Episode 29 - Dr. Irwin Goldstein: Specialist in Sexual Medicine

Transcript

Chip August: Welcome to Sex, Love and Intimacy, I’m your host Chip August, and today on the show we’re going to be talking about sexuality and health, and we’re going to be talking to Dr. Irwin Goldstein. Dr. Goldstein has been involved with sexual dysfunction research since the late 70’s and actually is responsible for creating maybe the only sexual health medicine department in a hospital that’s treated as a specialty like other specialties, quite extraordinary career he has, and he’s authored more than 350 books publications in the field of sexual dysfunction, edited books on erectile dysfunction and on women’s sexual health. He is the editor in chief of the Journal of Sexual Medicine, the official journal of the international society for sexual medicine. Dr. Goldstein is the director of sexual medicine at Alvarado Hospital in San Diego, clinical professor of surgery at University of California at San Diego and director of San Diego Sexual Medicine where he maintains his clinical practice.

Dr. Irwin Goldstein: We call impotence the iceberg of sex, and I’m not sure everybody understands that, but it’s a artery of the body that’s around a millimeter, probably about a .7, .8 of a millimeter, and the health of that artery is important to achieve a functional rigid sustained erection.

Dr. Irwin Goldstein: Should be known to the listeners, what should be known to all aging men and of course their aging partners is that if something’s wrong with your sexual health, something is wrong, and something should be found out about what it is that’s wrong. If in fact it’s early vascular disease then attention should be given to it.

Dr. Irwin Goldstein: But you have estrogen and women have testosterone and the concept that one is male and one is female is completely incorrect.

Dr. Irwin Goldstein: The product Five Alpha Reductase Inhibitor Proscar was a drug to slow the growth of the prostate on some men who had difficulty urinating, and what they found in some of the men is it grew hair, so the Five Alpha Reductase Inhibitor now got renamed as Propecia and the side effect of hair growth now became its actual indication.

Dr. Irwin Goldstein: It reminds me of if you take Viagra and it says “If you have erections more than 4 hours please call your doctor”, it would be nice if the doctor actually knew why they were calling them, but maybe, that would be maybe a different conversation.

Chip August: So welcome, Dr. Irwin Goldstein.

Dr. Irwin Goldstein: So, thank you so much for doing this, it’s, we’re going to have a lot of fun.

Chip August: Cool! I want to talk about sex and health and aging, and I understand that you are the guy. So lets just dive in. I’m a guy, so the first thing I really want to talk about, I want to talk about erectile dysfunction and all those pills that one can take for things, Viagra, Livitra and Cialis, and I know a lot of men who will tell you they don’t have ED, they take it recreationally. Is that a problem?

Dr. Irwin Goldstein: Well it’s not a problem, it’s a problem of being honest, that’s all. I, the data will show, epidemialogic studies in populations will show that prevalence of sexual problems in men changes after the 40’s or in the 40’s and it depends on, your friends you say they used it recreationally, how old they are, but…

Chip August: Most of them are in their 40’s and 50’s and 60’s.

Dr. Irwin Goldstein: Yeah, it’s classic that, we call impotence the iceberg of sex, and I’m not sure everybody understands that, but it’s a artery of the body that’s around a millimeter, probably about .7, .8 of a millimeter and the health of that artery is important to achieve a functional rigid sustained erection. If that artery is partially blocked then the outcome of that partial blockage will be a less rigid, less sustained erection, so that in aging men, who will inevitably develop some blockage in arteries as that’s just classic part of aging, it’s the early warning sign, it’s the sign of early impending vascular issues, and it’s often missed, it’s like okay, someone walks in, “I’ll have an erection problem”, “Well here’s one of the PD5 Inhibitors, go use it”, but what should be known to the listeners, what should be known to all aging men and of course their aging partners is that if something’s wrong with your sexual health, something is wrong, and something should be found out about what it is that’s wrong. If in fact it’s early vascular disease then attention should be given to it so that disease doesn’t happen in other lets say more important arteries like in the brain or in the heart. Impotence is a form of angina usually, and angina is less blood flow to the heart, that’s what we typically think of it as.

Chip August: So if I’m having trouble getting or maintaining erections and I’m over 40 and my own urologist doesn’t say this to me, or my own GP doesn’t say this to me, you’re basically saying I ought to talk to a heart guy and just get a, just get checked out and make sure that it isn’t, that isn’t showing up in other aspects of my health.

Dr. Irwin Goldstein: And that’s such an important and amazing message, that we got that out in the first few minutes of this show is awesome. Impotence is the early warning sign. There’s a beautiful article that came out in December of 2005 by E.M. Thompson. He published it in the Journals American Medical Association and he showed in a population of around 8,000 men, funded by the government, that once impotence was identified as a condition, if you just set the clock and had it started ticking as when you declared yourself to be impotent, the chances of having a heart attack five years later, a heart attack or a stroke five years later was 10 percent, and the chances of having a heart attack or stroke at seven years was 15 percent. It’s a linear relationship of when you have ED to when you have a serious cardiovascular consequence, and that’s a really important message.

Chip August: Yeah, but I also get, just so we don’t scare the hell out of people, those numbers, what you’re basically saying is that 9 out of 10 aren’t going to have that incident, that it’s not, it’s not, you know, like, don’t panic, just go find out.

Dr. Irwin Goldstein: Go find out and get, and change your life, diet, exercise…

Chip August: Yeah.

Dr. Irwin Goldstein: change medicines if you have to, go onto medicines if it’s, if it’s appropriate. I don’t think we should scare people, but on the other hand most people don’t take a sexual problem as representative as some form of either psychologic or biologic problem, they typically write it off and say it’ll just go away.

Chip August: Right, right, well, or I think there’s a, there’s a, sort of a, “Well I’ve been with the same partner for 15 years, of course my desires going to flag and that’s all it is. I don’t really need to worry about that.”

Dr. Irwin Goldstein: Well my statement to audiences and to any interview that I give is that if something is wrong with your sex life, something inevitably is wrong.

Chip August: Yeah.

Dr. Irwin Goldstein: It could be figured out, it could be a vascular problem, a hormonal problem, a neurologic problem, a psychologic problem, but something is wrong and it really ought to be found out.

Chip August: Got it. It’s like ignoring when something isn’t working the way, the way it’s supposed to work is probably a bad plan.

Dr. Irwin Goldstein: There you go.

Chip August: Got it, I understand. Now, we were talking a little bit about this before we started, I notice so much about sexual health and sexual medicine is about men and penises.

Dr. Irwin Goldstein: Yes, well the data would show, Ed Lowman published on sexual dysfunction in the United States, and actually there are many more times that women have sexual problems than men, but however unfortunately we choose to speak only, or most commonly of men and their sexual problems.

Chip August: Is that just because the male sexual problem is just more easily addressed medically?

Dr. Irwin Goldstein: Well, I mean, I guess it’s a double edged sword, it’s more easily able to be treated because that’s all we have…

Chip August: Got it.

Dr. Irwin Goldstein: for FDA products. Some products have been submitted to the FDA, but they, for women, but they were rejected so, we don’t have anything for women at this point.

Chip August: Any idea why it is that we don’t have like a female Viagra or a female Cialis, you know, why isn’t there a pill that women can take that would aid their arousal or is there?

Dr. Irwin Goldstein: There are medications approved for women’s sexual health issue in Europe, but not here in the United States.

Chip August: Wow.

Dr. Irwin Goldstein: The drug is testosterone and the name of the drug is Intrinza and the company is Procter & Gamble, and they have delivery of testosterone for women with sexual health problems and it’s successful, it’s in double blind placebo control trials, has safety and ethicacy and I wish it was also here in the United States.

Chip August: Okay, so now, alright, testosterone, that, that’s male hormone, why will giving a woman male hormone help women’s sexual function? It would seem to me that it would help her grow a mustache, but I, you know, I’m not clear why it would help, so teach me a little.

Dr. Irwin Goldstein: So Chip, you’ve said a few myths in your first sentence so…

Chip August: Cool.

Dr. Irwin Goldstein: I was smiling as you were talking. Would you say estrogen, I’m just going to ask you a question, treat you like a medical student, is estrogen a female hormone?

Chip August: Yeah, I would, my fantasy is that estrogen is a female hormone and testosterone is a male hormone and if you give me estrogen I’m likely to grow breasts and if you give a woman testosterone she’s likely to grow facial hair, that’s my, you know, that’s sort of the, I have no medical training as you can tell from the way I’m saying that, and so that’s the story.

Dr. Irwin Goldstein: So what happens if you Chip went this afternoon to a hospital and drew your estrogen blood level? What do you think you’d find?

Chip August: Well I assume it would be really, really, really, really low.

Dr. Irwin Goldstein: But you have estrogen. And women have testosterone, and the concept that one is male and one is female is completely incorrect.

Chip August: Wow! Wow!

Dr. Irwin Goldstein: A woman’s ovary makes a lot of testosterone, in fact all the estrogen from, that a woman makes is from testosterone synthesis.

Chip August: Wait a minute, wait a minute, so the very, the way they make estrogen is from…

Dr. Irwin Goldstein: By making testosterone…

Chip August: Wow!

Dr. Irwin Goldstein: and converting it into it.

Chip August: Wow!

Dr. Irwin Goldstein: And we have, as men, have estrogen. So the fact is they are not male or female, what we call them are sex steroids, and the classes are androgens, estrogens and progestins, and those are not to be discriminated by gender.

Chip August: Okay.

Dr. Irwin Goldstein: By the way, women have prostates and men have prostates, men ejaculate and women ejaculate.

Chip August: Well I know women ejaculate, but women have prostates?

Dr. Irwin Goldstein: Women have prostates, otherwise called schemes glands, otherwise called g-spot, but women do have an ejaculation of a fluid that has PSA, I’m sure you’ve heard of the word…

Chip August: Yeah.

Dr. Irwin Goldstein: the acronym, PSA, Prostate Specific Antigen.

Chip August: Yeah that’s what they test me for for prostate cancer, right?

Dr. Irwin Goldstein: Women get prostate cancer just like men get prostate cancer.

Chip August: Wow! I had no idea.

Dr. Irwin Goldstein: Unbelievable Chip, we’re going to learn a lot today, I told you we’d have fun.

Chip August: Cool! I had no idea about his. Okay, so…

Dr. Irwin Goldstein: So when we give women testosterone, we’re giving them a sex steroid that they otherwise synthesize naturally…

Chip August: Mm hmm.

Dr. Irwin Goldstein: and it, to which is as natural a synthesis as is their estrogen, by the way as estrogen is as natural to men as is the testosterone, and it, if it’s low and outside the normal range, replacing it can restore sexual function in those women where the sexual function can be related to that, so in fact it’s a real science.

Chip August: Got it, so it’s possible that as a, if I’m a woman and I’m aging and I’m losing desire, there may be a medical reason for this that’s related to my testosterone levels, that’s correct?

Dr. Irwin Goldstein: That’s correct.

Chip August: Wow!

Dr. Irwin Goldstein: And it is as natural to them as is estrogen. And giving testosterone in fact to a woman in double blind placebo control trials does not show any increase in mustache, you, that was the second myth…

Chip August: Right.

Dr. Irwin Goldstein: that you made me smile on. Women grow mustaches because women grow mustaches when they age.

Chip August: Right.

Dr. Irwin Goldstein: And it has nothing, not, it’s not at any increased rate if they take testosterone. Now of course the caveat is they have to take it at levels consistent with simply raising it to normal volumes.

Chip August: Right, right. Okay, okay, so, and this isn’t the case where more is better. This isn’t the case where well, “Well if, you know, I’m supposed to have x percent, I’ll just have twice that percentage and I’ll have twice as much good a fact.”

Dr. Irwin Goldstein: More is related to adverse effects…

Chip August: Got it.

Dr. Irwin Goldstein: you’re a hundred percent correct.

Chip August: Got it, yeah, got it. So, so it’s probably not something somebody should mess around, this is, this is stuff that really you need to do under the care of somebody who’s an expert in this field.

Dr. Irwin Goldstein: Ideally a sexual medicine physician, which is by definition a physician who applies the principles of medicine to men and women with sexual problems.

Chip August: Right, okay. So are there many of, I noticed the, you know, I’m a regular person with a regular health clinic that I go to when I’m sick, I don’t think there’s anybody, I don’t even think there is a sexual medicine department, is there?

Dr. Irwin Goldstein: Well there is in San Diego.

Chip August: Yes.

Dr. Irwin Goldstein: I think that it’s inevitable. We have pain medicine and those are doctors who apply medical principles to men and women who have pain concerns. And then there’s sports medicine and sleep medicine and family medicine, internal medicine and rehab medicine and nuclear medicine, and it seems inevitable that there will one day be sexual medicine. We have a International Society for Sexual Medicine, we have a journal, The Journal of Sexual Medicine. There are a awful lot of people who have sexual problems and often men and women can’t get the appropriate care that they would like because doctor’s are either not informed or too busy or themselves embarrassed to talk about this, this, this subject.

Chip August: Yeah. Yeah. We need to take a break. I want to let our, give an opportunity to let our sponsors support us and let us support our sponsors. I’m talking to Dr. Irwin Goldstein, this is Sex, Love and Intimacy and we’ll be right back.

Chip August: Welcome back to Sex, Love and Intimacy, I’m Chip August, I’m your host. We’re talking to Dr. Irwin Goldstein and we’ve been talking about sexuality and health and sex medicine, and I want to talk a little bit about, about antidepressants and the role of antidepressants on suppressing sexual function. I hear a lot of people, men and women, who tell me that they’re struggling with depression, they get, they get an antidepressant that seems to work for them and the side effect is, well they just don’t have desire anymore and they’d rather not have depression even if that means they give up desire and it seems to me like it’s a devils choice, you know, like life without, for me, life without sexual desire would be depressing, so can you talk a little bit about the relationship between, I mean, first of all, why do antidepressants even have an effect on sex and, can we talk about that?

Dr. Irwin Goldstein: Chip, you summarized a very complicated field beautifully, so I congratulate you, it’s the devils choice. One of the experiments of nature was the class of drug called Selective Serotonin Reuptake Inhibitor, which is…

Chip August: That’s SSRI?

Dr. Irwin Goldstein: yup, SSRI, and what that enabled us to appreciate was that the central neurotransmitter, the chemical that’s involved in cell to cell communication, Serotonin, was in fact a major inhibitor of several of the nuclei in the inner part of the brain, the thalamus and the hypothatlamus in terms of their inhibition of sexual activity, they, they basically closed the gates. If you can imagine that the sexual response like any other reflex is regulated either with excitation or with inhibition, then in fact Seratonin closes the gate and enhances the inhibition. The, the major effect of Seratonin on sexual response is to not just decrease the libido, but really does a number on inhibiting the ability to have an orgasm, an ejaculation experience. And what’s interesting is men who have, well actually the utmost common sexual problem is not erectile dysfunction for men, it’s men who can’t control the ejaculation and have an ejaculation before they would like, and that’s called premature ejaculation, and we now utilize off-label SSRI’s in un-depressed patients to get them to control their ejaculation reflex.

Chip August: Wow, so you, so I got it, so, you know, one person’s side effect is another person’s desired effect.

Dr. Irwin Goldstein: Absolutely, and that’s a very common thing and the product 5 Alpha Reductase Inhibitor Proscar was a drug to slow the growth of the prostate on some men who had difficulty urinating, and what they found in some of the men is it grew hair, so the 5 Alpha Reductase Inhibitor now got renamed as Propecia and the side effect of hair growth now became its actual indication.

Chip August: Oh, how funny, I had no idea. I didn’t know, so Propecia started out as something to stop the, to slow the growth of prostate. Wow, how funny.

Dr. Irwin Goldstein: Well anyways, the most important message again that we talked about earlier was that if you have a sexual problem, that means something is wrong either biologically or psychologically, and you can argue that depression is not that dissimilar. There’s many parallels between depression and sexual problems.

Chip August: Mm hmm.

Dr. Irwin Goldstein: One of the biologic reasons for being depressed is in fact to have a low testosterone value, and rather than giving someone an SSRI for depression, if one actually checked the testosterone blood test level value, one may find a hormonal basis for the depression where treatment of the depression would be best served by giving testosterone. Another example is hypothyroidism, where your thyroid is not producing adequately, that can also lead to depression, and managing that patient with thyroid medication would be far more serving his purpose or her purpose than by giving an SSRI.

Chip August: So it sounds, so it sounds to me like along with my trip to my psychologist, I also need a trip to my, to my general practitioner and some blood work to determine, is my thyroid working right, are my hormone levels right, that what I may think of as a psychological problem may have, may have its roots in chemical imbalances in my body that aren’t related necessarily to my brain.

Dr. Irwin Goldstein: Well I’ll give you a perfect example of this, although it switches gender. There are but 300 million humans that happen to be women who take the birth control pill…

Chip August: Mm hmm.

Dr. Irwin Goldstein: And essentially one hundred percent of these women end up having low testosterone by the effects of the birth control pill on the woman’s body, and we could get into that, it may be in a subsequent show because it’s really sort of interesting, but in any case, a very common trip to my office to seek the advice of the sexual medicine doctor would be a woman in and around college age on a birth control pill who is on a antidepressant, an SSRI, for depression.

Chip August: Mm hmm.

Dr. Irwin Goldstein: And since we are very attuned to the fact that birth control pills can cause low testosterone, these poor women are essentially twice manipulated in an anti sexual sort of way. And these are college kids who are taking birth control pills so they can have, eliminate their fear of pregnancy.

Chip August: Right.

Dr. Irwin Goldstein: So theoretically to have better sexual function. But the whole point here is that the birth control pill will make them have a low testosterone, the sex steroid called testosterone, and they will, x percent will get depressed, x percent will then go on SSRI’s, and now these people have extremely low interest, very poor orgasms, oftentain or what we call dispareunia during sexual activity and it’s a very sad event that we’re pharmacologically altering these human’s sex lives.

Chip August: Wow, so the very, the very way that the…

Dr. Irwin Goldstein: That our society manages women right now…

Chip August: Right, right, I get, basic…, oh my goodness gracious, so wow, that is actually kind of a frightening, I mean that’s like something straight out of a Margaret Atwood novel, you know.

Dr. Irwin Goldstein: Well I was just, I am very fortunate to be next to San Diego State University, as well as UCSD while I’m in San Diego, and there’s a human sexuality course that I lecture at SDSU and we just gave this talk to 200 undergrads about birth control pills and of course this is a psychology course and many of them are women, in fact most of them are women and most of them are on the agent that we were talking about as causing all these problems, and it’s quite a dilemma and our society has become more communicative in the sexual consequences of the therapies we give to people.

Chip August: Yeah, I think maybe what we’re seeing here is that it’s only quite recently that people are really willing to consider sexual health to be important. It’s like, it’s like people seem to want to ignore, I think we’re ashamed of being sexual beings. And so anything that, you know, we just surrender to, well that’s just the way it is because otherwise I’d have to talk about it and I think we feel mostly ashamed.

Dr. Irwin Goldstein: Well it’s not discussed in the medical schools. In the 4 years of medical schools it would be infrequent to have, lets say, more than a very brief discussion of sexuality and sexual medicine in the 4 years of medical school, so…

Chip August: Wow!

Dr. Irwin Goldstein: Most graduating physicians today do not have any background in this.

Chip August: Right, and of course they’re carrying their own shame as human beings, so it’s…

Dr. Irwin Goldstein: Therefore we need sexual medicine in the medical school.

Chip August: Yeah, yeah. Okay, I got, here’s another one that I hear all the time.

Dr. Irwin Goldstein: I think one point we learned is that it could really, the depression could actually do to some biology hormonal issues. But there’s some very important antidotes to the classic SSRI, and the antidote is that the agent, it has two names, Bupropion or the commercial name is Wellbutrin…

Chip August: Mm hmm.

Dr. Irwin Goldstein: But the antidote is very well examined and investigated to counteract some of the consequences sexual of the adverse sexual consequences of SSRI’s. So if someone is struggling with the sexual consequences of an SSRI, please consider asking your doctor for Bupropion or Wellbutrin to counteract that.

Chip August: So basically Wellbutrin is a kind of antidepressant that works in a different way?

Dr. Irwin Goldstein: Right, it raises, well as we spoke of serotonin being a central neurotransmitter which is inhibitory, one of the most powerful excitatory neurotransmitters is dopamine, d-o-p-a-m-i-n-e, and of course Bupropion is a dopamine agonist, it facilitates dopamine action in the brain.

Chip August: And, and is there, are there other, I mean is that pretty much the only choice?

Dr. Irwin Goldstein: No, there’s many, there’s many dopamine agonists. You may have watched on television, there are new ads out for men and women who have restless leg syndrome.

Chip August: Yeah, yeah.

Dr. Irwin Goldstein: My wife watches Lifetime and there’s many ads and the drugs are Merapex or Requip, that’s the most popular, and both of them are dopamine agonists, they’re used in Parkinson patients and of course the dilemma in Parkinson’s, in the port part of the brain called the substanigra is they don’t have dopamine, so the drugs for Parkinson’s patients raise dopamine, and all drugs that raise dopamine have sexual consequences, so where I’m going is, if you listen carefully to the commercial ad, it says, if you’re experiencing excessive sexual activity or excessive sexual interest, please call your doctor. I always smirk when I hear that. It reminds me of, if you take Viagra, it says if you have an erection more than four hours…

Chip August: Right, right.

Dr. Irwin Goldstein: please call your doctor. It would be nice if the doctor actually knew why they were calling them, but that would be maybe a different conversation.

Chip August: Yes, it would be nice. Now we need to take another break, give a chance to give a, give a chance to get a little support for, from out sponsors. So if you’re listening, please do listen to the commercials because there are some special deals just for you for listening to my show. I’m talking to Dr. Irwin Goldstein and we’ll be right back.

Chip August: We’re back. You’re listening to Sex, Love and Intimacy. I’m talking to Dr. Irwin Goldstein, he’s a doctor of sexual medicine and just a faunt of wisdom and we’re just, I feel like we’re just sort of breaking through all kinds of myths and stories that people carry around, I feel like we’re, we’re busting urban legends, you know, so. So I want to go on another one here. I lead workshops on sexuality and periodically I hear this war that sort of goes on between which is better, a penis or a clitoris and I hear stories about how, you know, how many more nerve ending clitoris’s have and how, you know, and clitoris’s are just full of pleasure, but a penis, and you know, I don’t know, you know. Can we talk clitoris’s and penis’s?

Dr. Irwin Goldstein: We certainly can and what’s fascinating is that there’s new very exciting research on clitoris physiology that’s just emerging.

Chip August: Cool!

Dr. Irwin Goldstein: So, lets ask you Chip, and obviously your listeners will now know the answer to this. In the Bay area Chip…

Chip August: Yeah.

Dr. Irwin Goldstein: adult women in sexual arousal, if you took a ruler and measured the length of their clitoris from the beginning to end, how many centimeters would be the official average length?

Chip August: Eek! The average length, how many centimeters, I…

Dr. Irwin Goldstein: Of the average adult woman in the Bay area during sexual arousal.

Chip August: Okay. Now are we talking only external…

Dr. Irwin Goldstein: No, no, no, the, the outside and the inside. The beginning to the end…

Chip August: Okay…

Dr. Irwin Goldstein: beginning to the end.

Chip August: If I had to guess, what are we talking about, like, well outside we’re talking millimeters, but inside I think we’re talking inches, so I don’t know, lets pick a number, lets say 10 centimeters.

Dr. Irwin Goldstein: It’s 15 centimeters, the whole length of the clitoris is six inches, and most people don’t appreciate it.

Chip August: Wow, six inches, so it’s, wow.

Dr. Irwin Goldstein: Yeah, and the architecture and anatomy inside of the clitoris is, is essentially mimicking inside a portion of the penis, it has an essential shaft, has the glands and then it has two individual chambers called the crus, c-r-u-s, that attaches to the pelvic bone way deep near the anus. So the clitoris and penis share the similar anatomy inside. The clitoris, let me ask you now…

Chip August: Yeah?

Dr. Irwin Goldstein: the second important question. If you were to ask your experience and those with whom you’ve had conversation, which is therefore the most important part of the clitoris, the inside portion, which is many, many inches and you said 10 centimeters, but it’s 15 centimeters, versus the outside, the glands clitoris?

Chip August: Well my, as a man who mostly loves women, I would say the outside, so, because that’s certainly the part that I’ve had access to on occasion and seems to get a desired result, so the outside.

Dr. Irwin Goldstein: Well the answer is incorrect.

Chip August: Oh dear.

Dr. Irwin Goldstein: You’re failing all this stuff…

Chip August: Oh my goodness gracious, well now you know why I was a philosophy major instead of med school.

Dr. Irwin Goldstein: Well it turns out this is new information, and what we’ve done is we’ve taken women engaged in sexual intercourse and we’ve ultrasounded their clitoris’s so we could see what is in fact happening to the internal portion…

Chip August: Mm hmm.

Dr. Irwin Goldstein: of the clitoris. And we’ve now interviewed a whole series of women who in Europe had their external glands, clitoris’s removed as part of the ritual of birth I Africa, and combining the two pieces of data we have appreciated that there is an amazing role to the inside part of the clitoris that heretofore has been poorly understood, and it turns out that the legs, the internal legs of the clitoris, surround the urethra and also surround the vagina, so with the vagina’s just an empty cavity…

Chip August: Mm hmm.

Dr. Irwin Goldstein: and nothing in it, the clitoris straddles the opening to the vagina and the tube called the urethra. As a large penis structure enters the vagina, what happens to the inside part of the clitoris is that it gets stretched wide to accommodate of course…

Chip August: Mm hmm.

Dr. Irwin Goldstein: the new entry, the new reality inside the vagina…

Chip August: Mm hmm.

Dr. Irwin Goldstein: So that stretches the inside part of the clitoris, and as the penis withdraws the inside part of the clitoris then snaps back together, and then is reopened as the penis enters, etcetera, so you get, this in and out motion of the penis leads to a movement internally of the clitoris. Well what it’s moving against is the urethra, and of course what surrounds the urethra is the prostate or otherwise called g-spot, so as the penis is moving in and out, the movement of the inside part of the clitoris is squeezing the woman’s internal prostate leaving her with a better opportunity for orgasmic response.

Chip August: And also I would assume female ejaculation.

Dr. Irwin Goldstein: And female ejaculation, right.

Chip August: Yeah, yeah. So, now I’m just jumping to this, but maybe I’m, maybe this is just wrong, so is it the, when women report a vaginal orgasm rather than a clitoral orgasm, is it that perhaps what they’re experiencing is just something at a deeper end of the clitoris?

Dr. Irwin Goldstein: Okay, so, that’s correct, but there’s three ways that women can have orgasms, so lets ask you Chip, what are those three ways?

Chip August: Well I would have said clitoral and vaginal and I guess, I don’t know, g-spot.

Dr. Irwin Goldstein: Okay, so the outside part, which you have become familiar with, have exposed your knowledge with us, has, is the external spot…

Chip August: Right.

Dr. Irwin Goldstein: that’s basically foreplay. Then of course the g-spot, and we’ve just discussed with you the methodology of that…

Chip August: Right.

Dr. Irwin Goldstein: that internal part of the clitoris being moved apart and then coming back together with, during the in and out motion. And then if the penis is big enough, the glands penis can actually make contact with the woman’s cervix. And if the cervix is not tender, that can actually activate uterine contractions…

Chip August: Wow!

Dr. Irwin Goldstein: which leads to very intense orgasm, that’s the ultimate in orgasm, the uterus ‘cause we’re both male and we’ve never had children, but the uterus, and I’m sure you’ve seen women while they’re in labor, the uterus is an amazing organ that has very intense contractile ability.

Chip August: Yeah.

Dr. Irwin Goldstein: And during that kind of orgasm, that woman has a really profound and intense orgasm. If a woman has that kind of orgasm, a uterine based contraction orgasm and has the need for a hysterectomy, or unfortunately not the need for a hysterectomy but has one anyways…

Chip August: Right.

Dr. Irwin Goldstein: that leads the woman to a great loss…

Chip August: Oh dear.

Dr. Irwin Goldstein: And that causes women great, great grieving for that quality of sexual satisfaction and quality of life benefit.

Chip August: So removing the uterus and removing the cervix, while it may be important for their, for sexual health, shouldn’t, it really needs to, you really need to look at this in a, because you’re going to lose some of your sexual function is what you’re telling me.

Dr. Irwin Goldstein: Yes, so for women who need to have a hysterectomy, they have to deal with that.

Chip August: Right.

Dr. Irwin Goldstein: Sometimes women have a hysterectomy for very vague, vague reasons and…

Chip August: Right, they go there pretty fast. They get, they get there faster than maybe medical science would encourage.

Dr. Irwin Goldstein: There you go.

Chip August: Yeah. I would, you know, I could talk to you forever, but sadly we’re running out of time here and I think we’ve run long on everything…

Dr. Irwin Goldstein: We have to do more of these Chip.

Chip August: I would love to talk to you periodically and just ask you millions of health questions and it would be a fun thing to do. I have a question though about, do you have like a, is there a favorite book or series of books for a person who doesn’t have a medical degree to learn more about their own sexual health.

Dr. Irwin Goldstein: Unbelievable. I was involved in a book called When Sex Isn’t Good, and it’s actually written by two of my patients who interviewed many of the women patients that I see. And then when that was put together, it was very interesting, but it wasn’t substantial so I ended up becoming the medical consultant to the book and writing all the biologic comments on how to better understand the basis for the sexual problem in these women, and then we added physical therapy, sex therapy to the book so, it’s basically lay text book for contemporary management of women who have sexual health problems, When Sex Isn’t Good.

Chip August: Terrific! I, I usually ask, I usually end with an exercise and I want to tell you the exercise that I would’ve recommended coming out of this for my, for the listeners, and then tell me if you agree, okay?

Dr. Irwin Goldstein: Okay.

Chip August: Now usually I do something that’s much more psychological, but permitting that we’re talking about the, the physical aspects of the body, an exercise that I give to clients all the time is just the practice of doing Kegle’s, of just doing, of contracting and relaxing the PC muscle, that I notice both in men and women, that for men it give, I think, strengthening the PC muscle gives us a little better ejaculatory control and therefore in some ways much better sex, and for women I think it actually helps with the orgasmic function, and so what I like to tell people is, you know, every time, when you’re driving every time you come to a traffic light do 25 contractions and expansions, you know, and, or every time your phone rings, you know, as you’re answering the phone just do 10 contractions and expansions, but the, to build up the strength in your PC muscle and by contracting and expanding will actually aid your sexual health. Would you think that, would you agree with that?

Dr. Irwin Goldstein: Well I’m the editor of a journal Chip, so if it’s not evidence based, scientific, with outcome data where the…

Chip August: Oh, so, I got to do, I got to do research on this huh?

Dr. Irwin Goldstein: There have been statements that these exercises are beneficial to sex, but it hasn’t left the anecdotal world into the scientific world.

Chip August: God.

Dr. Irwin Goldstein: So, one would need to do that. That’s what we’re trying to do with sexual medicine, to propel that, our field into the equivalent of any other medicine field, it would have to be based on more rigorous data collection.

Chip August: Alright, so all you listeners, I want you to practice doing PC’s and then I want you to send me anecdotal, like, you can reach me, [email protected], send me your anecdotal information and I’m going to find some researcher out there whose actually going to look at this anecdotal stuff and then get funding to actually do real research because we need to learn about this.

Dr. Irwin Goldstein: We sure do.

Chip August: Also by the way, if you want text and transcripts of this show or any of the Personal Life Media shows, just visit our website, personallifemedia.com, that’s all one word, personallifemedia.com. I do actually like to hear from listeners, so if you want to send me email I’d love to hear from you. My email address is [email protected], and I do read every piece of email that comes my way. Thanks for listening. Dr. Goldstein, thank you so much for being my guest.

Dr. Irwin Goldstein: You’re the best Chip, it was really great.

Chip August: And, we’ll talk again, and I hope you tune in to me again, but that’s goodbye for now.