Transcript: Urologist Rena Malik’s Interview on Shawn Ryan Show (SRS #250)

So squirting is this clear, odorless fluid that’s emitted at the time of orgasm. And it’s usually voluminous. It’s usually what I’ve been told tastes a little bit sweet. And so this is the fluid that some women, not all, so I’d say probably 40% of women will squirt when aroused fully.

Now, where is it coming from? Right. I think that’s what people want to know. Is it pee? And so obviously it’s coming from the urethra, which is the pee tube. And so the bladder, when it fills, normally you pee from the pee tube or the urethra.

Now it is coming from there, but it’s not urine. They’ve actually looked under microscopes and looked at, okay, let’s compare what’s in pee to what’s in squirting. And they’re similar, but different. So squirting is usually a very dilute form of urine and also has another substance in it called PSA.

So you guys might know PSA is something that you get tested when you’re screening for prostate cancer. The prostate emits PSA. It’s called prostate specific antigen. But, you know, think about when people develop, when babies develop, they start from the same structures, and then you have signals that say, okay, you’re going to become a female, you’re going to become a male. So we have homologs.

The female prostate is called the Skene’s gland, and that’s located basically underneath that urethra about 2 or 3 centimeters in. And it has these little tiny glandular structures that produce fluid. And so that is where the PSA comes from. So it’s a mix of a very dilute urine with this PSA substance that’s coming from the Skene’s glands when it’s stimulated or when you’re aroused.

And so there’s a few different theories that they’ve done lots of studies. Well, not lots, but they’ve done three or four studies on squirting. They’ve actually put dye into the bladder and then had people squirt and see, is it blue? They use blue dye. And they’ve seen, yes, it is blue. They’ve done studies where they’ll scan the bladder before someone squirts, and then the person squirts, and then they check the bladder again. Okay, it’s empty. So it’s probably urine.

And so there’s a lot of people who think, yes, it’s urine, but there’s other experts who would say, well, when you’re aroused, there’s a bunch of hormonal changes. And so it may change the way that your kidneys filter. And so you’re not getting exactly urine. You’re getting this very dilute fluid that’s very distinct in terms of color and odor and all that. But it is obviously coming through the bladder.

So I think ultimately there’s a lot of hubbub about it. At the end of the day, it doesn’t really matter, right? What matters is that is the person squirting enjoying it, right? Do they actually like it? And so when you look at that, what you find is that it’s mixed.

So some women are like, yeah, it’s a superpower. I feel great. I’m amazing. I can squirt. I really enjoy it. It’s very pleasurable. Other women feel like they don’t know what’s going on. They feel embarrassed. They feel like it’s messy. And other women are sort of ambivalent, whatever. Just kind of a mess to clean up, and it’s fine.

So I think the reality is that when you watch erotic films, it makes it seem like everyone squirts. And squirting is really amazing visual representation of pleasure. The reality is that pleasure, the way you can tell a female has pleasure is you ask her, right? Did you enjoy that? And what can we do differently to make it better or not better? Right? What was good, what wasn’t good? Just like you would ask anybody anything, right?

But we don’t do that. We want to see it. Right? And men are very visual because they ejaculate. So they’re like, oh, this is female ejaculation, which is actually different. But this is them reaching climax. I can be sure they’re climaxing because I see this visual representation of it.

And the reality is the majority of women don’t squirt. 60% or so don’t. And that doesn’t mean they’re not orgasming or having a climax. They are. And they’re probably having a lot of pleasure when they do climax. And even if they don’t climax, which some women struggle with, the entire process of having sex can be pleasurable.

So I think it’s really, let’s not focus on this one end product of sex and actually look at the whole thing and talk about pleasure as a society and talk about what that means for you and your partner and actually enjoy sex as something that we do and we join and we have this meaningful connection with another human being rather than focusing on these really arbitrary markers of pleasure.

SHAWN RYAN: So what is it about some females that enable them to do that versus others that, I mean, why do 60% of females not squirt?

RENA MALIK: Yeah, so we can’t be 100% sure, but I suspect that it is because of variations in anatomy and how women are aroused. So we think, yes, maybe if you arouse that Skene’s zone area, which is actually where we think the G-spot, or it’s actually a zone, G-zone is, is that right around that Skene’s gland, that maybe that would be more likely to cause someone to squirt.

The other thing is that, you know, it may be also how thick is that anatomy? There is variations. They’ve actually looked at ultrasounds and some is thicker, some is thinner, some is more, some Skene’s glands are more voluminous than others. And so there’s probably variation why some can and some can’t.

But again, it’s not mandatory. And I think that’s really the take home. It’s not mandatory. And just because someone can’t, they shouldn’t feel deficient in any way. And just because someone can doesn’t mean that they’re better than someone else. Again, the goal is pleasure.

And so I find it very awkward when some are like, oh, can you squirt? Oh, this is so amazing. That’s great if you can. And yes, there is some people who believe you can be taught to squirt. And again, I think there is some potential. You know, you can try to stimulate those areas. You can maybe fill the bladder. Don’t pee right before sex. There’s probably some things there that can make that more likely. But again, it’s not the squirting. It’s the pleasure that we want to focus on.

SHAWN RYAN: Man, that’s interesting. All right, so I want to move into, I want to do a little bit of a life story on you and then get into all the health stuff. But, I mean, where did you grow up?

RENA MALIK: I grew up in Buffalo, New York.

SHAWN RYAN: Buffalo, New York. What got you into urology?

The Path to Urology

RENA MALIK: Yeah, so it’s actually not something I even knew existed. It’s not a specialty. I went into medical school thinking I would be a cardiologist or something. And I went to med school. I did my rotations. And then I realized that I really liked surgery. I liked operating with my hands. I liked being able to fix a problem with surgery. Whereas when you take care of patients, medicine, it’s much more long term, trying to fix their issues.

But I didn’t love general surgery, which is surgery where you do all different body organ structures. And so I looked at the subspecialties of surgery, and so those were urology, orthopedics, ENT and ophthalmology, which is eyeballs. Ophthalmology, very quickly I saw one operation. This is not for me. I don’t like eyeballs. So that was easily taken off the table.

Orthopedics, very power tool heavy. The culture was very, at the time, bro-y and I was like, okay, I don’t really fit in here. And so then it was really between ENT and urology. There’s also other subspecialties. Oftentimes you have to go through a general surgery residency to do those, or neurosurgery is also separate. But that’s a very intense field that I wasn’t personally interested in.

So I looked at those two fields. I went to their operating rooms, I met the people, and I was like, okay, they both do pretty cool surgeries. They both have a very nice culture. But I honestly, when I met urologists, I was like, okay, I found my people. These are very smart, very intelligent, very innovative people. But they also don’t take themselves too seriously. Because when you’re dealing with genitalia all day, you just can’t be so intense about everything. It’s sort of a funny field and funny things happen. And so I was like, okay, these are my people.

And the reality is when you’re in medical school, you sort of take a leap because you can’t ever know what it’s really exactly like to maybe do the surgery or to be the one taking care of all the patients, all yourself. And so you take a leap of faith. You’re like, okay, I like this. I think this is going to be the right fit. And sometimes people switch their minds and go to a different specialty. But for me it was absolutely the right fit.

And I love every part of urology. I think we are very honored and privileged to take care of patients at their most intimate issues and take them through that. But we also get to take care of patients for a long period of time. So we take care of long lifetime issues so they don’t just come in, have surgery and leave. They may have to deal with medication or do other things. And so we touch base, we keep that long term connection with patients, which is really great.

Pelvic Pain and Reconstruction

SHAWN RYAN: Interesting. What is, you know in your intro, non-narcotic pelvic pain? Was it reconstruction?

RENA MALIK: Well, so there’s pain, there’s reconstruction. There’s pain medicine too. So pelvic pain is a really challenging issue for a lot of people. So they deal with chronic pain in their pelvic region. I see it in vets too. I mean commonly because it’s my specialty, but I see it and it’s very difficult to treat, and it’s very challenging for a lot of people to live with. And a lot of times they just get treated with pain medications. And so we try to offer them options that are not necessarily pain medications to help manage those issues.

But pelvic reconstruction is basically, we are sort of like the creative surgeon. So we’ll see a problem, and there’s multiple different ways to fix it, and you’ll sort of figure out what is the best way for that individual person. So it could be a narrowing of the urethra. It could be a narrowing of the tube that drains the kidney. It could be in women, when they have things like prolapse, where they have sort of a vaginal hernia.

There’s a variety of different surgeries that we can offer to help sort of reconstruct things when they’re broken. And sometimes they’re very complex, and sometimes they’re simple. But it’s sort of like, I was drawn to it because every surgery is a little bit different, and you get to sort of look at it and approach everything a little bit differently. And there’s no formulaic way to go about it. It’s sort of like, okay, every person is individual, so I have to look at them as an individual and really come up with the right plan for them.

Working at the VA

SHAWN RYAN: I’m just curious. I mean, it’s great to see somebody like you inside of the VA. I mean, I haven’t been there in a long time, so I don’t know how it’s really going, but didn’t have a good experience roughly about 10 years ago. And so I’m just curious, do you come from a family of veterans?

RENA MALIK: No, I just loved. So I trained in New York, and I went to the Manhattan VA and then when I started my first job, I worked at the Baltimore VA and I just love taking care of veterans. I feel, one, very honored to do so. You guys have served our country. You’ve done so much for us. So for me to be able to give you back some semblance of health is so valuable to me. I feel grateful at the end of the day.

And two, I just feel like it’s a different character of patient. They’re respectful, they’re kind. They want the best for themselves. They really do. And sometimes they’re struggling very deeply through some things in their life, but they have this drive to get better. And sometimes they don’t get the tools to do so, but they really do want to. They’re not going through life just accepting whatever comes to them. They want to get better. And I think that that is so unique. And honestly, it is really, I feel grateful every day that I get to go to the VA.

SHAWN RYAN: Well, thank you for doing that. And then your YouTube. So you said that you started in 2019.

RENA MALIK: Yes.

Starting the YouTube Channel

SHAWN RYAN: I mean, being a physician, and a really good one, I mean, how did that even pop up on your radar? Why did you start the channel?

RENA MALIK: Yeah, so when I was in academic medicine, I was doing research. And so one of the research areas that I found really compelled me was health literacy. So I would have patients come and they would get to see me for maybe 30 minutes, maybe 15 minutes, depending on what they were there for, and I would give them all this information, but it was just not enough time to really explain why and what.

I only have so much time because insurance only reimburses so much, and you’ve got all these pressures to see a certain number of patients or you’re going to get in trouble by the power of big brother. And so you get in this situation where you’re not able to really give patients the time and energy they deserve. And so you’re like, look, this is a problem that you have a lot of power to fix, but I can’t go through all of these things with you in 30 minutes.

And so I realized I really, really wanted to be able to reach people at home and be able to teach them so that they would be able to learn and understand better. And once I think people understand what’s going on with them, they can actually take the steps you need to take. But if you don’t understand it and your doctor just gives you a pill and says, go, bye, see you in six months or a year, you’re like, I don’t know what’s going on with me. And you just feel like that’s all you can do.

And even with surgery, I do a lot of quality of life surgery, and so if I do surgery on someone and they don’t understand what could happen, what complication could happen or how their life is going to change, I failed as a surgeon. Because I operated on someone who didn’t completely understand the situation. So I felt like this was something really important to me. But I realized that doing it through the traditional research route would take me decades before I got to a point where I was really reaching the masses.

So I said, let me try this. Let me try educating online. And so I was like, okay, I’m just going to try YouTube. And so for six months, I just made a video a week, and I had no idea what I was doing, but I just did it. And then as I started doing it, I realized, wow, there’s so much need for sexual health education. People know nothing. And they’re getting preyed on by people who don’t know much either, but are trying to make a quick buck. They’re preying on desperation. People are desperate to have better sex lives, and they will then pay money to get better sex lives to anyone that will offer it.

And so I felt like, okay, this is going to be what I give back to the world. I’m going to educate them on how to help them have better sex, have a better life, feel better. And it just was, after six months, I was like, oh, I have a thousand subscribers. That’s it. I’m going to keep going. And I felt like I was famous back then. I was like, this is great. And then I just kept going. And I’m still so grateful that people tune in to me every week and learn from me. And it’s so motivating, and it’s really amazing to be able to reach that many people.

SHAWN RYAN: Well, congratulations on all the success that you’ve done. Done an amazing job with it. I mean, I’m curious. I mean, do you get any backlash about some of the topics that you cover?

Handling Backlash and Controversial Topics

RENA MALIK: Of course. Of course. I mean, I think a lot of backlash comes from things that people feel very passionate about, and they feel like they know because of their personal experience. And what I really, I’ll give you some examples, but what I really want people to realize is I’m not trying to invalidate your experience. I’m just telling you what the science is. And your life experience is your life experience.

Example: Semen retention is something people feel very passionate about. Semen retention is the practice of abstaining from any form of ejaculation, whether it’s through a partner or through masturbation. And I started sort of No Nut November, and I was like, oh, let me just debunk this, because I was seeing patients who would try to abstain, and when they did, they would tense up their pelvic floors, which is these muscles sitting here in our pelvis that hold our organs up.

And then because of that, they would start having other problems. They would start either having pain with erections or ejaculation. They would start having the need to go to the bathroom more often, or they’d get constipated. And it was because they were white knuckling, trying to hold back, trying not to ejaculate. And it was causing them harm. And they were stressed. They were super, they felt like failures when they did. They were unhappy. They were feeling bad about themselves, and they were like, oh, I can’t do this. I’m struggling. I’m a failure.

And so I wanted to target those people who felt like, oh, I need to do this, because people are telling me it’s so great. And I’m like, look, it may be great for some people, and it may make you feel better, it may make you more able to focus on things or have more brain clarity, but that’s an individual experience, and it’s very nuanced. So I wanted to give people who felt this sort of failure or felt this sort of stress or anxiety around it to not feel that. Not feel like they had to do this to achieve some higher being.

SHAWN RYAN: I mean, how did that even, how did that, what’s the myth? What do you supposedly get out of No Nut November?

No Nut November and Semen Retention

RENA MALIK: So No Nut November actually came from a meme, right? Like, somebody was like, oh, No Nut November. We’re going to start November on November 1st. And by midnight, oh, I failed already. Right. But it took off.

But semen retention as a practice is actually like a Buddhist Taoist practice, and there’s some religious or spiritual background behind it. People felt that if they would abstain from ejaculation that they would be able to focus more on spirituality, on God or a higher power, and they wouldn’t be distracted by desire and urges for sex. And so that’s sort of where it came from.

And from that, they would think they would get all these health benefits. Like, they would get this brain clarity. They would get testosterone boosting. It would improve fertility, like, all these things. But the reality is those things have been looked at scientifically, and there has been no true meaningful increase in testosterone or fertility.

In fact, if you abstain for too long, you can harm your fertility. And so I think the reality is, is there a physiologic benefit? Not that we see right now, based on the evidence that we have, but if you see a psychological benefit, by all means, please go ahead. But just don’t make other people feel like they have to do that, because everyone is different and ejaculating or being intimate with their partner or masturbating may be a really valuable part of their lives that they feel like they have to give up on because they hear something that they think is like, oh, this is so much better for me to do this, man.

SHAWN RYAN: It just seems like something that would cause a lot of sexual frustration and that would be amplified during the month, as the month goes on.

RENA MALIK: But I mean, the thing is, some people, what happens is when you abstain, you stop. You may be able to, particularly for people who are very fixated on sex, they may be able to, then once they get over that hump, they may then also, oh, I’m more focused on other things. I don’t think about that anymore.

Like, the desire will naturally go down after some period of time because you’ve now overcome that constant urge. And that may lead to more productivity or more happiness or more joy in some people, but it’s not everybody. Right? And I think it’s very individual.

SHAWN RYAN: But, I mean, wouldn’t the body just take care of itself?

RENA MALIK: It does.

SHAWN RYAN: I mean, would a man just store up all of the semen for a month?

RENA MALIK: So what happens is, either you’re going to have a wet dream, so you’re going to have nocturnal emission. And so then that was the other thing. People would have wet dreams. They’d be like, oh, my God, I failed. And it’s like, no, you can’t even control that. Like, you are asleep and it’s normal and healthy. Like, your body is just taking care of itself.

Or they would just absorb it. Like, their body absorbs it. And your body’s constantly making more semen. Right. It’s just like it’s constantly doing that. So it’s sperm specifically, but it’s making more all the time. And so, like, there is no, it’s not like the actual semen itself has some powerful properties. It’s really just dealing with, I think, the mental aspect of it.

Viral Trends: Jelqing

SHAWN RYAN: Interesting, interesting. Let’s move into, actually, before we move on, are there any other viral trends that you’ve kind of had to correct?

RENA MALIK: Yeah, so there was one on TikTok for a while. There was a lot of people talking about what’s called jelqing.

SHAWN RYAN: Jelqing, yeah.

RENA MALIK: Which is like this practice to increase penile length and so it’s like you make an O with, okay sign with your finger and you actually sort of slowly extend the length of the penis over time. There’s exercises, stretching exercises, essentially. And so people would be like, oh, I did this and I increased my penile length and it was great. And so they were talking about this a lot.

And actually that sounds very safe, right? Like, oh, I’m just stretching, like, what’s the big deal? But sometimes, and you can probably realize men, when you tell them to do something, they don’t just do it, they want to do it the best, right? And so they’re like, but you don’t just, you tell someone to do something that might improve their life, they’re not going to just do it, they’re going to go 10x and do it even more. Right.

And so there’s actually some people who would come into the urologist because they’ve been doing this and my colleagues have talked to me. It’s even in some published data, people would jelq and they would come in and they would develop erectile dysfunction because they’ve now damaged their penis and that’s not necessarily reversible. And so it’s like there are ways to safely lengthen potentially, but jelqing is not one of them.

SHAWN RYAN: What are the ways?

Safe Methods for Penile Enhancement

RENA MALIK: So the safest way for length is a traction device. So you can buy traction devices online. These are sort of devices that slowly extend your penis with a little bit of pressure over time. And they are meant to be very minimal prep, like minimal tension over time.

So there are some that you least with six hours a day and go to sleep with them. There’s some that you can get that you can do 30 minutes twice a day. But they are a commitment, right. You have to be doing it a lot. And then they do work and they’ve been shown to increase penile length by about 2 centimeters.

SHAWN RYAN: When you’ve done it for 2 centimeters.

RENA MALIK: Yeah. For prolonged periods of time, for months on end, then you will see an increase. And that’s on average, right. So some may see a little more, some may see a little less, but that’s generally what they’ve seen in the studies. And so, yeah, I think there are ways to do it, but it’s a commitment, right? You have to be disciplined, you have to keep doing it and you have to, is that what you really want to spend your time doing? Right. And that’s fine if you do. No judgment, by all means. But I think that’s probably the safest.

Now there’s other things that are available. There’s surgical options. Basically surgical options are available to lengthen and enhance girth. Girth, probably the safest is to do fillers. Like women get fillers on their face. There’s the same sort of hyaluronic acid fillers that you can get injected into the penis, but they don’t last forever. They’re like 18 months or so and they’ll dissolve.

So there are options that’s safe. We don’t have a ton of data, but I wouldn’t inject anything else. So there are like permanent fillers. People have, like, in jail, have injected all sorts of things in their penis. Like, so all sorts of things which, please don’t inject your penis with anything.

But if you are very intent on doing it and you’ve talked to your doctor about it and it’s not like a psychological issue that needs attention from a psychologist because there is what we call small penis anxiety, right? People who really feel body dysmorphia, like there’s something wrong with them and that requires, not requires, but should have attention from a psychologist. So you can work on your thoughts around it.

But if you don’t have a dysmorphia and you just want a bigger penis, like, I think that’s the safest option in terms of an intervention. There are some people who will use vacuum erection devices or penis pumps. There’s no evidence in the literature that this actually results in enhanced girth. But some people report that they notice that.

Again, I think it’s all temporary when you’re using these traction devices and pumps. I don’t know that you’re going to have a lasting effect, but I don’t know. We haven’t looked at it in the long term in terms of scientific data. It’s only anecdotes, like what patients tell us and what we see.

So I think ultimately, I wish there was a way, right, like women can enhance their breasts. They can get breast augmentations, but men still don’t have that option, right, to enhance their genitalia if they really want to, in a permanent, meaningful way, yet in a very safe way. And I wish we had it because I think men, just like women, should have that option if they want it, right?

But at this time, you have one penis, it is very important. And if something happens to it now, you’re stuck with that complication. And so I just think it’s really important to think about that before you proceed with anything that’s irreversible.

Does Size Matter?

SHAWN RYAN: Now, I mean, this, I wanted to cover this later on, but we’ll just do it right now since we’re on the subject. I mean, size, does size matter?

RENA MALIK: Yeah. So this comes up all the time, right? Because we are in a society where size is revered, right? Like, you will see people joking about it. You will see, I mean, even my children will joke about their penis size and their prepubescent boys, right? Like, where did they learn this from? We don’t talk about it at home. Like, they learned it from their peers. So this is something that’s pervasive, right?

People automatically assume bigger is better. The reality is when you look at the data, people overestimate what average is. So they think average is like 6 inches erect. Average is more like 5.1 to 5.6 inches, depending on the study you look at. That’s erect, not flaccid.

And then, so fine, average is overestimate. We’re really bad as human beings at estimating. So when you actually look at people who, you show them like, this is a five inch penis, a six inch penis, this is a seven inch penis. What are you estimating? So when you have like an average size penis, they tend to overestimate the size. They think it’s like six or seven inches. And then when you have a slightly smaller than average penis, you tend to underestimate. And when it’s bigger, you tend to overestimate.

So we’re just really bad at one estimating. And a lot of men will measure their phallus and it’s so variable. How warm is it in the room? Like, how aroused are you in that moment? Like, if you’re more aroused, you might be a little bit tiny bit longer, a tiny bit girthier, right? And so it’s so variable that it’s hard to say, like, okay, this is my number. Like, this is how big I am, right?

And then it’s so in terms of pleasure, right? Because I think that’s what guy thinks, oh, if I have a bigger penis, I will more easily be able to get my partner to orgasm. It will feel better for her in a heterosexual relationship. And the reality is that’s not necessarily true.

Like, of course, there are women who prefer longer penises. They enjoy stimulation, deep stimulation during sex. But that’s not the majority. I would say 85% of women need clitoral stimulation. And the clitoris is above the urethra. It’s the area that is very sensitive. It is the homolog of the penis.

So it is essentially exactly the same. If you cut open a cadaver and you look at the anatomy of the clitoris and the penis, the clitoris and the penis look identical. The clitoris is just smaller and internal, whereas the penis is external. So if you stimulate the clitoris, you will reliably reach orgasm in the majority of women. And that doesn’t require a penis necessarily. Right. You can do that with your hand, with your mouth, with a toy, with a whole bunch of different things, and not necessarily from penetration.

Now, yes, will you be stimulating the clitoris when you penetrate? Yes, to some degree, because the clitoris is above the urethra, and so indirectly you will be stimulating it. And some women, like I said, the anatomy is variable. So some women may or not may orgasm more easily just through penetration alone.

But the large majority of women need either penetration and clitoral stimulation or just clitoral stimulation to climax. And so the reality is that size is not necessary for pleasure. Size is not necessary for a good orgasm. And it is something that we have just made into this big thing.

And if you ask women, like when we do surveys of women, 85% of them are like, I’m happy with my partner size and I’m totally fine with it. And it’s like 45% of men who feel like they’re satisfied with their size. So it’s a big dichotomy because we’ve made it to feel like it’s so linked to masculinity or the ability to provide pleasure. But the reality is not so much.

And when you look at even anatomy for women, the vaginal length before it’s engorged and aroused is about three to three and a half inches. So if you think about it, like, if you’re really large, you can’t even really penetrate the entire vaginal length. And so there’s actually products that you can wear, like buffers so that you don’t hurt your partner when you have sex with them if you’re a little bit larger than they are.

And so it’s not, it’s sort of like a fit. Right. Some people have a better, have a longer vagina. They may enjoy a longer penis. But again, it’s not universal. Right? It’s not universal.

SHAWN RYAN: What about girth?

Understanding Girth and Sexual Pleasure

RENA MALIK: Yeah. So girth, again, I think girth is because the clitoris goes deep into the pelvis and it goes around the vagina. There’s the clitoral bulbs and the legs of the clitoris. So when you have a little more girth, it can stimulate more of the clitoris. Right. You’re not just focusing on the top, you’re also getting the side of it. So it can be helpful. Absolutely. To be more girthy, but there’s a limit.

So, in fact, when they… This actually came out from people who do male to female to male surgery, when they were building phalluses, they realized that they were making them too girthy and it was actually difficult to have sex. So they actually had to look at what kind… What they did was they looked at what kind of sex toys women are buying to decide what was the right size for the majority of women.

Because they were, oh, we were just making them too big. And now this person who wanted… Who wants a penis is not able to use it because it’s too big for the partner to accommodate it. And so really, it’s if you look at what type of sex toys women buy, they buy a little bit longer than average and the same girth as average, which is about five inches or so.

So it’s very similar to the average guy. They’re not buying those really obscenely large sex toys. It’s just not. I mean, they might for a gag gift or something, but most women are not using those to pleasure themselves. And so that doesn’t necessarily… Meaning you don’t really need a lot more than average to pleasure a woman.

SHAWN RYAN: What is average girth?

RENA MALIK: Average girth is about 4 to 5 inches around.

SHAWN RYAN: Okay.

RENA MALIK: Yeah.

SHAWN RYAN: Okay.

RENA MALIK: Yeah.

Myths About Erectile Dysfunction

SHAWN RYAN: Wow. Interesting. Interesting stuff. So I wanted to, you know, erectile dysfunction. I mean, you see all the drug ads we see. I mean, it’s everywhere. What are some myths about erectile dysfunction?

RENA MALIK: Oh, there’s so many. I would start with, I think that the first time a man has an issue with an erection, he feels like it’s over. Right. And the reality is there is normal fluctuation. There are times where you will struggle to get an erection because we are not static human beings. You are not machines. Right. You are people.

And so you will feel stressed or anxious or maybe you won’t feel well that day, or maybe you had a really stressful day and your testosterone is lower than another day. All these things can play a role and you might have trouble getting an erection that day. It doesn’t mean you’re broken, it doesn’t mean that you’re doomed for a life of erectile dysfunction. But it often plays out that way.

Because the second a guy has an issue with an erection in the bedroom, the next time he’s having sex, he’s thinking about that. He’s not enjoying himself. He’s not thinking about, wow, this is so hot and I’m having the best time of my life. He’s thinking, oh my God, am I going to have an erection? Is it going to last? Is it going to go away?

And so you can’t be mindful and present and enjoy pleasure because you’re obsessing over this and it becomes this vicious cycle. So I tell all guys, all my patients, you may have a medical reason that you’re having trouble with erections, but every single guy also has problems thinking about erections. Every guy, every guy who has a problem with erections also has a mental issue because they’re thinking about it, right?

And women do too. It’s not just men. Women are, oh, if I can’t climax this one time, am I not going to be able to climax the next time? Right? They’re thinking about it too. But I think we see it very often, men, because if you can’t get an erection, it’s very visible. You can see it’s not happening, something’s wrong. Right?

And the reaction is often, oh, the partner might be, is something wrong with me? So now there’s a little bit of relationship conflict. And so there’s all these things compounded, makes it very difficult to get out of. And so I think that’s one of the biggest ones is that.

And then two is that… I did mention testosterone, but testosterone is not always the cause. In fact, it’s only the cause. Low testosterone causes erectile dysfunction about 3 to 6% of the time.

SHAWN RYAN: That’s it.

RENA MALIK: So it may be a part of it, but it’s not the only cause. Wow.

SHAWN RYAN: Only in 3 to 6% of the time it’s a testosterone deficiency.

RENA MALIK: Correct.

SHAWN RYAN: Interesting.

Erectile Dysfunction as an Early Warning Sign

RENA MALIK: More often it’s vascular problems. So high cholesterol, high blood pressure, diabetes, all these things play a role. And I will say, see, very, very healthy looking men whose cholesterol is off the charts. And I will say, look, this is what’s likely causing your erectile dysfunction. And you know, we can investigate further. But it behooves you to improve your cholesterol.

And so I think it’s also a really important sign of your health. I think people don’t realize this. They think sexual health is this thing we put in a box and we don’t think about. But oftentimes you will see problems with your sexual health long before you see them as anywhere else in your body.

And the reason is the blood vessels to the penis are significantly smaller, about half the size of the blood vessels to the heart. So before you have a heart attack, you’re going to see erectile dysfunction. And in fact, we’ve seen that, that when a man has an issue with erections, within seven years, 15% of those guys will have heart attacks. Wow.

And so it’s an opportunity for men. If you start having trouble, this is a wake up call for you to get your whole health evaluated. Make sure that you’re optimizing your heart health, your brain health, before you get a stroke. Right? All these things that in the long term will have you not having the life you want to live. Right?

Because if we think about sex, we want to live well, but we also want to have sex throughout our lives. Right. And if you start having issues, you have heart failure and now you get winded just walking a couple blocks right down the street, you’re not going to have sex, you’re going to be exhausted.

And so all of these things play a role. And so I find that anytime you think there’s a problem with your sex life, that’s an opportunity for you to get evaluated, right? To figure out what’s going on so that you can fix that part of your life and before it becomes a problem.

SHAWN RYAN: And with, I’m sorry, within how many years does 15%, 7 years. So it’s a… So it’s a… It’s an early warning system.

RENA MALIK: Yeah, we call it the canary in the coal mine. It’s that warning sign.

SHAWN RYAN: Wow. And then, I mean, with erectile dysfunction, I mean, does that mean… Does that mean there is zero erection?

Defining Erectile Dysfunction

RENA MALIK: No. So the definition is that you’re having trouble either maintaining or getting an erection. That’s sufficient for intercourse. So either you lose the erection before you penetrate, or you can’t climax because you’re not reaching it soon enough and you lose your erection before that.

Sometimes people get it confused. They’ll think, oh, I ejaculate very quickly. It’s erectile dysfunction. That’s actually premature ejaculation. It’s treated very differently. And so it’s important, when you go to your doctor to explain those things, because sometimes guys will come in and they’ll say, say, my erection’s not working. Right.

And so I will dig deeper. But sometimes if you go to your primary care doctor, they may not. Right. And that may be the only doctor you have access to. And so if you say, I’m not having trouble, I can’t, my erections are not working, they’ll give you a prescription and you’ll be on your way. But that prescription is not going to fix the issue if it’s an ejaculation issue.

SHAWN RYAN: Interesting. I mean, how do you determine if it is a psychological issue, whether that be erectile dysfunction or premature ejaculation or, you know, anything. I’m not thinking of. How do you determine whether it’s an actual, you know, something’s going on with the body versus a psychological issue where you freaked yourself out and now you have, you know, performance anxiety.

Diagnosing Physical vs. Psychological Causes

RENA MALIK: Yeah. So one is talk to the person, right. First I’ll talk to them, okay, what’s happening when you’re by yourself? Right. Do you get erections at night? Do you wake up in the morning with erections? Because that’s a sign that things are all working well, right?

When you wake up in the morning with an erection, that tells me, hey, your hormones are working, your blood flow is working. All that stuff is pretty good. Probably, right? Because your body’s doing it when there’s no stressor around, right. It’s just you’re sleeping, your body’s functioning normally. You get about three to five erections at night. And so… And you usually wake up with one. And so that’s a sign that they might are working okay.

There are tests that you can do. There’s even wearables that you can buy to do that. But wearables, there’s wearables that are now on the market. You can wear a ring around your penis that will measure how many erections you get at night, how long they last and how firm they get. And they’ll give you data.

But at the end of the day, those… That’s… I think some people really like that because they want to, they want data. They like to know those things. But at the end of the day, if things are functioning well and you’re happy and you’re getting morning erections and your partner’s happy, I wouldn’t stress about it.

It’s when you start feeling, okay, things are not going well. Okay, am I getting nighttime erections? That’s one. Waking up with one, two. If I masturbate, is it working fine? Right. And sometimes that’s… Your masturbation is different, but there’s no pressure. Right. When you masturbate, you’re not worried that your… Your partner might feel some way or whatever? There’s no anxiety typically around masturbation unless you feel shame about it, which is a whole different thing. So usually that’s another way.

Third way is we can do what’s called penile Doppler ultrasound testing so we can actually check the blood flow to the penis. So we’ll actually give you an artificial erection with a medication, and we’ll actually then test to see how fast the blood is flowing in, how quickly it’s leaving. And we have markers to say what’s normal and what’s not.

And so those are tests that we can do to be definitive. Yes, the blood flow part is working. Now, the hormone part, we check with blood work. We check if your testosterone is normal, if your free testosterone is normal, all those things. And there’s other hormone markers that will check as well if they’re low, to make sure they’re not playing a role.

And so those are things we can evaluate pretty well beyond that. I think everyone has a little degree of psychological component to it. Now.

SHAWN RYAN: How do patients get over their psychological anxieties?

Addressing Performance Anxiety and Cultivating Intimacy

RENA MALIK: Yeah, so it’s difficult. I’m not going to say it’s easy. I encourage them if they are willing to talk to a sex therapist or even a therapist that has some openness about talking about sex, because it’s really dealing with your thoughts and kind of working with those, and especially in the moment when you’re with your partner.

So it can be doing mindfulness exercises. There’s been studies on mindfulness that if you do 20 minutes of mindfulness every day, you’re more present in the bedroom, so you have more enjoyable sex because you’re able to really pay attention to what’s going on rather than getting lost in your own thoughts.

And I think just being present in general, cultivating that. I think the other thing about sex in modern day is it’s rushed. It’s like, we’re busy with our kids, we’re busy with work, we’re busy with that. And then we’re like, okay, we got five minutes. Let’s go. And there’s no… you haven’t actually made it feel desirable. There’s like, another checkbox to do, right?

And so it’s like actually, hey, when you were younger, you used to be like, oh, I can’t wait to see you on your date. You’d call each other, you’d text each other, whatever, you know, whatever it was. And you’d be excited to see your partner and potentially have sex with them. And there was like this whole thing, like you just felt so excited about it.

But when you’re in longer term relationships and the stressors of life come along, we often just are like, ah, we’ll do it when we get to it. We will have sex. It’ll happen. You’re always there, right? And so it’s like you have to be intentional about cultivating desire.

You have to be like, hey, foreplay starts in the morning, with a caress on the back or a flirty text or whatever, right? Whatever floats your boat. And feeling in the moment, excited. And I often tell people, instead of date night, where you go out to eat dinner, have intimacy night, where you are intimate together, you hold each other, you lie together, you explore each other’s body, depending on what turns you on, right?

But you actually make that a priority because it is valuable being connected with another human being. People who have more sex actually live longer. And I think partially it’s because of that connection they’re getting with another human being. And so it’s really important. And we’re losing connection so much with AI and the Internet and all these other things. We have to be intentional about keeping that.

The Science Behind Sexual Frequency and Health

SHAWN RYAN: I mean, how much, you know, we’re talking about, you’re saying people that have more sex live longer. How much sex should we be having? How many times a week should men be ejaculating?

RENA MALIK: Yeah, so there is science behind this and I’ll give you some data on that. So first of all, when you look at living longer, right? People who have sex 52 times a year, that’s once a week, live longer, have lower heart disease, have better health outcomes than people who have sex less often than that. So we know that for a fact.

And if you have… so a lot of veterans struggle with mental health, so they have depression, anxiety. People who have depression, anxiety and have sex more often, they actually don’t… they do better in terms of their mental health as well as living longer. So you might actually be improving your mental health as well as living longer. And so there’s evidence at least once a week, right?

And then in terms of how often should you ejaculate? There’s a very famous study where they had looked at ejaculation frequency and the risk of prostate cancer. And so they looked at databases where people filled out how often they ejaculated in the last month, and they put them into categories. So it was like 0 to 4, 4 to 7, 7 to 14, 14 to 21 and more than 21.

So what they found was that the guys who ejaculated 21 times or more a month, they didn’t specify through sex or masturbation, but they did more than 21 times a month, had a lower risk of prostate cancer. Now, is it the ejaculation…

SHAWN RYAN: Say those numbers again.

RENA MALIK: More than 21 times a month had a lower risk of prostate cancer. Now is it the actual act of ejaculation? Is it something else? I mean, there’s some theory that if you’re ejaculating, you’re sort of cleaning the pipes, right? You’re getting any stagnant fluid that might be in your prostate, you’re getting that taken out, and so that may be beneficial.

Now, I can’t say for sure because there’s not really a good way to test that, but basically what I tell people is, have sex, masturbate, enjoy pleasure, enjoy connection with another human being, and enjoy pleasure. Because for some people, masturbation is the only way they’re going to get pleasure. They don’t have a partner or they don’t have someone they can have sex with. So I don’t want to take that away from them either. Right?

And I think that those things are important for people to feel good. And there’s so much value to having orgasms, physiologically, right? Your heart rate goes down, your blood pressure goes down. Some people sleep better, some people have post-nut clarity, and they feel much better after they orgasm.

And so I think that, you know, it is something that we need to look at as a tool potentially to live better, you know, to have a healthier life, to be connected with another human being, to feel good, to feel pleasure. And I say this often, sex is play, and we don’t play as adults.

So play, enjoy life, be creative, have fun, and enjoy sex. Why is this something we have to hide behind a corner? It shouldn’t be. It should be something that we just openly welcome and we should be able to talk about sex and be able to express our concerns, our insecurities. And be open with… and the idea of being vulnerable, right, with another partner, with someone else is really powerful because to have great sex, you have to be vulnerable.

You are naked in front of another person, literally, physically and mentally, you are naked in front of them. And so you need to be able to be vulnerable and allow yourself to be vulnerable to truly experience meaningful pleasure. And so many people are so guarded. And sex is like just this thing you do, right for a quick release. But it’s actually so much more than that.

Partner Intimacy vs. Masturbation

SHAWN RYAN: Is there, I mean, are there any studies on whether you’re ejaculating with a partner versus masturbation? Is one better than another?

RENA MALIK: Well, in terms of how your brain responds, so there are certain nerve endings in our body that can only be stimulated by another human being. That a caress in a certain frequency, which is usually a loving caress, that is what turns those nerve endings on. And so that turns on different areas of your brain so it will stimulate more of your brain.

So you will likely have more pleasure and a higher, you know, sort of response to that. So in terms of experiencing pleasure, it will be probably more intense and more enjoyable with another partner compared to by yourself. But it certainly is, you still can enjoy pleasure by yourself.

The challenge, I think by doing it by yourself is I’ll go back to the example of when you’re a kid and you’re worried, you’re in the shower or you’re in your bedroom and you’re like, oh my God, someone’s going to walk in or someone’s going to be like, why are you in the shower so long? And so you learn to rush through masturbation and it becomes this just quick thing to get a release. It’s not a time to actually enjoy pleasure. Right?

And so I think that’s where it’s okay to explore your body and to feel pleasure by yourself and allowing that and using it as a tool to learn about yourself. What turns me on, what makes me feel good. I think particularly for women can be very useful in learning which sort of stimulation works well for you. And then you can communicate that with a partner.

And also exploring more than just your genitals. Your whole body can be an erogenous zone, right? You can stimulate anywhere on the body and almost anywhere on the body, someone can get turned on. So it’s really like, okay, we can use this, we can stimulate multiple areas of someone’s body and have them feel an amazing pleasure. That if you just focus on genitals is not going to be as robust.

Understanding Penile Implants

SHAWN RYAN: Interesting, interesting. I mean, let’s go back to the implants or penile. Is that what you call it?

RENA MALIK: Penile implants? Yeah.

SHAWN RYAN: I mean, are there a lot of people doing this?

RENA MALIK: Yeah, I mean, so I will say erectile dysfunction is very common. 50% of men over 50 will have erectile dysfunction. And every decade that increases by about 10%. So you can imagine there’s a lot of guys struggling.

Now because of medications like sildenafil or tadalafil, known as Viagra and Cialis, those medications help a lot of guys get erections without needing surgery. But before these medications were around, we didn’t have much. We had vacuum erection devices which are sort of similar to penis pumps, but they are medical grade. We have injections that you give yourself in the penis that work quite well. But some guys don’t want to inject their penis, which is reasonable.

And then we have surgeries. And so typically guys will go through these options and then if they still can’t get an erection, a penile option is a great option for them. And so what that is is we actually implant a device into the penis which they then either pump up with a pump in the scrotum when they want to have an erection and they deflate it when they’re done.

SHAWN RYAN: Wait a minute, they do what?

RENA MALIK: They pump it. They pump it. It’s got a little pump. I should have brought one with me, but there’s a little pump. You pump it up and then you get an erection and then we…

SHAWN RYAN: It’s inside your scrotum.

Understanding Penile Implants

RENA MALIK: Inside your scrotum? Yeah. And you can’t really tell. I mean, it looks sort of like there’s a little something there, right? But you can’t really tell that someone has a penile implant. In fact, in medicine we’ll get consulted like, “Oh, this guy has a priapism,” an erection that won’t go away. And sometimes they’ll be like, “Oh, the guy just has an implant.” So even other doctors sometimes don’t notice it is my point.

But so it’s very hideable. You don’t need to know. And then there’s other ones where you implant it and you just bend it up and bend it down. So when you want to have an erection, you bend it up and otherwise you bend it down. So there’s options.

They don’t make you larger or girthier. They give you what you have. So if you were to grab your penis and pull it, that’s how long it’s going to be. It’s not going to be longer. It’s not going to make you superhuman in terms of length or girth, but it’s going to give you function so that you can have sex and you can get a rigid erection when you want to.

And so I would say that it is a transformative surgery for a lot of guys who have been struggling and can’t get an erection and want to be able to get one and their partner wants to be able to have penetrative sex. Is it mandatory? No. You can obviously pleasure your partner with many different ways. It doesn’t need to be an erect phallus, but a lot of people enjoy that, want that, and it’s a great option for them.

Viagra vs. Cialis: Understanding the Differences

SHAWN RYAN: What is the difference between Viagra and Cialis?

RENA MALIK: So they are both what we call PDE5 inhibitors. They work by the same mechanism. Essentially, when you think about an erection, there is an ignition called nitric oxide, which then causes, and that usually comes from stimulation. You see something, hear something, feel something, turns you on, your nerves and your vessels release nitric oxide. Then that causes blood to flow into the penis and then it stays there, right? And that’s the erection. And then it goes down and blood flow leaves the penis and erection goes down.

And so during that process, one of the enzymes that will break down and cause the blood flow to leave, these medications prevent that breakdown. And so that’s how they work. And they work similarly, but they are slightly different.

So when you think about Sildenafil, which is Viagra, Avanafil or Vardenafil, which is Levitra and Stendra, those medications, they all work short acting. So meaning you take one about an hour before sex, you need stimulation. The nitric oxide has to come from some stimulation for them to work and you get an erection. Works in about 60 to 70% of guys.

It does require that you don’t eat with the medication. So sometimes people will eat a big meal and they’re like, “Oh, it didn’t work. But I got these side effects.” So they get side effects like headaches, flushing, stuffy nose, those sorts of things. But it does work in a lot of guys, allows them to have erections and have sex.

Now Tadalafil is slightly different because it has a longer half-life. So you can take this medication with food, which is nice for some people who like to have sex in the evening or they have dinner before and they can then take this medication and it works, but it lasts longer. So it can last for 36 hours. Meaning that if you take it on a Friday and you want to have sex on a Saturday or Sunday, you’re still good to go, which is nice for a lot of people.

You can also take a low dose every single day. So 5 milligrams of Cialis, because it lasts so long, you can take a low dose every single day. And I really like using that because it takes the psychological stress out of it. “Oh, I have to remember to take this pill. I got to do this, I got to do that.” You just sort of take the pill every day and then you’re good to go to have sex when you want to, right, for most people where it works well.

Now again, these medications are not 100% effective. Every medication that you take in your life will have some degree of inefficacy, but they help a lot of people, guys be able to get good blood flow to their penis and have erections and have sex.

Long-Term Effects and Safety Considerations

SHAWN RYAN: Is there any long-term effects if somebody is using that that may necessarily, they don’t necessarily need that?

RENA MALIK: Yeah, I mean, I think in terms of long-term, there’s obviously rare things that people will say like nosebleeds or things like that that are very rare, right? With Viagra, there are some receptors in the eye that are similar to the receptors that they work on. And so some people get blue-green vision discoloration and it can cause vision changes. So if you ever notice anything with your vision, you got to stop those medications.

The other risk is if you’re taking a medication called nitroglycerin or something you put under your tongue before you have chest pain. If you take both those together, it can lower your blood pressure to dangerous, almost deadly levels. So those are the two big contraindications.

But for most people, these are very safe, very effective. And Tadalafil, there’s some actually early data and it’s not mainstream, but that it might improve heart health. So they looked at how it’s taken in people who have cardiovascular disease and they’ve seen actually an improvement in outcomes. And even with muscle health, they’re seeing blood flow to the muscles being better. And it’s also great for guys who have an enlarged prostate because it can relax the prostate and allow you to pee better. So there’s a lot of benefits.

In fact, I just saw a study on women taking Tadalafil to help with overactive bladder. Now, it’s still very early. Again, this is not prime time. This is early data. But I feel like there’s a lot of benefit because ultimately with something like Tadalafil daily, you’re increasing blood flow throughout the body. So you’re actually not just seeing benefits of the genitals. You may be seeing benefits elsewhere and that could potentially be beneficial.

Now we don’t, these medications have been around for a long time and we haven’t seen any terrible long-term sequelae. Now could there be in the future potentially? I don’t know. But Viagra has been around for a long time and Cialis has been around for a good amount of time as well and people have taken it for decades without issue.

SHAWN RYAN: So I mean would it be in men’s best interest to, I mean it sounds like there’s a lot of other benefits other than. And so, I mean, would it be beneficial for men to be on 5 milligrams of Cialis every day?

RENA MALIK: You know, I can’t say that every guy should be on it, right? I do think there are benefits and I do think that if you have any sort of struggle with erections that I think that being on it is going to benefit you more than in more ways than just sexual function. And so I do recommend for almost all my patients should be on it because I think there’s more benefits than just sexual health.

Do I think a normal healthy guy should be on it? It’s hard to say yet. If I think there’s a long-term longevity life benefit for it, if I had to put money on it, yeah, probably there would be. But no one’s studying that specifically. And so yeah, I think maybe there might be a long-term benefit for being on it, but we don’t really know yet.

The Reality of Sexual Duration

SHAWN RYAN: Okay. What is the average length time-wise in sexual intercourse?

RENA MALIK: Yeah, so this always surprises people and in fact even my own friend got surprised. But this is a urologist. So when you look at the data and they actually look at people having sex and what they do is they tell people take a stopwatch, they give it to the female partner. They say start the stopwatch when you start penetration, turn off the stopwatch when you stop penetration. This around multiple countries and they found that the average length is about five to six minutes.

So a lot shorter than most people think and a lot shorter than you’re seeing on erotic films, right? And so that’s the reality is that that’s average. Now, if you look country to country, some countries are a little bit longer, some countries are a little bit shorter. For example, UK was longer, Turkey was shorter in the study that was done. But ultimately that’s the average length that a man will last during sex.

Now, does that mean that there aren’t guys? Of course there’s guys who last longer and of course there’s guys who ejaculate more rapidly. Now what does that mean? Right. So actually, interestingly, if you look at mammals who ejaculate, they all ejaculate rapidly. There’s no pleasure or enjoyment. It’s really for the purposes of having a baby or procreating. And so they quickly get done quickly because it prevents, one, they won’t get caught by a predator. Two, there’s competition, they’re first, right? So the next competition can’t come and get in the way, right?

And so there’s actually an evolutionary advantage for people who, mammals who ejaculate sooner. In humans, it’s different, right? The ejaculation, length and pleasure. We actually continue to have sex long after fertility is an issue, right? Long after women pass fertile ages. People continue to have sex because it’s pleasurable.

And so this idea of lasting longer, obviously, again, another thing that society is like, “Oh, it’s so great, you want to have sex forever.” But I also see guys who have what we call delayed ejaculation. So they take longer than 30 minutes to ejaculate. And while that’s less common, it definitely happens. And those guys are stressed too, because it’s exhausting. It’s like there’s so much friction, it becomes uncomfortable for their partner, it becomes uncomfortable for them. They’re working so hard and it’s no longer fun.

And so what I tell people, it’s not about fixating on how long you last. It’s like, are you enjoying yourself? Is your partner satisfied? And the reality is that women take a lot longer to get aroused and to get to climax. So women on average take about 14 minutes when they’re with their partner to reach climax. It’s less when they masturbate, eight minutes. But again, men take about five to six minutes.

So you realize that you have to prioritize female pleasure if you want her to climax because she’s going to take longer. It’s also going to take her longer to get aroused. And so really that’s where the difference lies. And so it’s really figuring that out for you and your partner. How do we work together so that everyone achieves pleasure and that we’re having a good time? Because the time that it takes is not the issue. It’s how much pleasure can you get from having sex and how do we maximize that?

SHAWN RYAN: Wow. So that’s a pretty big, I don’t know if you’d call it a big discrepancy from 5 minutes to 14 minutes. So, I mean, what do you recommend?

Sexual Intimacy and Arousal

RENA MALIK: Yes, I recommend that you start by, you know, first of all, make sure your partner’s aroused. This is the thing. I think women take a lot longer to get aroused. They also take a lot longer to be present in the moment. Right? They ruminate about a lot of things.

And when they’re younger, it’s about body image and insecurities, and that can evolve. Women become more confident in their bodies as they age, but then it’s like all the other things in their life that they’re stressed about. Their kids, their parents, whatever they’re dealing with in their life, and they have a hard time shutting that off.

And so one, it’s like getting them in the mood, like, spending time with them, allowing them to feel desire and to feel arousal. So what happens a lot of times with both men and women, but more often with women is they get what’s called responsive desire.

So when you’re younger, you think you see your partner, you’re like, damn, they’re so hot. We want to have sex, right? You’re turned on immediately, like, there’s no need to do anything. You’re just like, you see each other and you’re turned on. You want to have sex. That’s it.

But as you’re with a partner for a long period of time or, you know, as you evolve in life and you’re busier and you’re more stressed or whatever, you get what’s called responsive desire. So you actually need to be aroused a little bit before you start feeling desire.

So you’re like, oh, it’s like going to the gym. You don’t really want to go until you’re there. And then when you’re there, like, thank God I went to the gym. I feel great. So it’s sort of like, yeah, I didn’t really want to have sex, but now that I’m turned on, like, oh, there’s the desire. Oh, I remember. I like this. This is really fun.

And so it’s not an abnormal thing. It’s actually a completely normal brain response, right, that you sometimes need to get your head in the right place and allow desire, right? Allow some arousal to happen.

And so that’s why I love, like I said, intimacy time. Like, hold each other, be together, be physical, touch each other, whatever. I mean, obviously everyone’s not into touch, but figure out what it is that gets you turned on and allow it to happen, right? Like, in a mutually consensual way.

And that’s why sometimes it’s like, hey, let’s have this night where we’re going to do this, right? Let’s actually give each other the time where we’re not looking at our phones, where we’re not distracted or thinking about something else. We’re just focused on each other.

I mean, thinking about it before phones, right? You’d be lying in bed, there’s nothing to do. You’re like, okay, well, I’m bored. Let’s have sex, right? You’re right next to me and your body’s right here. And oh, this feels warm and nice and cozy. And you would have sex with your partner.

And now it’s like, well, you don’t. You have something else really exciting to look at that has so much interesting information. And whatever you’re interested in in the moment, you can read about it or watch it or whatever. And so you’re doing that until you’re dead and you’re like, I’m so tired. And you fall asleep. You put your phone and you go to sleep, right?

And so there’s just not as many opportunities, right? Because now there’s so much more to distract you than there was before. So we have to work a little harder.

The Importance of Foreplay

So that’s one, is making sure that they are in the moment. But two, prioritizing foreplay and actually spending time getting them aroused. Because it’s not that they need penetration. Like I mentioned earlier, penetration is not necessarily how they’re going to climax. It’s going to be clitoral stimulation and sometimes both.

But you need to sort of focus on foreplay and making sure they feel pleasure and feel that desire turning on. The ramp up to, I mean, everyone can relate to this ramp, right? You feel like you’re turning on. It goes up and up and up until you climax.

And so you’re trying to get them to get up that ramp a little before you do so that they can get there. And then you both can sort of try to climax around the same time or she climaxes before you. Either way, you know, it allows you to then to make sure that you both are feeling great pleasure.

SHAWN RYAN: I mean, so we’re just talking about, you know, average length of sex, you know, and how long, you know, on average men last versus women. And you know, is there a, I mean, what is too long?

RENA MALIK: Well, again, too long is how long is too long for you and your partner. So some people, they’re fine with however long, right? Even so I have people who have very short sexual encounters and they love it. And they have people who have long sexual encounters and they love it.

It really is bother. That’s the key. Like, are you or your partner bothered? Does it cause distress or relationship conflict or issues? If it doesn’t, who cares, right? Like, just be yourself and enjoy each other. As long as you are both having a good time. Or if there’s more than one person, more than two people in the bedroom, if you’re all having a good time, by all means, continue doing that, that’s fine.

It’s when there is a loss of pleasure, distress, that we need to worry, and then we can talk about how to fix it, right? Even if you don’t meet some clinical definition, but you’re like, this is too long or too short. Let’s talk about it because we can sort of help you figure out what’s going on. Maybe there’s a psychological issue, maybe there’s a medical issue. Regardless, it’s all things that we can work with you on.

What Women Find Attractive

SHAWN RYAN: Thank you. Thank you for that. There’s just so many questions that are coming to my mind. But I mean, when we talk about, you know, I saw a video. I didn’t watch this one yet, but it was, I believe it was something about, you know, what females find attractive.

RENA MALIK: Yeah, what.

SHAWN RYAN: What do females find attractive?

RENA MALIK: Yeah, interesting. A lot of people think it’s like tall men, right? Physically, I’m saying not emotionally necessarily, but it’s all this idea of like, oh, women all want tall men. Now, that’s true that height matters, but what actually matters is, at least in the data that I found, was that strength.

So the display of upper body strength is very attractive to women. And this makes sense evolutionarily, right? Where you would need to maybe fight for resources or you need someone to protect yourself. Having somebody who is stronger is more likely to one, protect you and two, also get those resources that you would need. Right.

And so evolution, it makes sense that when you see someone who is very developed in their upper extremities or their upper body, that you would feel like that’s the right partner who can protect me and who can also get resources for me.

And so that’s one, and the other one is like having sort of a V shape. So your shoulders are broader than your waist. And that’s not only showing obviously upper body strength, but it’s also showing metabolic health. Right.

So if you have a smaller waist and you have less visceral fat around your abdomen, you are more metabolically healthy, which means that you probably have better genes that you’re then going to pass on to your children that you might have with this person. Right.

And so there’s actually reasons why women find certain things attractive. Now, height. If you look at the data, they’ll say like 70% of, when you ask women like, okay, what’s important, 70% of that attraction quota is the strength. And then if you add another 10%, 80, you’ll get go up to 80% if they’re tall.

So they’d rather have an average height strong guy than a tall, not strong guy. Does that make sense? And so it’s really about how you portray this strength and health through the visual eye, like what they’re seeing.

And interestingly, this is obviously more important when you’re just trying to hook up with somebody. But when you start looking at long term partners, that still matters. But then it becomes also like, are they kind, are they going to stick around and be with you and be the right kind of honest person that you can depend on and they can be reliable. So that becomes also part of the picture when you’re looking at a long term partner.

SHAWN RYAN: Anything with the penis, I mean, you.

Does Penis Size Matter?

RENA MALIK: I think you can’t see specifically, right. When you first courting someone, they’re not walking around naked. So you can’t utilize that. And I think that like I said, most people, as long as they’re feeling pleasured by their partner, the size of the penis matters less.

And that’s true even in the data, like I said, there are some women like maybe 10 to 15%, at least in the data, that are very focused on penile length. And that may be because they may really enjoy deep penetration because that stimulation may lead to orgasm from cervical stimulation.

And some women actually find that painful, but some women actually really like that. And so they may really enjoy that feeling, and that may allow them to feel pleasure. In those cases, that just might not be a right fit for you, right?

If that person is like, I need a guy who is really well endowed, well, more power to you. We’re not the right fit, right? Because I can’t give that to you. I mean, unless you feel comfortable wearing a strap on or something. Right? But for most people, that’s not going to be the right fit.

And look, we don’t fit with people because of personalities, because of a variety of things. And so it’s okay if sometimes it doesn’t fit because of genitalia, right? But it’s like, that doesn’t mean that there’s something wrong with you. It just means that that’s not a fit, right? And there’s going to be another person where that is a fit, and so that’s okay.

SHAWN RYAN: Right.

RENA MALIK: It’s just like anything else. There are things that you need in a partner that they may not meet that criteria and they may not be the right person because that’s a deal breaker. And there’s other things where you can compromise on those things. And the same goes for sex.

Oral Sex and Semen

SHAWN RYAN: What about, let’s move into some other sexual activities. Oral sex. I mean, I’ve read, I don’t know if any of this is factual, but I mean, I’ve read that there are supposedly some type of health benefits for females to consume semen. Is there any truth to that?

RENA MALIK: Yeah, there’s not a ton. So there’s, you know, if you actually look at the nutritional value of semen, it’s very little. So it’s very marginal. Yes, there is some protein. Yes, there are some vitamins and minerals and stuff in semen, but it’s not any, it’s not like the equivalent of a multivitamin, right? Significantly less.

But there’s no harm either. So if you enjoy that and your partner enjoys that, by all means, go ahead. But you don’t need to make semen smoothies or other, you know, you’ve seen those videos. But you don’t need to do that, right?

If you enjoy that, if some people have kinks and fetishes, they have a cum kink, right? And they enjoy that, that’s fine. Great. By all means, that’s you. I don’t want to yuck anyone’s yum. But it’s not necessary.

SHAWN RYAN: What about, you know, semen volumizers or people that are trying to, you know, increase the load?

Semen Volume and Ejaculation

RENA MALIK: Yeah. So again, I think that that comes a lot from erotic films, pornography, right. Like, they see these people having very large voluminous loads, and the partner in the video is like, oh, my God. It’s just like this amazing thing.

And so the reality is that the amount that comes out, it’s really small. It’s like a tablespoon. If you look at the average amount, and we’ve actually done this because we do it for fertility, you actually measure when you get a semen analysis, you measure how much comes out. So there’s an abundance of data on semen volume because of that sort of research. And the average is about a tablespoon, like 5 mls, 5 to 10. And so it’s not a lot.

And so when you think about what you’re seeing on these films, oftentimes it’s very augmented through video editing. Other things are being exploded around the genitals that look like it’s coming from the penis. So that’s one.

Two is, it’s variable through age, and there’s force variability. So when you’re younger, you have very robust pelvic floor muscles. And pelvic floor muscles are the muscles that sit in the pelvis that are responsible for so many different functions. But one of the functions that they’re responsible for is they contract when you have an orgasm.

And they contract at like a rhythmic, like 0.8 seconds. And they give you that pulsing feeling when you have an orgasm. They also help you propel semen forward. And so when they are strong, like when you’re young and healthy, they will propel up to like 15 to 30 centimeters. So pretty far, they can propel pretty far. And that can look more voluminous because of going further.

And when you age, it drops half that, and some guys will come in and they get to dribble now, or it’s like very not forceful. And that’s because their muscles are just not as strong anymore. And you can work on strengthening muscular health, including your pelvic floor, but that’s the reality for most people.

The volume also is variable. It depends on when was the last time you ejaculated. Like, if you abstain for five days, it’s going to be more voluminous. And if you don’t abstain, and you just ejaculated the day before, it’s going to be less voluminous. Also, how much did you drink that day? How hydrated are you? There’s a whole bunch of factors, just day to day that play into it.

And so, yes, you can store it up for five days and fifth day and go, wow, that was a pretty big semen volume. And so, again, it’s not a reflection of your fertility because only 5% of the entire volume is sperm. Most of it is all these fluids that help nourish sperm, help them move through the female genital tract. They’re there for a reason, but the large majority of it is not sperm.

And so the only way you can know your sperm health is by actually getting a semen analysis and actually testing that. And when we do those, we actually ask you to abstain for 24 to 48 hours before you give it. So we have a reference. This is what the average guy has after one day of abstinence or two days of abstinence. And so you should be around this. This is what’s average.

SHAWN RYAN: What are those? You mentioned some exercises. What are those exercises?

Pelvic Floor Exercises

RENA MALIK: Yeah. So I’m cautious about saying this because I don’t think everyone needs to do them. So there are pelvic floor exercises called Kegel exercises that most people have heard of that can strengthen the pelvic floor. Now, you don’t have to just do those exercises, but those are the most popular. They have the best PR of any exercise I’ve ever seen.

But essentially they are, so for guys, I tell them, it’s like you are lifting your penis from the ground without touching it. That’s sort of that. Or if you’re peeing and you stop the stream of pee, you’re actually activating those muscles. So you don’t want to do it when you’re in the bathroom, but you can use it to learn what that feels like.

And then you do those periods just like you do crunches or you go to the gym and you do reps. You do like 10 reps in the morning, 10 reps at night. You need to make sure you rest and you breathe just like you would do at the gym. You rest, you breathe, you make sure you’re not just squeezing, squeezing, squeezing real hard. You squeeze and relax and squeeze and relax.

Because you can get dysfunction. Which is why I don’t tell a lot of people to just everyone should do them, because some people will actually have dysfunctional muscles. And guys, it’s very under diagnosed. No one’s really testing their pelvic floor because it requires a rectal exam. Finger in the bottom.

And so to test, are your muscles tense? Just like people get TMJ, they clench up their jaw, their pelvic floor muscles can get tense. And so they can tense up and they won’t really know that it’s happening, but it will cause these other issues. And so if you strengthen an already tense muscle, you’re going to create more problems. So not everyone should do it.

But if you have normal function, everything’s working great, it’s probably reasonable to go ahead and try doing those exercises to strengthen those muscles. It may help you with having a more forceful ejaculate. It may help you with getting stronger erections because there’s more blood flow going, you know, it’s causing more blood flow to come to the area because you’re getting more, just like any exercise.

And it may cause you to have more intense orgasms because you have more muscle contracting when it does contract. And so it can be beneficial and it can be a great way to augment your sex life. But again, it’s not for everybody.

SHAWN RYAN: And then, and how long is it? Five days. It takes a man to fully reload.

RENA MALIK: Yeah. So when they look at, I mean, actually you’re constantly making sperm. So on average it takes about 24 to 48 hours after ejaculate for you to get the semen back in. I’m sorry, to get the sperm back into the semen.

But you will have some potentially in the tract, other things, but you still have some. It’s not like it just all goes away and then there’s nothing left. There’s storage mechanisms and things. But in terms of if you’re trying to get a partner pregnant, ideally we say every other day will allow you to replenish and have the most amount of sperm getting to the egg, if that’s what your goal is.

Anal Sex

SHAWN RYAN: Anal sex.

RENA MALIK: Yeah.

SHAWN RYAN: Any benefits?

RENA MALIK: Well, so like I mentioned, we talked about the Skene’s gland or the G zone. You know how some women find that really pleasurable? That area is similar to the prostate. So some people, and there’s also the clitoris and the legs of the clitoris that are around there. So they’re all around the rectum and the anus.

And some women will find it very pleasurable to have something inserted in the anus and that will augment their pleasure. And so not everyone does. But just like some people find certain things pleasurable, some people don’t. So in terms of health benefits, not really. But in terms of pleasure benefits, yes. For some people, that can be a great way to, for them to feel pleasure. It can be augmented with other things. Like you can stimulate them clitorally at the same time, whatever. There’s different ways to use it.

But what I will tell people is it’s not like you can’t just have anal sex if you’ve never done anything in the anus before. You need to prepare. Sometimes that means using a toy or using a lubricated finger to get the anus ready or prepared to have a phallus inside. You also need to, there’s no natural lubrication, so you need lube.

And go slow, go easy, take your time, and talk. You have to communicate. You have to be like, is this okay? There has to be a back and forth dialogue where you feel comfortable and trust each other, because it can cause damage. If you do it too aggressively or too rigorously and not enough lube, you can actually damage the walls of the anus, which are really friable and thin. They’re not as elastic or muscular as a vaginal canal.

And so, yeah, absolutely. It can derive a lot of pleasure. It can be a lot of fun for people who just have to go slow, go easy, and talk to each other.

SHAWN RYAN: What about risks?

RENA MALIK: Again, the big risk is that you can hurt yourself, but also there is a sexually transmitted infection risk. So oftentimes people will have anal sex, and because they can’t get someone pregnant that way, they won’t use a condom. But you can still transmit sexually transmitted infections.

And it’s actually a high risk because there’s more blood vessels, things can tear more easily in that area. Like I said, it’s not lubricated. And so they’re at a higher risk of getting STDs. And so it’s really important if you’re having anal sex with someone where you are not monogamous and tested and clear, and you are safe to not use condoms, even vaginally. You need to use a condom anally because you want to protect yourself.

SHAWN RYAN: What about from a bacterial standpoint?

RENA MALIK: Yeah, I mean, from a bacterial standpoint, you know, it’s not like you’re going to get a colon infection. If they have some sort of infection that’s usually not an issue. It’s more the sexually transmitted infections.

SHAWN RYAN: Okay.

RENA MALIK: Okay.

The G Zone

SHAWN RYAN: G spot.

RENA MALIK: Yeah.

SHAWN RYAN: How do men find it?

RENA MALIK: So the G zone. It’s not a spot, actually.

SHAWN RYAN: G zone.

The G-Zone and Sexual Communication

RENA MALIK: A lot of guys think it’s like this magical button that you have to find. It’s not like some, there’s not necessarily like an obvious visual. Like when you look down, they’re like, oh, there’s a spot, you know, like bullseye. No, but honestly, I think there’s a lot of misconception. Like people are like, wait, what’s something wrong with me? I don’t see it. Or like, you know, it’s not.

It’s an area where there’s a lot of nerve endings. So the Skene’s glands, which we talked about earlier, the clitoral body, the shaft. So just like the shaft of the penis, the shaft of the clitoris is around that area. And so all those areas are really highly innervated. I mean, they really have a lot of nerve endings. It’s about 2-3 cm inside the vagina at the top. And so we’ll say it’s like a come hither motion is sort of where you’ll kind of feel it.

But again, you have to talk. I think people feel like that when they have sex, they should just be like magical gods at sex. And it should just be perfect and like, it should be this amazing experience, like off the bat. And it doesn’t make sense to me because we, you have, it’s a skill just like anything else. Like, you don’t expect to like, go do a public speech and be amazing at it the first time. Right? You, it’s a skill that you develop with time, even talking to someone or any, or dating. It’s all skills that we learn and we cultivate.

And so just like that, sex is a skill, you have to get good at it. And that requires you to get feedback from the person you’re having sex with. But we just expect that like, okay, we’re just going to have sex. There’s going to be just moans and groans, but no talking. And it’s going to be great. And everyone’s going to have great orgasms and we’re going to be wonderful at it. It’s like, but we have to invest in having better sex. Like, what is the point of having sex that’s not worth having? Right?

Nobody wants mediocre sex. Let’s have good sex. And so that means, like, let’s talk about sex. Let’s talk about sex outside the bedroom. Let’s find out like, hey, what turns you on? What is something that you’ve always been fantasizing about? Or what is, what was good? Like, what did you like about that? And what could be better? And let’s not take it so personally. We are trying to be better lovers with each other. And so it’s important to sort of be like, okay, what’s good? What’s not good? How can we change this up?

Breaking Sexual Monotony

The other thing is, monotony is a huge issue. So people find what works, and they do it every time. And that’s great. It’s comforting to have a routine. But if I was to tell you, hey, you’re going to have chicken and broccoli every day for the rest of your life, you’d be like, I don’t know if I can do that every day. Right? I need a pizza someday, or, I need a steak someday. Whatever, right?

And so it’s the same thing. Like, you need to sort of have a little bit of variety. It doesn’t need to be crazy. Like, it doesn’t need to be like, let’s get out the whips and chains. And, like, it can be just as simple as doing it in a different room, doing it a different time, doing it in a different, like, slightly different position. Using a pillow, not using a pillow. Like, just slight variations. Variations that make it just different enough where you’re like, ooh, this is kind of different. Like, this is kind of cool and keeps you sort of interested, excited, engaged in the process.

SHAWN RYAN: Are there any positions that men could do that are easier in finding the G zone? Well, that women enjoy more?

Optimal Positions and Clitoral Stimulation

RENA MALIK: So we know that when women have control, meaning they’re on top or they can sort of angle their bodies in certain ways that they tend to have more pleasure because they can, again, sort of angle you in a certain way that allows them to achieve more pleasure. So certain things, like putting a pillow, so she’s on the bottom, putting a pillow under her pelvis can make it more comfortable and more pleasurable. Having her on top can also allow for more pleasure because she can control sort of the angle that goes in.

And there’s also certain things not for the G zone, but there’s things that can help you stimulate the clitoris better while you’re having vaginal penetrative sex. So certain positions where you’re, like, sort of aligning your pelvis right on top of her clitoris so that you’re kind of like rocking motion, that can also lead to better orgasms.

So the G zone, people focus on the G zone because they hear about it a lot, but it’s analogous to the male prostate. And not every guy wants prostate play. Like, not every guy wants their prostate stimulated for pleasure. And so I don’t think we need to focus on the G zone. We need to focus on clitoral stimulation and also talking to our partner, finding out what they like. Because again, not everybody wants their G zone stimulated. Like, it may not be pleasurable for them or it may not really do anything for them. Whereas some people are like, yeah, that’s it. I love that. And that really turns me on. But you won’t know until you have.

Orgasm Frequency for Women

SHAWN RYAN: What about, you know, we talked about, you know, how, how often it would be, what an ideal, what do you call this ejection, ejaculation cycle, you know, for a man, what’s healthy, you know, 21 times a month. Great. What about women?

RENA MALIK: Yeah, so, you know, there’s so little data on women, but I would say, venture to say probably, you know, having regular orgasms is good for you. Right. They don’t necessarily always see an ejaculate like men do. And that’s different from squirting. Ejaculate is just like this milky white fluid that comes from the Skene’s glands. And it’s usually a very small amount. So we don’t always see it. It’s not always very clear. Some women be like, yes, I see it, I know exactly what you’re talking about. And some I’ve never seen it, that’s okay.

But it’s more about the orgasm, I think, because that’s what you can sort of reliably say. And I think that the orgasm is what we should focus on, is getting orgasms for women. And really the thing is, I think for women it’s probably, I mean, there’s no, we don’t get Skene’s glands. Cancer is very common, right? Prostate cancer. One in eight men get prostate cancer. Right. So it’s very common. So it’s not, I don’t think there’s a benefit in that term, but I do think for health benefits, for stress reduction, for pleasure benefits, I think orgasms, regular orgasms are great.

Again, I can’t give you an exact number, but I think if you feel like you are enjoying how often you’re having orgasms, do it. And if you feel like you could have more, that’s fine. And if you don’t like having orgasms, that’s okay too. But like, you should have something that gives you pleasure in life.

SHAWN RYAN: Perfect. Rena, let’s take a quick break and then when we come back we’ll get into some prostate stuff and all that.

RENA MALIK: That kind of stuff.

SHAWN RYAN: All right, Rena, we’re back from the break. Couple more questions about bedroom stuff. Yeah, and so one is, you know there’s this rumor going around that pineapple makes semen taste better. Pineapple, I think I’ve heard bananas. There might be some other stuff. I’m not sure. Is there any truth to that?

Diet and Semen Taste

RENA MALIK: So, I mean, like, you can’t really design a study tasting semen. So I can’t tell you, like, I can’t tell you with the degree of certainty. But if you think about the composition of semen, right, there’s fructose in semen, and fructose is what makes it sweet. It also has all these minerals in it which give it that sort of like, metallic sort of taste. But, you know, at neutral, it’s sort of got this little bit of like, metallic slightly sweet taste.

Now, if you want to make it sweeter, you would think, okay, I want to increase the amount of fructose in the semen. And so you will see that things that have a lot of fructose can potentially help increase the sweetness of semen. So things like pineapple, other fruits, potentially, yeah, they might increase the sweetness, but it’s not going to be, I think, what people think of, oh, I got a date tonight, I’m going to eat some pineapple in the morning and I’m going to be good to go. It’s not that quick, right?

So it’s sort of like a dietary thing. Like, if your diet consists of healthy fruits and vegetables, you’re more likely to have better tasting semen. Now, certain vegetables, like asparagus, is pretty strong, and so people might notice that their pee stinks after they eat asparagus. That will also affect your semen. Things like coffee, smoking, caffeine, those can make the semen taste a little bit stronger. And certainly, so if you really does, your diet can really alter the taste.

At least that’s my suspicion. Based on what we’ve heard from people anecdotally, what we’ve talked kind of the biology behind it. And so I would suspect that generally speaking, if you eat a healthy diet, drink lots of fluids, you’re going to have good tasting semen. If you eat a less healthy diet or you smoke, it’s not going to taste as good. And so, you know, I think, like, obviously everyone’s taste is sort of their own, right? It’s based on their biology. And so unless it like your partner’s like, oh, all of a sudden it tastes really different and it tastes unappealing, I wouldn’t worry about it.

But, like, you know, again, I think that, like, it is, it’s nothing that you should ever really worry about, right? As long as you’re a healthy person, your semen should be tasting good.

Semen Color and Consistency

Also, the color of the semen can vary. I get this question a lot. So, like, people be like, oh, it looks a little yellow now, or it looked a little grayish. And really the color can vary. It’s not dangerous. So the good news is not dangerous. I always say, if you’re worried, just drink lots of fluids. It’s going to dilute everything. Right. It’s going to make things a little bit clearer.

I think a lot of times we are drinking a lot of energy drinks or not really, really just water. And so sometimes it’s just like, increase your water intake and things will clear up. If you get blood in the semen, that’s a little bit concerning. But usually 99% of the time it’s not dangerous. And if it happens once, don’t worry about it. If it continues to happen over and over again, that’s a time to sort of get a red flag.

Ejaculation and Cancer Risk

SHAWN RYAN: Okay. And then we may have covered this. Forgive me if we did. Threw a lot of information at me, but I’ve heard rumors or maybe read some things. Wherever it came from, I can’t remember. But does ejaculation for men lower the risk of cancer?

RENA MALIK: Yes. So ejaculating, we know there’s an association. So when you ejaculate more than 21 times a month, there is about a 20% lower risk of prostate cancer.

SHAWN RYAN: 20%.

Ejaculation and Prostate Health

RENA MALIK: Yeah. And so now is it the ejaculation that’s causing that lower risk? I mean, the study that found this data actually tried to control for a lot of different factors, you know, like other health conditions. But you would imagine that someone who is ejaculating that frequently has a partner or is healthy enough to do so. So maybe there are some other factors that we can’t really quantify scientifically.

But the theory is that perhaps ejaculation is allowing fluid to move through the prostate more readily so that fluid doesn’t stick around and cause inflammation or other issues that then may lead to transformations that could lead to cancer.

SHAWN RYAN: Okay, and what, I mean, what age, how long can people have sex?

Sex Span and Longevity

RENA MALIK: I mean, as long as they live, but a lot of times people don’t. And so we call that “sex span.” Right. Like you think of your lifespan is how long you live, but your sex span is how long you’re going to have sex.

And so if you remain strong and healthy so you’re strong enough that you can still maintain the positions of sex. And to be honest, there’s even like furniture now and like things that can help you have sex if you’re a little bit weaker or like can’t get certain positions, like there’s like wedges and slings and different things that can help so you can continue to have sex, but also that you don’t get winded right when you’re not like exhausted, that you can’t actually exert enough to have sex.

But if you are a healthy person, you’ve maintained your muscular health through fitness, you’ve maintained your cardiovascular health through fitness, it is very likely that you continue to have sex well into your old age. I’ve seen 90 year old patients who are still having an active sex life.

SHAWN RYAN: 90 years old and don’t have erectile dysfunction?

RENA MALIK: And they’re like very healthy. And again, they have prioritized their health and they have maintained their exercise, they’ve maintained their health, they’ve eaten a healthy diet, they’ve slept, they’ve dealt with stress, they’ve created an environment which is healthy around their bodies and they are still able to have sex with their partners.

SHAWN RYAN: Now do you see a lower sex drive in older couples or just older folks in general?

Low Sexual Desire in Men

RENA MALIK: Well, so yeah, let’s talk about it for each individual. So for men, the most common reason for low sexual desire, especially as they age one, is low testosterone. So testosterone declines at about one to one and a half percent every year after about 40.

So if you are very healthy and you started with a normal testosterone, it’s unlikely that it should get low enough that it would cause you a problem. But that’s not the reality for many people. So about like overall 20% of people have low testosterone, but that percentage goes up as you age.

And that’s because add in other medical conditions that will affect low testosterone. So we know that as people get more metabolic conditions like high cholesterol, diabetes, high blood pressure, they tend to get lower testosterone. Add in potentially lack of sleep and more stress in their life, that causes more testosterone. Add in sedentary lifestyles, add in even environmental exposures like microplastics and things like that that we have some control over, but not completely.

And now you’re in a situation where you’re more likely to have a larger decline than is expected. And so we are seeing more and more low testosterone. And testosterone is the hormone of desire. And so when you have low testosterone, oftentimes it will present in men with low sexual desire and loss of morning erections. So those late night, those morning erections.

It also, testosterone is important for so many things in your body. So it increases muscle mass, it helps with mood. So sometimes people who are depressed, men who are depressed will find that their mood gets a little better when they start on testosterone. Brain fog. So it helps guys with brain clarity. And that’s actually one of the very common things I’ll see in older guys who have low testosterone is they’ll give them testosterone and the first thing they’ll notice is that their brain is a little clearer.

And it helps with the ability to just do normal, functional things like walk upstairs, hand grip strength, things like that, like functional. And so there’s so many facets. It also helps with bone health. And bone health is so important as we age. So it’s not just a hormone of sexual desire. It’s so much more than that.

But so that is often a cause in older men of loss of sexual desire. Also if they’re unhealthy, right. They have a health issue. And sex is like off the table because they don’t feel well. Right. And that happens to a lot of guys where like, I’ll see women, my husband can’t have sex because he’s unwell, right. Or he, his partner is unwell. And so they can’t have sex because of that. So that becomes very common reasons.

Low Sexual Desire in Women

Now for women, low sexual desire is even more common. So it’s actually estimated like 40% of women have low level libido. So low desire. And there’s a variety of reasons for that. One is, yes, women also have testosterone and their testosterone also declines similarly to men. And so they can’t. That can be part of it.

There’s also changes in menopause that can really affect women as they age. So they can have dryness vaginally, which can make it uncomfortable to have sex, and lack of lubrication. They can have their tissues actually change. So they get what’s called atrophy. So the tissue tissues get thinner, more friable, so it’s more painful. And it’s actually like not as flexible or as stretchy as it used to be. So actually penetration can be painful.

Their clitoris can even have changes. Just like men have erectile dysfunction, women can have changes in their clitoris where they may have less pleasure from the same stimulation they were getting before. So it’s more difficult to get orgasms. And so when you are having sex, that’s not really leading to pleasure. It becomes like less of a priority. Right.

And so, you know, we have things that can help women too. And I see patients all the time. Sometimes it is off label testosterone, sometimes it’s other medications that we can offer. But also it’s like dealing with those things or those changes that are happening because they can really make you not want sex.

And then your partner, if you’re, you know, male partner, is like, I still want to have sex, but she’s like dealing with all these changes hormonally. She doesn’t want to, right? She’s like, I’m not sleeping well, I’m having hot flashes all the time. You know, everything’s dry down there. I might be getting UTIs all the time. All these things are often hormonally mediated and they can be remedied. The same thing for men. If your testosterone is declining, we can improve that either naturally or with replacement.

Menopause and Perimenopause

SHAWN RYAN: So how, I mean, what age does menopause usually start?

RENA MALIK: So average is 51, but up to 10 years before that. And that’s average, meaning that half of women will be before 51, half will be after, but well before perimenopause. Before menopause is perimenopause. That can be four to seven to ten years before menopause. And again, so that could be as early as your 40s or late 30s. Some women are experiencing these symptoms.

And that’s when the symptoms are really intense because there’s like this hormonal chaos like that. Some days your estrogen is really high, some days it’s low because your body’s like something is all unregulated, right? And so during that time, they’re just like, they’re super stressed. They’re not sleeping, they’re having hot flashes. They, they don’t feel like happy. Sometimes they feel depressed.

I mean, there’s so many things going on and they honestly feel like they’re out of control if they don’t feel like themselves. I mean, men will say the same thing when their testosterone is low, that they don’t feel like themselves.

Having the Conversation with Your Partner

SHAWN RYAN: And so, I mean, how do you, I mean, how do men strike up a conversation with, with, with their partner who is…

RENA MALIK: So I think it is you. You have to really do this cautiously because I think the, the thing is like, oh, if you say, oh, I think it’s hormonal, it almost feels like the partner may feel like affronted. Like, you’re, you’re telling me I’m hormonal, You know, so you have to sort of do it in a, in a way.

Like, look, you can try like, hey, look, I saw this video on, online, I listened to this podcast, and they were talking about this and I’m like wondering if, you know, do you like, are you having any symptoms or would you like to see a specialist? Can I help you find one? Can I go with you to the appointment? I love it. Male patients bring me their wives all the time and I love it. And so supportive, so wonderful. And they have this wonderful, beautiful relationship and they just want to support each other.

I think it’s just being. Look, I love you and I want you to feel well, it’s not about wanting sex. It’s not about wanting you as a physical being. It’s about wanting you to feel like yourself and feel happy and fulfilled and feel like normal in your body. And I think like showing them that you want that is so valuable like that, oh, you love me and you care about me and you want me to feel good. It’s not necessarily just about sex. It’s, you know, it’s much more than that.

And so I think that’s where it’s like, you don’t want to start the conversation to be like, oh, we’re not having sex. I want you to see a specialist. Or I think you’re going crazy and you’re horrible and like, you know something’s wrong here. It’s more like, look, I love you, I’m worried about you and I want to help and like, I really, you know, want to be there for you.

Treatment Options for Women

SHAWN RYAN: What are, I mean, what are some of the initial treatments? I mean, it sounds like lubricant would be an obvious answer.

RENA MALIK: If it’s dry down, lubricant is great. And I think the one thing people don’t realize is that lubricant comes in different formulations. Like, you can get a water based lubricant, which is the most common one you see, but those dry up. And so, like, if you’re going to have sex, it’s going to last more than a few minutes. You’re going to have to reapply, otherwise it’s not really going to work.

So you can get water based, but silicone based and oil based are a little longer lasting. And so those are convenient in terms of allowing you to just apply once and have sex and not worry about reapplying. And so just figuring out what kinds you guys like, it might be experimenting with a few and figuring out what feels good for both of you and what you both like, because it’s a very individual. But I think lube is great. It’s cheap, it’s available, it’s accessible, and it’s like, hey, let’s have fun with it. Let’s make it fun, right?

There’s also moisturizers. So for dryness specifically, you can get vaginal moisturizers. Just like you have facial moisturizers, there’s vaginal moisturizers. That’s just skin. It’s just skin. So just like moisturizing the skin, keeping it healthy.

And then specifically for what we call the genitourinary syndrome of menopause, or the dryness and the other issues, you can use hormonal cream. So like vaginal estrogen, which is very safe. So it’s not. When you think about. There’s a lot of confusion about hormones. Vaginal hormones don’t. Very little gets systemically absorbed. So there’s never been a risk of breast cancer, ovarian cancer, uterine cancer. In fact, it’s probably safe for about anybody unless they have an active breast cancer. So anybody else can get vaginal hormones.

And so in those cases, you can do them in a cream, a pill, a ring. There are lots of different options, but they can really, one, keep the tissues healthy so they feel comfortable and they feel good, and it feels good when they have sex and can prevent recurrent UTIs. And it can even help. Like, if you’re looking down there, you may notice that their vulva actually changes. Like the lips, the inner lips will actually shrink and resorb because the lack of estrogen.

So sometimes if you apply the cream on the outside, it can help keep those tissues healthy too. And so not everyone needs it, like I said. But I think it does benefit people. The majority of women would benefit from it. And I think that it’s really very, very safe because again, it’s just topical. Very little bit gets absorbed systemically.

SHAWN RYAN: Are there? I mean, sounds like it sounds like you recommend TRT for men.

Testosterone Replacement Therapy (TRT): When and Why

RENA MALIK: I recommend TRT for men when they have symptoms of low testosterone, which we sort of talked about, but like low sexual desire, brain fog, fatigue, loss, maybe decreased mood when they have multiple symptoms that can be related to testosterone and their testosterone is low.

And so testosterone is measured through a blood test. The challenge with testosterone is it only gives me a number of what your level is at that time. I don’t know what your level was in your 20s. So if you have younger listeners listening, I generally recommend that people get a baseline level when they feel good. What is your testosterone when you feel good? So that when you, as you age, you have a reference and like, if something happened and you like, oh, man, I’m so exhausted. I don’t know what’s going on? You check your testosterone. If it’s the same as it was when you were in your 20s, okay, it’s not your testosterone, it’s something else. But it gives you a reference.

Because what we don’t know and what’s difficult to study is your receptors, which is what testosterone attaches to. Some people’s receptors are more sensitive, so they need less of it, less testosterone around to get the same results. And some people need more because their testosterone receptors are less sensitive. And so I can’t tell that we don’t have a commercially available test that we can say like, okay, you have better receptors, you have more, you need more testosterone to saturate those receptors. We don’t know. And so it’s a very individual thing.

Now they can say benchmarks based on what we know, population based data, and that’s usually 300 nanograms per deciliter is the normal benchmark. But I mean, there are some people who have testosterone that are higher than that, that still have symptoms, and that may be because their free testosterone is low, which is the testosterone that’s around in the bloodstream that is active. What’s actively working on all those receptors, because most of it is just with other little molecules that are little carriers, little cars they sit in, but they don’t let you get off the car. So you can’t actually go and work on the organs. They’re just there.

And so only about 5% or I think it’s actually 1 or 2% of the testosterone is free. And that’s what matters. So that’s what we want to see. Because other things that can affect those carrier molecules, the sex hormone binding globulin, so it can cause it to be more so as you age, sex hormone binding globulin goes up. So your testosterone may look the same, but your SHBG is going up. And now you have less free testosterone. And so you’re symptomatic.

Natural Ways to Boost Testosterone

And so I think that it is valuable for men when they’re low to improve their testosterone. Now it doesn’t always have to be through replacement. There are things you can do naturally to help improve your testosterone.

That includes sleeping more than seven hours a night of quality, quality sleep can increase your testosterone by 15%. If you have sleep apnea, there’s actually been very good studies that when you use a sleep app, which is a machine that helps people who have sleep apnea, they increase their testosterone quite significantly. So if you snore or you have a really big neck circumference, think about getting a sleep study to find out if you have sleep apnea, because fixing that will fix so many of your issues, including your testosterone. It’s actually a mortality risk. People who have sleep apnea die sooner because they’re not getting as much oxygen to their brain throughout the night and their organs.

If you exercise, resistance training, heavy resistance training of your muscles can help boost testosterone if you eat healthy. So meaning, diet is very challenging to study and it’s very difficult to give population based. But what we know on a population level is that Mediterranean style diet, meaning prioritizing healthy fruits and vegetables, unprocessed foods. I basically tell people unprocessed foods, natural foods, and ideally prioritizing fiber and protein are probably your best bets in terms of overall health for both testosterone and just overall health.

And then with testosterone, importantly, you don’t want to get on too low fat of a diet. Testosterone is a molecule that’s made from cholesterol and so if your fat goes too low, you won’t make enough testosterone. I think that’s really valuable for military men, is that you guys do a lot of really intense endurance work. When you do really intense endurance work, your testosterone goes down because it’s chronic stress on your body. And so that is something to look out for, is if you’re doing a lot of intense endurance work during those times, you might be like, man, I’m exhausted. Yeah, you’re doing a ton of endurance work. But also your testosterone is low. And so that can come back obviously when you stop doing those things. But it is something that you might notice during those stressful periods of time when you’re putting your body through these really intense things.

SHAWN RYAN: I mean, would you, I mean, I’ve read lots of things, interviewed people about it. I mean, it seems like testosterone is declining in men at a rapid pace as years go on and they talk about, you know, how the World War II generation, ever since then it’s just been on a decline. And so, you know, now TRT is wildly popular. Do you want to have, you know, is an older man? Does an older man want the same level of testosterone he had when he was 20 years old, 25 years old? I mean, it seems like, I mean, I don’t know why you wouldn’t want to have that, but I’m not a physician.

RENA MALIK: I mean, I think it’s a good benchmark to know what it used to be, right? But at the end of the day, we have to see how you feel. So I think people get very fixated on numbers, and it’s important. Numbers help guide us, but what should be guiding us is how you feel, right?

So, if you’re like, I’m full of energy, I feel great. I’m having great sex, and my mood is great, and I’m focused, I’m able to be productive. I don’t feel a deficit in any area of my life. Then who cares what your numbers are? You feel good, and that’s what matters, right? And I think that’s important.

Now, I do think that there’s some value in keeping track of things because you want to catch things before they become a real. You don’t want to be miserable and can’t get out of bed and can’t move before you go see the doctor. You want to sort of be a little bit proactive. But again, and I think it’s not necessarily the number always that matters. It’s, we have to talk about what you feel. Where is the deficit? What’s going on?

A lot of people think, oh, my erections aren’t working. Testosterone’s the answer. And that’s not always the case. In fact, it’s not very often the case. And so it’s we have to look at you as a person, not as a lab test or as a blood value. We need to look at you and be like, okay, what’s going on in your life? What’s outside of our clinic room or outside of whatever this blood work is showing me, what else is going on? Are you having a ton of stress at work? Are you dealing with a financial calamity? Is your partner super stressed because her mom’s in the hospital? And it’s affecting your whole life in homeostasis at home. What is going on? Because you’re not just one blood work. You are a whole person.

Risks and Concerns About TRT

SHAWN RYAN: Are there any, I mean, are there any concerns about going on testosterone replacement? I mean, you know, I’ve heard that it can increase the risk of cancer, increase the rate of cancer, enlarged prostate. I’ve heard all kinds of things about it.

RENA MALIK: So there’s a lot of misinformation, and some of it was a misunderstanding that now we know better. But let me go through it. So testosterone replacement is, as I mentioned, very helpful in improving all those things that we’ve talked about. Now, what are the risks, the true risks.

So in terms of the things you mentioned, cancer. Testosterone replacement does not cause prostate cancer. We know that unequivocally. The issue is that if you develop prostate cancer, which 1 in 8 men will get prostate cancer, and I give you testosterone. I don’t know you have prostate cancer because it hasn’t shown me yet. Your PSA is still normal. Everything, everything else is fine. But maybe you are destined to get prostate cancer, and then you get prostate cancer, it will cause that prostate cancer once it’s there, to grow more rapidly.

And so that’s why it’s really important, if you go on testosterone replacement, to get your PSA, which is a blood test and screening for prostate cancer, checked regularly, because we want to make sure that, God forbid, you are 1 in 8, that we stop the testosterone, we treat your prostate cancer, and we fix that because we don’t want an untoward thing to happen. So that’s one.

In terms of enlarged prostate, they’ve also looked at that, and there’s actually been no evidence that testosterone, again, in and of itself, causes an enlarged prostate. Now, if you already have an enlarged prostate and you have symptoms that are bothersome, when you give testosterone, it will cause a slight increase in both your PSA and it may cause a slight increase in the size of the prostate. And so if you’re already sort of struggling and I give you testosterone, it might make you struggle a little bit more, whereas the average person, it won’t bother them at all.

The one that it does sort of cause problems with is if you have that sleep apnea we talked about earlier. If you have really uncontrolled sleep apnea, it can make it worse because it’s going to increase muscle mass. It also increases the muscle mass in your neck, which then makes that sleep apnea worse. Now, usually that gets better with time, but if you’re really struggling with sleep apnea already and you’re waking up all night and you can’t breathe at night, it’s going to make it worse.

The other one that we absolutely know is that it can cause thickness of the blood or it can increase what’s caused your hematocrit. And when your blood gets too thick, it’s about 7% of people who get this change. Depending on which formulation of testosterone you go on, it causes you to be at higher risk for blood clots and strokes that we do know. Testosterone replacement will put you at higher risk for those things. So we need to keep a close eye on it. And so those are the big ones.

I think the other big thing that people need to know is when you start on it, you need to think of it as you’re going to be on it for life. You can do a trial, you can do two or three months and be like, is it, am I noticing a difference? And if not, go off of it, that’s not so difficult. But if you’ve been on it for years and years and years, if you go off of it, you are no longer, you’ve shut down your body’s process of making testosterone so you won’t make any for a while and you will feel like crap for a while until your body revs it up.

Now we can use off label medications to sort of help jump start your body to making testosterone, but it’s not something that every doctor does and that every doctor knows how to do. So I just tell people think of it like you’re going to be on it for life.

SHAWN RYAN: Is that HCG?

RENA MALIK: Yeah, HCG or Clomid, both those things can be helpful and FSH in some cases to help restart things. The other thing is if you want to have kids, it will make you infertile and not your sperm count will go down to zero, but it will go down low enough that fertility becomes challenging.

Now everyone’s heard of people who’ve been on steroids or on testosterone, have had babies. It’s because it doesn’t go down to zero, it goes down to a very low number. After about 18 months of being on it, you’re pretty much at a very low number that it would become impossible to, nearly virtually impossible to impregnate another person.

A lot of young guys, as you know, you mentioned testosterone is declining. A lot of young guys are like, oh, I need testosterone, I don’t feel well. And they do indeed have low testosterone. They start it because no one tells them that. Then they get married and they want to have kids and now they’re in a situation where they have little to no sperm and they have to sort of again use HCG, Clomid and try to get it back. But depending on how long you’ve been on it and how old you are, it can be more and more difficult.

SHAWN RYAN: Okay, okay, so before we move on, I want to talk about prostate health and that stuff. But you know, are there any, you know, basically what I’m getting at is Gen Z. You know, they’re the up and coming generation. You know, are there, is there substance abuse? Is there certain substances, they can affect erectile dysfunction, they can affect hormones, testosterone.

Smoking, Vaping, and Marijuana’s Impact on Sexual Health

RENA MALIK: So we know smoking unequivocally—I mean, I don’t think this generation smokes that much, but they do vape. So smoking can affect erections. Absolutely. It will destroy your erections because it’s going to destroy the blood vessel health. And again, those blood vessels of the penis are really, really small. So you’re going to see issues with erections before anything.

So if you’re smoking, I’m like, this is the best non-smoking ad: don’t smoke to help protect your erections. I think everyone would quit, right? I think instead of showing people lung cancer, they should have shown a penis that doesn’t work. I think people would have quit smoking a lot faster.

So that’s one. But a lot of young people are using marijuana, and marijuana, chronic use of marijuana can absolutely lower testosterone and cause issues with hormonal health.

SHAWN RYAN: Really?

RENA MALIK: Yes. So when you’re using it chronically, you will see that. And it can cause issues with fertility. So we see a lot of young guys who are trying to have kids and they use marijuana all the time for a variety of reasons, recreation, whatever. And now they have really poor semen health, poor sperm health, and they can’t get their partner pregnant.

So I think marijuana use is legal in some states and it’s okay on occasion recreationally. We don’t know if there’s a—we know now that alcohol is not healthy in any amount, but we don’t have that same granularity about marijuana in terms of is any bad. But definitely chronic use is bad for your sexual health and your hormones.

SHAWN RYAN: What is chronic use?

RENA MALIK: So chronic use is like every day or multiple times a week. And if someone is feeling sort of like they are always mellow because they’re on it, they’re always sort of basically feeling the effects of marijuana, they need the effects and they’re almost using it because those effects feel so good and they’re using it all the time. That’s probably a sign they’re using it too much.

Prostate Cancer Screening Guidelines

SHAWN RYAN: Okay. And so let’s get back to prostate cancer. What age should men be checking their prostates?

RENA MALIK: Yes, so the guidelines would say 55 is the year, the age to start screening for prostate cancer. I would say also if you have a family history of prostate cancer, specifically your dad or your brother, meaning direct first-degree relatives, that puts you at a much higher risk. If you’re African American, that puts you at a higher risk. If you have a BRCA gene—so if your mom had breast cancer and had a BRCA gene positive, that also puts you at risk for breast cancer. Or if you have multiple cancers in your family, I would still encourage you to get tested earlier.

And so that would be based on at least five years earlier. Or if your parent or brother had prostate cancer, let’s say at 50, I would start testing you at 45.

And so what is the test? So I think it always used to be a prostate exam and a blood test. Nowadays the prostate exam, which is a finger in the bottom, is sort of decided it’s not always necessary because urologists, we do prostate exams all the time. We know what we’re looking for, we know how to do an exam very well.

But general practitioners, primary care doctors, family care doctors—what we found is they don’t always really know what they’re feeling for because they don’t always necessarily feel abnormal prostates. It’s not their area of focus. And so it was actually creating a lot of false positives where people were like, “Oh, I feel something,” sending the urologist. Now the urologist has to do a biopsy, which is unnecessary. And it sort of led to this unnecessary further testing and evaluation.

So they said, okay, based on that, we don’t necessarily recommend that everyone needs a prostate exam. I still think that if you’re going to a urologist, it’s valuable to get one because we know what we’re looking for.

Understanding PSA Testing

But a PSA is a simple blood test. It’s a screening test. So it doesn’t tell you yes or no you have prostate cancer. But it’s a quick and easy way to say, okay, maybe you’re at risk.

But there’s other things that can increase your PSA that can be inflammation. So you might have masturbated or you might have sat on a bike seat, or you might have had some sort of low-grade inflammation that you didn’t really know. And that can cause an increase in PSA. You can have bleeding in the genitourinary tract for whatever reason that can increase your PSA. If you went to the hospital and you had a catheter placed or anything in the urethra, that can increase your PSA.

So there’s a variety of different things that can increase your PSA. So this is why it’s a screening test. It’s not yes or no, it just says, okay, you might be at risk. Now what do we do?

So if it’s high, usually we’ll check a second one to make sure it’s not inflammation, it’s not anything else. And if it’s still high, then we talk about what’s the next step.

The Role of MRI in Prostate Cancer Detection

So before, we used to be straight to biopsy, right? You go and you get a biopsy of your prostate. Now, we have a lot of different things, but the biggest and most revolutionary in urology has been just a prostate MRI.

Because now they’ve looked at prostate MRIs, and they found this grading scale to say, okay, you do an MRI and you see if there’s any areas that look concerning, and you grade them based on the way they look. And from one to five, one being very unlikely cancer, five being very highly likely cancer. So that gives you more of a degree of confidence on, okay, do we need to biopsy this? And if so, where are we biopsying?

Because when we do a biopsy in urology, when I was training, it was like we’re just poking 12 areas in the prostate randomly. I mean, obviously throughout, we’re doing it systematically. So we get a little bit of every little bit of it, but we’re just getting 12 random cores in the prostate.

Now we could do it with a little bit of degree of, okay, now we have this MRI. We can overlay it on the ultrasound and see where we’re going to biopsy. And so that’s helpful.

And also, if you have a high PSA and your prostate is huge, which is also another reason that your PSA can increase, and there’s no lesions on your MRI, I might say, “Hey, let’s keep an eye on it. Everything looks good on this MRI. And you have a very big prostate, which also causes an increase in PSA. Let’s keep an eye on it.” We don’t need to do a biopsy at this time, so it can sort of help us.

And there’s a bunch of different biomarkers and urine markers that we can test if we want to sort of get a little bit more granularity. Now, there’s not one that’s better than the other. And I would say talk to a specialist in prostate cancer, a uro-oncologist, when you’re deciding if you want to get more testing before you either get a biopsy or get treatment if you do find that you have prostate cancer.

Prostate Cancer Symptoms

SHAWN RYAN: I mean, what are some symptoms that people should be looking at?

RENA MALIK: Most people have no symptoms. This is why we have screening. This is why we do screening. Most people have no symptoms, and by the time they get symptoms, it’s actually a problem. It’s usually a more advanced cancer.

So symptoms could be that you have blood in the urine, could be that you have back pain, could be that you have night sweats or weight loss, could be that you are going to the bathroom a lot or more frequently or having trouble peeing. But those can also be signs of an enlarged prostate.

So that’s why we do screening. We don’t rely on symptoms. And absolutely, if you’re having symptoms, we should screen you for prostate cancer at that time too. But in general, that’s why we do screening on people who have no symptoms, because that’s when we find it.

SHAWN RYAN: Okay. So I mean, when it comes to an enlarged prostate, I mean, can it be reduced?

When to Treat Prostate Cancer

RENA MALIK: Yeah. So enlarged prostate—so I will say 80% of 80-year-olds have an enlarged prostate and 80% of 80-year-olds also have prostate cancer. So if I took all the autopsy studies and you look at the prostates of 80-year-olds, they all have some focus of prostate cancer.

So before I get into enlarged prostate, I want to round out that discussion because I think it’s important to understand this: if I diagnose you today with prostate cancer and you are 70 years old and you are really unhealthy and your dad died at 75, and you also have so many medical issues that you will likely pass in the next 10 to 15 years, I should do nothing about that prostate cancer. Because something else is going to kill you long before the prostate cancer does because it is very slow growing.

And it’s really important for people to understand. Nobody wants to face their mortality or think about how long they’re going to live. But I’ll give you a personal example. My grandfather got prostate cancer in his 70s. No one talked to me about it. I was in residency and they put him through radiation, and a couple years later he died from a heart attack.

And if they had asked me, I would have told him, “Don’t do anything about this prostate cancer. He’s not healthy. He’s 70 years old.” And he just went through this radiation for no reason. Right? Now if he was 60 and he was healthy, or even 70 and healthy, I would have said, “Yeah, treat it.”

But I think this is a really important discussion because not all prostate cancer needs to be treated, and some can even be watched. So we have protocols, like active surveillance protocols, where we can do routine MRIs and biopsies and keep an eye on it. Because, as I mentioned, it’s slow growing, and in some people, it’ll never become a problem.

And so we’re trying to find those people and not put them through surgeries or radiation that have multiple side effects and potential complications because they won’t need it. Right?

So I think it’s really important before we talk about enlarged prostate to just get that point out there, because I see so many people who are like, “No, I just want to know.” And I’m like, “Do you really want to know, though?” Because once you know, then the urge is to do something about it, and then you might do something about it that you didn’t need to do and have a side effect that you have to live with for the rest of your life.

So there’s a lot of regret in some guys who have prostate cancer treatment because they may develop erectile dysfunction or urinary problems afterwards. And now they could have lived without those things because they maybe didn’t even need the treatment.

Now it’s very individual. It’s a very individual discussion to have, because every prostate cancer is a little bit different, and some look more aggressive and some are less aggressive, and we grade them and we use all these nomograms to do that. I’m not going to belabor all the specific nuances, but I just think it’s really important to have that discussion.

SHAWN RYAN: Thank you for such a—enlarged prostate.

Enlarged Prostate: Causes, Prevention, and Treatment

RENA MALIK: Yes. So enlarged prostate is very common as well. Enlarged prostate occurs because of a variety of different things. So one, we know genetics. So if your dad had enlarged prostate and he was young, you are likely also going to have an enlarged prostate. And sometimes you’ll know because he won’t tell you that, but you might remember, oh, my dad was always going to the bathroom, or he was in the bathroom for so long trying to empty his bladder. You might remember those things, or he might tell you that. So that’s one.

Two is, we know, like, as you are more unhealthy, that causes more inflammation in your entire body, right? So if you have other metabolic issues, your prostate will also get inflamed, and then that inflammation causes growth, and then growth causes more inflammation that then causes growth. So it creates a sort of vicious cycle in the prostate. Those are the common reasons why prostates grow. But most guys have some degree of enlargement.

Now, what does that mean for you? Right. So can you prevent it? Let’s start with that. So people always want to know, can I prevent it or can I shrink it once it’s grown? I don’t think you can necessarily shrink it, but you can definitely prevent it.

# Prevention Through Diet and Exercise

So there’s some data, there’s not a ton of data on this, but basically they did trials looking at people for prostate cancer prevention, and they looked at a whole bunch of different factors, but in that, they also looked at enlarged prostate. And what they found was that people who ate more vegetables tended to have less enlarged prostate. People who walked more—so two hours of walking a week even was good. So exercise, generally speaking, tended to have a lower risk.

Maybe lycopene. So this is red based—tomatoes, watermelon, fruits and vegetables that are red in color may have a protective benefit. So I’ll tell people, generally leading a healthy life, exercise and diet can help potentially reduce your risk of prostate cancer. Whereas if you have enlarged prostate, if you have diabetes, your risk goes up of having an enlarged prostate. If you have high blood pressure, your risk of having enlarged prostate goes up. So again, the same sort of things, the unsexy things will help prevent that.

# Understanding Prostate Enlargement Symptoms

Now, when you have an enlarged prostate, I think people always assume it’s very simple, like, oh, you have an enlarged prostate, you have a problem with urination. That’s all there is to it. But it’s actually a little bit more complex. You can have a big prostate and have no problems, and you can have a small prostate and have problems. It’s really based on how it’s shaped and how it’s blocking the flow of urine.

Because the prostate sits underneath the bladder around the urethra. So when it gets big, it can get big on the outside or get big on the inside. If it gets big on the inside and it blocks the flow of urine, you can start having trouble peeing. Now, it can also affect your bladder because now your bladder is pushing to get urine through that prostate.

So sometimes guys will present with what we call—there’s two categories. There’s voiding symptoms. So that means that they can’t pee. They’re waiting for their stream to start. Their stream is weak, they’re stopping and starting, takes a long time and they don’t feel like they empty. That’s one type. And oftentimes with both types, they’ll wake up a lot at night to pee.

And then with the other type, which is called storage symptoms or bladder symptoms. So the bladder is responding to this blockage because the bladder is like, oh, it’s not clear. So I’m going to work harder, so I’m going to have more overactivity. I’m going to go more often. I’m going to feel the urge to go more often, and it’s going to be really, just really bothersome to me, right? And so those are also common.

Now, which kind of symptoms you have doesn’t really necessarily affect what we do unless you have other issues. So if you’re diabetic or you’ve had nerve injuries, then we’re wondering, is it the prostate or is it the bladder? Because those things can affect the bladder. But for most guys, it’s because of the blockage. And when we fix the blockage, all the symptoms get better.

# Lifestyle Modifications

And we can fix the blockage in a variety of different ways. For lifestyle, you can do some things to reduce the irritation related to enlargement. So you can limit how much you drink before bedtime so you’re not waking up as often. So we’ll tell people, don’t drink two hours before bed.

We’ll also tell people, look at what you’re drinking and eating, because certain things can irritate the bladder, which can then make things a lot worse. So things like caffeine, alcohol for some people, spicy foods, acidic foods like tomatoes and citrusy fruits and juices, even artificial sweeteners for some people. So I tell people, make a journal, see what you’re eating and drinking, and take a note of your symptoms and pay attention.

You’re smart. You can figure out, oh, I had a coffee, I had three coffees this morning, and I’m going to the bathroom more often, so maybe I should just drink one and drink two decaf if I love my coffee. Because you won’t take my coffee from me, I won’t take your coffee from you.

So I think those are things you can do also if you’re constipated. So many people don’t know this, but when you’re constipated, you’re affecting your bladder. So it will worsen all your symptoms, whether you’re having more trouble peeing or you’re going more often and more urgently. So if you’re constipated, you need to correct that. So whether that’s with adding more fiber in your diet, adding supplemental fiber, or taking medication to help you go better or moving more, those things can all help improve constipation.

Those are things that you can do in your lifestyle to improve and then also trying to go twice. So for some people, some guys, sitting is actually easier to empty their bladder when they have an enlarged prostate. For some guys, they still want to stand, but it could be that you need to pee standing up and you got to sit down and pee again and try to empty your bladder completely, or you need to take a deep breath and sort of relax the muscles a little bit, try to work on that and then pee again. So there are little things that you can do to make your life a little better.

# Medical and Surgical Treatment Options

But very often, we’ll do—there’s medical options and there’s surgical options to help reduce the prostate. And so that’s important to talk to your doctor about. But really the thing that I want all guys to know is that a lot of these treatments do have side effects that can affect ejaculation.

So a lot of guys feel like when they ejaculate, that is a big source of pleasure for them. Not just the orgasm, but the actual act of ejaculation. And so a lot of these treatments, medical or surgical, can affect how much ejaculate comes out. And so if that’s important to you, because sometimes if you’re with someone who’s rushed that day, they may forget to tell you that that’s a side effect, right, of the medication they’re going to give you or the surgery they’re going to give you, then you will be really unhappy after the fact.

And so I just want people to know that because there’s always trade-offs, right? Sometimes we treat something and there may be a side effect. But if you are literally not emptying your bladder and you’re getting recurrent bladder infections or bladder stones, or you’re bleeding a ton, we need to do something. Whereas other times it’s just quality of life. We want to improve your quality of life.

Prostate Massage: Medical Use and Pleasure

SHAWN RYAN: What about a prostate massage? Does that help at all? I mean, what is that? Is that simply for pleasure?

RENA MALIK: Yeah. So prostate massage, actually when I was younger, before long before I trained in urology, it was actually a thing that urologists did. So it’s essentially like a prostate exam. You insert a lubricated finger into the anus and you actually massage the prostate with your finger. So you sort of stroke the prostate in all the zones of it.

And that was thought to sort of help alleviate some potential—usually for prostatitis. So when people had inflamed prostate, they would do it for that because it’s thought that it might actually sort of cause some relaxation maybe of the muscles, it might cause some expression of fluid that’s stored up in the prostate when you ejaculate or when you pee the next time. And so that was thought to maybe help.

And so the study that originally showed potentially some benefit ultimately didn’t show any long-term benefit. So I would say that prostate massage, some people still find it useful. Just because the study said it doesn’t do something doesn’t mean that an individual can’t find it helpful. Some people still do find it helpful to massage their prostate for prostatitis or for other issues.

But in terms of something that we do as a medical community, not so much anymore based on the data we have. A lot of guys find it pleasurable to have their prostate massaged or include prostate play in the bedroom. And so I think that, you know, it’s great if you’re open to exploring that. You might find it unlocks a little bit of pleasure for you. You might not. But I think it’s really a very individual choice. And if that’s something you’re interested in, by all means.

The Effects of Pornography

SHAWN RYAN: Okay, let’s talk about the effects of pornography in your real sex life.

The Impact of Pornography on Sexual Health

RENA MALIK: Yes. So pornography has really changed. When I was younger, you had to get a VCR, you had to go to a sketchy store and find a tape and find a place to watch it. It was very difficult or, you know, to have a magazine that was hidden somewhere. And so it was not easy and it was not accessible. And it was definitely very different than what porn looks like today.

Now, I think that porn, there are some things I feel strongly about in terms of, I don’t think children should watch porn. I don’t think that it should be so readily accessible to people. I think there should be some challenges in getting access to porn because I think that that makes it much more difficult to want to engage in real life, like desire and sex. And it does sort of make it more difficult for some people to enjoy regular sex or even seek out regular sex, because they have these very exotic and erotic things very easily accessible.

However, a lot of people, adults who are fully formed frontal lobes, can use pornography in a very normal, healthy way. And I think it’s very individual. People tend to know when they have an issue with pornography. They’re like, “Oh, I’m using it all the time. I don’t enjoy my partner as much. Nothing is as good as what I feel like when I watch porn. I find myself using it more than I actually want to have sex with my partner. I find I’m using it more than when I want to go out and hang out with my friends.” And so you sort of start seeing the issues. You start seeing it in yourself, but it creates a shame spiral.

So you’re like, “Oh, I use porn. It makes me feel bad.” And some of that may be also because you have a moral incongruence, like you think porn is bad and you use it, you feel bad. And then you’re like, “Oh, man, I feel bad, but I need to feel good again. So I’m going to use it because it temporarily makes me feel good and I feel even worse.” And it creates this sort of shame spiral which can be really debilitating for people.

Now what I’m seeing in the younger generation is that they’ve only learned about sex through porn because no one talked to them about it. And so they watch porn, they think, “This is how I have sex and this is how I get my partner to orgasm.” And when they actually go to have sex with their partner, it does not go anything like that. Because porn is a produced product. It is meant for entertainment, is not real life. The camera angles, everything is meant for the viewer’s enjoyment, is not for the pleasure of the actual people having sex. They are actors.

And so when they go and they have sex with their partner, it doesn’t go the way they thought it was. And now they think they’re broken and something’s wrong with them. And so that’s a real problem because it creates these unrealistic expectations on both sides. Men feel like they don’t look or have the same results as the porn star. And women also feel like, “I don’t climax immediately upon penetration or I don’t look like that and something’s wrong with me.” And so it creates these really unrealistic expectations. So that’s a problem.

But when you have a fully formed frontal lobe, you understand that it’s a fake product. You can use it as a way to have arousal from time to time. Should it be your only source of arousal? No, I don’t think so. Can it be used in a healthy way? Yes, I think it can. And I think most people do use it, period. And I think a lot of people can use it in a healthy way. But I do think there are some caveats. And I do think it should not be freely accessible because I worry about kids.

And on average, kids see porn at 10, man. And so long before my kid turned 10, I talked to him about porn. I said, “You might see this. You might see something that makes you confused. You might see people having sex. Your friend might show you on their phone, something might happen. I want you to know this is not real. And I want you to talk to me about it and feel open to talk to me about it, because I don’t want you to be confused. I don’t want you to feel like that’s what real sex is like.”

SHAWN RYAN: I mean, when you talk to patients about porn addiction or just porn in general, I mean, do you, and we covered this a little bit earlier, but, I mean, do you feel like it would be, is it healthier to save that for your partner?

RENA MALIK: I think it depends on the person. So I think that you should vary your arousal. It should not all be based on pornography. You should be able to get aroused by thinking. You should be able to get aroused by fantasizing. And if you want to use porn occasionally, it can be nice to explore other areas of things that might be of interest to you to learn. Maybe something else that might turn you on that you never thought of before.

It can be as a couple. If you are both on the same page and you watch it together, it can actually increase sexual satisfaction and relationship factors. We’ve seen that in studies. But again, I think it’s very individual. And I think that if you are finding yourself solely relying on porn, like, you cannot masturbate without porn, then that’s a red flag to me. You should be able to have arousal without that.

I remember when I was in medical school, I had a friend be like, “I love springtime in New York.” And I was like, “Why?” He’s like, “Because it’s the sexiest time. Girls are all wearing skirts and you can see more skin.” And I was like, it’s so funny to me now because nobody would ever say that now because it’s like, you don’t need to wait till springtime. You just look at your phone and you’ll see whatever you want.

And so there’s no, it’s like, the simple thing. Think about even way back when, you would have to court a partner. You would have to walk with them and talk with them, and you would barely be able to touch their hand. There would be this buildup, this tension, this, “Oh, I’m so excited to be with you and to touch you.” And I feel like we’ve lost a lot of that actual enjoyment of being with someone else and glamorizing that versus, “Oh, I can just watch this on porn and have fun for a few minutes.”

SHAWN RYAN: Yeah, I think it’s a big problem in the entire world right now.

RENA MALIK: Yeah. Again, I think it’s just about, I really feel like it’s dangerous that our kids have access to it.

SHAWN RYAN: Yeah, me too. We’ve covered that a lot on this show, which actually, we were talking about it this morning with Ryan Montgomery. And you watched Tim Tebow one, it sounds like.

RENA MALIK: Yeah.

SHAWN RYAN: And those were cornerstones of those both of those interviews. But you know what? We’re kind of winding down the interview now. And, you know, one thing I wanted to ask is, you know, what are some of the most common sexual health problems in men that go ignored?

Common Sexual Health Problems That Go Ignored

RENA MALIK: Yeah. Well, number one is, I mean, the most common is erectile dysfunction. And I think that it’s not that it gets ignored, but I think that men are embarrassed and they don’t come and see the doctor or when they do, they just get given a prescription and say bye. And I think if, and that’s why I’m writing my book that’s coming out next year is I want people to know, you can fix this. You can fix your life, and you have the power to do that, and you can improve your health and by way of then improve your erections, because sexual health is health.

But I think they get very discouraged, and when they finally do go get help, they just get a prescription. They don’t get any information. So I think that’s a big one. And then they’re embarrassed, too. And I guess, you know, there’s now there’s a little bit more where you can get these online companies which will at least prescribe you the medication, but at the same time, they’re not still giving you that education, which is really what I think is the missing piece. And they’re charging you a lot more for the medications than you could get. An online pharmacy, you can get them for cents on the dollar. So I think that that’s a big one.

Another one is whenever they feel less masculine. So if they feel like maybe their desire is not there, maybe they’re struggling with premature ejaculation, they don’t ask for help. They struggle in silence, and they live in silence. And it is heartbreaking because by the time I finally see these patients, they have been through a lot, and it has shaped who they are as a person, and they cannot, and they can’t talk to anybody.

Men just have this, they don’t talk to, women talk to women. They’ll be like, “Oh, I have a problem.” It’ll come up somehow. They’ll feel comfortable confiding in another woman. A man will never talk to another man about his issues in the bedroom or really many issues. They just don’t. They’re stoic. They tend to be problem solvers. They don’t want to sit there and whine or complain. And so they just sort of grin and bear it.

And they grin and bear it in front of their partner. They may, I mean, it can go so deep where they’ve even had divorces or ruined relationships because they won’t talk to their partner about their issues. And it runs so deep that they’re just suffering in silence. And it really, I just, I want anyone listening if you’re struggling, please, at least talk to a urologist. At least talk to your doctor. Talk to somebody. I don’t care who you talk to. Talk to somebody.

Because even just saying the issue out loud can help you sort of process it and deal with it and, you know, learn, educate yourself, watch content, mine or anyone else’s, learn about your body and empower yourself to take the actions you need to fix it.

Sexual Health Challenges for Veterans

SHAWN RYAN: And then, you know, working, being a VA doc, I mean, I come from special operations background. A lot of TBI, lot of PTSD. I mean, what are some of the commonalities that you see within, you know, war fighters who are coming home who have these kind of invisible injuries? I mean, how does that play in?

RENA MALIK: The most common is PTSD. So I think the large majority of patients that I see have PTSD. Large majority. And they’re all on medications to help with nightmares, and they’re struggling. And we know that with men who have PTSD, their rate of erectile dysfunction is significantly higher. Three times higher, three times higher than guys who don’t have PTSD, than veterans who don’t have PTSD. So just even within the military community, if you have PTSD, your risk is significantly higher.

SHAWN RYAN: Wow.

RENA MALIK: So it is, I mean, mental health and sexual health are very, very intertwined. And I know that the VA tries to do a really good job of getting help for veterans in terms of PTSD and mental health. But it is a real struggle, and it is something that is really, really challenging. So, you know, I think that’s a big one.

And then also, it’s crazy to me that, you know, my vets will come see me and I’ll be like, “Do you want something for your erections?” And they’ll be like, “Oh, no one told me I could have that, or no one’s even asked me about that.” So beyond, they’re already at high risk from TBIs. So TBIs can affect hormone health. So a lot of guys with TBIs will have low testosterone and so they usually will get tested for testosterone, but they’re not asked always about their erection.

So even with those patients, it’s like they may be given medication, but they’re never educated on it. And no one’s really linking that mental health aspect. We need to fix the mental health aspect so you can actually, I mean, think about it. If you’re having better sex, you’re probably helping your mental health too. It all goes hand in hand. So I think it’s really a challenge because they have so much going on that those things become forefront and sexual health goes in the back.

SHAWN RYAN: I mean, is there, do we know why PTSD makes it three times more possible for somebody to have erectile dysfunction?

Mental Health and Sexual Function

RENA MALIK: I mean, all mental health issues are linked with sexual dysfunction because it’s sort of like if you’re, I mean, just very simplistically, and this is not, this is too simplistic, but if you’re sad, you can’t get aroused, right? You’re not going to get turned on because you’re sad, right? Like, it’s just, sex is not on your mind. You’re thinking about all, and you’re in a sort of a fight or flight sympathetic nervous system.

So when we think about erections, to get an erection, we call it “point and shoot.” You need parasympathetic nervous system, which is your rest and digest, your relaxed nervous system to be activated. For you to get an erection, you need to not be in a state of anxiety or stress. And then when you have your ejaculation, that’s when your sympathetic nervous system turns on.

So if you are constantly stressed, depressed, anxious, PTSD specifically, there’s a lot of sympathetic nervous system activity right when you have PTSD. So you just can’t get into the mind state, the nervous system state to be able to get an erection.

Techniques for Lasting Longer

SHAWN RYAN: Okay, is there anything that men can do to last longer in bed?

RENA MALIK: Yeah, so a lot of guys think like, oh, if I just think about my grandma or something super non-sexual, right, it’s going to work. Now for some people, if you don’t have any issues and you’re just trying to last longer, sometimes that does work, but most times it doesn’t. It actually hurts, right? Because now you’re introducing this very non-sexual, non-pleasurable thought in a moment that you should be feeling really good, right?

So I think a lot of it is, I mean, of course there are medications and things, but I think that just talking about things that you can do that are actionable. One is, interestingly, breathing. So doing diaphragmatic breathing, so really deep into your diaphragm, is actually going to help rev up your parasympathetic nervous system. And so people who do this type of breathing, even outside the bedroom and they do it regularly, have been shown to last 900% longer. So I made a video on that.

SHAWN RYAN: 900% longer?

RENA MALIK: There was one study that said 900% longer. They do diaphragmatic breathing plus they’ll do some exercises which are like the stop-start technique. So you get almost to the point of climax and then you kind of bring your arousal down and then you go again. You do that three times and then on the fourth, it’s sort of like edging, and on the fourth time you ejaculate.

So those sort of actions at the same time with breathing has been shown to increase the ability for people, at least men with premature ejaculation, to last 900% longer. And then sometimes doing those breaths during arousal, so sort of calming things down. Because if you could think about it, it tends to be very quick, sort of like, “Oh my God, oh my God, oh my God.” When you’re having sex, you get really excited, right? So you just need to calm things down and then you can last longer.

Now another thing that has been shown, these are small studies, but I think they make sense and they actually are so easy to do that I’m like, every man should be trying to do these in general, right? They’re good for your health too. They’re good for your mental health. The other one is using exercise. And the reason certain exercises, specifically high-intensity interval training, because it helps your brain sort of understand where your body is in time and space.

So you get what’s called interoception. And that then, as you do that in practice when you’re exercising, then when you’re in position with your body, you can start figuring out the cues, like, “Oh, I’m getting close.” You can sort of follow your arousal, like when are you getting close to climax and sort of dampen things down a little bit. So you sort of learn your body better because you’re doing those exercises.

And the study was seven minutes of high-intensity interval training daily showed an improvement in as quick as two weeks in terms of increasing length. Now they looked at other exercises too, yoga and running, because again, those are also very mindful exercises like long-distance running, yoga. Fastest to do improvement was the HIIT, followed by running and then followed by yoga. But again, they all can help.

And so I think it’s just really about being mindful of where your body is, learning what does it feel like when I’m getting close to ejaculation and being able to be present in the moment. And mindfulness, again, exercises like meditation and just really learning how to be one with yourself. It’s really understanding your body so you can say, “Hey, I’m letting my arousal sort of climb slowly rather,” and I’m sort of enjoying the process of getting there. Not so fixated on all the stressors of like, “Oh, when’s it going to happen? Too soon?” That’s also revving up your sympathetic nervous system.

Talking to Kids About Sexual Health

SHAWN RYAN: Last question, second to last question. I mean, you have kids. How do we talk to kids about all of this stuff? Sexual health. What age did you start talking to your kids about?

RENA MALIK: So I started talking to my kids, just basics, anatomy when they were little. So this is your penis. I mean, for boys it’s easier. I think for girls you have to tell them what is their anatomy, right? So this is your vulva, this is where you pee from, this is your vagina. And same thing for boys. This is your penis, this is your scrotum, this is your testicles.

And it’s actually so funny because I have so many funny stories with my kids because they’ve always been very open with me. And so, I hope they never watch my podcast interviews because they’re going to be so mortified. But when they were little and the first time they would get erections, they’d be like, “Mommy, why is it getting big?” Right? And I’d be like, “This is completely normal. You’re having an erection. It’s a completely normal thing.”

Whereas I know other friends, like, “Oh my God, what do I say?” They would sort of freak out and I’d be like, look. And they would ask me and I said, “Just tell them it’s normal.” It is normal to get random erections. There is nothing wrong with it.

So that was one. I would also tell them, they would be like, oh, my son would go on a roller coaster and they go, “It tingles down there.” I’m like, “Yeah, that’s okay. That’s a normal sensation.” But when he asked these questions, I would answer them as best I can.

I remember one time he asked me about sex, and I was not prepared in that moment to answer it, right? And I was like, “Okay, give me a second. I will answer this question later.” And I talked to my husband about it, and I was like, “Okay, how do we go about this?” He’s like, “No, you should talk to him about it. You’re obviously more skilled at talking about sex.”

And I was like, he’s like, and we decided it’s obviously going to be better for me to talk to him about it now when he’s curious, rather than him going to ask someone else, right? So he asked me. I told him, “This is what happens during sex, and this is how it happens.”

And then when I had the same conversation with my younger son, he’s like, “So wait, what if I just fall? What if I fall onto her? Will we be having sex?” And I was like, “No, no, no, that’s not how it works.” It’s so innocent, their conversations. But it’s also like, this is, and so we’ve been doing it so long.

And so now we have sort of a routine. We’ll go on walks, and they’ll know that if that’s the time they want to talk to me alone, they’ll sort of be like, “Hey, Mommy, can we talk?” And they’ll ask me questions. Or they might have seen something in a movie, or maybe their friend said something at school. And so they know that they can ask me anything, right?

And then I will also, I talk about sex all the time, but I had forgotten that, oh, I need to talk to him about wet dreams, because they’re going to happen. I don’t want him to feel embarrassed, right? Because you probably can recall when you had that happen. Like, “Oh, my God, what happened? This is horrible. This is scary. Am I dying? What’s going on?” Right? And everyone has a different reaction.

But I didn’t want him to freak out. So I remember telling him, “This might happen. It’s okay, just let me know. We’ll wash the sheets and it’s totally normal,” right? But such a simple thing that you don’t even think, especially as a mother. I never had that experience, so I had to remember, “Oh, yeah, this is something I need to tell him before it happens so he doesn’t freak out and think something’s wrong with him.”

SHAWN RYAN: I mean, what do you, how do you describe, what age was that when you were having a discussion with your child?

Talking to Children About Pornography and Sexual Health

RENA MALIK: We’ve had so many for so long that I think I started because the average age where kids see porn is 10. I think I started talking to my son at 8 about porn because I didn’t know who he’s going to see it from. I’m going to do my best to put all the locks on my phone and anything that he has access to, but I don’t know what his friends have locks on their phones or what they have. If they have phones, right? Like, all those things. I just don’t know what he’s going to see when I’m not with him. I’m not with him 24 hours a day.

So I had to prepare myself for the fact that he might see something. And even though I don’t want him to see it and I wish he doesn’t, I know he might. And he’s actually told me that some kids in school have talked about porn now that we’ve had this. He’s 12 now, but he’s told me that kids have talked about it, like, “Oh, you know, we watch porn.” And I was like, “Have you seen it?” And he’s like, “No, I haven’t. I’m not really that interested because we’ve talked about it, right?”

And I think he realizes it’s not really all that cool. Like, it’s a fake thing, you know, and it’s not necessary right now. So, you know, I think he knows he can come to me. I can tell him any question he wants. I’ll answer it. I might not answer it right that second, but I will think about it, and I will answer it.

And so, yeah, I mean, I started talking to them, like I said, when they’re little, just about their anatomy. And so, slowly but surely. But the sex question, he came to me, and I think he was around 8. He came to me and asked me about it, and I was like, “Okay, now is the time to answer it. He’s asking the question, so I have to answer it.”

You know, and so I made this routine where we go for walks and I tell him about whatever and he knows that’s a great time where he can ask me. I don’t have to look at him in the face either. I can look straight ahead and answer and he can look straight ahead. And we don’t have to have an awkward face to face interaction. But, you know, we’re just talking and I think you got to find, you obviously know your kid and you know how you want to parent.

But I think we as parents have a responsibility in today’s society where we have less control over what they’re going to see because they’re out in the world at school and kids have phones, which is crazy to me. We don’t have as much control as we would like. And I mean, so we have to be responsible and teach them because the other thing is it’s sort of scary, some of the things they’re going to see.

The Dangers of Pornography’s Influence on Young People

So, for example, choking is a big thing in porn right now. And so I had a researcher on my podcast, Debbie Herbenick, who wrote this book called “Yes, Your Kid.” And so she did research on college age students and she found out that choking became very, very common in sexual encounters. And it’s fine if someone finds it pleasurable, but it’s dangerous, right? You’re asphyxiating someone. You could cause really serious harm.

But they’re doing it so casually, like it’s almost like kissing. And when they did the surveys, they found that women were most often getting choked. And a lot of them were not that into it. I mean, they were okay. They were like, “Yeah, you can do it.” They were getting asked, but they were really not that into it. And they were just doing it because they felt like that was what was done.

And so that’s just one example of how these things are being perpetuated from what they’re seeing. And these things are not focused on pleasure. They’re just focused on getting you entertained. And so they’re not learning how to pleasure each other. They’re not learning how to have a meaningful, intimate encounter. And it’s really sad.

SHAWN RYAN: Yeah, I love the walking method.

RENA MALIK: Yeah, that is, it’s a good one.

SHAWN RYAN: That’s great. It’s like, you know, it’s not face to face. You could look…

Communication Tips for Couples

RENA MALIK: And I tell even couples, do talks when you’re not looking at each other, because in the beginning, no one taught us how to have sex, right? Or how to talk about sex or have sex really. But no one taught us how to talk about sex, right? So it’s super awkward and it’s not a one time conversation.

If you want to have a meaningful, really robust, amazing sex life with your partner, you got to talk about it. And so I tell people, when you’re in the car, when you’re on a walk, so you don’t have to look at each other across the table. And definitely never in the bedroom. Just have these conversations in places where you have a little room to wiggle and look and feel awkward, but don’t just show it to each other.

SHAWN RYAN: Love that. Love that.

RENA MALIK: That.

SHAWN RYAN: All right, last question. If you could recommend three people for this show, who would they be?

Guest Recommendations

RENA MALIK: Oh, gosh. Three people. Okay. Well, if you want to do more sexual health, I had Dr. Barry Komisaruk, who is a researcher who researches female orgasm and brain MRIs. That was a really interesting conversation.

Who else? Trying to think. I think your audience would really like Dr. Alok Kanojia. He’s a physician who really focuses on gaming, but he has a lot of insights into the psyche of the young man right now and how to sort of manage these gaming addictions and also sort of people who struggle with pornography and things like that all in the same. And let me think of a third one. Trying to think.

SHAWN RYAN: Do you know any sex therapists?

RENA MALIK: Oh, yeah, I know a lot of sex therapists. I’m going to think of the best one for you. Let’s see. Let me think on that one.

SHAWN RYAN: All right.

RENA MALIK: I want to give you the right name.

SHAWN RYAN: Perfect. Perfect.

RENA MALIK: Yeah.

SHAWN RYAN: Well, Rena, this was a fascinating conversation. Like I said, thank you so much for coming, and I’d love to see you again.

RENA MALIK: Yeah, thank you so much for having me.

SHAWN RYAN: All right, cheers.

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