA: Right. Because it’s considered—well, in many countries, it’s—in Australia, it’s available. In the UK, it was available, and many women are being prescribed testosterone. Okay. It’s just off label.

STEVEN BARTLETT: It is the first time that I’ve seen someone on my show anyway really emphasize the point that testosterone isn’t just for men. It’s for women as well.

DR MOHIT KHERA: And it can significantly improve their quality of life.

The Decline in Male Testosterone

STEVEN BARTLETT: Talking about testosterone, one of the big conversations that’s rattling on on the Internet is about this decline in male testosterone over the last couple of years. What exactly is that decline if you had to sort of quantify it?

DR MOHIT KHERA: If you look at the original studies that we call the Framingham Heart Study back in the seventies, testosterone levels were roughly around the 700s. Average men between the ages of eighteen and forty were around the 700s. And every decade, we’re starting to see a decline almost by fifty nanogram per deciliter. And so the latest twenty fifteen numbers were roughly in the mid-400s.

So we’ve seen almost a three hundred nanogram per deciliter decline in serum testosterone, which is significant because it has two implications. It’s not just about the way you feel and energy, muscle mass, erectile function. But that low testosterone can have implications on fertility. That’s really important. So we didn’t talk about that. But fertility sperm need testosterone.

Low testosterone decreases your sperm count. Sperm counts have also been on the decline as well. So, you know, I think it’s really a testament to the fact that decade by decade, we’re becoming a more unhealthy population.

STEVEN BARTLETT: Do you think that’s really the heart of it? Is that is this sort of our diets and the way we live and becoming more sedentary, less exercise, more processed food, etcetera?

DR MOHIT KHERA: I think that’s the key. That’s absolutely the key. The types of foods we eat, the processed foods that we eat, high fructose, high carbohydrate diets, and the way we know that is just look at the obesity. Look at the diabetes. There has to be a reason why it’s on the rise.

Fertility Advice

STEVEN BARTLETT: And on that point of fertility, I’m in a season of life where I’m going to be trying to have kids pretty soon. What’s the most important things I should be thinking about from a lifestyle perspective in your view?

DR MOHIT KHERA: Yeah. So I tell patients Darwinism. In other words, survival of the fittest. Healthier people are more fertile. Right? You’re passing on the genes.

So essentially, we tell patients the number one cause of infertility in the world for men is a varicocele. A varicocele is the swelling of the veins around the testicle. You know how women sometimes can get swelling of the veins in their legs? You see those veins that are kind of obvious?

Well, men can get those veins dilated around the testicle, and those varicoceles can impair sperm production. Now fifteen percent of men in the world walk around with varicoceles, but up to forty percent of men with infertility will have varicoceles. So it’s really important to assess for the varicoceles. But lifestyle modification, each one again, diet, exercise, sleep, have been shown to help improve fertility in men as well. So I say healthier people are more fertile.

I need you to start getting healthier. That’s very important. We raise the testosterone level in many of these men naturally. We don’t give it to them to help improve their fertility as well. But check Steven, check your semen analysis. That’s the simplest thing you check it.

STEVEN BARTLETT: I did not.

DR MOHIT KHERA:

Semen Analysis as a Predictor of Overall Health

DR MOHIT KHERA: Yeah. It’s a great predictor. There were so many amazing studies showing that a semen analysis is a phenomenal predictor of overall health. Many studies showing that if your semen analysis today is impaired, it’s a predictor of you having comorbid conditions today like diabetes, obesity, metabolic syndrome. It’s also a predictor of prostate cancer.

We know that if you have infertility, you’re at a higher risk of having testicular cancer than those that don’t have infertility. It’s also a predictor of who will have problems in the future. Mike Eisenberg once showed a very nice study. Men who have low sperm counts can have a thirty percent increased risk in diabetes, fifty percent increased risk in ischemic heart disease in the future. Tom Walsh showed those men could have two point five times higher risk of high grade prostate cancer in the future.

So again, to me, it’s just a marker of overall health. Check the semen analysis.

STEVEN BARTLETT: I did that and it was quite nerve-wracking. To be honest, I was very nervous about it because as someone who’s in my early thirties and wants to have kids, I was really scared that it would come back and say that my sperm is dysfunctional. And I’ve got a huge amount of empathy and feelings for people that do those analyses and get bad results back.

The Prevalence of Infertility

DR MOHIT KHERA: Fifteen percent of all couples in the world suffer from infertility. That’s a lot. And if you think about it, thirty percent of the time, it’s a male factor. Twenty percent of the time, it’s a male and a female factor combined. So indirectly, a male is involved fifty percent of the time when you have an infertile couple.

And it can be devastating for that couple. I mean, psychologically devastating. And what’s also interesting is that most couples, fifty percent of couples, don’t seek therapy. And of those couples that do seek therapy, this is globally, only twenty five percent of those couples actually go forward. And so I call this a group of individuals that also suffer in silence.

They should know that there are excellent treatment options available.

The Alarming Decline in Testosterone Levels

STEVEN BARTLETT: This graph that I had printed out is just shocking to me. Going back to the point about testosterone. But the really shocking thing is how quickly this has happened. Because this is the year two thousand, and this is the year two thousand fifteen, sixteen year.

And the decline there is from roughly six hundred nanograms, is it?

DR MOHIT KHERA: Nanogram per deciliter.

STEVEN BARTLETT: Nanogram per deciliter to roughly, for some age groups here, four hundred nanograms per deciliter, and that’s only in sixteen years. So if you play that forward another sixteen years, there’s going to be a bit of an infertility crisis.

DR MOHIT KHERA: There is. Fortunately, that graph, it’s plateauing a little bit, which makes me feel a little comfortable.

STEVEN BARTLETT: Okay. Oh, yeah.

DR MOHIT KHERA: It is actually plateauing just a little bit, but you’re right. It could be a significant crisis. And again, as I mentioned, it’s the adolescents, the younger folks who are having the greatest rise of obesity, and that’s where fertility comes in.

Because fertility obesity in someone in sixties is not concerned about fertility, but a young patient who has infertility, obesity will have a higher risk of infertility.

Natural Ways to Improve Sexual Function

STEVEN BARTLETT: If me and my partner came to you and we said, listen. We’ve got sexual problems in the bedroom. What are the steps that you would look at that we haven’t focused on so much today?

Is there anything particular you’d say? I’m trying to stay away from being prescribed a pill, so I want to do anything natural I can before I get to that, and then we’ll talk about some of the other more drastic measures one can take.

DR MOHIT KHERA: So let’s talk about natural things because everyone wants to know about what’s the natural things I can do. So when we talk about diet, there’s certain diets that have been helpful to improve sexual function. For me, it’s the Mediterranean diet. The Mediterranean diet is rich in whole grains, legumes, fruits, vegetables. And if you look at red meat and sweets, it’s once a month.

If you look at poultry, it’s maybe once a week, but mainly fish. Those diets have typically been anti-inflammatory diets. Many studies have shown that that diet can significantly improve erectile function. And one study, the Medida trial, actually showed that it improves sexual function in men and women. So I’m a big believer in using the Mediterranean diet.

When Esposito did her first trial, it was a prospective trial, a hundred and ten obese men. Fifty five men get a Mediterranean diet. Fifty five men don’t get any intervention at all. She follows them prospectively for two years. What does she find?

Not only a significant improvement in endothelial function, remember that lining of the blood vessel, but a significant improvement in erectile function in these men. No Viagra. No pills. Nothing. Simply changing the diet improved the erectile function.

The same with sexual function in women. So that’s an important one.

The Importance of Sleep and Exercise

The second is sleep. Let’s talk about sleep. So studies show that if you’re getting less than six hours of sleep a night, it significantly increases your risk for sexual dysfunction in men and women.

Your ideal amount of sleep should be seven to eight hours. Now let’s say you say, well, that makes sense. Maybe I’m going to get sleep for nine to ten hours because the more sleep I get, the better my sexual function. But that’s not true.

It plateaus. So if above nine hours, it does not increase your ability or sexual function. So seven to eight hours of sleep at night, I need you to get.

Third is I really need you to focus on exercise. So I published a very nice study looking at it was a meta-analysis on how much exercise one needs and what type of exercise to actually improve erectile function.

In this study, typically, need one hundred and sixty minutes a week, so forty minutes, four times a week, for a course of six months of moderate to severe exercise, vigorous exercise. And so most people can get a hundred and sixty minutes in a week of exercise, but that’s getting your heart rate up and doing the exercise. Significantly improved erectile function in men if you did that. And the more severe your ED was, the greater improvement you saw in erectile function strictly by exercise alone. No other interventions even.

Just exercise. So here you have a patient that now is first doing some exercise, starts sleeping better, starts changing the diet. It’s all additive. You are now significantly improving erectile function just by lifestyle modification alone.

STEVEN BARTLETT: Pretty profound that exercise can have such a big impact, isn’t it? Is that the same for women?

DR MOHIT KHERA: It is true because many of the things – so unfortunately, once again, the research we have in women is not close to what we have in men. But the Medida trial was also in women. The sleep studies were also in women. And so these studies also show that sexual function can be improved with sleep and with diet. I think that men and women are not that different.

I mean, you see a significant improvement in a male sexual function with diet, exercise, sleep. You can also see it in women as well. Actually, there was a great study. This looked at one hundred and ten women, and they had coronary artery stenosis. They did angiograms on one hundred and ten women. And they showed that the greater stenosis she had, the worse her sexual function.

So the greater the blockage in her heart, the worse her sexual function. They put those women on a cardiac rehab program to actually improve their cardiac function, so a diet and exercise program. And those women that actually went through the program had a fourfold increase almost in their sexual function.

STEVEN BARTLETT: What? Four hundred percent?

DR MOHIT KHERA: Fourfold. Yes, sir. Because we use a questionnaire called the FSFI, which is a questionnaire. So significant improvement in sexual function just on improving cardiac function. So remember, cardiac function and sexual function are related, and it’s bidirectional.

You improve one, you improve the other. It’s very important.

The Prevalence of Erectile Dysfunction

We talked about this earlier. Forty percent of men in the world at forty will suffer from erectile dysfunction. Fifty percent at fifty. Sixty percent at sixty. Seventy at seventy. Eighty at eighty. You do the math.

It essentially is a very prevalent condition. This condition is associated with increased cardiovascular events. It’s the first sign of a heart attack. We talked about that. This condition is associated with two and a half times more likely to be anxious, three and half times more likely to suffer from depression.

And this condition is also associated with diabetes. In other words, men with ED, two times more likely to have undiagnosed diabetes. And yet, only fifty percent of men even talk about it because they’re so embarrassed. So you show me another condition in the world that affects more men’s lives that’s associated with more adverse conditions, and they’re too embarrassed to speak about it. They suffer in silence.

There’s not another condition. There’s not another condition, but yet we’re embarrassed to discuss it. I used to give these lectures. Now I’d look out to the audience and say, please raise your hand if you suffer from hypertension. And many people raise their hand.

They have high blood pressure. And say, okay, please raise your hand if you suffer from sexual dysfunction. No hands go up. But statistically, you know that over fifty percent of those people had sexual dysfunction. So why is it okay to raise your hand if you have hypertension, but not okay to raise your hand if you have sexual dysfunction?

It’s got to stop. We have to destigmatize. It’s okay to have sexual dysfunction. It’s a common condition. It’s curable.

STEVEN BARTLETT: Why don’t men raise their hands from a psychological standpoint? Why is that?

DR MOHIT KHERA: I think they’re embarrassed.

STEVEN BARTLETT: Why?

Destigmatizing Sexual Dysfunction

DR MOHIT KHERA: I think that historically, sexual dysfunction looks like a weakness. I’m not a man, less of a man. You know, you have hypertension, it doesn’t mean you’re less of a man, right? But they have this assumption that it’s a weakness, less of a man. And think that it’s okay.

You have to be comfortable saying that you have sexual dysfunction. There are amazing treatment options for sexual dysfunction. Amazing. That work very, very well. You just have to raise your hand and let me know that you have it.

I just want to make one other comment about diabetes. There was a study that came out of St. Louis looking at young men, eighteen to forty years old, and they were screening them for erectile dysfunction. And what they found was within those men came in for erectile dysfunction, thirty percent of those men had prediabetes or diabetes on that day, on the day they were being diagnosed, thirty percent. And I thought to myself, young men do not go get screened.

I remember when I was thirty years old, I didn’t go in for my annual blood pressure check and my annual sugar check. There’s no way I’d get my glucose checked. But if a young man gets erectile dysfunction, he is at my front door first thing tomorrow morning. They show up. That’s the first thing they’re going to do because it’s a very big condition to them, and they want to get treated.

And that is the opportunity to treat these young men and treat the condition. If you see a young man or someone who comes in for ED and you screen them for diabetes and I catch the diabetes at thirty as opposed to forty, that is ten years of damage on the vessels that you’re saving because you catch the disease early. So ED is the gateway to men’s health and to treating men early before it’s too late.

So I really use sexual health as a tool, a vehicle to improve overall health because men take sexual health much more seriously, particularly young men.

STEVEN BARTLETT: Have you ever had sexual dysfunction?

DR MOHIT KHERA: I have not.

STEVEN BARTLETT: Never in your life?

DR MOHIT KHERA: I have not.

STEVEN BARTLETT: I have.

DR MOHIT KHERA: But it doesn’t mean that it’s not okay if I did. There’s nothing wrong with it. Right? It’s normal. It’s okay. And it’s transient. It can be temporary and come back. Right? It’s nothing wrong with having sexual dysfunction.

We must destigmatize it. It’s completely okay.

Navigating Sexual Challenges

STEVEN BARTLETT: The reason I’m showing this is because if anyone else has been in the situations I’ve been in – generally, my sex life has been good my whole life, but there’s been certain times with certain partners or, you know, you might be drunk a little bit. Or, in the days when I was single, there was the odd person who, for some reason, it just wasn’t working for me. And there were other instances in a previous relationship where near the end of the relationship, I’d lose my erection during sex, and that became a little bit bothersome for me because I was like, oh my god. It almost made me not want to have sex with this person, or it convinced me that maybe I don’t like them anymore or something else was going on. And for me, it has always been what’s the word you use, psychogenic.

Yes. It’s always been in my head that the problems have arisen. And the other part of the thing that I’ve experienced a lot is in terms of libido. When work is very busy and I’m very tired and I come home very late, it’s not that I’m not horny, but the act of sex is just really unappealing.

DR MOHIT KHERA: But you’re just like everyone else. You’re not unique when it comes to that.

STEVEN BARTLETT: Yeah. But much of my life is like that.

DR MOHIT KHERA: Like, I’m-

STEVEN BARTLETT: I come home late a lot. Right. So I’m tired and stressed quite a lot.

DR MOHIT KHERA: Right. But what if I took you and your partner and put you on a beautiful island in Hawaii for two weeks?

STEVEN BARTLETT: Great sex. Okay. Yeah. So that’s kind of how we orientate our life, honestly. That’s genuinely how we orientate our life because I just don’t think the way I’ve – obviously I want to make lifestyle changes to make sure that I’m not always coming home tired and stressed at eleven PM. But one of the things that’s really helped us is going away on the weekends. Going away with you on Friday and coming back on Monday and getting out of the same context. So, like, getting out of the house and going to a – even going to a hotel room, especially a game changer that you can just go to a hotel room in the same city, like book a staycation.

Yes. And that seems to have a big impact because it just removes you from the context. And then going away for the weekends, holidays, and stuff. A lot of friends say to me, they go when they’re struggling with their sex life, they just book a local staycation. And I wonder what – also, I don’t have kids, so I’ve not experienced the impact that kids can have on the significant impact.

DR MOHIT KHERA: Really? Right. Because it increases your stress. Particularly for many times for the partner as well. So if you both are stressed because of the children, sex goes lower and lower on the totem pole.

STEVEN BARTLETT: And then the sleep as well. Right. If you’re not sleeping, if you’re going to wake up in the dark. Oh gosh. Isn’t the stats that say like when someone has a kid, their sex life like vanishes for eighteen months or something?

DR MOHIT KHERA: I don’t know. I’m not familiar with that, but I believe it. I believe it.

STEVEN BARTLETT: I read something about post having a kid libido, but also just like sexual function.

DR MOHIT KHERA: It makes sense. I see it in couples. And particularly, you know, many times, it can take years for them to start engaging sexually because the stress is so high, particularly when they originally have the child.

STEVEN BARTLETT: There was a British study done that found over eighty percent of women experience sexual problems three months postpartum with nearly two thirds still affected at six months. Yes. Which is a lot of-

DR MOHIT KHERA: It’s a lot of women.

STEVEN BARTLETT: A lot of women and a significant amount of time. So what about premature ejaculation?

Understanding Premature Ejaculation

DR MOHIT KHERA: Let’s talk about it. Very important. Sexual dysfunction – we’ve been talking about ED today. Right? But there are many different types of sexual dysfunction. There’s premature ejaculation. There’s Peyronie’s disease. There’s delayed ejaculation. We’re just focusing on one aspect.

Premature ejaculation affects thirty percent of men globally. You define that? There’s two ways to think about it. When they come in, you have to figure out, is this lifelong going their whole life, or is this acquired?

It’s very important because it takes me down two different roads. You say, look. I’ve never had premature ejaculation, and yesterday, it started. That’s very different than if you come to me and say, my whole life, I had premature ejaculation. And we now define premature ejaculation as having an ejaculation less than two minutes.

It used to be one minute, now it’s less than two minutes. You have to have a loss of control. Like, I couldn’t control it, and you have to be bothered by it. So if you tell me, Steven, look. I ejaculate in thirty seconds, and I’m happy. I say, great. Then we’re done. You know? You are content. You have to be bothered by the condition.

The average ejaculatory time in the United States is five point four minutes on average. The average time for a woman to achieve orgasm is typically thirteen point four minutes, so there’s a big discrepancy here as you can see. So thirty percent of men suffer, but we know that only a small percentage these men, nine percent of these men, will ever seek therapy. And it can be a significant problem in a relationship, and that needs to be addressed.

STEVEN BARTLETT: Okay. So there’s not like a time limit. It’s not like, okay. If you’re coming within two minutes, then you got a problem.

DR MOHIT KHERA: Well, let’s say you’re not bothered by it. Let’s say you and your partner are completely satisfied with it. What’s the problem? What’s the problem?

And sometimes, like, if you think about acquired, means that typically we define it as fifty percent less than your normal time. So if you say, look. I typically used to ejaculate in eight minutes, and now it’s four minutes, and it’s bothering me. I’d say, okay. That’s an issue.

So we talk, it’s relative. What’s comfortable for you? And some men will say, I think it’s very important to look at the definition. The treatment options are actually quite simple. One of the best treatment options is sex therapy because we can train your mind.

We can train you to delay that ejaculation. There’s techniques, the start stop technique, the squeeze technique, how we can delay it. But there is. But most men say, just give me a pill. I don’t have the time for this. Just give me a pill. But there are ways to do it with sex therapy, which I think are fantastic. Sex therapy is a cure. The pill is just a Band Aid.

Sex therapy is a cure. But the pills that we use, the most commonly used pills are antidepressants because they increase serotonin and make it harder to ejaculate. Well, that’s what we want in this situation. We want to delay the ejaculation. So we can use antidepressants. They sometimes have to be taken daily, which work better, or you may have to take it on demand. But if you take it on demand, six to eight hours ahead of time. So you need some notice.

STEVEN BARTLETT: But there’s going be significant side effects of taking antidepressants.

DR MOHIT KHERA: Yeah. There are side effects of antidepressants. So I try to stay away from them. And the other ones I try to use are topical lidocaine sprays. Because if I decrease the sensitivity of the penis, you’re more likely to be able to engage in sexual activity for a longer period of time.

So those are commonly used. So sex therapy and sprays are very easy to use. You don’t need a prescription for sprays, and they’re commonly used.

The TRAVERSE Trial and Testosterone

One thing that we have to talk about that’s really important is the TRAVERSE trial. It’s really big. Everyone historically has always said that testosterone is dangerous. It causes prostate cancer, and it causes a heart attack and a stroke. And in 2015, there were some studies that suggested testosterone may cause a heart attack. Before 2015, all the studies suggested that there was no increased risk. So in the United States, they mandated that there be a large trial, five thousand two hundred patients, six years long, strictly to decide, does testosterone increase the risk of a heart attack?

So myself and eight others designed the study, ran the study for six years, and we published it last year. It finally came out. And it showed that there was no significant increase in cardiovascular events, finally. But until that time, until that came out, many people said, I still believe that testosterone causes a heart attack. But when the TRAVERSE trial came out, the largest randomized placebo controlled trial ever published, we finally showed that giving testosterone did not increase the risk of a heart attack.

In fact, the study also showed it did not increase the risk of prostate cancer. Many people were worried that testosterone causes prostate cancer and no negative effect on urinary symptoms. So many people have thought that if I give testosterone, the urinary symptoms become worse. The study showed no worsening of urinary symptoms. So very important study.

The TRAVERSE trial finally came out. It’s the largest trial in men ever published on testosterone. Will it reduce my lifespan? Will low testosterone, I believe, will reduce your lifespan.

STEVEN BARTLETT: Oh, I mean, taking, like, testosterone injections and stuff. Sometimes I think about, like again, I don’t really know what I’m talking about here, but I think about athletes taking steroids.

DR MOHIT KHERA: Different. Okay. Those athletes are taking supraphysiologic steroids. So the normal range is typically three hundred to a thousand is a normal range, and they will take testosterone levels to much higher, two thousand, twenty five hundred.

STEVEN BARTLETT: Okay.

DR MOHIT KHERA: And there’s a reason for that. There’s something called a plateau effect. So if you take testosterone and you have better libido, you intuitively would think, if I take more testosterone, I’ll feel even better libido, but that’s not true. There’s a certain point at which it plateaus. So the more you take, you’ve already hit an on off button.

You’ve hit it. You’re done. The exception is muscle. The more testosterone your body sees, the more it upregulates androgen receptors in the muscle, and you put on more muscle. So bodybuilders are addicted to higher levels of testosterone, but they’re also taking other off label medications, Anavar, Deca, Winstrol.

They’re taking other medications, and those testosterone formulations have a lower androgenic ratio. Androgenic means facial hair, acne. They’re more anabolic. So it’s very different than what you’re taking. You’re simply or you would be taking is just all you’re trying to do is take a medication that you had before and put yourself back into the normal range. Nothing fancy.

STEVEN BARTLETT: So the more I’ve learned about testosterone, the more I start to think that maybe when I’ve had my kids and I’m done having kids and maybe I’m forty five, I should consider it providing that my levels are low.

DR MOHIT KHERA: And you’re symptomatic. If you’re forty five and you say, I feel great.

STEVEN BARTLETT: Yeah.

DR MOHIT KHERA: I’m gonna say, Steven, you’re not getting it. Right? I feel great. So if you say, look. I’m forty five. My levels are low, and I’m starting to have symptoms. I said, Now is the time to consider taking the medication.

STEVEN BARTLETT: Those symptoms you said were like tiredness, energy levels?

DR MOHIT KHERA: Well, the most specific are my libido has gone down. My erections are worse. My energy has gone down. Increased fat deposition, decreased muscle mass, poor sleep, and depression. And we have to talk about depression.

So early on in my career, I conducted a very large trial looking at depression and testosterone. And we had almost 850 patients. And we showed that men with low testosterone levels were much more likely to suffer from depression. Almost ninety two percent of those men with low testosterone had some degree of depression. And when we treated seventeen percent of those men actually had severe depression.

We treated these men for one year with testosterone supplementation, and that seventeen percent dropped down to two percent. Now I’m not advocating to treat major depressive disorder with testosterone, but what I am advocating for is to at least check the testosterone level in men who are depressed because it can help them. In fact, in our study, even the men who are on an antidepressant, like say Prozac, we put them on testosterone, those men also saw significant improvements in depression. So maybe some synergy between testosterone and what we call SSRIs. So again, it’s very important to check a testosterone level in men who suffer from depression.

STEVEN BARTLETT: You wrote a book called-

DR MOHIT KHERA: Recoupling. Yes.

STEVEN BARTLETT: A couple’s four step guide to greater intimacy and better sex. What are the four steps in this book? And you wrote this alongside-

DR MOHIT KHERA: Over ten years ago. Yes. So I wrote it with a sex therapist. She’s an amazing sex therapist. Her name is Mary Jo Rapini.

And we decided to write a book together to really help couples get through. So the four steps really are number one, foremost, communication. You gotta communicate. You gotta at least be able to tell each other. Did you know that only forty four percent of men who start developing ED even tell their partners?

Now think about that. You say, what do you mean they don’t tell their partner? You know what they do? They just start avoiding sex. They just start avoiding sex.

So they gotta communicate, number one.

STEVEN BARTLETT: And making excuses. Right?

Communication and Sexual Dysfunction

I lost my erection, I’d probably say, “Oh, sorry. I’m just tired” or something similar because I want to avoid blame. There’s much of the reason why it’s hard to communicate is because it can sound a lot like blame, and it also can make someone feel like you’re not into them. Right? So if I said something, maybe you’re not that into them. And also, maybe you’re not like that attracted to them.

So that could be the problem.

DR MOHIT KHERA: Yeah. That’s an issue. And that’s why the sex therapist is amazing. Right. That’s what they do.

That’s what they do. They work through these issues with couples, and they’re fantastic. But the number one step we put in the book was communication. You have to communicate.

The second chapter was my main chapter, what I wrote about. What can we do to improve sexual dysfunction in men and women? Testosterone replacement therapy, using Viagra, vaginal lubrications, local vaginal estrogen therapy. We didn’t talk about that. It’s critical.

For postmenopausal women, local vaginal estrogen therapy is very important. Decreases risk of UTI, decreases pain with intercourse. So very important.

STEVEN BARTLETT: Sir, what is that vaginal?

DR MOHIT KHERA: So younger women have estrogen in the vagina. That estrogen is so important. It keeps all the bad bacteria away and keeps the good bacteria within the vagina. It keeps the wall, the lining of the wall thick. It allows for the vaginal wall to function with arousal properly.

And as she gets older and she goes through menopause, the estrogen goes away. The bad bacteria come in. The risk of urinary tract infections go up. The wall starts to atrophy, means it gets thinner. It’s more susceptible to injury and tear.

It hurts.

STEVEN BARTLETT: Ah, okay.

DR MOHIT KHERA: So you can’t ask a woman to enjoy sex if it hurts every time she has sex.

STEVEN BARTLETT: I’ve heard a lot of women talking about that, about this idea that the reason they don’t like to have sex is because it hurts.

DR MOHIT KHERA: It hurts because when they lose the estrogen, the wall gets very thin, and it can tear. It hurts.

STEVEN BARTLETT: But even young women?

DR MOHIT KHERA: Young women, but it’s usually typically a different reason. They could suffer from vaginismus. There’s other things that could cause vestibulitis. But in older women, the most common cause is atrophy of the vaginal wall because of the lack of estrogen. So what do you do?

You give back local estrogen therapy. It can be in the form of a suppository, form of a cream. It doesn’t happen overnight. I tell my patients it can take up to three months. But after three months, they notice a difference.

And the urinary tract infections go away, the pain goes down. So these are simple things that women can do to help. Because again, if someone’s having pain with intercourse, man or woman, they will tend to avoid it. Right? It’s an important concept.

So the second chapter is really important on what are the many different things that you can do to improve your sexual function. The third chapter is really about intimacy. And the fourth chapter really is ways to improve your sexual experience. It was written by my sex therapist.

She talks about vibrators, masturbation. So there’s a four step guide that I think is very helpful. And I think what’s unique about this book is that really it’s two perspectives. It’s one who is the medical care that I provide and the psychological care that she provides.

Improving Communication in Relationships

STEVEN BARTLETT: Now she’s obviously handling the psychological side of things and she’s not here. But just on this point of improving communication, what is the best advice you’d give to people that are currently in a situation where they’re both kind of suffering in silence because they’re just not communicating with each other?

DR MOHIT KHERA: Number one most important is time. We don’t spend enough time. It’s basically the shadows in the night. You coming in, I’m going out, and you have to make time. That’s extremely important.

And the second one is open dialogue. You have to be able to express to your partner what you’re suffering from. Otherwise, you can’t get treated. You just have to be able to express it. But time, I think, is important and open communication and dialogue.

There’s nothing embarrassing about this. It really is something that needs to be destigmatized and the consequences of addressing it. So couples who engage in regular sexual activity have a significant improvement in their quality of their relationship. They tend to be happier and suffer from less depression. I mean, there are physical and emotional benefits from regular sexual activity.

STEVEN BARTLETT: In the opener of the book where you start talking about communication, there’s a sentence that says, “When sex isn’t going well, it can become ninety percent of the relationship, and couples seldom know how to communicate about any of these problems.” And that is true. You know, we’ve done a couple of conversations now in the diaries here about sex and intimacy in these subjects, and the amount of messages that I get from couples saying that everything else in their relationship is great. Everything is great.

Love this person so much, but there’s this massive elephant in the room. No pun intended, which is, the lack of sexual intimacy. Now when we talk about sexual intimacy, does it mean penetration?

DR MOHIT KHERA: It doesn’t. Because with the definition of sex, it’s the ability and the desire to engage in satisfying sexual activity. I have patients that come to me and say, “We do not have penetrative sex, but we have a wonderful sex life.” I say, “Great.”

If this is working for you because it’s satisfying sexual activity, you’re set. Right? It’s if you want penetrative sex and you cannot have it, then we will address it and we can fix it. But you get to define, Steven, you define what is satisfying sexual activity.

Sexual Aids and Enhancing Intimacy

STEVEN BARTLETT: On chapter four, where you talk about things like vibrators and stuff like that, I know that was the chapter handled by your sex therapist according to what you said. Is there any risk that using vibrators or other toys and tools will impact normal intimacy without vibrators? Like, are there any studies that say, okay, you get desensitized to the real thing if you start using a vibrator?

DR MOHIT KHERA: I’ve seen the opposite. I’ve seen that the studies showing that vibrators and these kinds of toys can actually enhance the ability of the relationship so that you could because you’re communicating as you’re doing it. Right? So you’re communicating with your partner what is giving me pleasure, what is not giving me pleasure.

You’re learning about each other. It’s a great tool to use to learn about each other. So when you’re engaging in sexual activity, you’re more aware.

STEVEN BARTLETT: I think it was a game changer for me. I’m going to be honest. I think like just having other things.

DR MOHIT KHERA: You know why?

STEVEN BARTLETT: You know why? It’s a game changer. And I’m not just talking about vibrators. I’m talking about all toys in the bedroom, whether it’s like dice or handcuffs or whether it’s something else, a blindfold, is just because novelty, doing new things for me is so critical as it relates to being excited sexually. And there’s only so many things you can do. There’s a relatively limited list of things you could do if you’re not bringing in other tools and toys and stuff. You know?

So I think that for me, it actually has helped me to prolong the novelty of my sexual relationship in a way that nobody told me about before.

DR MOHIT KHERA: Yeah.

STEVEN BARTLETT: Because I think as a guy, especially, I think you kind of think that toys are something your partner buys for herself maybe. Something she uses for herself. And now I think if anything, I’m the instigator of using other things.

DR MOHIT KHERA: That’s chapter four. And we prescribe vibrators for men. We use something called Viberect. It helps with men with delayed orgasmia.

These toys can be very helpful in a relationship.

STEVEN BARTLETT: I think she prefers the toys to me, personally, that’s another conversation for another time. What’s the most important thing we haven’t talked about that we should?

Peyronie’s Disease and New Treatments

DR MOHIT KHERA: Well, there’s a couple of things I want to talk about. One is we didn’t talk about Peyronie’s disease. It’s an important disease. Nine percent of men the world suffer from Peyronie’s disease.

STEVEN BARTLETT: What is that?

DR MOHIT KHERA: Peyronie’s disease is an abnormal curvature of the penis when it’s erect. So I want you to think about this. The way I can describe it is if I have a balloon. I put a piece of tape on the balloon. I blow the balloon up. What’s going to happen? It’s going to curve in the direction of the tape.

Right? So if a penis curves greater than sixty degrees, it’s prohibited for intercourse. Many of these men suffer from severe depression. It’s disfigurement. It’s disfigurement of the penis.

So think about it. Nine percent of men in the world suffer from this condition, and most men have never even heard what Peyronie’s disease is. And essentially, in the US, we have now one FDA approved treatment for this. It’s an injection called collagenase where we can put an injection into the rock plaque and break it up. There are surgeries that we can do to make the penis straight again.

But again, it’s very important to realize that patients who have Peyronie’s disease are also suffering in silence. They don’t know where to get the treatment. And there are many good treatment options, whether it be surgical or medical, to solve this condition. So my whole takeaway from this is this, is that I know that millions of people right now, men and women, are suffering from sexual dysfunction. I know they’re silent, they’re not saying a word because they don’t know where to go.

They don’t know what to do. But they have to realize that there are excellent treatment options available, and they should seek therapy. They’re not suffering alone.

STEVEN BARTLETT: What else?

DR MOHIT KHERA: I want you to think about sexual dysfunction as no longer a Band-Aid. We are not looking for Viagra. We are looking for a cure. We want a cure for ED. And a cure for ED could be based on many things, as I mentioned earlier, diet, exercise, sleep, stress.

We’ve also moved into a new generation of regenerative therapies in my field, stem cells, PRP, shockwave therapy. Now we’re starting to look at radiofrequency in our laboratory. We’re looking at hyperbaric oxygen. Men are looking for ways to cure this condition. They no longer want to take a pill to solve the problem.

And so I think that’s very important. And many of these new therapies are promising. I think shockwave therapy is very promising where we have a device that delivers shocks to the penile tissue. We’ve been doing this for five years, and it was invented in 2010.

It’s actually quite brilliant. If I take your finger and I take a hammer and I hit your finger multiple times, what do you think your finger’s going to do? Your finger’s going to start bringing in new blood vessels and new ways to heal your finger. So before urology, the cardiologists have been doing it for the heart for many years, and they would shock the heart many times, and you would see new blood vessels form. It’s called neoangiogenesis.

Orthopedic surgeons have been doing it for a long period of time. In terms of injury, in terms of healing injury, they use shockwave therapy. We are new to the game. But what we see is when you give these shocks, it can potentially improve the blood flow and sexual function in men. And I think the new era could potentially be hyperbaric oxygen therapy and also radiofrequency.

Radiofrequency is a way to increase heat within the tissue and improve sexual function as well. So again, I think what you’re going to see five to ten years as we move forward is new ways to cure erectile dysfunction. Stem cells potentially have some promise as well. But patients don’t want a pill anymore.

Trauma and Sexual Dysfunction

STEVEN BARTLETT: One thing we haven’t talked directly about, but we’ve talked about it indirectly, is the role that trauma plays in sexual dysfunction, and trauma in all of its forms. I think I had a partner who was very public again about the fact that the reason why they had sexual dysfunction was because, in their view, because they had been through a sort of traumatic experience. How often do you see that in your office? How often do you see a patient come to you, man or woman, with some kind of trauma?

DR MOHIT KHERA:

Trauma Disclosure in Medical Settings

DR MOHIT KHERA: We query all men and women if they’ve had any kind of trauma, sexual or just physical trauma. It doesn’t have to be sexual trauma. It could be any kind of physical trauma. I will tell you that most patients don’t disclose or not very commonly describe having it, but they will many times disclose it to the sex therapist, and I’ll find out on the back end, to be honest with you. But I think when someone discloses sexual trauma or trauma, it takes more of a relationship and time.

And on the first visit, sometimes they’re not forthcoming.

Penile Implants: A Revolutionary Solution

STEVEN BARTLETT: What’s that that you have in front of you on the desk? I’ve been hesitating talking about it.

DR MOHIT KHERA: This is a penile implant.

STEVEN BARTLETT: Oh, gosh.

DR MOHIT KHERA: And this is a device that was invented in 1973 by a very famous urologist named Doctor Brantley Scott.

Brantley Scott, I will have to brag a little bit, was from my institution, the Baylor College of Medicine, and it’s been around for fifty-one years. The penis actually has two bodies sitting on top, and it has the urethra sitting on the bottom. Those two bodies have muscle inside them or casing. This device is a surgery that I perform quite often, where we put these balloons or cylinders into those two bodies and fill them up. There’s a small pump that goes into the scrotum, and there’s a small reservoir that just holds water, normal saline, that goes behind the pubic bone, typically.

When a man squeezes this, he starts filling up these cylinders with water, and it gives him a very rigid, very good erection. When he finishes engaging in sexual activity, he’ll press this button here, and it will actually release, and all the fluid will come out of the penile bodies and go back into that reservoir. So theoretically, anyone who’s willing to have this surgery, we can cure ED, but it’s a surgery.

STEVEN BARTLETT: And what’s the consequence and cost of that in terms of sexual experience?

DR MOHIT KHERA: So monetary costs, I would say that in the US, Medicare covers this product. So that’s actually quite good. In terms of pleasure, men report no significant decline in pleasure. If you look at overall satisfaction, it’s greater than ninety-two percent per patient and partner with the penile prosthesis. So it’s a game changer.

It really is a game changer. Most patients have never heard of it, or most people have never heard of this penile prosthesis. But let’s be honest. If you had a bad shoulder, you’d get a prosthetic. If you had a bad hip, you get a prosthetic.

It’s a prosthetic that fixes an organ. And, Steven, the satisfaction rate is extremely high. But I’ll tell you something. You owe me something. Because when I brought this on the plane, and I went to security, they pulled this out and I had to explain what this was, and nobody had heard of it.

No one had seen this. I had to explain it, I had to pump it up and show them. And I had a little bit of an audience.

But I will tell you this. This is something that really has revolutionized the way we treat men for erectile dysfunction.

STEVEN BARTLETT: But this is surely like a last ditch attempt.

DR MOHIT KHERA: It is a last ditch attempt. Because if I take it out, no other treatments will ever work again. Oh, really? It’s the end.

So if I take it out, no other treatments will work again. So I want you to try every single option before we come to this.

When Is a Penile Implant Necessary?

STEVEN BARTLETT: What situation does someone have to be in for you to insert this into their penis?

DR MOHIT KHERA: So remember when I told you that forty percent men at forty, fifty percent at fifty, and most patients will take Viagra, but I told you Viagra is not a cure, it’s a band aid. What’s going to happen is that Viagra is just like that pain pill. And that pain pill eventually is going to happen is you can’t walk. Well, same thing happens with ED. Eventually, the meds stop working.

So once the meds stop working and then the second level, we use something called penile injections. Some men use penile injections. Once you’ve tried everything and nothing works, what are you going to do?

STEVEN BARTLETT: Okay. So this is like a last

DR MOHIT KHERA: What are you going to do if you still want to get—but if I look at satisfaction rates, if I give men questionnaires for the pill, for the injections, vacuum reduction device, for the implant, highest satisfaction is with the implant.

STEVEN BARTLETT: At what point? What do you mean

DR MOHIT KHERA: How satisfied.

STEVEN BARTLETT: From the starting point to

DR MOHIT KHERA: Right. If I

STEVEN BARTLETT: Because I’m starting at a point where I’m completely unable to get an erection. If anyone helps me get that thing up, my satisfaction is going to be really high.

DR MOHIT KHERA: Right. But let’s say you have an erection with a pill. You get an erection with an injection. You get an erection with a vacuum, and you get an erection with this. All four, you know, over time gave you an erection.

Which gave you the best erection, and which one were you most satisfied with? This will win.

STEVEN BARTLETT: It’s crazy. And can you still ejaculate with this?

DR MOHIT KHERA: Yes. No issues.

STEVEN BARTLETT: Gosh. I mean, again, I have tremendous sympathy because it ruins people’s lives. Right?

DR MOHIT KHERA: It does.

STEVEN BARTLETT: If you can’t perform in that way and it destroys your relationships, and relationships are, like, the essence of life.

DR MOHIT KHERA: Essentially, you’re taking someone who can’t have sex who can now have sex again. And some would argue that they can have sex whenever they want as long as they want with this device. It only goes down when you tell it to go down.

Unexplained Phenomena in Medicine

STEVEN BARTLETT: Doctor Moe, we have a closing tradition on this podcast where the last guest leaves a question for the next guest not knowing who they’re going to be leaving it for. And the question that has been left for you is have you ever experienced anything that you cannot explain from a position of rational materialism?

DR MOHIT KHERA: I mean, there’s so many things in science that we can’t explain, so many things that are idiopathic that I have no explanation for. For example, for fertility, which is something we talked about. Forty percent of men who come to me, our explanation is no explanation. We don’t know why you’re infertile.

So obviously, that’s very uncomfortable for many patients to hear that. But many things in science, I have no explanation for. And many things that I do have an explanation for, we find out ten years later we’re wrong. So I think that’s what comes to mind.

STEVEN BARTLETT: What about any personal experiences at all in your life? Spiritual, religious?

DR MOHIT KHERA: Yeah. I’m very spiritual. I’m very religious. Sometimes death. It’s hard to explain.

Hard to understand. Why? It’s real. I see it every day. We see it in what we do at work.

I see it personally in my own life. My father passed away at an early age from idiopathic pulmonary fibrosis. It’s a condition where your lungs start to scar. It’s probably the worst condition you could ask for. And he had a transplant at seventy, so he was pretty young.

And he retired at sixty-nine. And he worked very hard. He was a general surgeon, solo practice. And he said, “One day, I’ll enjoy. One day, I’ll enjoy.” And then at sixty-nine, he retires.

He’s ready to enjoy. At seventy, he gets idiopathic pulmonary fibrosis. At seventy, gets a lung transplant and lives for five years with someone else’s lungs, which is pretty tough. And his one message was, “Don’t wait till the end. Enjoy the ride.”

I wish I’d enjoyed the ride because waiting till the end, sometimes there may be no end.

Life Lessons and Work-Life Balance

STEVEN BARTLETT: And by that, I interpreted that to mean that he’d worked his whole life very, very hard.

DR MOHIT KHERA: Extremely hard.

STEVEN BARTLETT: And he just sort of delayed the gratification to a point that it it didn’t really come necessarily.

DR MOHIT KHERA: He thought it would come at seventy, and he’d enjoy the last fifteen years and enjoy. But at sixty-nine, he got idiopathic pulmonary fibrosis. At seventy, we got a lung transplant. At seventy-five, he passed away. And if anything I learned was don’t wait to the end. Enjoy the ride.

STEVEN BARTLETT: Are you doing that?

DR MOHIT KHERA: I am. Every second, I can.

STEVEN BARTLETT: And how do you do that sort of practically when you’re so busy?

DR MOHIT KHERA: So I make time. I meditate every morning. I work out every morning. I have my own time to myself. I pray.

I’m very religious. I think those are very important things that keep me going. It’s God, family, work, patients. I mean, it’s in order. My family is extremely important to me, and I make time for them as well.

And I think that keeps me grounded.

Closing Thoughts

STEVEN BARTLETT: Doctor Mohit, thank you. Thank you for the work you’re doing because as you say in your work, there’s a huge proportion of people, couples, men, women that are suffering in silence, and they are in search of answers. And there’s not a lot of people in your friendship group that are necessarily going to know this stuff or even talk about their own experiences with this. So I think it’s important to have these kinds of conversations that anyone in the private or comfort of their own home or with their AirPods on can tune into to get a better understanding. If there was a closing message for those people that are suffering in silence in some way, whether they’re couples, individuals, what is that closing message to them?

DR MOHIT KHERA: It’s okay to suffer from sexual dysfunction. It’s normal as we age, and there are many treatment options, good treatment options that can help you today. And I ask you to seek therapy. Raise your hand. Tell your doctor you suffer from sexual dysfunction because they’re excellent treatment options.

STEVEN BARTLETT: And if people want to learn more about you and your work, where’s the best place for them to find you?

DR MOHIT KHERA: Well, it’s my website, doctormohitkhera.com and SexSpanHealth.com. I have SexSpanHealth.com where you can learn all the different ways to improve lifestyle modification. I started a nonprofit called the testosterone project. It’s really geared at education, advocacy for testosterone. We’re trying to get testosterone approved for women in the United States.

I think that’s important. We’re trying to get testing done as well. We want everyone to be tested for testosterone. It should be norm as well, and we’re trying to get it deregulated. So, thetestosteroneproject.com is a great way to get information as well.

STEVEN BARTLETT: I’ll put all of those links below. Doctor Moe, thank you so much for the work that you’re doing, and please do keep doing it because it’s so incredibly important. Pleasure to talk to you.

DR MOHIT KHERA: Thank you.

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