Sex Expert: How to Increase Your Sexual Desire & the Fastest Way to Better Orgasms, with Dr. Rena Malik
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We're so focused on the end result, which is an orgasm. But sex is not just about who can get an orgasm. In first-time sexual encounters, 95% of men will have an orgasm. It's almost a part of sexual intercourse, whereas only about 45% of women will have orgasms.

But when you look at same-sex couples, so women and women, that rate of orgasm goes back up to 90%. So we know that this is probably partially the men's fault. Sorry. It's an educational issue. It's that men aren't taught how to

have their partner achieve a reliable orgasm. We're not taught about it. And if you're watching erotic films, for the most part, you're seeing penis in vagina sex, which is not going to always elicit an orgasm. In fact, 85% of women will need clitoral stimulation, which is not specifically in the vaginas, to achieve orgasm.

In order to have climax and pleasure, you have to allow yourself to be totally vulnerable. You can't be thinking about your insecurities. You can't be worried about other things. You have to be totally present in the moment. Part of having the best sexual experience you can have.

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Hey, I just found out something astounding. Approximately 63% of those of you listening to or watching Mayim Bialik's Breakdown are not subscribed. We know you're listening and we know you're watching because of all of the awesome comments you leave telling us how Mayim Bialik's Breakdown is helping you lead a happier and healthier life. We love that. But...

The best way to support our show is to subscribe. It's also the only way to get latest updates and to know when new episodes drop. So anywhere that you listen to podcasts and on YouTube, please subscribe. Hit the bell icon so that you know when a new episode drops. Thank you so much, and on to the episode. Hi, I'm Mayim Bialik. And I'm Jonathan Cohen. And welcome to our breakdown. This is the place where we break things down so you don't have to. Today we're going to break down, does penis size matter?

Why am I not having orgasms the way I want to? What is up?

with pelvic floor health? What's up with pain during sex? What's up with intimacy as a contributing significant factor to if I'm going to have an orgasm? What not to say to your partner if he can't get an erection? And why are women choosing to have sex with other women? Are you interested in any of those things? Then you're going to like this episode. We're also going to talk about sex as a potential way to...

fight off dementia, and improve your overall health and your brain health. Dr. Reena Malik is a board-certified urologist. She dispels medical information. She's got over 300 million views and 2 million subscribers. She's got a YouTube channel, Reena Malik, MD. She's a go-to destination for frank, evidence-based discussions of taboo topics.

topics. She's located in Beverly Hills and Irvine, California, but she sees people virtually from a bunch of states in the United States. And she got the title of 2023 American Urological Association Young Urologist of the Year. She's got a prolific portfolio. She really has a great sense of humor and a great way to help us approach these topics. Let's welcome to The Breakdown, Dr. Reena Malik. Break it down.

Hi, Dr. Malik. I'm Mayim. Nice to meet you. Nice to meet you too, Mayim. I don't want to be here. I'm nervous about this episode. I feel weird. Like I'm comfortable talking about these things. I talk about them with my doctor, with my children, with myself. But I am really just feeling like, oh my gosh, we're going to do it. I really respect, I respect your work greatly. I'm sure you're a wonderful doctor in your office, but the service that you provide of like, you

like, you know, dispelling myths and like talking about this stuff openly and talking about it in a way that people want to listen. Because I think that's also, you know, a lot of what we've been told has for many of us been by like old white men. And that's not the person that I want to get my information from about my lady parts. So.

So, um, I think it's also really important that you've sort of bridged this gap between like talking to men, talking to women, talking to all sorts of people. Um, and that's a really important and very needed, you know, component, I think to our general kind of sexual, um, education. Um, all right. So I think that a place that we would like to start is, you know, a lot of the, um,

a lot of your kind of sweet spot, for lack of a better term, has to do with kind of myths and misconceptions that people come into their life, this culture, the world with. I'm going to just like fire some

some myths out there and I'd like to hear you speak about them like you do. Also, I'm distracted by the very pretty shade of purple behind you. And I'm wondering, is there something about the color purple? Do I need to make my bedroom purple to have better sex? Like what's with that purple? It's very regal. It's powerful. Thank you. It just compliments. It's a contrasting color to my skin tone. So it looks good.

It's color theory. If you have Dr. Malik's skin tone, think about purple in the bedroom, but it has nothing to do with sex. How often do people in relationships, like committed relationships, how often should they be having sex?

Yeah, I love this question because there is no right answer for any individual person or couple, right? It's really a relationship decision. Now, people want to know, like, how often are people having sex? Well, the average person is having sex...

around 50 times a year. So that's about once a week. When you look at people as they age into their 70s, that goes down to around the 20s. When you go down to people who are in their 20s or younger, they're going 70 or 80 times a year. So it's really variable. And of course, this is just like statistical data. It's not

it's not you. And so I think there's no right amount of sex. It should be that you are enjoying the sex you're having, that it's pleasurable, that you are having the joint experience of intimacy and pleasure and orgasm through that, and that you are both having a good time. And that's really, or more than two of you, if there's more than two of you, that everyone involved is having a good time.

Jonathan's on this really annoying kick that I'd like you to talk about. He's into this, like, men aren't supposed to have orgasms. It's bad for their chi and their libido, and it's better to never have an orgasm. And it's like, I don't know what his life is like, but what is with this trend of trying to regulate, you know, orgasms based on testosterone? Like, I know a little bit about endocrinology. Like, I don't know that it works exactly like he wants it to. Can you please fix this?

Yes. So in terms of, you know, semen retention, this goes back to like Taoist theory. Did you just say semen retention? I said semen retention. Yes, I did. So that's basically what they're practicing, right? Is this ability to not ejaculate because, you know, ancient Taoist literature will say it's your life force. One drop of semen is like...

so much blood or something. And that's all fine and well in terms of like, if you believe that not ejaculating makes you feel more focused, more energized, feel more mental clarity, by all means, like go ahead. But there is no scientific evidence that retaining semen in any shape or form is going to improve your testosterone, improve your fitness performance. Like if you're going to go work out or you're going to go perform athletic endeavors, that it's going to

for some reason, make you better in those ways. Now, I think if some people are getting these cognitive benefits that they theorize from semen retention, maybe that helps them. But there is no physiologic mechanism by which semen retention is doing anything to your body. So if you don't ejaculate, you will either do it at night because your body will just...

You'll have a wet dream or your body will resorb the semen and it'll make more. Like it's not, it's not a big deal. It's just like any other process in your body. And so I think if people derive benefit and they feel like they can control that and it makes them feel better by all means go ahead. But in terms of like thinking that it's going to improve your quality of life,

by improving your testosterone or physiology, that's not the case. I think it's important to clarify, and this is really good information. There's a lot of online conversation of like, oh, you'll get a drop in your testosterone after ejaculation, or that if you don't ejaculate a certain number of times a month or a week, then you can have prostate problems. Can you help parse some of that out? Is there no evidence that...

There's a drop in testosterone after ejaculation. And what about the frequency for healthy prostate or just general health?

Absolutely. So there's like one study, which was done in like 10 men, okay, that everyone is sort of using as a guide to tell them that your testosterone increase, it did show an increase in men who abstained from ejaculation for 21 days. And then, and then they ejaculated and their testosterone went down a bit. But again, this is transient. And this was in 10 men.

It was not like applicable or generalizable. It's never been repeated. It's never been done again. It's never been shown to occur. And it doesn't really make sense, right? Like your testosterone is gonna go down just by virtue of like being throughout the day.

using testosterone for a variety of endeavors. And so like your body's using it, right? And it's going to go down. It's going to go up. That's normal. Like it's going to have some degree of change. That's why in medicine we'll check testosterone twice before we say, okay, you truly have low testosterone because it can be variable. Now, in terms of the other thing you brought up, that's really important.

in terms of prostate cancer. So there is some data, some very strong data. Actually, it was a very well-done study. So they really controlled for a lot of factors. They took men and they asked them how often they ejaculated per month. And they categorized them in like four to seven, seven to 10, so on and so forth. And above 21 times was the last category. And what they found was that men who ejaculated 21 times or more a month...

were less likely to develop prostate cancer than those who ejaculated four to seven times a month. But hold on, that's an association, not necessarily a correlation, because what else do people who have sex that much do? It could also be that like the dudes who have a lot of sex love going to the gym or taking DHA, the alpha omega crap that Jonathan also thinks everybody should take.

Yeah, exactly. And it's, it's, they did try to control for a lot of those factors, but you, as you know, science is not perfect. And so I tell people like, this is just, if you enjoy either ejaculating through sex or masturbation, by all means, like it's fine. It's great. The one

One thing I really find myself worried about as a clinician with semen retention is not the prostate cancer risk. It's more that when people are trying to white knuckle through avoiding masturbation or ejaculation, their pelvic floor can tense up. And that's this bowl of muscles that sits in the pelvis that holds up your organs like your rectum, your bladder.

And when that becomes tense, just like any other muscle in your body, it can create problems when you have tension that doesn't relax in a certain muscle. And so in those cases, you can develop problems. You can have problems with urination where you go to the bathroom more often than usual. You can have constipation. You can have pain with erections. You can have pain with ejaculation. You can have lower back pain. I mean, there's a whole host of symptoms that can present

And then you sort of have to rehab those muscles to get them to work normally again. And so that is my real concern is that when people are really trying to force themselves to do this and they're not seeing benefit and they're doing it because of peer pressure or whatever they read or whatever the case may be, and they're actually causing harm to themselves, that's where as a physician, I take issue. Otherwise, by all means, if you're deriving benefit and not having any negative consequences, it's totally fine. One more point here, and it's related to Sting.

which is this notion of delayed orgasm or channeling that energy into what has been described as an ingasm. And I've heard, you know, you talk about a little bit with Dr. K, the difference between sort of, you know, the people who are white knuckling, trying not to ejaculate in sort of

almost a Western way versus trying to learn your body's cues as that sensation builds, as the energy builds and trying to direct it and sort of become in relationship to that changing our traditional understanding of an orgasm, which is output of energy to orgasm.

internalizing it in some way. I know we're getting a little philosophical and we'll sort of move on from this point after this, but anything to help people understand about sort of these two methods, because I think what you're talking about in a way is that white knuckling is, I think,

very Western and maybe just sort of people aren't understanding the opportunity here. Yeah. So I, I'm not an expert in the internalizing of the energy, but I will just tell you that basically what Dr. Aloke Kanoja, our healthy gamer on YouTube, he, he basically, this was a monk. He went to India and he talks about how in India they use semen retention as a way to enlighten oneself. So they learn how to channel the energy and,

it becomes like a sort of meditative state. And that's sort of different than the way we use it here in the West, where people are just essentially trying to abstain and often failing or feeling very defeated when they can't because they're just basically like, no, no, no, I can't, I can't, I can't. They're not actually doing anything with that sensation or that buildup necessarily. My MB Alex Breakdown is supported by Helix Sleep. You know who has problems sleeping?

People without Helix mattresses, before you switched to your Helix, what was going on for you? I'm one of those people who like my body will fall asleep, like and it'll wake me all tingly because if a mattress is not right or if it's not comfortable, that used to happen to me all the

the time. I'd lay on one side and like half of my body would fall asleep. And then I'd try and switch to the other and the other half would fall asleep. That does not happen with my Helix mattress. That's a true story. We're very excited that Helix has wanted to partner with us for so many years. I've had my Helix for about three years now. So that's three years of my body not randomly falling asleep because I can't get comfortable and my neck is not aligned correctly. Jonathan loves his Helix. My kids love their Helix. Jonathan's son loves his Helix.

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I'm glad you brought up the pelvic floor because it's something we all should be talking about. And you are one of the people who has really made it, you know, acceptable, welcome, significant to talk about in a way that it used to be kind of like it was the thing that your OB said after you had your first kid. And then like we just pretend it doesn't happen, like that we keep talking about it or we pretend that it doesn't exist. So, yeah.

you know, you, you hear a lot now about like there's pelvic floor therapists and

There's people who are trained specifically to help you tone the pelvic floor. And I wonder if you can, first of all, explain what the pelvic floor is. Give us a little bit about the anatomy so that we can sort of understand literally what we're even talking about. It's kind of hilarious that of all the things we're told, like the fact that we can literally careen a human being out of our body, but that

the deeper understanding of like your body is something that we were never told. Tell us about the pelvic floor. Yes, I love this. So I'm really glad we're talking about it, right? I think the pelvic floor is this bowl of muscles and there's multiple layers and they sit underneath your pelvis, in your pelvis, and they're holding up your organs, your bladder, in women, the vagina, the uterus, the rectum,

And essentially, they're attaching to a bunch of bony landmarks. They attach to your hips. They attach to your back. They have ligaments attached to them. And many things run through them. So like the urethra, the vagina, the rectum, all these things. There's holes in these muscles or they wrap around these structures so that, you know, they help with the function of these structures.

anatomical structures. They help with pregnancy, as you mentioned, of supporting the baby. They help with urination. They help with defecation. You can even have problems with your pelvic floor if you have problems with your hips because they're connected, right? And it can create problems in your lower back. And

So these are just muscles that have been ignored, right? They're so important for so many things. They're not just for sex, right? They're also for stability. Every time you take a step, you are activating your pelvic floor. Every time you go to the gym and you lift something heavy or you lift something heavy at home, you're activating your pelvic floor. So it's being used all

the time in addition to for support for stability and these are probably the most important functions of it and i sort of describe it like when you have tmj right like if you sleep at night and you tense your jaw and you wake up with a headache and you have no idea that you're actually tensing those muscles very similarly when you tense your pelvic floor muscles

You don't know you're doing it. You have no idea. You like, you'll go to the doctor. Like I had no idea that my pelvic floor was tense. You'll see a pelvic floor physical therapist and you'll have no clue. And so it's important for these muscles to squeeze. We need them to squeeze and relax. We need them to relax. So for women, they're very important for when you need to do anything. So just like coughs, sneezes,

They are squeezing appropriately so you don't have incontinence. They also contract and relax when you defecate. So if you're having normal bowel function, that means they're relaxing when you're having a bowel movement and they're closing back up afterwards or tightening up.

They're also important for orgasm. So when you orgasm, what's happening is there's a tension building up in these muscles and they have a very strong contraction and then they relax. And so that's why having good, strong, functionally appropriate muscles is really important. So doing, so that's where this whole thing about Kegel comes in, right? Like people do your Kegels, do your Kegels.

because most often, if you've had any babies as a woman, you're gonna weaken that pelvic floor, but probably everyone's pelvic floor will weaken a little bit as they age. I don't love it as a blanket statement though, because I don't know the statement of everyone's pelvic floor. And if you have a tense pelvic floor and you do Kegels, you're gonna make it worse.

And Kegels are just like a strengthening exercise. There's many strengthening exercises. That's just the most popularized one, which is essentially learning how to squeeze those muscles up and in and relax them in either the vagina or for men in the pelvis and feeling like

It could be like you're holding in a fart or for women, it's feeling like you're pulling something up with your vagina. For guys, it's like lifting your penis without touching it. So those are sort of the cues that we'll often use to help you really understand where those muscles are and how to contract them and how to, and then relaxing is sort of letting that go. And the relaxation is as important as the contraction. Okay. So I want to

kind of slow us down a little bit. You described it as a bowl and that's because anatomically, that's sort of the way they interlace, correct? Correct. And in traditional Chinese medicine, like this is a really, really important source of energy. Like if you do acupuncture or any kind of energy work, they talk about this bowl and that it's like the holding place. It's your womb, you know, it's all these things. It's the second chakra, right? There's all these other sort of

you know, Eastern understanding of this part of the body as a tremendous source of energy, largely because it can, A, hold a baby, B, give you pleasure. But also those contractions are what help you release, you know, oxytocin is modulating all of that stuff anyway, no matter what the, you know, kind of outcome is, right? But I wonder if you can talk about the emotional connection with the pelvic floor, because, you

When we're talking about sex, a lot of women, a lot of women have pain during intercourse. And this is like a thing that like women used to like not talk about because you feel like, oh, there's something wrong with me. There's something with my vagina. Like it's wrong. It's the wrong size or there's something deeply wrong about me that no one should know. So I'll just pretend like everything's fine. Right. So when people have pain, right.

which I think is a much larger complaint than we've really known about because we didn't talk about it for so long. Is there a connection between that kind of pain that women report and things that are going on psychologically? And if so, how does toning the pelvic floor and taking care of it connect to our emotional experience? Because you can do Kegels all day long. If there's some connection that actually is disrupted or needs some support, that also may not help.

Yeah, absolutely. So we hold stress in our bodies, right? So a lot of people who develop issues with their pelvic floor will actually have some history of trauma. They may be type A personalities, highly anxious. And so, you know, it's, it's sort of like a thing we'll, we'll walk

in the room and will know that this person may have pelvic floor dysfunction because they're so, you can feel it. You can feel that energy off them. They're anxious, they're stressed, they're high energy, always focused on work and not taking enough time for

which is important in life too. And so I think that what you brought up was really nice is that breath work, which is often done in Eastern medicine and a big part of that is actually very helpful for the pelvic floor because when you take...

a big diaphragmatic breath, right? You're actually relaxing and contracting that pelvic floor. So even doing those things, which is so popular and valuable for sympathetic nervous system regulation is also improving your pelvic floor. So it's sort of like your body's way of

of responding to trauma and stress. So often I'll even tell patients who like, maybe they don't have access, they can't see a pelvic floor physical therapist, they don't have the time, I'll say, take a hot bath. Like take a hot bath and do diaphragmatic breathing and that will help relax those muscles a bit.

you know, sort of working on those things in and of itself can ultimately cure any problems you're having. And again, being able to strengthen those muscles comes from having normal functioning muscles to start with. So you can't strengthen until you've

conquered those other issues, right? And I think the thing about doing Kegels all day is like, you don't want to do them all day, right? And you don't want to be doing them like on "Saxon City" where she was like sitting around doing them all the time until you're strong enough to do that, right? The average person doesn't have a lot of strength in their pelvic floor. And so they're going to need to start to learn how to strengthen it. Just like you go to the gym, you don't pick up a 50-pound dumbbell. You pick up a 5 or 10 or 15-pound dumbbell.

Similarly, you need to lie down, focus on those muscles and really just isolate them. Try your best to just focus on that. Don't clench your abdomen, don't clench your butt and try to focus on those pelvic floor muscles. Learn where they are, get good at doing maybe 10 of them in the morning and 10 of them at night and then slowly work your way up.

but sort of really kind of trying to have that mind-body connection, which is where a pelvic floor physical therapist can be really helpful because it's very challenging for a lot of people because it's not intuitive as to how to find those muscles and really utilize them effectively. So I wonder if you can kind of underscore this a little bit. I know that you're not saying like anxious, A-type, business-minded people have problems with their vaginas and therefore can't have fun sex.

I'm going to turn this into a myth question. Can you tell which kinds of people have a healthy sex life based on personality? No, I wouldn't say so. I wouldn't say so. I think it really is, I would say based on after having a discussion with someone, how open they are about communicating about sex will tell me that they probably have good sex because if you can talk about sex

comfortably, or at least somewhat comfortably, and like I talk to people about sex all the time, you could probably talk about it with your partner, right? And which means that you can ask for what you need and they probably can ask for what they need and you can be more adventurous potentially and add more novelty because you're open to talking about those things. So I think more than the function of your pelvic floor is more about like actually talking about it with your partner and

and being able to communicate your needs and desires is probably more predictive of a great sex life than someone like type A or whatever anxiety personality. No, not at all. Because that may be the way they de-stress, right? Sex is obviously orgasms specifically are very great for de-stressing and reducing blood pressure, heart rate, feeling,

feeling great, obviously, and then sleeping well. So all those things, if you're having orgasms, that may be a really great tool or way that some people help themselves self-soothe. I wonder if we can talk a little bit more about orgasms. There's a lot of attention and, you know, this is one of the places where

you know, the, the, the women's movement really kind of brought these kinds of topics more to the forefront. Um, you know, and I think, um,

all of us stand on the shoulders of women who weren't afraid to say, are women actually happy? You know, are we being satisfied emotionally, you know, sexually? Are we, you know, kind of moving towards more communication, more openness? So I like to give a nod to sort of a movement that has a lot of complexity for some people. But that was a huge component, you know, of the women's movement was to try and talk about these things and normalize

the discussion and the rights of women to have pleasure, to experience pleasure, and to do that in ways that are safe and healthy.

There's been a couple really interesting books and kind of sex therapists who have talked about what has kind of turned into an obsession with the female orgasm. Meaning there are some basic things that, you know, and I've taught high school biology, so I've taught sex ed. And, you know, what's important to remember is that in the act of sexual intercourse, it is an act that in its inception, right?

is designed to propagate the species, right? In theory, meaning you're having a release of sperm. And the notion that the act of sexual intercourse, and again, I'm speaking sort of in a heterosexual relationship, right? The act and the completion of that act is a male orgasm.

A female orgasm is not required for the sex act. It's nice. It's a good bonus. There's some beautiful research about, you know, the amount of commitment you're understanding your partner has to give you an orgasm, which might make you more likely to conceive, which was a really fun article that came out many years ago. But I wonder if you can talk about this kind of obsession and framing we have about

trying to equate male orgasm and female orgasm, meaning the sex isn't good unless I've had an orgasm or he was selfish because I didn't have an orgasm, right? Can you talk a little bit about framing female orgasm? Yeah, well, I think that the reason there is this huge orgasm gap, so we know that in first-time sexual encounters, 95% of men will have an orgasm. As you've sort of described, right, it's almost...

a part of sexual intercourse, whereas only about 45% of women will have orgasms. But when you look at same-sex couples, so women and women, that rate of orgasm goes back up to 90%. So we know that this is probably partially... The men's fault, sorry. It's not their fault. It's an educational issue, right? It's that men aren't taught how to

get or have their partner achieve a reliable orgasm through school. Obviously, we're not talking about that. Unfortunately, we're not taught about it in our homes. Most parents are not talking about those things. And if you're watching erotic films, you're not seeing any other form of stimulation. Typically, I mean, you can, but like for the most part, you're seeing penis in vagina sex, right? Which is not going to always elicit an orgasm. In fact,

85% of women will need clitoral stimulation, which is not specifically in the vagina to achieve orgasm.

So the clitoris is, you know, the structure on the top of the vulva, which is homologous to the male penis. So when you're having penis and vagina sex, it's as if a woman was like stimulating someone's testicles or perineum. Like that would feel nice, but it might not really lead to orgasm, right? It might, but it might not, right? And also,

So can we just, I just want to take a pause. Like this is a mechanical anatomical conversation. This is not about there's something wrong with your vagina if you can't have an orgasm just from sex. We're talking that statistically speaking, the structure of the penis and the vagina and the placement of those things when in intercourse is

statistically speaking, does not produce a female orgasm. Like that's not what it's for. It can happen if you're one of those women, mazel tov, like really happy for you. That's great. But generally speaking, the sex that we see in pornography of just like intercourse and the woman all of a

sudden having an orgasm or like in any movie that you see, that's actually not an accurate representation of the way that anatomically the system is supposed to work. So it's a little bit like, you know, if you're having sex with a woman, like you might as well be patting her shoulder and seeing if that will give her an orgasm. Yeah.

Well, maybe, but you know, like I think ultimately the thing is, right, that there's that. And there's also sort of a difference that occurs in terms of timing. So when you look at, statistically speaking, how long it takes a man to climax and how long it takes a woman to climax,

It takes a male about five and a half minutes on average to ejaculate an orgasm. Whereas a woman, it takes about 14 minutes of stimulation, of consistent stimulation to climax. And that doesn't include the time it takes for arousal, right? So people often get confused because I will describe that it can take some women up to 20 minutes to be fully aroused. And then another 12 minutes of stimulation to climax. Ladies, we need to close that.

That's the gap we want to close. We need to get aroused sooner so that everything's aligning because we don't have all night. Yeah. Well, I mean, you know, I think in terms of arousal, that's your body's physiologic response, right? Like it's certainly you could find things that make you more aroused and communicate those with your partner. Like I said, communication is key, right? And then it takes time for a female body to be prepared for a phallus and penetration. So very often...

when it's hurting, it's because the female body is not ready. So when she's getting aroused, her vagina is actually doubling inside. It's increasing in width. It's increasing in length to allow

for the phallus. Did you say doubling? Doubling? I mean, think about it. Our bodies are amazing. We push full babies out of our vaginas, right? It's very flexible and adaptable. And so if you're penetrating before the female body's ready, it's not going to be comfortable and it's definitely not going to lead to orgasm because you're having pain. So I think the

think the question is like there's a gap there that can be corrected it's not that we should look at orgasm as a thing that we are not allowed to have I think it's like hey you know it requires part

on both parts, right? The male partner needs to understand the physiology of the female in a heterosexual relationship and allow for her to climax, you know, or time it in such a way and understand her physiology in such a way to allow her to achieve climax. We're not that complex.

It's just about learning what stimulation works, how long it takes, what sort of things each individual needs. And it's not like I can give you a script where like this is, you know, for this first five minutes you do this, next five minutes you do that. No, everyone's going to be different. But it's more of like really understanding that and learning that. And, you know, I think for a lot of partners, they want to see their partner climax. It's not a very self-serving thing. They just don't know and they don't have the education to help them. Right.

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Mind Be Alex Breakdown is supported by BetterHelp. You know, I don't know if she listens to the podcast, but I'd like to take a moment to shout out a big thank you to my therapist. I'd like to shout out your therapist too. She's very helpful.

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Before we get into sort of some of the particulars of that, I wonder if you could talk a little bit about this notion that for women, since we do have a different kind of system, it doesn't mean that sex is not something still to enjoy or, you know, consider.

like a success if you don't have an orgasm, meaning there are a lot of women who are having orgasms who aren't enjoying sex. And there's a lot of women who are enjoying sex who aren't having orgasms. And I think like this notion, and I understand in the, in the name of equality, it's like he has one, I have one. Right. But, but that's actually not, that doesn't have to be the only equation.

Absolutely. I mean, I think a lot of times we're so focused on the end result, which is an orgasm, but sex is not just about who can get an orgasm. You can do that by yourself, right? Like you can self-stimulate, you can get an orgasm alone. It's about connecting with a person, right? Being intimate with that person, enjoying that person, playing with that person. And so it's about the

that whole journey together. So whatever that means for you, it doesn't mean it's a failure if you don't have an orgasm. Maybe you don't enjoy the loss of control during an orgasm. I mean, that's okay, right? It's not a negative thing. I think the most important thing is that you are enjoying the process by which you are being intimate. And I think we have this narrow view of what sex is, right? Sex is not just penis and vagina sex,

Sex can be anything you want it to be. It can be stimulating any erogenous zone. It can be masturbating next to each other. It can be, you know, oral, anal, any other type of intercourse you want to participate in as long as both parties are consenting and agreeing and enjoying. I think that's all that really matters.

I want you to talk a little bit about, because what you've described, you know, when we talk about, and this is just some of my favorite, you know, kind of like developmental neuroanatomy of like, you know, how these parts in particular of, you know, the human body evolve. When you talk about, you know, that the clitoris, I'm saying clitoris, is that wrong? You say clitoris, you're the doctor. I think it's fine. Either one is fine. I'm not exactly sure which is correct. I've always said clitoris.

I'm going to say clitoris just rhymes with Dolores, like on that Seinfeld episode. So when you talk about the clitoris as, you know, sort of the, the equivalent and developmentally, that's what you're talking about as the kind of like equivalent of the penis. Here's the thing. And you don't even have to have a lot of sex to know this. The penis does a very specific movement, right?

It does a very specific thing. And men's masturbation typically mimics that thing that it does. And then eventually there's an orgasm, right? Now with women, we're dealing with a much smaller...

more discreet, you know, bit of tissue, very sensitive nerve tissue. And there's not a one size fits all movement here that is going to help you achieve an orgasm. So this means it's a different level of commitment. It's a different level of understanding. It's a different level of learning. As you said, what's going to work for your partner? I would like to make a public service announcement on behalf of all women.

What you see in porn is not necessarily going to be what works and what works for your ex may not work for me. So I wonder if you can talk a little bit about, and I don't want to scare people from being like, well, if he didn't learn by now, he's never going to learn. You're making it sound like it's rocket science.

is really not rocket science, but it does involve a level of patience, communication, and yes, intimacy. Talk a little bit about the kind of like variability in ways to have an orgasm. Yeah, absolutely. So I want to go back to something you said, which was, it's a small bit of tissue. So actually, if you look at the clitoris,

it is much longer than what you see. So it actually goes deep into the pelvis, goes around the vaginal canal. And so you can stimulate the clitoris in the obvious way, which is stimulating the head of the clitoris, which is very similar to the head of the male penis. So if you look at the clitoris and the penis, when we're fetuses, they're identical from the genital tubercle. And when you differentiate into male or female, they're going to develop a penis or a clitoris.

But if you take anatomical sections of the clitoris and you cut it open, it looks the exact same. It's a small penis. It's the same exact structure. And so it stimulates the head of the clitoris. And that can be in a multitude of ways. Some women prefer light touch. Some women prefer more firm touch. Some women prefer vibration. Some women will prefer adding some warming or cooling lubricants. And you know this, that this will stimulate different parts of the spinal cord.

So people will have different responses and that may depend on how they masturbate. They've maybe habituated to some type of stimulation that works well for them. And that's fine as long as you guys are happy with doing that. Or they may be more sensitive, but it is really important. It's the same thing as like some men don't like as firm of a grip, some like more firm of a grip, whatever it is, right? Even men have variability in terms of what they enjoy. So I've heard. Right.

The pressure from intercourse is somewhat similar to most people, but there are other degrees of sensation. And so similarly, you can stimulate the head. You can also stimulate the shaft of the clitoris, which would be through the vaginal wall, right? The top side of the vaginal wall is where the clitoral bodies are running above that.

And in fact, people talk about this G zone, right? This G spot. It's not a spot. It's a zone. It's an erogenous zone where there are lots of nerve endings. Also happens to be where these special glands called the skeins glands are. And these are similar to the male prostate or homologous to the male prostate.

And so these also have nerve endings that are somewhat erogenous. And so stimulating this zone, which is about two or three centimeters in the vagina at the top side, so like a come hither motion, that is sort of where you'd be stimulating that area. That for some women can be very stimulating and result in orgasm, but not all.

all, right? Like if I were to stimulate a male prostate, not every guy is going to have an orgasm. So similarly, not every female is going to have an orgasm from G-zone stimulation, but that is another very popular erogenous zone. Some women will also achieve orgasms through cervical stimulation. Some women find that uncomfortable. So very, you know, sort of

dichotomous area, but certainly stimulating that area through, if you're very well endowed or through toys or through fingers can be very stimulating and result in orgasm for women. Because that's higher. I just want to, that's higher up there. Yeah. If women will know if they've had a pap smear, that's what they're getting at when they do the pap smear. So it's pretty far back. Yeah.

It's pretty far back there. So, you know, I think, I think ultimately they're all orgasms. They may result in different sorts of sensations. Like you might feel one is I've had an orgasm specialist on my podcast and he talks about how women describe a cervical orgasm as like a

cosmic feeling, like you're feeling like shooting stars, whereas it's different from an orgasm coming from clitoral stimulation versus G erogenous zone stimulation because they're stimulating different nerves and those nerves are creating a different sensation. But ultimately, orgasm of itself is a buildup of tension and a release, right? So that's what

the basic kind of premise of what an orgasm is in terms of that. And so you can experiment with stimulating those different areas together at the same time, separately, and sort of figure out what works. And I really empower all women to take some time to yourself to figure out what works for you, because then you can communicate that to your partner. And realizing that this communication doesn't always have to be verbal. It can be nonverbal, gentle moving of the hand or, you know, um,

things like that, that maybe you feel more comfortable with are also quite effective, but ultimately, um, you know, you got to know what you like so you can tell your partner. I wonder if you can talk a little bit about the, um, the tremendous, I mean, from what I can tell preponderance of the use of vibrators, which I, I'm are wonderful things. I'm happy for people who use them. That's great. Um, but I,

As someone deeply interested in anatomy and the emotional and intimate connections that form when you have sexual experience with other people, and this is just me being, you know, like a couch, you know, sex therapist. I sometimes wonder if women are missing out on learning more about their bodies by not relying only on vibrators because it is a really...

specific and different kind of experience. Can you speak to that since it's literally your job and your vocation to understand these things? Like, am I being uptight and weird? What's going on here?

Yeah, I think that there is no one right way to achieve climax, but you can sort of, a vibrator is a very efficient form, right? It's very efficient. You're going to get an orgasm quickly, reliably, and you're going to have, you know, be able to do that quickly. And so in those cases, that can't be replicated by a mouth or a hand. You can't get to that frequency. Right.

quite as efficiently and quite as reliably with any of those other ways. So you can't habituate to a certain type of stimulation and then get frustrated because something else is not giving you that same response. But I think ultimately that's not everyone's experience. And if you do like to climax that way, you can always bring toys into the bedroom. Like that's a

bad thing. The point again is to have fun and to enjoy each other. And if that means that you're masturbating and your partner watches or your partner is assisting with the toy, and that's great for you guys, by all means, that's great. But yes, I think I generally tell people, if you are frustrated by this habituation, then it behooves you to take a break and try different things. Like

Try different types of stimulation, even get a feather, like use very light touch, use, use, use lubricated fingers, oral, use all sorts of different techniques to sort of see what your body responds to and give it a little break. You don't have to stop, but you just sort of, just so you can kind of explore a little better. But if you're not bothered by it, then by all means continue, because again, it's very reliable, it's efficient and it works.

Can you also speak a little bit to, um, you know, we've had a real shift in sort of hookup culture and dating culture and, um, you know, again, a real emphasis on, you know, women really feeling that they have a place and do have a place and deserve a place, you know, in their sexual lives in ways that have, you know, even shifted since the, in the invention of the pill, as it were. Um, a lot of what you're talking about though, um,

You know, even me as like a grown woman who like, you know, was with someone for 15 years, was married, had two kids, you know, like all those things, you know, that's a very intimate, emotional relationship, right? In theory, to be married to somebody and with them for over a decade, right? And even still, some of these conversations can be a little bit

you're like finding the words or the way. And like, I think especially in our culture for a lot of, I'm speaking, but I don't know if I'm speaking correctly. A lot of women feel like, oh, I should just like, it's okay. Or like, it's something about me or I need to work on it as opposed to sort of like having a conversation about like, hey, let's talk about what's working, what's not. Here's some constructive criticism and you don't want to like hurt his feelings because he in our culture can't be criticized, right? Like just all these things, which a lot of it is in our own head.

When we think about hookup culture, when we think about like apps that literally tell you how close a penis is to you, how close the nearest vagina is that would like you to meet it is,

You know, I'm trying to imagine these kinds of conversations in those kind of situations. And I know they're not happening. And maybe it's because the people are like have a different set of standards. If you're using those apps, I don't know. It's not my thing. It's just not my language. But can you talk a little bit about what it means to have sort of connection that is intimate, that allows for the kind of satisfaction that you're talking about that we all deserve? Yeah.

Yeah, so it is very challenging. I will not say that this is easy, but talking about sex is a skill, right? We learn how to talk, have difficult conversations in medicine, for example. I learned how to break bad news. I'm sure in your field, you learn how to do certain things that are very challenging, but it takes practice.

And so one is just, you know, it's going to be weird. It's going to be awkward. Sometimes it's going to flop, but you're building that muscle about talking about sex. So one, I think being okay with that and being a little vulnerable, but realizing that sex is being the most ultimate vulnerable person you are.

right? You are literally undressing yourself and being totally open to somebody in a very vulnerable way. So sort of like realizing, okay, yes, I'm going to be vulnerable with my body with this person. So can I be vulnerable with my words? And no, it's not easy. I'm not saying it's easy. I'm saying this is something that I think is sort of a mind shift frame. You can also do it in a way where it's sort of

more, less serious and less deep, right? It's like, hey, what are you into? What turns you on? What's a good experience you've had in bed? What's a bad experience you've had in bed, right? In terms of like, you're not really saying this is what I need, but you're sort of being more inquisitive about,

what your partner's experience has been. And then that will allow you to potentially give your experience. And if they're not reciprocating by asking you, then maybe that's not somebody you want to have sex with, right? Like maybe they're not really like you're giving the opening, right? And you're saying, hey, what turns you on?

and they answer. And that's, you know, we say it's a dirty talk, but like, it's actually like educational for you and for the partner to say like, this is what really turns me on. What about you? Right. And so this allows you to have these conversations as sort of a cheeky way, but you know, then you kind of have a roadmap and like, it's almost freeing to like, no, oh, this is what this person likes. Like now I know what I have to do. It takes almost that stress away of like having sex with someone new because you know what they like. Right. So you just sort of

shift your framework around it and realize you're going to have bad conversations. Like we all mess up when we're learning a new skill and it's never always going to go perfectly. But like, you got to allow yourself to be vulnerable with your words to experience the pleasure that you deserve.

So what are some of the challenges then of, you know, a hookup culture or, you know, a culture that is very fast and loose about sex? Because honestly, what you're describing is the way a lot of, you know, children and grandchildren of immigrants are raised. Meaning I was raised, you know, even outside of the religious construct, you know, that many of us are raised in if our family, let's say, came from places where religion sort of guided their families, right?

You know, I was raised with this notion that like there's something very sacred about sex. And it's for exactly the reason that you just said. You are doing the most vulnerable intimate act. You are participating in an activity if there is a penis and a vagina involved, if there is semen and ovaries involved, right?

you're, you're participating in an act that can create life that can potentially get you pregnant, right. Within, within certain bounds. Right. So for those of us that were raised kind of with that structure, um, and it means also that you should have the most fulfilling sexual experience, you know, within an intimate and close relationship. But, um,

you know, for those of us who kind of came of age with that as our framework, a lot of the new way that the kids these days and adults, you know, are often participating to me feels like, gosh, where, where is the room for that sacredness and that intimacy, which I was raised to believe facilitates the ability to have these kinds of conversations.

that the way I'm describing it is more so that in order to have climax and pleasure, you have to allow yourself to be totally vulnerable, meaning you have to allow yourself to like accept that pleasure. And so in order to that, you can't be thinking about your insecurities. You can't be worried about things. You have to be totally present in the moment. And to do that,

you have to be vulnerable. Like it's part of having the best sexual experience you can have is allowing yourself to be vulnerable with that person, like to allow them to, you know, explore with you, do those things. And so I think like,

it's not about feeling like this emotional connection necessarily, but more about like how you feel about yourself and allowing yourself to really give yourself to somebody and experience pleasure and be in the moment with them. And I think that that's sort of how I think about it. And I think that the real concern I have with

Today's it's so fast that we're not getting we're seeing things on erotic literature. And for example, we might just do them. Right. So, like, for example, I had a researcher, Debbie Herbenick, on my podcast and she wrote this book. Yes, your kid. And basically she's done research to find that strangulation has become as commonplace.

commonplace almost as just like kissing in terms of foreplay because it's become so accepted in erotic films and people think this is what other people like. And when you actually dig deeper in the literature, like women are like, it's most often the male strangling the female. And most often women are like, yeah, it's

it's okay, I don't love it, but it's fine. I think he likes it. And it's like they talk about it and they're like, they might say, can I do this? They say yes, but it's not like this, like really thoughtful conversation. And I think there's obviously dangerous to strangulation as you know, for long periods of time, you're losing oxygen to your brain. And so I think there's really room for us to change that narrative a little bit and realize that like, yes, you can have fulfilling, passionate sex with whoever you want to,

but within the confines of safety, consent, and allowing yourself to be vulnerable to truly experience pleasure.

This leads to a conversation about what are the influences that are guiding our expectations about sex and sexuality. There's more prevalence of online material and people are seeing it at a younger age. Have you seen in your practice how this is impacting people's expectations? You obviously described strangulation. Are there other ways that people are getting false expectations or having a harder time making those connections?

Yeah, absolutely. So I've, I've seen, I see definitely more men in my practice than women, but in, in the male side of things, I'll see younger guys coming in with a lot of performance anxiety because they're watching these erotic films and they're like, they go into their first sexual encounter or their whatever next sexual encounter. They're like, why didn't it

happen like that? Why didn't she respond like that? Why didn't I respond like that? Or vice versa, the female can be like, well, why am I not climaxing? Am I broken? What's wrong with me? Why am I not enjoying it like the woman on the film? And I think that the issue is that their brains are not fully developed and they're seeing this and they don't really realize that it's like a product.

right? They're making it look this way. And these are professionals who chose to be actors in erotic films because they have a certain characteristic or they whatever, and they are, they are trained paid actors. And this is a film which has, you know, special effects and special things that make it look a certain way. And so I think ultimately, um, that's where I'm seeing is this really X,

expectation that people are getting from what they're seeing. And then that's not resulting in what's happening. And one, they have no one to talk to about it because no one talks about sex. And two, they're now feeling very insecure about their bodies, about their performance, about their ability to give pleasure to a partner or to receive pleasure.

And you mentioned you're seeing people not only with self-confidence issues, but also with physical performance issues. How much is this impacting erectile dysfunction? And have you seen pornography related erectile dysfunction?

So I would say that the brain is the most powerful organ for sex, right? So if you think, if you're stressed about sex, you're not going to have an erection. So if you think about like, say you have a bad experience in your last encounter with a person and you don't have an erection, the next time, and for whatever reason, that might be stress, that might be fatigue, that might be you drank too much, whatever it is,

whatever reason, the next time you have sex, that's all you're thinking about, right? You're like, am I going to get an erection? Am I going to get an erection? Am I getting an erection? Even if it's not the forefront of your mind, it's in the back of your mind. And so that stress is going to basically make it very difficult to get an erection, even when the physiology is all working correctly. Even when you have good blood flow, good hormones, everything else is in good order, you could still have issues getting an erection. And then it becomes this vicious cycle, right? Because then you don't, they don't get an erection. And then again and again, I don't like to say it's

porn related. It's really from a psychological state of anxiety and stress, right? And if that comes from watching pornography and having an unmet expectation because of pornography, then yes, it's related to watching that. But many, many people watch pornography without these issues, particularly people who have an understanding of what real sex is like. But I do think that there are some cases where this leads to this problem in particularly younger people.

And it can be a bit of a self-fulfilling loop because if they have that anxiety, they're struggling there. They may go back to trying to derive pleasure from digital formats, which make the interpersonal connection less vulnerable. And so they could be reinforcing those pathways, making it harder to connect with human beings in the real world.

Potentially, yes, because that's an easy, easy, accessible way to get an orgasm or get an erection. And and and that doesn't give them that same sense of rejection or failure, potentially, if they have issues with their partner. I really appreciate a lot of this conversation around erectile dysfunction. And, you know, again, it's this kind of thing that it's uncomfortable to talk about. This is a weird question. I don't know if you've been asked this.

What are some do's and don'ts if your partner is experiencing erectile dysfunction? What are you supposed to do? What do you say? Like, how do you not make it worse? How do you not be like weird? What do you do?

So first and foremost, don't stop and make it about yourself, right? Like I think a lot of people are like, oh my God, you're not turned on by me. And they just like make a big production out of it, right? And I think realizing that like erections are variable, people will have in their lifetime an experience where they lose their erection, maybe once, maybe multiple times. And especially as men age, half of men over the age of 50 are going to have ED. 60% of 60-year-olds are going to have ED. 70% of 70-year-olds are going to have ED. So like it's everyone's like...

the likelihood of you having ED versus not is more than likely, right? And so I think that first and foremost is like, don't make a big production out of it. Don't stop unless that's what they want, right? You can continue if they want to. If they stop, you stop, right? But I think like, don't talk about it right in that moment. Like don't bring it up and make the bedroom this place of like this big argument or discussion. Like let the time pass, talk about it in a remote location. Be like, hey, like-

Was it something I did? Was it something like, is there something you want to talk about? And from a pace of, you know, inquiry and inquisition and not a place of like, oh my God, something's wrong with you or something's wrong with me. Like really like trying to understand, like, is there something I can do to help you or support you through this?

Like, and if they want to, if they do, if they're still like being intimate with you, you can continue being intimate. Again, as we talked about earlier, orgasm is not the only thing that you can enjoy during pleasure. Maybe they will enjoy pleasuring you, or maybe they, they can still orgasm without an erection. I think a lot of guys don't know that is you can still orgasm without an erection. Jonathan, did you know this?

I did not know this. And your face revealed that you did not know this. Nope. Adding it to my list of things Dr. Malik taught me that I did not know. Dr. Malik, explain. Well, yeah, if you're stimulated enough, you will still have an orgasm. Ejaculation and orgasm are actually two separate entities, but they very often occur together. And so, you know, if you don't ejaculate or with an erection, you can still ejaculate.

stimulate yourself and have an orgasm. So a lot of guys who can't get erections will still have orgasms. They will still stimulate themselves or their partners will stimulate them to achieve an orgasm, but it just won't be in the traditional way. Now for many people, right, there's this

this very developed neural pathway with like, I see an erection that's telling me I'm aroused. And that's a big part of the cycle of sexual response, right? And so sometimes without that, they can't mentally get into this framework of arousal and obtain an orgasm, but it can be learned.

But I would say that, yes, for many people without it, they just can't be in the mental headspace to orgasm. I was taught like the there's erectile tissue, you know, like it's blood flow is like a thing that happens. You have an orgasm. It's not true.

Well, an orgasm is a brain event, right? It's a brain event, whereas an ejaculation is a reflex. So they're two separate entities, right? You ejaculate as a reflex. It's a spinal cord reflex, whereas an orgasm is a brain event. So yes, it does connect, obviously, to the pelvic floor muscles causing contraction, but

Ultimately, they're two different processes, but they very often occur together. Okay, so in the list of do's and don'ts, if your partner's experiencing erectile dysfunction, don't be like, it's okay, you don't need to have an erection to have it work out so much.

Let's drive in. Don't do that. Not the time to have the discussion. No, not the time. Again, not the time to have a discussion. Go with your partner's cues. Continue being intimate if they want to. And if they don't want to, that's fine too. But don't make a big production about it, right? This is a very sensitive...

And very loaded experience for the guy who's dealing with it, especially if it's the first time. And and so I think if you want to support your partner and be a supportive partner, like the worst thing you can do is make a big production in the moment. Oh, my God, we have to stop or like, oh, no, are you OK? Are you OK? OK. Like they don't want that either. Right. Like just follow their cues and and sort of go with what they want and then talk about it later. Not in that moment.

We've come kind of full circle because while we are not talking about semen retention or engasms, we are talking about the separation between ejaculation and the orgasm. And what I hear you saying is that there are multiple ways to have an orgasm, which I

I think is a lot of people don't know. No, I think you're right. A lot of people will, who practice semen retention will still orgasm. Sometimes they will train themselves to orgasm without ejaculation. Some of them will actually put pressure on the perineum

And so what they're doing is they're creating retrograde ejaculation. They're actually forcing the ejaculate to go backwards into the bladder rather than out. So they're actually truly ejaculating, although they're not seeing it. And sometimes men will have an ejaculation or retrograde ejaculation due to medications or conditions like diabetes. So they'll orgasm, but nothing will come out. And so I think...

I think there are a multitude of ways this happens. And yes, so yes, you can, if you're practicing semen retention, still have orgasms without ejaculation. Have there been any studies on the physiological differences between these two experiences for people?

I have looked high and low for studies about this. So if somebody in your audience has found a study that is really well done, I'd love to see it. The theory that a lot of people will say is that, well, when you ejaculate is when your prolactin goes up, which is sort of a

related to the refractory period. So like the time it takes between when you can get another erection and continue having sex. So for some people that this is how they believe that they can get more multiple orgasms in men is by training themselves to orgasm without ejaculation because there's not such a high prolactin release. Now, I have not been able to find that in any form of scientific literature that is very compelling, but that is the theory.

And so I don't know if it's true, to be quite honest with you, but I think that because prolactin is not the only thing that is involved in refractory periods, but that's the most discussed one. And so I think it's much more complex than that. But ultimately, yeah, I have not found any compelling literature to support that. I want to talk about prolapse.

This is one of these other really, really verboten, we don't talk about this until we have to and until the situation's really dire. And there's these legends in my family of she had to have a hysterectomy because it just fell out on the floor. These notions, it was this myth of what happens to the body. I'm going to tell a story which I think that you will find funny because you are a doctor. So...

My grandmother of blessed memory did have prolapse. A lot of women do already. I'm like, is that a secret of my family that I should know? It's like, it's a thing. And a lot of women experience it. So I, um, was at my OB and, um, I said, you know, I just found out that my grandmother had this and like, I'm just, since I'm here for a checkup, I'd like us to do just like a check. Like, I just want to know where are we at? I love my OB really, really wonderful. Um,

And I kid you not, she looked me dead in the eye and with a straight face said, when you have to go number two, when you have a bowel movement, do you need to insert your finger in such a way so that the feces come out of your anus and not your vagina? And I said to her,

If that were the case, don't you think I would be running down the hall into your office screaming, what the fuck is happening? Like, you're asking me this seven minutes into... No, I would have told you if that was happening. And I said, I know a lot. This is something I didn't know. And she's like, oh, well, that's one of the things we ask. Can you please explain again the God in heaven that would create this aspect of...

and devolution of this part of my body. Yeah.

Yes. So thank you for sharing that. So pelvic organ prolapse is a very serious thing. I don't want to joke about it. Correct. No. And she was legitimately like, is this happening to you? And I was like, no, I would have told you first thing. Yeah. Well, to be honest, to be fair, most people are very private and they won't even necessarily share that. They would be very vague and say, I feel like a little bulge or I think something's wrong down there. So I think that's why we ask. But, um,

So pelvic organ prolapse is essentially weakening of the vaginal skin is now prolapsing or coming down. So something is actually bulging in the vagina and it can be the top of the vagina, which is where the bladder sits. It can be the

apex of the vagina, which is where the uterus, or if you've had a hysterectomy, small bowel sits, or it can be the bottom side, which is where the rectum is. So people will say, oh, my bladder's falling out. My rectum is falling out. It's really all just your vagina's coming down in a specific location. Um, or it can be unfortunately all the locations. Um,

I'll give you a minute. You seem like horrified. I'm not horrified. And also like I'm a home birth mom. Like I'm like that lady who gave birth in the next room. Like I know a lot of parts of me, but this was a level of like, well, I'm sorry, what? Yeah.

Yeah. So anyways, this happens. It's very common. It happens to women because they've given birth and those pelvic floor muscles get weak because they have collagen disorders. So we talked about like, you know, flexibility, like some people have collagen disorders, sometimes neurologic disorders can affect the strength of the muscles. Having jobs where you're

standing a lot or doing a lot of strenuous heavy weightlifting or coughing, if you have a chronic cough, those can put you at risk for this issue. That doesn't mean that all the people who do these things are going to have prolapse, but these are sort of putting you at risk for this happening.

And so when this happens, it actually happens quite commonly, but most of the time you're not bothered by it. So if you look at like, they did a study where they examined women's pelvic floors, you know, vaginas, and they looked at the degree of prolapse and a lot of women had like stage one prolapse and yeah, they're walking around just fine and they're not having any issues and it doesn't matter. Right. So,

What matters about prolapse is are you bothered by that prolapse? And so what does bother mean? You described one of the things. If you have posterior vaginal wall prolapse or a rectocele, sometimes when you're pooping, the poop actually gets stuck in that bulge and you're having trouble getting it out. So sometimes people will have to splint and actually put their fingers in their vaginal canal and push that to make it straight so the stool comes out.

And that's bother, right? It could also feel like something's falling out, like you have a tampon that's falling out. It can feel like if you're feeling pressure or even lower back pain. And then it can sometimes cause dysfunction in the bladder or with stool, like I mentioned with having to splint. And sometimes for women, they have trouble peeing because that bulge gets so

big that they actually have to maybe push their bladder up to help them empty their bladder or because the bladder is really stretched out, they'll get some urgency and frequency, like they got to go, got to go. So there are real things that can happen with prolapse and this can be fixed by a variety of things. You can, again, we talked about pelvic floor physical therapy, but going to a pelvic floor physical therapist can help strengthen those muscles, particularly if you don't have really high grade prolapse.

You can use things like pessaries or dishes, like sort of like a diaphragm that you place inside to hold things up and you take it out at night or when you have sex. And, and then you can have surgical correction of prolapse if you need to. And I think the,

The important thing is just don't suffer in silence. If you're feeling symptoms and you're dealing with it, like see your gynecologist or urologist who specializes in urogynecology and get them to evaluate you and start doing those things early, like pelvic floor physical therapy to help correct that rather than waiting until it becomes a bigger problem. And not everyone will it become worse. So I think when we look at studies, not everyone gets worse.

about, you know, 20% of people stay the same. So, you know, it's not to say that everyone who has some degree of prolapse is destined to have surgery and is going to have a horrible experience. But I think doing things to be proactive can be helpful.

I wonder if you can talk a bit about ways to improve your experience as a female surrounding orgasm. So you've talked a little bit about, you know, being able to communicate and kind of knowing your body. Can you talk a little bit about some pointers for women?

Yeah. So I think in terms of how to improve your orgasm experience is really to experiment on your own first. And if you're very against that, certainly doing it, having a partner who's willing to experiment with you and just trying a variety of, of different, as I mentioned earlier, stimulations, but also, you know, you can, there are sort of, um,

arousal gels that you can get over the counter. Some people find those really useful. Some people you can get from compounding pharmacies, certain medications that can improve blood flow to the clitoris, which would then improve arousal potentially. So there are sort of things in those realms which you can experiment with if you'd like to. And then in terms of, you know, I think

Uh, there are also, I think a lot of women don't know this. There's a lot of medications and options for low desire. And actually about 40% of women experience low desire related to sex. And so, you know, having more desire for sex could ultimately lead to more enjoyable orgasms. Um,

And so, of course, desire is very complex. It's not always just like, let me give you this pill and you're going to be better. Oftentimes, it's, you know, if there's too much stress, if there's too much anxiety, if there's too much work, if there's too much responsibility due day to day, it's going to make you have lower desire. If sex hurts, it's going to make you have lower desire. So obviously working on those things is really important. I think a lot of people find this interesting is that when

Men look at sex, of course, we're again talking about heteronormative relationships. They look at it as a stress relief. But very often women will unfortunately look at sex as a chore, something to do to please their partner, not necessarily to please themselves. And so there's sort of a difference in how

gender's view sex. And so I think part of it is making it more of an enjoyable experience. So oftentimes we'll tell patients to schedule time for intimacy, particularly when they've been in a long-term relationship. So like, if you think about when you're in a new relationship, you're super excited about going on a date, you for females, maybe they'll shave their legs, they'll wear their favorite perfume, they'll, you know, whatever they'll do. And, you know, to prepare, to be very attractive to their partner, to feel comfortable and confident in their body.

because they might have sex, right? And they're excited about, they're thinking about it, like, oh, we might have sex. And then you have sex and you're like, there's just more anticipation and excitement about it. So if you schedule time and not just a date night, right? Now we're going to go out to eat and then we're probably going to be home and bloated and not want to have sex because I feel bloated and disgusting. It's like, you know, let's like actually schedule time to be intimate together. Not like a forced time to have sex, but like, let's like lie together and

be next to each other, whatever intimacy means to you, but some sort of physical contact with your partner. And, and actually if sex happens, that's great. And if it doesn't not, but we're actually prioritizing intimacy and that can really help. And people are like, Oh, I don't want to schedule it. But really in today's world, like if you've got kids or you work a lot, like there,

there's not a lot of time unless you actually make time for it, right? You have to make it a priority, just like you make your Pilates class a priority or whatever it is. Um,

So that's one thing that can help with the load and the stress of sex, because I think there's also the stress of saying no if you don't want to or asking if you want to. And so it takes that out of the equation too. In terms of the things that we have, so if you've sorted all the other issues out that could be related to low libido, there's two medications that are available for premenopausal women with low libido. They can be used for

postmenopausal women too. They've just been studied in that age group. So they're FDA approved for that age group. And one is a pill called flabanserin. It's a medication you take every night, one pill at night. And it helps, it works on serotonin receptors of the brain to help improve both of these work on brain receptors to help improve essentially the pro-

erotogenic or pro-desire hormones and reduce the hormones that are low desire, basically, in the brain. And so this one works on different serotonin receptors to help improve desire.

And then there's an injectable medication called Bremelanotide, which is injected on demand. So 45 minutes before you want to have sex. And it also works on melanocortin receptors in the brain and causes this increase in desire acutely. So when you want it. And then lastly, off-label, there's testosterone that is very helpful for women who are experiencing low libido and have physiologically low levels of testosterone. I mean, I think a lot of

people, forgive me, use alcohol in order to loosen up and have sex with their partner. I think there's a lot of cultural components here is that women bear the load of housework and childcare even if they are the primary breadwinners of the home. So it's a little bit like...

women are. We're exhausted and taxed at a different level. So that I think that in many cases, people are like, if I have a glass of wine, if I have two, I mean, that also it's going to shut off the critical mind, which reminds you of all the things he didn't do or all the things that you didn't get done. I mean, I'm not

encouraging people to get drunk and have sex. But I think we all know that like alcohol is a social lubricant. It's a sexual lubricant as well because it does, it sort of removes, you know, a lot of our, our thinking about the things that can make us not feel amorous or, or generous even with ourselves. Um, can you, can you talk a bit about

you know, this magical decade of your life called perimenopause, you know, which then leads to the magical rest of your life, which I have not found magical. I wonder if you can talk about some of the changes, you know, that women go through. And, you know, I think the one that that

people most talk about is like, your vagina is going to be dry. Like beware, your life is over. Your vagina is going to get dry. And, you know, obviously there are certain things that hormones do in our bodies, but, um, can you talk a little bit about the complexity of, of perimenopause, um, and, and menopause on, on all of these things?

Absolutely. And just to go back really briefly to your alcohol comment, I definitely don't recommend alcohol, but I do recommend a mindfulness practice. And so there's actually been studies where they've had women do a mindfulness practice outside of the bedroom, obviously just like develop a mindfulness practice. And they've seen that there's an increase in desire because they're able to offload some of that chatter in their brain and be present during the experience of intimacy. So that's something to consider.

So back to your question about perimenopause. So perimenopause and menopause. Perimenopause is a crazy time for a lot of people because your hormones are sort of all over the place. One day your estrogen will be really high, one day it'll be really low. And so you can start experiencing symptoms of menopause during that time, which could be things like hot flashes, could be things like the genitourinary syndrome of menopause, which includes

vulvar atrophy is the medical term, but essentially thinning and more thinning of the tissues in the vagina itself. And even

shrinking of the labia, maybe some even clitoral shrinking and things like that that happen because there's a lack of vaginal estrogen and androgen hormones that are in the vulvar tissues. So absolutely, you see these changes. There's also a whole host of symptoms, but most importantly, there's bone loss with this loss of hormones that can be really serious and why women more likely to get fractures as they age.

But those are probably the most common. Now, a lot of times there's changes with your skin, there's changes with your brain, there's changes with your heart. They're all also related to hormone changes. And so we know there are estrogen receptors all over our bodies. And so during menopause, your estrogen goes from in the hundreds to 10. So you're dropping your estrogen dramatically, which can have serious effects.

And so one of these is vulvar atrophy and also having maybe recurrent urinary tract infections, maybe having pain with sex, maybe even going to the bathroom more often. These can all be related to these changes that occur during menopause and perimenopause.

And so this, you know, it can also decrease lubrication. And so these are things that like, yes, they are going to happen. 80% of women are going to have these symptoms and not to say everyone does, but a lot of women will. And so it is something that, you know, you don't have to live with in terms of dealing with it. So in terms of non-hormonal options, you can

You can get vaginal moisturizers, which are like hyaluronic acid based, which are sort of like what you put on your face, right? You can moisturize the vulvar tissues and the vaginal canal to help with some of that dryness. You can use lubricants, obviously, during intercourse, but that's only going to help for those areas.

times. I generally recommend a longer acting lubricant if you don't have any sensitivities to silicone-based or oil-based because they'll last longer. If you like water-based lubricants or aloe-based, you'll just need to reapply because they dry out. They're going to evaporate. And so those are sort of ways that you can support yourself without using hormones. But vaginal estrogen is very, very safe and very, very effective. It is... Now,

not going to cause breast cancer, uterine cancer, ovarian cancer. It's never blood clots. It doesn't get systemically absorbed to that degree. Yes, there is some systemic absorption out, but it's usually very, very little. And so it's not going to go anywhere near your premenopausal levels of estrogen and it will help reduce that dryness, increase lubrication, prevent recurrent UTIs. And so there's a whole host of benefits from using it.

And I think that is something that a lot of people, unfortunately, are not offered or even told about. And there's different formulations on how you can get it. You can get it as a cream. You can get it as a repository. You can get it as a ring. And so there's different ways that you can use it, whichever, depending on which works for you best.

One of the things that you sometimes hear women talk about is like sex gets better in your 40s and like, you know, the best sex of your life after menopause. Like, is that a thing? Is it just because like I've heard a lot of women, especially women who are with other women, say it's just because I actually know myself and I actually am enjoying my life and, you

you know, choosing partners that are a better fit for me, right? As opposed to what society thought I should choose. Can you talk kind of about both of those things? I'm kind of a, this is a two-hander here. Can you talk about women choosing female relationships and finding a different, you know, level perhaps of understanding of intimacy from those kinds of relationships? And also on the other hand, what is it about sex getting better? Is it anatomical? Is it psychological? What is it?

Yeah. So there's actually data supporting exactly what you said, is that when we look at these studies of women having satisfaction with sex, that it goes up in, you know, as women are a little bit older. And we theorize that this is exactly what you said, that it's because women know themselves more, they're less sexually inhibited. So they are more open to experiences and more open to asking for what they need or telling their partner with what they need.

Um, and so I think, you know, there are a lot of sexual insecurities that, um, especially as young women, we're almost like primed to have like, oh, we should smell like key lime pie and peaches and not smell like ourselves. And like, uh, menses are dirty and like all these things that like really is society telling young women that like, they're not good the way they are. Right. And so, um,

I think that that's really not a reflection of like women are weak minded when they're younger. It's like literally society is telling us to douche, to smell a certain way or that our odor is wrong, our discharge is wrong or this is wrong. And then, of course, there's experience. Right. So if you typically women are having sexual experiences and they get everyone gets better with age because they

are learning, right? It's a skill just like anything else. So if you're having more sex, you're probably going to be better at it because you've just practiced more. And can you talk a little bit about women who, you know, in many cases may not identify as, let's say, lesbian, but want to have relationships with other women? You know, there's a lot of reasons that we can say like men are stinky or whatever. That's not what I'm looking for. But I wonder if you can talk about, you know, is there a different kind of

communication and intimacy that you, you know, as a doctor have heard about or understand. I mean, I can't tell you the number of women I know who are like, I don't really want to be a lesbian, but I'd like to have emotional interactions with people that also can produce orgasms. If you're not particularly hung up on a penis in penis form, a lot of people are seeming to pursue, at least in the city that I live in, I could just be speaking for where I live.

Yeah, I mean, I think that generally speaking, when you are in a relationship or an intimate moment with people of the same gender, you have to talk about who's doing what, right? It's not this assumed script of penis is going in the vagina, right? So I think because of that inherent...

need to discuss what's going to happen, who's going to pleasure who and how, that you're going to just be more comfortable because you know what you're getting into almost. And also you will probably then be able to talk about other things like, oh, I like it like this versus not, because you've already had this very uncomfortable potentially discussion about who's doing what. And so you've already broken the ice about having a difficult conversation about sex because you have to. Otherwise, you know, it's going to be like,

you know, the blind leading the blind.

That's really interesting. I appreciate that. Um, yeah, I appreciate that kind of, um, flavor to that conversation. Um, I wonder, uh, in the last couple of minutes we have with you, you know, I was really like blushing and giggling at a lot of the videos that you put out, you know, you really kind of, you put yourself out there, um, as someone who's kind of not afraid to talk about, you know, a lot of things that many doctors won't talk to you about. Um,

There's one about predictors for the size of a man's penis. Can you talk about that one? Yeah.

Thank you. So, you know, there is everything's like, oh, bigger feet, bigger penis. So there was a study that's a small study. It was done in Japan and they measured hands, feet, height and and this other organ, which I will soon tell you that is correlated with to see what's correlated with penile length.

And what they found was that none of those other predictors I mentioned were actually correlated with penile length, but actually the length of the nose. So like this, like that,

the bridge of the nose, the length of your nose was actually correlated with penile length. Now, again, this is one study in Japanese population. It may not be generalizable to the entire world, but I thought it was interesting. And just to say like, you know, basically a big hands, tall guy doesn't always mean that he's going to have a large member. And again, I hate talking about length and size because it's not about that, right? Everyone can have pleasure. Everyone can give pleasure.

And as we've talked about here, the size of the penis, bigger is not necessarily going to give you an orgasm. It's knowing how to pleasure the female anatomy and your particular partner that's going to lead to orgasm and climax. So ultimately, as long as you're enjoying the experience and you're both having a good time, size is really not that relevant. Well, this goes back to the expectations, you know, I think.

When people are watching images where, you know, in digital media, they tend to over represent very large men and women who look a certain way. You can get a misconception and equate the acting with the physical attributes of the people.

Not realizing they are acting, not realizing it comes down to the emotional connection between the two people and the conversation between the two people and the preferences of those people. And some people might like a certain type of body size or configuration and other people may not. And so I think there is an enormous amount of miseducation out there that gives people complexes.

Absolutely. And if you think about the average sizes, right? So the average length penis is around 5.1 to 5.5 inches erect. And the average vagina is about 3 to 3.5 inches prior to arousal, which will then potentially up to double in size. You're getting about matching, right? The average woman is going to match the average guy. If you look at the types of sex toys women buy, they are generally average length and average girth.

And so, you know, when you could pick anything you want at a store and they've done studies looking at that, most women are picking the average size dildo, maybe a little longer, but there's a handle, right? You have to hold it somehow. So...

So ultimately, people are going to fit, so to speak, most people. And so I think sometimes people have to buy products as a spacer because their partner is too well-endowed or it's painful because they're too well-endowed. And so I think there's just this

this societal discussion of, oh, bigger is better, but it's not reality what happens. Even the phrase like well-endowed to me implies that like other people are not well-endowed, right? Like, and even that, even just the language that we talk about it. Here's a question. Are there women with smaller vaginas? Yes.

Yeah. So absolutely. There are some women, I mean, if you're generally speaking like a smaller person, you're probably going to have a smaller vagina, right? Like it's all generally proportional. I don't know if there's data on that. But I would say that, yes, there are, there's just like, there's a standard deviation of penile size. There's a standard deviation of vaginal length and, and growth. But again, it's a little bit more flexible, right? So it's going to increase in size and length quite, and men do too, right? There are growers who will tend to grow quite a bit. Why can't

that be? Why is that variable gut in heaven? Why do you have to make it so that some people grow at a different proportion so you don't know and it's different? And why would that evolve that way?

It's just a function of, I think, the collagen and the flexibility of the tissues, right? Some people have more, and so they're going to stretch more, and some have less. And I think that's genetic. And we know that younger men more likely will be growers. And then as they age, that flexibility of the tissue changes a little bit, so they may not grow quite as much. And so that's usually why that's the case.

One final question. There's some really interesting research that, you know, good sex can be good for your brain. Is this true? And where is the hope for those of us who want to strengthen our brain with good sex?

So I think really the thing about improving your brain is probably just from the, what is, if you're having a lot of sex, right? That means you have good blood flow to the genitals that, you know, you're having good hormonal function, that you're having good nervous function. So sex is like a biomarker of health, right? And so what's good for your genitalia, which is like exercise and eating right and, you

you know, improving blood flow, preventing high cholesterol and diabetes and hypertension and those things is also good for your brain. So I think it's more of like a, it's not necessarily that having sex is good for your brain. It's that the things that allow you to have sex because you are, you know, having climax and having good arousal and good blood flow are also signs that your brain is healthy. All I heard was have good sex and your brain will be super healthy. Okay.

Well, that's fine if you're having sex, right? It can be solo sex too, so. Tell people where they can find you. Your videos are hilarious and really, really informative and interesting. Where can people find out more about you? Thank you. So yeah, I also have a podcast for those of your listeners. It's called the Reena Malik MD Podcast. And I have a YouTube channel where you can watch videos where I cover all sorts of topics and have the video version of the podcast. And then I'm on all social media platforms as Reena Malik MD, except for Facebook, which is Dr. Reena Malik.

Thank you. You've been a really good sport. I know we gave you a hard time, but we really appreciate this. And our listeners are really, really hungry for this information. As you can imagine, democratizing this kind of information is so important. And having a young, articulate, fantastic woman like you, you know, doing it really means a lot for those of us old dames who are like, what? Someone cares about my body? So thank you so much. You're welcome. And thank you for calling me young. That makes me feel really nice.

Well, I'm done with menopause. So, you know, we get to look down on all the youngins. Thank you guys so much. I have a top three things that I learned from this episode that I did not know before. Let's hear them. So the first one I have to say that like, I probably knew at some point, but literally had forgotten that the clitoris on the outside is just the head of the clitoris. There's like a whole other part inside.

Like I think of like Platoris, like that thing. It's over there. The whole section to it. I feel like you should know that. I feel like you knew that. I knew it at some point. I knew it, but because it had not been part of my constant vernacular and I wasn't in school and they weren't testing me on it, that one just got shoved away and I became like all the other Luddites. Like the Platoris is just that little thing. Number two. Number two.

Another one, again, that I may have known at some point, but maybe not. I didn't know there's such thing as a cervical orgasm. The thing that I know about the cervix is they keep checking it to see if you're going to go into labor. It goes from one centimeter to 10, and that's when you get the okay to push the baby out. I did not know that

people would have a cervical orgasm. In addition, part B of number two, that was 2A, 2B, different orgasms have different qualities. The cervical orgasm is a, I believe she said, cosmic shooting stars orgasm.

description for some people, which also not everybody may feel that when this cervix is stimulated. But if you do feel like that, who doesn't want to sign up for some shooting stars? Cosmic shooting star versus a clitoral orgasm versus a vaginal orgasm. They've all got different flavors.

Can't say we're not complicated. She didn't describe or give attributes to the other two. If one is a cosmic shooting star, what are the others? A nature walk? A dive into the ocean? What are we working with here? I'll let you figure that out. You can Google it later. Okay, that's another good Instagram poll. We should have people name the other two if...

One of them is a shooting star. The third thing, which again, I may have heard at some point, men can have an orgasm without an erection. And without ejaculation. So that one I knew. That one was in my wheelhouse of understanding in the universe. Because like I've heard Sting talk about tantric sex. Like, you know, a lot of people talk about that. But without an erection, that was... I'm...

Yeah, because orgasms are a brain event. I was like... So if it's a brain event and you're separating ejaculation from orgasm, then theoretically it would make sense that if the erection isn't working, you can still access the brain event. Okay, but think about any other physiological process. Yes.

you wouldn't be like peeing is a brain event. Sometimes I don't pee or like hunger is a brain event, but sometimes I don't eat. Like happiness is a brain event, but sometimes I'm not happy. I don't know. It doesn't make sense. I don't know. They just are. I think

It's a very interesting and unexplored area. It's an unexplored area. I think it's interesting that she actually mostly sees men clients, but obviously knows a ton about women. But she said that most of her, you know, kind of clients and patients that she sees are men. And I just was kind of fascinated at the, you know,

the, the amount of information she knows about some of the most intimate and vulnerable aspects, you know, of our anatomy and of our human experience. And, um,

you know, it's hard. Like some of the stuff is so heteronormative to talk about, but I think the ultimate kind of, you know, umbrella that all these things fall under really is about knowing your body, knowing how your brain connects to your body, knowing what works for you and knowing how to talk about it. And those things, you know, surpass gender, sexuality, all of it. One of the most impactful pieces of information that could change the way people date

try to have sex is the idea of the 20 minutes to arousal and the 14 minutes to climax for female people. And if men could understand that, like as a young man particularly with hormones rushing and you're excited and you're just fascinated to be there and you have all this feeling running through you, it's very hard to then slow yourself down and pace to a partner

Who's at a totally different on a totally different time clock than you. I think part of that is when we talk about what's attractive, like maturity, sexual maturity is attractive. And, you know, not just in male partners, but in partners in general, whether they're male, female, you know, whatever you're,

partner is, you want someone who has aspects of maturity. And that does mean patience. It means understanding. And then it also means learning what's particular for your partner. I thought that was really interesting and was really glad she spoke about it. Like, even though she said, of course, there's variability for the male experience, like for women, there's, I think, a lot more variability in terms of, you know, what's going to work and what's not. Also, Hollywood has lied to us wildly.

In movies, men, women, they look at each other. All of a sudden, they're having sex. They orgasm at the exact same time all the time. They roll off. Everything's amazing. There's like no conversation about what feels good, what doesn't. There's no

fighting during. There's no, I can't get an erection. There's no, you're not doing it right. There's no, why are you falling asleep? I wanted to talk about my feelings. There's no, stop touching me. That's too much stimulation. They're lying to us. They're selling us a belief that something is going to exist that really just doesn't.

There's no separate clocks or timelines. Everything is just in sync all the time. And that's what we expect magic to look like. We're like, oh, if we find the right one, it's going to be like a rom-com. I'm going to look across and see them. And then we're just going to be magnetically drawn to each other. Or we're going to hate each other at first, then go on an adventure, then fall in love and realize that they were there in front of me the whole time. All right. From our breakdown to the one we hope you never have. We'll see you next time.

It's my B.R.L.X. breakdown. She's going to break it down for you. She's got a neuroscience Ph.D. She was and now she's going to break down. It's a breakdown. She's going to break it down.

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