The Rise of Young Male Erectile Dysfunction: Porn Use and Intimacy Issues
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Hey, chat. Welcome to the Healthy Gamer GG podcast. I'm Dr. Alok Kanodja, but you can call me Dr. K. I'm a psychiatrist, gamer, and co-founder of Healthy Gamer. On this podcast, we explore mental health and life in the digital age, breaking down big ideas to help you better understand yourself and the world around you. So let's dive right in.

Today, we're going to talk about erectile dysfunction. Now, the biggest problem is that erectile dysfunction used to be an old man's disease. About 5% of people in 1999 under the age of 40 had erectile dysfunction. In 2011,

14 to 28% of people under the age of 40 had erectile dysfunction. And that number has only gone up. I suspect it's somewhere around 30 to 40% of people under the age of 40. So why is erectile dysfunction increasing so rapidly? So I think this has to do with the way that we are literally training our genitals as men. So the first age of pornography exposure is around nine years old.

And most people start masturbating in their early teen years. We're also seeing a delay in socialization, the development of relationships. Online dating is getting hard. So it used to be that the average age of first intercourse was maybe somewhere around 18. And that number has only gone up.

So what that means is that from, let's say, the age of 13 until about 22 or 23, for a period of 10 years, most teenagers, boys, and young men are using pornography and masturbation as their primary source of sexual activity. When we're teenagers, our brain is still developing. Our nerves are still developing. Our physiology is still developing. And it develops in a particular way. So just to give you all a couple of examples—

If we look at the average intravaginal pressure, so what is the grip strength of a vagina? It's somewhere between 5 and 15 milligrams of mercury. Now, if we look at the average hand grip strength,

The average hand grip strength is somewhere between 65 and 105 pounds per square inch. So if you sort of like think about your hand, first of all, there's skeletal muscle, which is way stronger than smooth muscle, which is most of what the vagina has. And then we also have bones, right? So if like if I squeeze my hand like this, the amount of space I can't even stick a pen in, like that's how tightly I'm squeezing.

So what tends to happen is that our genitals get used to a certain kind of stimulation over a very critical period of development, and then it's hard for us to climax during sexual intercourse. Now we have to get into the definition of

of what erectile dysfunction is. And this is really important, okay? So erectile dysfunction means the inability to achieve climax for the duration of the sexual act. So I'm not able to finish with the pressure of a vagina. So therefore, like, I get defined as erectile dysfunction.

So this is a key thing to understand is a lot of people who have difficulty finishing think there's something wrong with their penis. And there's in a sense sort of is right because we've trained it in a particular way. We're going to get to how to fix it. And the good news is that like most of these cases are 100 percent fixable. But then this creates a problem because the kind of sensory stimulation I need to achieve climax isn't there with vaginal penetration, which results in erectile dysfunction.

So today what we're going to do is go into erectile dysfunction with a lot of detail. We're going to explain the physiology of how an erection forms. We're going to talk a little bit about the sequence of the sexual act, which is incredibly important to understand. We're going to go over medical conditions that contribute to erectile dysfunction. And once we understand how the sexual act is supposed to happen, the arc and the trajectory of the development of an erection to sexual intercourse, to how the sexual act is completed, then

Then we will understand kind of how the engine works, how the car is actual, what's going on under the hood. And it will give us a lot of insights into how to fix the problem. Hey, y'all, if you're interested in applying some of the principles that we share to actually create change in your life, check out Dr. K's guide to mental health. And so we start by understanding what literally is meditation. How does experience shape us as human beings?

How do we strengthen the mind itself as an organ? And so by understanding our mind, we understand a very, very simple tool, a crucial tool that we have to learn how to use if we want to build the life that we want to. So check out the link in the bio and start your journey today. So here is our penis. And I hope I can draw a picture of a penis without getting in trouble. Now, in our penis, we have arteries that send blood into the penis. And we have veins...

that bring blood out of the penis. Okay. So we have a couple of different chambers. We have something called the corpus cavernosum, which is here. We have two chambers called the corpus cavernosum. And then we have a chamber in the glands of the penis, the tip of the penis called a corpus spongiosum. So normally there's, when we have a non-erect penis, the flow into the penis and the flow out of the penis match.

But what happens in an erection is that we will send blood into the penis and there's a nitric oxide production in the penis. So nitric oxide is a vasodilator. So what that means is that it will increase the blood flow to the penis. So as nitric oxide production increases, and by the way, testosterone basically increases nitric oxide production. So this is a vasodilator. So what happens is I have an artery here.

And when I add nitric oxide, the size of the artery increases, right? So now there's this much blood. There used to be only the middle part, and now there's a lot flowing in. So when I add nitrous oxide production, it causes vasodilation, which means that blood is now flowing into the penis. So as I vasodilate, right, so as I increase the blood flow, these start to fill up with blood. And when these fill up with blood, this blocks off...

the veins. So as the core, you can kind of think about it this way, like as the corpus cavernosum fills up,

We start to block the veins. And once we block the veins, then we've trapped the blood inside. And arterial pressure is greater than venous pressure, which means we're still pumping blood in. And then this is how we get an erection, right? So if we sort of think about a flaccid penis, it may be like one inch in size. And then once you get an erection, it literally will increase five-fold in volume. So there are a couple of key things to understand here about erectile dysfunction.

The first is that testosterone is what facilitates nitrous oxide production. So the other thing that we also discover is that since nitrous oxide is responsible for the vasodilatory mechanism that creates the erection, we also have the ability to develop phosphodiesterase 5 inhibitors.

So this is the enzyme that then breaks down nitrous oxide. So if we have medications like sildenafil or Viagra, they block...

the breakdown of nitrous oxide. So if I'm breaking, if I'm blocking the breakdown of nitrous oxide, then I will be able to maintain an erection because I'm maintaining the chemicals that allow me to keep an erection going. So this system is mediated by testosterone and nitrous oxide, right? So testosterone results in the production of nitrous oxide, which is a vasodilator, which allows us to maintain an erection. Now, normally...

we have an enzyme called PDE5, phosphodiesterase 5, which then breaks down nitrous oxide. So when we lose our erection, right, so we're producing nitrous oxide, it's vasodilating our penis. And PDE5 comes in and breaks this down, which then breaks down the vasodilation, which then kills the erection. So if we look at something like sildenafil or Viagra,

What this medicine does is blocks this enzyme from functioning. So it prevents us from breaking down nitrous oxide, which is how we're able to maintain erections. So this is a quick overview of the physiology of the penis. Now let's talk a little bit about what governs whether nitrous oxide is built or not built, right? So nitrous oxide is what results in the development of an erection. But when does it turn on? When does it turn off?

So now what we have to do is talk about something called the autonomic nervous system. So we have a part of our body called the autonomic nervous system, which is divided into two components, the sympathetic nervous system and the parasympathetic nervous system.

I don't know if you all have noticed this, but we basically have two modes of action in our body. There are times where we are excited. There are times where we're angry. There are times where we are lustful. There are times where our body is basically in a high state of activity. Our blood pressure is high. Our heart rate is high. Maybe we're diaphoretic. We're sweating. So this is the activation of the sympathetic nervous system. This is governed...

by things like adrenaline and cortisol. So when you sort of think about going on a roller coaster or some kind of like adrenaline spike, that's your sympathetic nervous system acting. So these are hormones, which means that they travel everywhere in your body through the bloodstream. And the purpose of a hormone is to coordinate

your whole body's response. So when I get adrenaline, I want to shut off my digestive system. We don't need to be digesting anything right now. I want to shut off the sexual act, right? So when we're going on roller coasters or we're being chased by...

tigers, we don't want to be having erections. We need all of our blood flow, not to our penis, but to the skeletal muscles in our arms and legs. And that's what adrenaline and cortisol will do. They will redirect blood flow to certain parts of our body. The second half of the autonomic nervous system is the parasympathetic nervous system. And this governs our rest and digest kind of mode, right? So sometimes when we're, after we've had a big meal, what happens? We're

Our blood flow doesn't travel to our brain, doesn't travel to our skeletal muscle. It travels to our gut. It travels to our liver. And we sort of feel a little bit sleepy. We get a little bit of a food coma. And the other thing that happens is we can sometimes get an erection. So y'all may have noticed that you get erections when you're feeling relaxed.

So when you wake up in the morning, a lot of men will wake up with something called morning wood. Right. So we will have a an erection early in the morning. I used to get erections all the time in organic chemistry class. It's not because I thought organic chemistry was super sexy. It's because I thought organic chemistry was super boring and it would put me to sleep. So this also leads us into sort of the stages of the sexual act.

So what we know is to develop an erection, you need activation of your parasympathetic nervous system. You need to feel safe. You need to feel relaxed, right? So for those of y'all that are lucky enough to engage in, you know, healthy sexual relationships, you may be in bed with your partner. You're kind of feeling relaxed. You're kind of chilling. You're kind of relaxing. You know, things feeling good. And then you start to get a little bit frisky, right?

You start to develop a little bit of an erection. Now your mind is sort of noticing, oh, like look at how soft they are and look at the, I mean, see how they smell and they smell really good. And like, now I want your body. And then, and then, so what happens is in order to develop an erection, we need activity of the parasympathetic nervous system. So then what happens is like, once we have the erection,

Then our sympathetic nervous system can turn on, especially if we get a certain kind of stimulation, genital stimulation, associative stimuli, we start making out, whatever. And then so basically we need, you know, the way that it was described to me in medical school is in order to arm the penis, you need parasympathetic nervous system activity. In order to fire the penis, you need sympathetic nervous system activity.

And the sympathetic nervous system will also recruit some of the things that will result later on. It activates certain mechanisms that will result in the return of the penis from erect to flaccid. So this also shows us a huge problem with psychogenic erectile dysfunction or erectile dysfunction that is not caused by a physiologic cause, which is that if you are stressed out, if you are depressed, if you are anxious,

then it will be hard to develop an erection. So if your physiology is not able to enter the right state of relaxation because you're stressed, anxious, depressed, whatever, it will be hard to develop an erection and even start the sexual act. So one of the key signs of psychogenic erectile dysfunction, so non-physiologic, and we'll get to this in more detail in a second, is that you are able to develop erections like while you sleep. So penile tumescence at night is still intact. So what

the fuck does that mean? That means that, you know, you wake up with morning wood, but when it comes to the sexual act, it's difficult to engage. So if there's a physiologic problem with the penis, then even some of these situations like morning wood or nocturnal erections will be impaired, right? Because there's some problem with the corpus cavernosum, some problem with the blood flow to the penis, the corpus spongiosum. So if there's a problem with kind of the hardware, then you'll have difficulties with erections basically all day long.

But if there's a problem with the software, which is a psychogenic erectile dysfunction, then the penis is capable of working in non-sexual situations. Does that kind of make sense? Psychogenic erectile dysfunction is mostly found in young men. A study by Kaskurlu et al. reported that 85.2% of 526 men under the age of 40 are struggling with psychogenic erectile dysfunction.

So this doesn't mean that 85% of people under the age of 40 have erectile dysfunction. This is a study that is looking at if I take all the people under the age of 40 and I try to figure out what is the cause of their erectile dysfunction, the cause of their erectile dysfunction is a psychogenic 85% of the time, which sort of makes sense, right? Because our bodies are young and healthy, which means that some of these other causes that we're going to talk about are going to be less common. So let's talk about physiologic dysfunctions.

causes of erectile dysfunction. Okay. So psychogenic ED accounts for 85% of people under the age of 40. And by the way, the rate of erectile dysfunction under the age of 40, according to evidence is up to about 28% in 2011. I suspect this number is about 30 to 40% in 2025. So what are the physiologic causes of erectile dysfunction? So heart health is penis health.

So as we sort of explained at the very beginning, vasculature is very important. So you need healthy arteries, healthy veins. So what we tend to see is that people who have cardiovascular problems, things like hypertension, things like obesity, things like diabetes, things like chronic kidney disease, this is not vascular.

people who have sleep apnea, very common cause of erectile dysfunction. So these are some of the very, very common physiologic causes. So basically problems with, you know, if we look at poor cardiovascular health, like poor exercise results in erectile dysfunction. So you need a healthy heart that's pumping the blood, you know, healthy veins, healthy arteries, big, big, big causes. Now there are also neurogenic causes. So

remember that in order for the penis to work properly, it has to receive a bunch of nerves, right? So when we touch the penis, it feels good. How do we know that it feels good? All of that information is transmitted via nerves. So 10 to 19% of erectile dysfunction over the whole population—okay, this is not young people, this is just everybody—is caused by neurogenic problems.

So these can be things like multiple sclerosis, spinal cord trauma, things like stroke can cause erectile dysfunction. Surgery can cause erectile dysfunction. So neurogenic causes are about 10 to 20% of them. So if there's a problem with your nerves in some way, there's going to be problems with erection.

So this is another like really good, this is a great opportunity to share something kind of cool. So a group of people that has great cardiovascular health and also has erectile dysfunction problems are professional bicyclists. So if we sort of think about a bicycle seat, what the bicycle seat is doing, the way that you sit, if you're like a professional, you're a biker, right? So if you go on marathons and stuff or you bike for eight hours a day, you are compressing

the nerves and arteries and veins that go into the penis.

So I don't know if this kind of makes sense, but if you look at the anatomy of the penis, the arteries and veins that go into them kind of travel through the area that's called the taint, right? So the area between the perineum and the scrotum is full of nerves, arteries, veins that sort of imbue the penis with what it needs. So if we compress that for extended periods of time, we block those nerves, then it can result in erectile problems.

What's really interesting is that this principle is also utilized beneficially by yogis. So there's an asana called Ardha Siddhasana or another asana called Siddhasana. And in Siddhasana, we place the heel gently against that area. And then in full Siddhasana, we'll sort of compress that area more severely. We compress...

from the perineum side and we compress above. So you basically sandwich your scrotum and penis between your heels or your ankles, if that kind of makes sense. I do not recommend, don't do this without the guidance of a guru. Okay. So these are, and

And the reason that they do that, they do that on purpose to reduce blood flow to those parts of the body, to reduce testosterone production, because we're also blocking some of the nerves and arteries to the scrotum, which is where a lot of our testosterone comes from. So they'll sort of utilize this. But my point is that there are all kinds of anatomical, neurological, arterial things going on. So we have physiologic erectile dysfunction, neurogenic erectile dysfunction. Another major cause, huge, huge, huge is medications.

So we are like notorious for this in psychiatry because a lot of our medications cause erectile dysfunction. At the top of the list are SSRIs. So these are antidepressant medications, anti-anxiety medications, anti-OCD medications will cause erectile dysfunction.

Another good example of this are antihypertensives. So these are medications that are going to affect your cardiovascular capability, right? So they're going to prevent your arteries and veins from contracting in the way that they normally do in order to combat hypertension. So that can cause problems with erectile dysfunction. We also know that your diet is really important for erectile dysfunction. So sugar, processed foods, alcohol, nicotine, low fiber,

and then various substances that we haven't included can sometimes cause problems with erectile dysfunction. Now, the mechanisms of this are a little bit complicated. We don't need to go into a whole lot of detail. And I know this is going to be hard, right? Because I can imagine that

That there are some people in our audience who don't exercise, maybe have sleep apnea, maybe are a little bit overweight, eat processed foods, eat sugar, use weed, use alcohol, use nicotine. And they're like, no wonder am I screwed. Don't worry, we'll help you out. Okay. Now we have to talk a little bit about how psychogenic erectile dysfunction develops and what to do about it.

And in order to do that, we have to take a look at neuroscience. So I want you all to think a little bit about the process of the sexual act, okay? Think about the process of the sexual act. Oh.

Key thing here is that when we think about getting aroused and we develop an erection, there's a lot of sensory input. Another really important part of sexual arousal is emotions, right? So I know that there's all these stereotypes about women need to fall in love before they have sex and men are horny and DTF all the time. I think that there may be some, if you measure 10,000 women and 10,000 men, there may be some net

effect that men are more likely to have sex without emotions than women. That statement may be true, but generally speaking in the brain, as we'll see, emotions are really important, right? So if someone is annoying you, the likelihood that you become aroused from that is low. So sure, there may be some kind of fetish or something at play, but generally speaking, if people are just annoying you, or if you're afraid of them, or if they're pissing you off, the likelihood that you will be

horny for them goes down versus if you fall deeply in love with someone, if you're obsessed with someone, the thought of having sex with them, whether you're a man or a woman is generally speaking more appealing, right? There are exceptions to that. So emotions become really important as well. So let's talk a little bit about these parts of the brain. So first thing that we're going to talk about is thalamus.

and posterior insula. So what do these parts of the brain do? So the thalamus receives sensory input, and the posterior insula is responsible for interoceptive information. So what does that mean? So if you're listening to this video right now,

I want you to notice what your body is telling you, right? So you may notice the weight of your, the body in the chair. You may notice that you're a little bit hungry. You may notice that you want to scratch something. Maybe you're walking around. Maybe you're sitting in a car. You're noticing the air conditioner blowing on you.

Your body is sending you signals. So one of the things that we know is very important for sexual activity is for you to be receiving sensory input and receiving input from within your own body. So I know that sounds kind of nutty, but just think about it for a second, right? So when you're having sex...

a huge part of that is being aware of the signals from your genitals. So the posterior insula is the part of our brain that basically gives us information from within our own body.

And what we find is that people with psychogenic erectile dysfunction have difficulty with that. Okay? So cognitive attentional syndrome and metacognitive beliefs in male sexual dysfunction, overall their cognitive and attentional patterns worsen negative internal states, reducing sexual excitement, detach them from their bodily sensations, and hindered sexual functioning.

So if you're having sex with someone and you get in your own head, oh my God, am I doing a good job? Oh my God, are they enjoying it? Are they enjoying it or not enjoying it? Is it going well or is it not going well? Then this kills your boner. Or I have to think about something else. So like, you know, if you get in your own head, what happens is this posterior insula stops becoming a part of your attention.

So there's a lot of studies on psychogenic erectile dysfunction show that there is an attentional problem. You cannot focus on the physical sensations. You're not even paying attention to what's going on in the penis. You are stuck in your own head. You're worried about something else. And without your posterior insula activating, it is very difficult to achieve climax or maintain an erection. So if we sort of think about the process of an erection, right?

And hopefully y'all are lucky enough to have experienced this in a positive and loving way. You know, if you're just sitting there and your partner is a little bit frisky and they start playing with your junk, your penis will start responding. And as your penis starts responding, you're sitting there trying to play Call of Duty and your partner is like starting to touch your stuff. And then your attention shifts.

from Call of Duty to what is going on in your genitals. May not be true because I don't know if Call of Duty players ever get laid, but, you know, that's neither here nor there.

This is what we mean by interoceptive information in the posterior insula is that your attention needs to be able to shift to the penis. Now, here's what I see a lot in psychogenic erectile dysfunction. This is basically the crux of the pattern. So I'm a boy who started masturbating. Then what happens is I physiologically trained my penis to ejaculate with 65 to 105 pounds per square inch of pressure.

And the vaginal intercourse of 5 to 15 milligrams of mercury is insufficient for me to achieve climax. So then what happens is I finally have sex for the first time, right? I'm a virgin and I'm like, oh my God, I want to have sex. I want to be a good person. I don't want to be a virgin loser anymore. I have sex for the first time. And then I'm not able to climax. And now this creates a problem. So the problem is actually that physiologically this stimulation doesn't work.

But now I get in my own head. Now I have problems with an erection. Now I didn't finish. Now I didn't pleasure her. Now I just went limp dick while I was having sex. So this creates a shame. This creates an anxiety. This creates a depression. And so all of these thoughts... Now the next time we try to have sex, a bigger problem arises. Now that I'm anxious because I screwed up the first time... Now I'm worried about the second time. Am I going to be able to perform? So now the second time I try to have sex...

My sympathetic nervous system is active before I even start the sexual act. So what that means is I'm stressed out about having sex. My partner starts playing with my stuff, but I'm so stressed that I don't even develop an erection. Now it's even twice as bad. It's not that I went limp dick during sex.

It's that I can't even get hard. This worsens the anxiety, worsens the depression. So then I try again the third time. This creates a vicious cycle that I think is one of the reasons why like up to 40% of people under the age of 40, I've seen this pattern so much, have erectile dysfunction. Second thing, anterior insula. The anterior insula is what processes the emotional features of

Of stimuli. So this is, let's explain this for a second. Okay. I have kids, right? And like, I love my kids. So what happens is when I see my children, this is just visual information, right? My kids look the same all the time. And lots of people will receive, if I'm walking down the street and I see my kids and everyone else on the street will see my kids too. But the emotional attachment to that stimulus is very different, right?

There is an emotional component that my brain attaches to my children that strangers won't attach to. I love them. I see this child and I'm like, this brings up a feeling of love. So this is also really important for the sexual act. So when I see my partner and I see a nipple, that nipple is not just a nipple. It carries a lot of emotional association with it.

So this part of our brain, in order to have a healthy sexual erection and even achieving climax, the emotions of it are really important. This is why makeup sex is so good, because there's an emotional block that made when we were feeling angry.

Then our sympathetic nervous system was active. And then we don't feel like having sex. And then we form this emotional connection. Now the anger goes away. Now we feel relaxed. Now we feel in love. And so we have this really intense, passionate sex because our interior insula activates. And when that emotion activates, it helps our posterior insula activate. And then we're there. We're in the moment. We're not thinking about tomorrow. We're not thinking about yesterday. The whole point is we've forgotten yesterday. We forgot the conflict. We're not in our head.

And so this leads to healthy sexual acts. The third part of the brain that we're going to talk about is roughly the prefrontal cortex and inferior frontal cortices. So these are responsible for sexual inhibition and sexual disinhibition. So our frontal lobes are the parts of our brain that give us confidence.

context-dependent behaviors. They're the parts of our brain that say it is okay to do this here and not okay to do it over there. So my favorite examples of this are like picking your nose. If you're like by yourself at home, like, you know, binging out on some TV show and like eating popcorn...

You'll go to town. But if someone else is around, you won't hopefully won't pick your nose and hopefully you wash your hands after you pick your nose. So like good examples of how, you know, the the inferior frontal cortices are different amongst people is like if we look at the fetish of exhibitionism. Right. So some people, if they are observed by others, their brain tells them this is not a good place to have sex.

Other people, their brain, their frontal lobes are like, hey, there are people around. Let's try to have sex. Another really great example of this is like if I'm sleeping in my hotel room alone at night and someone grabs my junk, that is going to be a very different experience from if I'm at home with my wife in bed in the middle of the night and someone grabs my junk.

even though technically the stimulus is exactly the same, there's a part of my brain that is saying that this stimulus is okay in one situation, arousing in one situation, and scary in the other. So when I'm in my hotel room alone by myself and someone touches my junk, I'm aroused. And when I'm in bed with my wife, this is very scary. Oh my God, she wants to have a third kid. What do we

So I'm going to kind of go back to, I think, the most common factor in psychogenic erectile dysfunction, which is basically pornography use and masturbation under the age of 40. So when I'm developing as a human, I have some natural impulses, and then those natural impulses get shaped by my environment.

So, for example, when I have patients who have schoolgirl fetishes, how do they develop a schoolgirl fetish? They develop a schoolgirl fetish because when they're 13 years old and they go to private school where all of the things that they are sexually attracted to have a particular uniform, their brain forms an association between objects.

I am horny and this is the object of my horniness. And when all of the girls in the class are wearing the same thing, my brain will associate this, right? So from the ages of, let's say, 15 to 18, for a very formative period of my sexual life, every girl I have a crush on is wearing the same damn thing.

So my brain over that 15 to 18 period is going to associate this with sexuality. It's associative learning, like classical conditioning. This is also why some people will have like a thing for a MILF, right? So when I'm a 13-year-old boy and my friends—I have one friend who has a hot mom—

The emergence of these sexual feelings is associated with a particular kind of stimulus. And so now like I'm like suddenly like this mom that I've known her for four years, right? We were friends since we were nine. I never had a sexual thought about her. And then once I start to develop like all these surges of hormones in my brain, I get really confused because now my brain is like horny all the time. And there are like all of these MILFs around me everywhere, hot MILFs in your area, right?

right? Then I will start to become attracted to milk. So this is how the brain works. We learn, right? It's not just, you kind of have this, like, you can think about sexual appetites as a, all of them are acquired tastes. If I get exposed to one school girl and then over the next five years get exposed to a hundred others, I will develop a preference. I will develop a preference for milfs, whatever. So here's where pornography comes in because

We're not just developing a cognitive preference. We are also the genitals. If you're masturbating every day, you know, and you're from the ages of like 13 to 23, what's going to happen is our body is going to get a certain kind of genital training, which we've kind of already talked about. So now I am used to, or my brain or penis learn my interoceptive part of my brain, my posterior insula and the nerves in my penis learn that there is a certain kind of stimulus that gets me to climax.

So now porn enters the picture. So if, you know, 100 years ago I was like I developed a schoolgirl fetish, what is my brain going to prefer sexually? What does it get exposed to? So now what's happening with the consumption of pornography, the easy access to pornography, we begin to believe that these things are sexual. And what we know about pornography and there's a whole – we've done lectures on this so you guys can check this out.

is that pornography uses things that are supra-normal stimuli. So they use tits that are bigger, butts that are bigger, things that are shinier, 4K, a

A lot of color, a lot of camera angles, a lot of things that you will never see during sex. Right. So like a really simple example of this is most human beings who engage in sexual intercourse, the man will never see the vagina or maybe you see it at the very beginning. But once you're actually like in a penetrative position, you don't see the vagina. Right. It's like kind of weird. But so like what starts to happen is our brain starts to get conditioned by pornography. Right.

And we know that this conditioning tends to get radical over time. So this is a paper that's looking at pornography-induced erectile dysfunction among young men. They report that an early introduction to pornography, usually during adolescence, is followed by daily consumption until a point where extreme content involving, for example, elements of violence is needed to maintain arousal.

A critical stage is reached when sexual arousal is exclusively associated with extreme and fast-paced pornography, rendering physical intercourse bland and uninteresting. This results in an inability to maintain an erection with a real-life partner, at which point the men embark on a reboot process giving up pornography. This has helped some...

of the men regain their ability to achieve and sustain erection. So one study, I don't remember if it was this one, found that I think about 40 to 50% of men will end up watching pornography that they used to think was disgusting or like not good in some way.

And so here's the issue. So if we look at a normal brain with a normal sexual relationship, there isn't an option for more extreme, generally speaking, right? There's some amount of extremity. Maybe your partner indulges you during your birthday or something like that or anniversary or there's special occasions where you convince them to play with your kinks. But it's not like on,

demand. So once we acclimatize to a certain kind of pornography, if we increase the intensity, the pace, the color, the extremity, the violence, whatever, if we increase something about it, our dopaminergic centers get a little bit more activated.

So over time, what happens is normal porn becomes bland. And if you watch pornography, you may have noticed this, that you can't watch the same porn over and over and over again, right? It doesn't, you don't enjoy it as much. You go looking for new things and maybe something that was less extreme now becomes a little bit more arousing. So we are basically conditioning ourselves to a particular kind of input in order to achieve success.

climax in order to achieve erection. So this is a huge problem. So the good news is that for the majority of people who are under the age of 40, if you have erectile dysfunction,

I would say that it can be 95% resolved. That's my gut check as a clinician. So if a patient walks into my office and says, hey, doc, I'm 30 years old. I can't maintain an erection. I can't achieve climax when I'm having sex with my wife. Can you help me? And I would say, yeah, dude, I think that, you know, there's a really, really, really good chance that you can get back to a healthy sexual relationship. And the studies actually support that. Okay, so let's understand what the different pieces are.

are. So the first is cardiovascular health is penile health. So if someone is obese, overweight, has diabetes, has sleep apnea, doesn't exercise, if someone just starts exercising on a regular basis, maybe loses a little bit of weight, but more importantly, achieves more cardiovascular health, their erections will improve. So this is true of people who are over the age of 42. So when we start to get to

physiologic causes like hypertension and things like that, right? So when I have a 45-year-old dude in my office who just got diagnosed with hypertension and has trouble maintaining an erection, getting them to exercise and bringing down their blood pressure will 100% help their erection. So there are also things that we've talked about, sugar, processed foods, things like that. So the first thing is that if you get physically healthy, your erections and your ability to achieve climax will definitely get better.

So now we have to dive into psychogenic erectile dysfunction and how to sort of treat that. So this is where what we know is that there are studies that show that attentional control, so getting better at shifting your attention, will help you maintain an erection and achieve climax. So if we look at people who struggle to maintain erections and climax, what we find is that once they get into their head, they cannot get out of their head.

So this is where there are really simple practices like meditation is a really good one that trains your attention. But it's not just things like meditation, right? So there are specific studies that have attentional control exercises, which you can learn. And it is shifting your attention from being in your own head. And so this is what I would encourage you all to do if you're struggling with this. Pay attention to your body, right? Just enjoy the experience. Don't think about whether you're making her come or not. Don't think about your rectum. Just enjoy the sensations.

Be in the present moment as much as possible. And when you do that sort of thing, it'll activate that posterior insula, all of those interoceptive senses, and it will move you closer to the right direction. The next thing to think a little bit about is the anterior insula, which is our emotional processing. So this is a big part of the work that I do with people. This is why psychotherapy can be incredibly helpful for erectile dysfunction.

is that the sexual act is associated with all kinds of stuff. And we have to deconstruct all of those associations because those associations aren't real. So when I ask, let's say a 20 year old kid, I mean, I had a patient once who was like this, who came into my office and said, Dr. K, I can't achieve orgasm. And then I asked them like, you know, tell me more about that, help me understand the problem. And so they said, I can get to the first stage of orgasm. I can get to the

the pre-cum stage, but I can't get to the actual ejaculation. Like I can't handle it. And I was like, what do you mean you can't handle it? So what they sort of told me is that, you know, like I, I will engage in sexual behavior and then like a little spurt will come out. And then I, and then my penis becomes hypersensitive and I, and it goes limp. And I was like,

what do you think an orgasm is supposed to be? And they're like, you know, it's like gallons, buckets of ejaculate that lasts for 60 seconds and lots of moaning and awe. And then I'm like rock hard afterward. And what this person, it's sad, but what this person was struggling with is that they were orgasming. They just had this impression that an orgasm is like, you know, liters of ejaculate. And

The average ejaculate volume, I think, is like maybe five milliliters, like maybe like a teaspoon. I don't really know. But anyway, so like this is where we have all these ideas or impressions of what sex is supposed to be like. And there are also studies that look at like metacognitive beliefs about manliness. Like what do you think a manly sexual act is supposed to look like? And this is where we have to get to some statistics. OK, so like a lot of people don't know that the average sexual act is three to seven minutes.

And that if 50% of women will want the sexual act to end at 10 to 15 minutes, like they're done after that. A lot of men don't realize that only about 21 to 30% of women can achieve an orgasm through vaginal penetrative intercourse. So this is where we get a little bit technical, but the tissue that becomes the glands penis, right?

is the same tissue that is the clitoris. So during embryology and development, there's a small piece of tissue. So we're all default female, by the way. And then what happens is the clitoral tissue, under the influence of an androgen like testosterone or androstenedione,

will develop into the glans penis. So there are some cases of like if you get a woman, a biological female who has like a testosterone secreting tumor, you will see the clitoral enlargement. So the clitoris will start to morph somewhat into something that looks closer to the glans penis. It doesn't turn into a glans penis, but...

My point is that embryologically, the tissues are the same. So here's a simple question. If you all are worried that you can't make your female partner orgasm with vaginal intercourse, we're going to do a really simple experiment. So imagine that you are trying to achieve climax without ever touching the top half of your penis. Can you climax by stimulating the base of your penis? Probably not. I don't know. I've never done this experiment.

Right. So if we sort of think about it, like which part of the penis is the most important for achieving climax? It's the glands. It's the corpus spongiosum and that tip of the penis where all the nerve endings are.

I mean, the shaft is good, too. Don't get me wrong. But that's usually what we need. Right. And so women are the same way. They need clitoral stimulation because that's what the majority of the nerve endings are that will allow them to achieve orgasm. My point is that when we're engaging in a sexual act, if we don't know these facts, we don't know that the average intercourse lasts five minutes. If you're screwing for three minutes or 10 minutes, like that's normal for most people.

So you don't need to get anxious about that, but then that triggers all of these problems with attentional control and then you're in your own head and stuff like that. So that creates a lot of problems. So usually what I tend to do when I'm working with people is I will help them unpack these beliefs. I will help them think about where they constructed these ideas. I will help them deal with their emotions.

I will help them develop emotional regulation techniques and help them develop relaxation techniques, right? Because if you are approaching the sexual act and your adrenaline and cortisol are high, you will never develop an erection. So we need to do some of that physiologic rewiring, psychological rewiring. As you dig into these things, things tend to get better. And the last thing that we're going to talk about are other forms of intervention. So this is just to let y'all know. So we have medications for things like erectile dysfunction, and sometimes these can work incredibly well.

So if you have, you know, stress-based sexual erection problems, and we do something like prescribed sildenafil, which is a trade name Viagra, this can work really well because you're afraid, like, you can't get an erection because you're stressed out. The Viagra helps you get an erection. Then you are able to have sex. Then you're able to stay hard enough, hopefully, to climax.

And then like, then you've had one success. And once you've had one success, it becomes easier to have your second, easier to get the third. Then you start penile retraining. Then you start engaging in sex. And then this is how you basically rehabilitate the penis.

And then once you rehabilitate the penis and now you're no longer anxious, you don't need the Viagra anymore, right? You don't need the sildenafil because now everything is working the way that it should. There are also cases of things like intraurethral suppositories, which are a localized amount of some kind of medication that is inserted into the tip of the penis.

You know, so it doesn't have to be like if you have a medical contraindication, like if you've got right-sided heart failure or something like that, then you shouldn't take sildenafil. So there are things like that. And then there are also a couple of other things that people will do. One is they'll use vacuum-assisted devices. So these are things like penis pumps that remember that a lot of the maintenance of erection has to do with pressure gradients from your arterial blood flow and your venous blood flow. Problem with a lot of these, these

of vacuum assistive devices is that about 30 to 46% of people will stop using them because of like bruising and other side effects. And the last thing that we have is we do have surgical interventions for erectile dysfunction. These are things like penile implants. So you can put some kind of implant into the penis a little bit outside of my wheelhouse. You got to go see a surgeon or a urologist for that kind of thing so that you can do that kind of stuff too. So there's a lot of stuff that you can sort of

do from a lifestyle perspective, from a psychogenic perspective, you know, to understand how the brain develops an erection, what's going on in your nervous system, what's going on in your head, the ability to shift your attention, and then you can absolutely move in the right direction. The last thing that we tend to see is that abstinence or severe reductions in pornography and masturbation will help a lot. If you think about the frequency of sexual activity,

The less sexual activity you have, the easier it is to achieve climax. This is a huge problem for a lot of dudes. If you haven't gotten laid in a while and you have sex with your partner, you're done pretty quick. So as a psychiatrist, I'll sort of do like this kind of, I mean, it's not really sex therapy, but I'll work with couples to develop a plan where I let them know, look, we're going to do this for a month where you got to stop pornography. You got to stop masturbating.

And then y'all can have sex. The goal is not to finish. When you feel an erection or whatever, you guys just like try it out and feel each other out for about 30 days. And the goal is, first of all, let's see if you can get an erection. Let's see if you can enjoy the, just enjoy the sensation. Don't worry about sex. You're not trying to have sex. You're just trying to get a penile massage, right? That's the goal. And then you start to enjoy each other's company. You start to develop intimacy, you know, so you start to like, you know, maybe you have some kind of

massage, but don't have sex. And then like tension builds up and then they end up having sex. And it ends up being great because like both of them are horny because their genital massaging each other for like 15 days without any kind of like, you know, sexual activity. And then things turn around. So there's some studies that show that, you know, abstinence from pornography can be incredibly effective. So the last thing that I want to share with y'all, I know we sometimes try to sell you things, but this is something that I couldn't resist.

So in order to help you all with this problem, I'd love to tell you all about a new guide we've made, which is Dr. K's Guide to Penile Retraining.

Much like our other guides, it dives into a lot of depth about what is the neuroscience, what is the psychology, gives you lots of practical tips on what you can do. Also includes meditations that are designed to support this problem. So we're going to be exploring esoteric tantric meditations. And then the best part of the guide, which is now available not only on our platform, but also on OnlyFans, is I'll show y'all step by step exactly how to do the retraining of the genitals. But in all seriousness...

If y'all are worried about, oh, how do I regulate my emotions? How do I focus my attention? How do I process my shame? All of these things actually do exist in our real guides. So we have a guide to trauma where we'll talk to you about, you know, how to let go of past experiences. We have a guide to anxiety where we teach you a lot about the physiologic effects

rewiring that is necessary so that you can reduce your anxiety. We have guides to depression. We talk about how to deal with shame. So if y'all are interested in that stuff, definitely check those things out. And of course, if you're working, if you're struggling with this problem, you can absolutely work with a professional. Thanks for joining us today. We're here to help you understand your mind and live a better life. If you enjoyed the conversation, be sure to subscribe. Until next time, take care of yourselves and each other.