Dr. Paul Gittens, a leading specialist in sexual function for men and women. He discusses the challenges men face to even get to a doctor, much less receive treatment. The cultural norms of men just "toughing it out" or not complaining have undercut their willingness to pursue the right care.
Dr. Gittens covers, erectile difficulties, low libido, psychological components, recommended/proven therapies and treatment options, including non-medicinal approaches, male infertility and the hope of treatment.
What we Discuss
What is the main cause of erectile dysfunction and how do you fix erectile dysfunction?
How can you raise low libido and is low libido curable?
What are the psychological factors of sex?
What are recommended/proven therapies and treatment options, including non-medicinal approaches for erectile dysfunction, low libido and other men's sexual health concerns?
What are the main causes for male infertility and what are the treatments for each?
"Men’s health is such a big topic. It starts when boys are young. It’s important that we instill in our young boys that we don’t have to be the tough guys. If something’s wrong, they need to talk about it. We also need to educate older men as well. By doing that, men’s health will improve." - Dr. Paul Gittens
Georgie: I appreciated hearing how empathetic your approach was at the recent Endo summit. At the ASRM conference last year, I heard data shared about men’s health. The information relayed was that men only go to a doctor if their mother, wife or sister recommend them to go. They have issues that they don’t want to deal with or don’t know how to deal with them.
While I often talk about a lack of awareness around women’s health, there’s a different aspect to look at for men’s health. There’s such a societal pressure for what men could or should be. I believe that impacts what men might seek help for. Given these dynamics, I thought it would be important to hear your wisdom.
Dr. Gittens: I totally agree. The physician at ASRM was correct in his statement. Most men don’t pay attention to their health until it’s really too late. This goes back to how men are socialized. When they’re younger, they’re taught to be tough and ignore aches and pains. And then as they grow older, in their teens and twenties, they feel like they’re indestructible. Then in their thirties and forties, they’re consumed with a career. In their fifties they realize that they maybe should have gone to a physician or paid attention to aches and pains. At that point, they’re fearful of undergoing exams and having issues like cancer or high blood pressure or diabetes.
Women are introduced to physicians a lot earlier than men. They’re introduced to their gyn and family practitioner a lot earlier than men which may mean they’re more comfortable than men.
Georgie: before we dive in further, I thought it would be helpful to give a little color around what you do to help men.
Dr. Gittens: I’m a board-certified urologist and have a clinical associate professorship in OB/GYN. Going through residency, I found that there was a need to treat men for sexual dysfunction. One of the main reasons was that, at that time, no one paid any attention to it. I had a personal experience where, as a resident, I was following a patient for prostate cancer. He had had surgery. One of my attendees came into the room and said, “your prostate cancer is healed. Your PSA is low. I operated on you and your cancer is non-existent.”
After he left the room, as a resident you’re taking notes and running around and I’m in the room by myself and the man started crying. I couldn’t understand why. After talking to him for about 20 minutes he told me that he was obviously ecstatic that his prostate cancer was removed but he suffered from low libido and erectile dysfunction. It was really disruptive for his relationships at home.
I took that experience and furthered my understanding in sexual health for both men and women.
Georgie: I didn’t know about that experience. Thanks for sharing that. It’s amazing how the little things that happen to us in life can lead in many ways.
Dr. Gittens: now my practice is varied. I treat men with erectile difficulties: low testosterone, problems with ejaculation and orgasm. We have a special program for sexual health after prostate cancer. Another large part of my practice is male infertility, which I also did a fellowship in.
Georgie: I have firsthand understanding of how the medical process works. I know there are urologists who treat men but that there are also specialties. Talk to us about the medical journey that men face when they have an issue and have to search for answers, especially with the cultural taboo that may factor in.
Dr. Gittens: if a man has any sexual dysfunction or male infertility, it’s a blow to who they feel they are as a person. It can affect their self-esteem. There are high rates of depression. It can affect their sexual and emotional relationships. It takes a lot for a male to feel comfortable enough to find help.
Usually, the first thing they’ll do is go on the internet. They search for terms related to their condition. After that, they’ll probably go to their urologist or primary care doctor. There are some issues with the system. Our traditional medical system doesn’t provide as much patient interaction. That’s part of the business of medicine. Oftentimes, they’ll go to their primary care doctor and speak for 5-10 minutes and then are rushed out. Then they may go to another PCP or urologist without the underlying problem being addressed.
I often see patients after they’ve seen 3-4 physicians. They’re tired of being shuffled around. We work through things pretty slowly to get to the bottom of the problem.
Georgie: what are some of the most common conditions that you tend to see in your practice?
Dr. Gittens: erectile difficulties with men. Erectile dysfunction (which I like to call erectile difficulties) is the inability to have an erection that allows a man to complete having intercourse. We break that down to a couple of different phases: initiation and maintenance. The causes of that vary. I see men that have had high blood pressure, diabetes, cardiovascular disease. It could be medication, neurological problems and even stress. These can all contribute to erectile dysfunction.
I may see men with low libido, which is just not having the urge to have intercourse. That is probably the second most common thing.
The third most common thing I see in the office is male infertility. If a couple is trying to conceive, the male or female may not have gotten a workup. We can do a semen analysis and see low sperm count or other problems.
Georgie: I know some people say, “why not just take Viagra”? It sounds like there are some underlying things men can do. I’d love to hear your thoughts around the medication and other options to support men.
Dr. Gittens: erectile dysfunction is not like breaking your arm. If you break your arm, everyone is healed in a similar way. Erectile dysfunction has so many different pathways. There are vascular pathways (blood pressure, cardiovascular issues), neurological components (Alzheimer's, parkinsons, stroke), hormonal issues (low testosterone, thyroid problems) medications (antidepressants, anti-psychotics, too much alcohol, recreational drugs). Another category used to be called “psychological.” Instead of psychological issues, I like to call this an adrenaline (epinephrine) mediated. When adrenaline increases, blood flow goes to the arms and legs for fight or flight. Anxiety due to previous failures or relational stress can cause blood to flow away from the penis.
PD5s, such as Viagra and Cialis are the most common medications and can be helpful. But with all of those pathways, there are many other options to help with ED. Hormonal pathways, such as increasing testosterone or balancing the thyroid. For some of the other pathways, you have to comb through those medications and find the ones that are contributing to the issue. If it’s a psychiatric medication, you have to partner with mental health care providers. Stroke is highly correlated to ED. We encourage better diets, losing weight, developing healthier lifestyles.
Going back to the types of therapies, there are a number that we use. Some are FDA approved, like Viagra and Cialis. We use core wave therapy, which is low-intensity wave therapy which can rehabilitate the penis. This provides better volume and rigidity. We use PRP. There are pumps and injectable therapy. As a last resort, we can surgically implant into the penis with a scrotum pump. There are tons of therapies out there but it starts with looking at an individual, figuring out what’s wrong with them.
We do ultrasounds of the blood flow to and from the penis. Armed with all of the information, we come up with an individual plan tailored to each person.