Male Sexual Health after Transplant

Presenter:  Eric Zhou PhD, Dana-Farber Cancer Institute

This video is a recording of the workshop conducted at the 2018 Celebrating a Second Chance at Life Survivorship Symposium.

Summary:

• It is important to discuss sexual health issues after transplant with your doctor.  Be proactive. Don't wait for your doctor to raise the issue first
• Chemotherapy, radiation, graft-versus-host disease and changes in self-perception of body image can contribute to sexual difficulties
• A variety of therapies are available to address erectile dysfunction and/or loss of interest in sex
• It’s important to understand what your partner is thinking and feeling so that you can work together toward better intimacy

Key Points:

05:21  Sexual problems are common in men after transplant: 

06:17  Approximately 50 percent of men experience erectile dysfunction (ED) after transplant

07:44  Factors that can predict sexual health problems in men after transplant

08:46  Changes in body image and delaying sex after transplant can contribute to problems with sexual health

09:39  Graft-versus-host disease, chemotherapy and total body irradiation (TBI) can cause loss of interest in sex

12:58  There are three core ingredients of sex: function desire, and relationship

15:11  Options to fix erectile dysfunction after transplant

27:04  Enhancing desire for sex after transplant

30:59  Understanding what your partner is thinking and feeling is important

33:48  Ways, other than penetrative sex, to increase intimacy with a partner

Transcript of Presentation

00:00  Doctors often don’t talk with transplant survivors about sexual health.  Good morning guys. So, 9:45, is that an appropriate time to talk about sex, on a Sunday much less? It's a fun conversation to have. I'm really glad that you guys are here, and we get to have this conversation. I work ... part of my life is in this actual health clinic at the Dana-Farber. It's remarkable the number of men that I see for whom I've become the first conversation that they've had about sex. Now, I'm curious for folks here, how many of you have had a conversation, and by conversation I mean more than just a passing, "How is sex? Check yes or no," how many of you had a conversation about sex with your transplant doc?

Keep your hands up for a second so I can do the math. You guys, turn around and I hope you see three. Now, I hope you all don't share the same transplant doc, because that would make me feel disappointed, but the reality is why haven't the rest of you? I'm certainly not faulting you for not having that conversation, but I want you to ask yourself that question, why hasn't it come up? What do you think? It's interesting. You talk about embarrassment, this really is something that we think about as a question that doesn't get asked by transplant physicians nearly enough.

You guys are pretty fantastic evidence of that. We think about that as really just a massive elephant that sits in the room, that many physicians either don't recognize, or pretend like they're not going to talk about. In part, it's not your embarrassment, it's actually their embarrassment.

01:45:  Sex pervades our culture:  I have this next slide up, because it's amazing how much sex pervades our culture. These really are advertisements that exist in the universe, and I'm sure you've probably seen better examples of this. I mean, this is on the streets. You have a 14, or 15-year-old you'd said? Fourteen year-old, your 14-year-old can walk out onto the street and this is what he sees—a half-naked woman in a neighborhood somewhere. We see Paris Hilton telling us that size doesn't matter. We see even State Farm with their double entendre that you even can do it on an escalator in the middle of New York. This is everywhere. How many of you folks can say that you have not seen, while you've been here in Denver, on TV, on the road, some sort of an ad that use sex to sell you something? You haven't?

02:43  Audience talks about problems with sexual health after transplant:  Well now you have. But despite its popularity, I come back to that question, why haven't the rest of you talked about something so meaningful with the people who are responsible for making sure that you have a good quality of life? I don't think it's a far reaching pitch to make that sex matters. That's why you're here on a Sunday morning, which I appreciate. I'm interested though for you, what made you decide that you want to learn more, and think more about sexual health as part of your recovery from your transplant?

03:25  Audience member 1 -problem with erection: I found that after having radiation, that I just am not able to get an erection.

Dr. Zhou:  Absolutely.

03:36  Audience member 2 – lack of desire:  I think it's a pretty key part of the relationship with my wife and just how we bond and connect. I don't know, afterwards when you don't have that urge anymore, and you don't have that desire, and you talk about it, and ... I don't know, I just ... it's hard for me to watch her not have that kind of a connection with me as much anymore, but ... and to want to make it special for her again, and special for me again, and to be able to bond in that way. I don't really know how to describe it other than having some help to get over that barrier.

Dr. Zhou:   That's a pretty wonderful way. I saw heads nodding. I appreciate that. What is your name?

Speaker 3:  Chris.

Dr. Zhou:   Chris, I want to tease you a little bit. You said at the beginning, ‘I pretty much want to help this, and I'm going to say, [I’m] pretty sure your wife is going to be pretty pissed that you said you only ‘pretty much’ kind of want to help this. I may have to tell you on when I see her.

04:39  Audience member 3 - ability to have sex means regaining normalcy:  For me it has to do with an attempt to regain normalcy.

Dr. Zhou:   One thing that's amazing, I don't know the average age, I don't know your specific age, but think about the first time you had an erection. It's been a long time. I mean the first time, like when you were really young, think about the first time you had any sort of sexual encounter, think about the first time you had intercourse. It really has defined who you are for a number of years in your life. Many men think about the ability to develop an erection as something that they associate with being a man. So absolutely it's a return to normalcy. These are all really wonderful answers actually.

05:21  Sexual problems are common in males after a bone marrow or stem cell transplant:  Now, in terms of for men post-BMT, I have this slide here because I really want a normalize this message that it should be a part of conversation with your physicians, because it's so damn common. We look at this and you're talking about a third of men who lose some capacity to develop interest, that's one out of three men. If you go to your transplant clinic, one out of the person sitting next to you, on either side, has lost interest, that's a lot of people. Over half of men after transplant, say that they feel less sexually attractive. I think that's a hard thing to admit for a lot of men if they've had something happen during transplant, or chemo, or radiation afterwards, they don't feel like the man that they were even a year ago. That's remarkable.

06:17  Approximately 50 percent of men experience erectile dysfunction (ED) after transplant:  About half of men experience ED. Not going to ask you put up your hands for that one, but I want you to think about that because as you get older, I mean think about the odds, even without transplant: about half of men at 50 experience some form of ED, about 60% at 60, 70% at 70, and on. Even without BMT, it's starting to happen. Then about a fifth of men start to experience some difficulty with their experience of orgasm, which again has defined their sexual experience. This is a whole lot at issue, and if you're in this room, and I want you to recognize that there are other men who are sitting here because they, and as you've guys have shared, are experiencing the same worries that you have.

07:03  Many men are not sexually active after transplant:  Now in terms of sexual activity, a number of studies have looked at this in BMT patients, and essentially it's stunning. You're talking about a group of men who 60% of which were sexually active in the month prior to undergoing transplant. Then you're talking about simply three years later, that 20% fewer men are in any which way sexually active, which means, think about for yourself, when was the last time that you were active sexually? How has that changed during your journey?

07:44  Factors that can predict sexual health problems in men after transplant:  We know that there are a number of things that are predictive of men who are more likely to have worse problems. The closer you are to BMT, the worse you are likely to be. Conversely, the further out you are from radiation therapy, especially if that radiation therapy may have been directed somewhere near your penis, the worse off you are. The older you are, the more likely you are to have problems. The more physical health issues you have other than having to have a BMT, the more likely you are to have some form of sexual health issue. The more depressed you are, and also the worse you do in having conversations with your partner if you are partnered. If any of these ring a bell for you, think about this as another issue you'll want to address in addition to the conversations that we get to have today.

08:46  Changes in body image and delaying sex after transplant can contribute to problems with sexual health:  Now, common issues, this is not everybody, and it certainly does not encompass everything that may happen, but just related to transplant, how many of you lost your hair? Changed who you are, right? Changed how you looked. If you were partnered, probably had your partner say to you, "Honey, [you] kind of look like a different person." And if your hair grew back thinner, or different, you look different then you have your entire life. Of course, you know that sexual activity immediately after transplant is certainly not encouraged for fear of infection. I'm going to say a little bit later on that during that period, you get into a rhythm of not being physically intimate, and it's a pattern that people fall into.

09:39  Graft-versus-host disease, chemotherapy and total body irradiation (TBI) can cause loss of interest in sex:  As well, you talk about GVHD, graph versus host, great talks this morning about that. I went to one where I saw photos, if you went to the one about oral GVHD, Dr. Treister showed some photos of what that looks like. I can't imagine that if you're experiencing GVHD you are thrilled at the thought of kissing somebody as well. This changes what sexual life looks like. If you've had chemotherapy, any sort of a regimen, it's possible you started losing interest, and you started having more likelihood of having ED. Radiation therapy, depending on where it was directed, may cause nerve damage, which impacts your ability to develop an erection, and it certainly causes fatigue. If you're tired, it's the, "Honey, no thank you," moment.

10:29  Sexual problems after transplant are common among both men and women:  Now this is something that both for men and woman is across the board. I have this here, not because I'm going to go through all this, but I want you to be aware that for women who undergo transplant as well, this is a major issue. It's a major issue that's also not talked about. One of the things that I do want to touch on here is, how interrelated all of these pieces are. For example, if you have a problem developing an erection, do you think that it's more likely that if you start a relationship with somebody you'll have erectile anxiety? Of course you might have performance anxiety. These are things I want you us to think about altogether.

10:29  Sexual problems after transplant are common among both men and women:  Now, this is a piece that I feel as though we don't get to touch on enough, and I wanted to dedicate a slide to this because of self-image and how important it is to our ability to feel sexy. Now it seems silly for a guy to say that, right? You certainly hear a woman say, "I want to go out. I want to do this. I want to do that. I want to feel sexy. I want to look sexy." When's the last time you and your buddies went up to the bar and said, "Guys, I feel sexy tonight." But it's important, right? Really is. If you think about it, when you feel attractive, when you feel good, doesn't that change your interest, your enthusiasm, and your desire for something physical with somebody else?

11:48  Discussion of what makes men feel less interested in sex after transplant:  Now I mentioned hair loss early, but did anybody here experience anything else post-transplant that they feel like, "Okay, this actually changed how I feel about myself. I used to think I was confident," clearly you thought you were a 10 out of 10, "but now after transplant, I feel like maybe I'm only a nine-and-a-half." Just for you Phil.

12:11  Audience member – role reversal between partners can affect how you feel about yourself:  I think part of the problem for me also is the role reversal in the relationship where you're the man, you're the provider, you're the strength, and you become the patient and you're weak. When that dynamic changes, it's kind of hard to regain that role when you're constantly having problems, and you're the one that needs attention instead of being the provider, and the one taking care of things.

Thank you, Brian, that certainly doesn't make you feel very sexy, right? It really is powerful to think of how you view yourself, and how that changes. That's a conversation for you, I want to you think about as you're going home, how this may have changed who you are as a man.

12:58  Three core ingredients of sex—Function Desire, Relationship: Now, I think about sex not just as penetrative sex, which I think many of us, when we define sex, is all it is. But sex is really complicated. It's what I think about as a recipe list with three core ingredients. What do you guys think those core ingredients are for sex, a successful sexual encounter?

 Audience:  Wanting to do it, absolutely, okay. Other ingredients?

Audience:  Trust, I like that answer. I think it touches on-

Audience:  Opportunity.

Dr. Zhou:   Opportunity, yes, absolutely. You guys are actually touching on some of the components. I'm think about bigger scope issues, but you're defining exactly what I'm thinking about, which is I think about sex as certainly far more than Viagra tells you it is. Viagra tells you that if you are a beautiful woman, that she will just lay in bed and it'll magically happen once you take Viagra. For a number of men in here I suspect that you've taken a Viagra with a beautiful woman, and that nothing has happened. And, so, it certainly is not as simple as just having a little blue pill.

What sex is, I think about, as terms of an ingredient is, you have to have the function piece which can touch upon the energy that you mention.

You actually have to be able to have something going on physically. You have to want it, and if you're with somebody you actually have to consider that relationship, right? If you think about it, if you're with your partner and you have the first two pieces, you want to have sex, you can get an erection however we do it, but your partner is really pissed at you that day and they and went out for a run, it's not happening.

If you have function and the partner's interested but you're not interested, it's also not happening, so it really is something you have to think about juggling many balls in the air as you're trying to figure out how to make this work. It doesn't distill down to just one thing that you have to fix. I hope that, that's a take home that you remember is that we have think about so many pieces when it comes to sex.

14:56  Rehabilitating Sexual Function after Transplant:  So I think about it as almost a rehabilitative process, right? Like if you hurt your shoulder you go to the PT and you do things in addition just to going to your doctor, to help your shoulder. In the same way thinking about that related to sex.

15:11  How to fix erectile dysfunction:  We're going to first talk about the physical function because I think that's the easiest to wrap our heads around. We talked about erectile dysfunction, now we get to talk about different forms of work that we can actually do in order to correct that.

Some of this may be old hat and thank you for your patience. Some of it I do want you to think about as potentially as an option for you. I want I to work first from the lowest intensity into the higher intensity solutions that you can consider.

First, is reversing what we consider to be reversible causes of erectile dysfunction. So these are things like weight management. That's a huge factor in improving erectile function which is things like be more physically active, managing your diet.

16:06:  Testosterone replacement:  For some men who have low testosterone after BMT, or have always had low testosterone, this is a potential conversation to have with your team to see if some form of testosterone replacement therapy is perhaps in your cards.

Now it's common, particularly about six months post-BMT, up to a couple of years post-BMT for some men to actually go on testosterone replacement therapy and there's different options— patches, injections— whatever floats your boat and works for you in terms of getting your testosterone level to where it has been or where it should be. It's a conversation to have, and we know that testosterone plays a huge role in your desire to have sex.

16:49:  Vacuum erection devices (VED):  Then in terms of the physical piece of erectile dysfunction, probably made most famous by Austin Powers in his movies, how many folks here have ever held a vacuum erection device? One guy. Does everybody know what a VED is?

So it's simple mechanics. It's a physics based event. You take a cylindrical tube, you put it around your penis and if you pump air out of that tube, by the laws of physics, blood will flow into your penis and give you an erection. Sounds simple, right?

If you put a ring at the base of your penis before this process starts it will keep blood in your penis so that you can have an erection long enough to have penetrative sex. It is, and that's the beauty of it, it's simple. So this is a very, very low intensity and this is why I consider this the lowest intensity solution to erectile dysfunction, is you don't need more than a tube and a ring.

Only caveats, only details I want to add. One, you do have to pump, it can be uncomfortable especially if you're not careful. I have heard more than my fair share of men who have pumped too much air out of the tube and you can imagine what that feels like. Similarly, you'll have to have a ring as I mentioned, at the base of your penis, which means you'll have to shave the hair around the base of your penis for it to form a good seal. For some men this is an issue as well.

The final thing that I want to note, that for some men is a concern, is the blood that actually flows into your penis is not arterial blood, which means it's not flowing from my heart, it's venous blood, which means flowing back to my heart.

If you can appreciate that you will understand that the erection you will develop is not as warm to the touch as a "normal" erection  which means with this device your erection will feel cooler than it has previously, which for some people is actually a deal breaker.

When folks asked me for the brand recommendations or where they can find this the answer is simple, I want you to go to a sex shop. If your transplant hospital or the cancer hospital where you may have gone to does not have a store where these devices exist, at my hospital they do, but if at yours they don't, take a look, go to a sex shop and actually spend a few moments going through the models they have on hand.

There is no Ferrari version of these. They make them in different colors, different styles and certainly different dollar amounts. You can go on Amazon and find one that you like. It really is a case of shopping around to think and to figure out what works for you and what fits best for you, your size and your situation.

20:14  Effectiveness, cost and side effects of using Viagra®, Levitra® or Cialis® for erectile dysfunction:  The next one piece, you mentioned the little blue pill, this is certainly the most heavily marketed drug I think in the history at least of modern pharmaceuticals. It has made many, many people very wealthy. How many of you guys have tried something like a Levitra or a Cialis? What was your experience with them?

Audience member:  I felt like I was having a heart attack.

Dr. Zhou:   Absolutely, it's not discriminative, right?

Audience member:  Yeah.

Dr. Zhou:  It smooths your arteries all over your body, so for men who actually have cardiac issues it's not a viable solution unless your cardiologist gives you the okay. What did you guys think about having to take it in advance? The thought of the flushing, some of the side effects, the experience that you had because it doesn't change the libido it only changes function. Any other thoughts on your experience?

Audience member:  It doesn't continue to work. I mean you get tolerance I guess to it and at some point it just doesn't work.

Dr. Zhou:   Like many drugs, that can be an experience, and also, as I mentioned earlier, as you get progressively older erectile function becomes worse and worse, and it may be the case that this oral agent is not sufficient.

Also, some things that we should know, they're still really expensive. For most of the healthcare plans in Massachusetts they are out-of-pocket expenses and they're not cheap out-of-pocket expenses. I have heard upwards of $50 depending on where you're buying it from, per pill, which for some men, if you think about the idea of wanting to have some sort of a sexual encounter, putting $50 on the line every single time you want to have sex or the potential of sex is a bit of a doozy. There is some math involved there.

However, the simplicity of just taking a pill about a half hour to an hour before desired sexual activity, is attractive. This is what I think about as a second line intervention.

22:08   Injection therapy to correct erectile dysfunction:  However, for those of you for whom you've tried and you've spoken to maybe your urologist about using an oral, what are they called? PDE 5 inhibitors, is if that's failed, well you can think about injection therapy.

There are multiple mixes, Bimix and Trimix are some of the common ones that you can use, and it essentially takes what is in that little pill, puts it in about a diabetic gauge needle and injects it into the base of your penis.

So, you're essentially directing the drug to exactly where you want it to go, and not surprisingly it is more effective, and has been shown for men who failed the oral agents, that this has been successful for a proportion of those men post BMT. I wish you guys could have seen some of the faces that I looked at when I said you were going to inject the needle into the base of your penis.

Audience member:  I just want to share that I did try that, and at first it didn't work and again they've upped the dose to 20 on Trimix. You know, it still isn't real successful, but at first it was kind of like, "Oh no." I've gotten used to it, how does that sound?

Dr. Zhou:   That sounds like a ringing endorsement for everybody else here. I still see faces in the back by the way that are grimacing.

A different audience member:  I also tried that, but it was pre- transplant it was totally unsuccessful. There was an event where one of those four hour erections had to be reversed with another shot. So then I finally said, "Oh okay, that's all right. I'm going to take this home and try it out anyway" and had the same kind of experience. So that went in the trash.

Dr. Zhou:  Okay. Well I'm glad to hear that you tried it. I'm glad to hear that actually for both of you that you didn't mention that it was something that was so painful and aversive that you never would want to try it for the reason of that injection, which for other men I will say that is usually the first psychological barrier ,that your experience is that thought, but then that certainly if it fails that's reasonable, but that as an option it's considered.

Alternatively, you can do it transurethral, which means essentially putting it in a little pellet in your urethra which is where urine regular comes out of, anybody tried this one, option as well if you don't want to do injection? Again this is a higher level of intensity as a treatment than what it is that we're talking about with the pill or the vacuum erection device.

24:40  Penile prosthetics:  Finally, this is really end of the line in terms of where you can go, as far as you can go, is penile prosthetics. Were folks aware this as an option? I see a face that suggests, no. The nuts and bolts of it is essentially that you actually have some tissue carved out of your penis and then you have this inflatable prosthetic that through the pressing of a simple button you can inflate or deflate to have an erection. As an option how do folks feel about this one?

Audience member:  If all of the things don't work it is the last resort.

Dr. Zhou:  It's kind of how I feel about it too. It is the only non-reversible option that we have when it comes specifically to function, which means if you go this route you can't go back. You can't go back from this and say, "Ah just kidding. I kind of wanted to do the injection first."

So, this is a much longer conversation to have with your urologist, with your transplant tea to figure out if this is what you want to do, but remarkably the success rate post-surgery, the satisfaction post-surgery, is really, really high.

Men who choose this route are really, really satisfied that they've made this decision because then there's no worry about when that moment strikes you as the ads tell you. You just go, "Great. This is fine, I'm going to push a button and then I'm going to be able to do what I've always wanted to do." Now, this is just the function piece. Any questions about the function, the ability to develop can erection?

Audience member:  What about complications related to penile prosthesis in terms of rejection, and for transplant patients who have a rather compromised immune system anyway, it doesn't seem like a very viable option?

Dr. Zhou:  If you do have a compromised immune system that is ... and I certainly see in some patients not too, too long after transplant that this has been a viable solution for them, but it was after an extensive conversation with their transplant doc. So the same complications you might expect from other surgeries are the same worries that you will have with something like this.

27:04  Enhancing desire for sex after transplant:  Now moving beyond just function, this is the piece that I love to talk about because we don't talk about it enough, it's desire. Now anybody here know of a pill that works for desire, other than ecstasy? Unfortunately big pharma has not figured out what good solutions we have. There isn't one.

If there is one it would be heavily marketed to you, other than testosterone, which is, what I mentioned earlier, for folks who are in low T situations.  There really is no magic bullet here. If you think about desire, I want you to think about the last time that you may have experienced some form of sexual desire.

Audience member:  When I was in Las Vegas for my honeymoon back in 2007 I did take the little blue pill, Viagra®, and that was the only pill of any kind that I ever took. Never took Levitra®, I never took Cialis®, but after let's say about an hour or two it had an effect on me like I was an animal which is basically what Viagra does. It's kind of like a special starting of an engine so to speak. That was, like, 11 years ago. And since I've been divorced for the last three years and the lady and I are no longer together, thank God. The desire is coming back. But a question is how to do it right.

Dr. Zhou:   Well I appreciate that you actually mentioned a few things there in terms of adding to your desire. Because if folks here heard your depression, perhaps, post this breakup. Your issues with your relationship before that breakup are all things that were pieces that added to or subtracted from your desire. Desire is really not just one thing. The reason I asked folks here what made you feel sexual desire, the last time you experienced it, is because it's not always one thing. It's not just I saw somebody attractive in front of me. Because that is colored by so many other things that you have going on. And that's why we talk about this list of things that, perhaps, may be causes. Some are physical for example. If you have hypogonadism, something you need to think about. If you're depressed, that's something to think about. If it's something, if you're taking specifically some antidepressants which impact libido, it's something to think about or having a conversation with your psychiatrist to see, perhaps, you can switch to another SSRI that has fewer sexual side effects, because this matters so much for you.

But the stuff that I talk about at the top is stuff that I think about as being important in that we really do want to think about it as use it or lose it. Now, I know you mentioned it a little bit earlier Chris, that for you it’s been a struggle in this experience where you felt like you have disconnected, somewhat, because you haven't been sexually active. I'm not going to pick on you, but I saw a lot of nodding heads there. If you think about it, if you don't engage in any form of sexual intimacy with your partner, and it doesn't happen for the 100 days after transplant and it doesn't happen for another 100 days after that. What are the odds you're going to want to start day 201?

Audience member:  You know, at least in our building up to it, I guess creating the mood or whatever. I mean, you're out of practice.  In some ways. I don't know, I might be.

Dr. Zhou:   No, I think that's a great answer because it's not only out of practice, it's the fact that you have a habit, you have a routine. Your Friday routine now does not include anything to do with sex. We all have routines in life and that's something that is not in your routine.

30:59  Understanding what your partner is thinking and feeling is important:  So then, if you think about this from your partner’s perspective, they have thoughts too, right? They play a role in what's going on here. Often, we hear from women that they actually end up pulling back from their partners because they're worried whether they might infect them, whether they might hurt them.

 For folks here who are partnered, how many of you have asked your partner what their thoughts are on engaging in some form of intimacy with you. If they have any fears, any worries themselves. Has anybody had that conversation?

Audience member:  Yeah, my wife and I have talked about this a lot. And, so, we go back and forth who's going to initiate, right. So there's that awkwardness of who's going to initiate that, and is the time right or how much time has elapsed and that sort of thing.

Dr. Zhou:   amazing. How long have you been married, if you don't mind my asking?

Audience member:   33 years.

Dr. Zhou:   Thirty-three years. You're talking like a guy who's 14 years old, going on a first date.

Audience member:  Yeah.

Dr. Zhou:   Right? If you think about the silliness of you having to talk to your wife of 33 years about ‘should I start today honey’? It's that kind of trepidation that leads to a very, very uncomfortable situation where most folks would say, "You know what, forget about this. It's not worth it. Why do I want to feel uncomfortable and have a 15 minute conversation with my wife. She's not in the mood today so why even bother". It's something that happens so frequently.

And so I think about this, particularly for those who are currently partnered. And if you are not currently partnered, that this is a conversation that you absolutely need to have as early in your relationship with a new potential partner as possible in order to avoid some of that real significant awkwardness that, if you avoided it at the beginning, you're that ostrich burying its head in the sand. Because that issue is going to come up. So this conversation I want to think about for everybody here as an opportunity for you to really write a new chapter. You will not be the same man you were pre-transplant. I think we can agree on that, whether that be function or desire or appearance.

But a new chapter doesn't necessarily have to be a worse chapter, but it does necessitate that you cannot have the expectations that you had a year, five years, 25 years ago. Does that make sense?

Which means for performance. If you used to be a 10 out of 10, maybe now the expectation is you only get to a four out of 10 because that's good enough. Maybe for desire, it's you used have sex five days a week and now you might want it once every five months. And that's good enough, so long as that's a conversation that you have with your partner.

33:48  Ways, other than penetrative sex, to increase intimacy with a partner:  We think about ways you can actually increase intimacy. I made a joke with you about you sound like you were a 15-year-old. And in fact I actually want folks here, who are partnered, to think back to when they might have been 15 or 18 or 20 or 25. As adults, when you think about sex, I'm going to make an assumption for folks, here, that you think about penetrative sex to orgasm. Is that a reasonable assumption to make,? Right? You guys, if you are having sex with your partner or had sex with your partner previously, how many of those events did not end with penetrative sex to climax for you? Pretty uncommonly, that's just the automatic adult expectation. And if we think back to when you were 15, and you had not had sex yet, what did you enjoy doing with a partner? Exploring. Nice choice of words. All the other stuff.

Now, if you remember teenage you, did you like exploring? If you're shaking your head, I'm concerned. 15-year-old you, 20-year-old you really loved everything that had to lead up to sex. And this is a conversation where you think about, and you get to think about, being able to do more of those things.

So common homework that I assign with patients is having a conversation with their partner and structuring in time, say, going to your primary care. This idea of using it or losing it, which means spending 15 minutes this week putting it in your Outlook calendar or in your day planner.  And you will, with your partner, do something physically intimate that doesn't have to be sex if you're experiencing difficulty with erectile function.

So for folks here who haven't been sexually active. When was the last time you were physically intimate? And I don't mean sexually active. I mean laying naked with your partner, even kissing them on the couch. How long has it been? Does the worry about not being able to develop an erection or being able to have a good orgasm for your part prevent you from doing all of the other things that your partner enjoyed? I want you to think about this, though, as the start of a conversation for you to have.

36:17:  Schedule time with your partner to discuss sex and intimacy:  So there are great resources available online.  There's a great book that you can read, and this is something that you should think about as a continued conversation. Whether it be with your providers, or the therapist, with somebody who forces you to do the work. Because the reality is. I can tell you that you probably should go out there and eat healthier. How many of you guys are going to do that? Well, thank you. But the reality is simply telling you what you need to do is really hard to translate into practice.

Which means if this is important to you, enough that you came here to have a conversation about it this morning, don't end it today. On your way home, call your partner and say, "We're going to talk about this when I come home". Or if they're here already say, "Before we fly out of Denver, let's talk about this. Let's set up an appointment with a therapist in the community in two weeks so that we can continue this conversation about how we can actually program into our lives a conversation about what we need, what works for us, what doesn't work for us, when we can be physically intimate without sex. Maybe what we do is we take a sex holiday because I have ED and that gives me anxiety. So we don't have sex for two months, but we get to do every other thing that I enjoy, that you enjoy, and I don't have that anxiety associated with it.

So, think about this as the start of a conversation which, hopefully, we'll get to continue now if you have any questions. 

Audience member:  So you mentioned building habits and just times when you do things. Have you found that when people start, saying scheduling in as you say, or trying to rebuild that habit and that connection that the desire and things tends to come back?

Dr. Zhou:   It really is like riding a bicycle. If you haven't done it for a long time and you start to practice.  You start to build into your normal routine and it becomes something that is not abnormal. And it becomes something that is—you are often reminded of why you enjoyed doing it in the first place. I find that very few people structure in time for intimacy with somebody that they are either sexually attracted or love, or both, and don't enjoy that 15 minutes that they have to spend being with this person in an intimate setting. So, I say it to almost every patient. The worst case scenario is you spend 15 minutes, in your case, with your wife rubbing her back. I can think of worst ways to spend 15 minutes.

Audience member:  Reasons why you may not be able to retain an erection:  What about situation where you're able to achieve an erection, but you're not able to keep it. So physiology you're able to function to some extent. But what would be the cause of not being able to maintain that?

Dr. Zhou:   Did everyone hear that at the back? Okay. So, a number of reasons potentially. First and foremost it should be a conversation with you have with your urologist to make sure that some physical things you may have to be worrying about are things that they are checking out. We can talk about some of those things afterwards. But, it also sounds like that — that is a form of ED, that some men can't sustain an erection. It's not just being able to develop it, it's also being able to maintain it. In your situation, some of the options that we talked about physically earlier may be viable solutions. Maybe something as simple as a ring at the base of your penis. Even without a vacuum erection device could be effective for you.

A part of that is also expectation anxiety. If you worry that something is about to happen, the likelihood of it happening is probably pretty profound. If you are entering that situation going, "Oh crap, the last three times I developed an erection and before my partner showed up, I lost it". Well that fourth time you're probably going to lose it again. And so perhaps physically you can think about things that you can do to supplement your ability to develop an erection. And then make sure that you have an evaluation with somebody.

Alright, well thank you guys. I appreciate the conversation this morning.