Your Sex Questions Answered by Dr Michael Krychman

I interviewed Dr. Michael Krychman about sexual health and libido. I'm so excited to bring this interview to you, and I made sure not to hold back on any of my questions because this is a taboo topic but so important.


Dr. Krychman is the Executive Director of the Southern California Center for Sexual Health and Survivorship Medicine, and he is the former Co-Director of the Sexual Medicine and Rehabilitation Program at Memorial Sloan Kettering Cancer, you will find him to be extremely knowledgeable, and incredibly compassionate in this conversation. I learned so much and am excited to share it with you.

Georgie Kovacs: You have a unique background from many clinicians, Dr Krychman. Tell us about it.


Dr Michael Krychman: I'm a little bit different than most clinicians, because I'm an MD and I'm also a sex counselor and therapist, so I look at the whole picture. For many, many years, we looked at women primarily as having psychological issues when it came to being diagnosed with a sexual problem. If you look at the traditional treatment paradigms, they said, go get a warm bath, go buy some shoes, wear a nightie because you're depressed and you're frigid.


It's like cringe worthy, right?


When you have a man what happens he comes in and he says, “My erection isn't as wonderful as it would like to be.” We instantly check his blood pressure and his cholesterol and his sugar level. We don't think that he's anxious or depressed. So it just shows the dichotomy, right?


Women are heavily weighted in psychology, and they really didn't put value on biology. And then the same thing with men. We overemphasize biology and didn't put in psychology. And I think the important trend now, really, is to understand that it's an interplay between both. I always say women have veins, arteries and nerves and hormones that influence tissue and responsivity.


And, you know, men get anxious and they get depressed, and they have fatigue, and they have psychological concerns as well. Right. So it's kind of we're playing catch up. And it's a delicate balance between the two..

Georgie Kovacs: Forty million women have a sexual dysfunction. When looking at the dysfunctions, I read sexual desire, libido, arousal and orgasms. What is the difference? And how would one know what it should feel like to be in a healthy, emotional, physical sexual state versus when would someone know it is time to see a specialist? We may think whatever we're living with as normal, but there could be something even better.

Dr Michael Krychman: I think we have to make a distinction between sexual dysfunction and sexual problem. Sexual dysfunction is kind of this pervasive, invasive, distressing condition. That's very impactful, and I think impact is very important.


A sexual problem, I always say, look to your right, look to your left, somebody is looking at you, and one of you has a sexual problem. Everybody has sexual problems, every single person. And what that means is sex waxes, it wanes, it gets better during certain times, it gets worse. We've seen sexual health really take a nosedive during the COVID pandemic. You know, too much of a good thing is not a good thing in terms of togetherness with your partner and your family. Four walls are closing in on you.


So I think the important thing to remember is, if it is distressing and distressing to you, then it's the point where you get help. And when I say get help, it's not necessarily only medical or psychological. It's time to start researching how you can feel better.


And it's the same kind of concept about what is normal. I wish I could give you the right answer about what is normal, because I'm still trying to figure that out after being involved in the Sexual Medicine arena for two and a half decades. Sexuality and sexual expression is individually defined. So, you know, we have to decide for ourselves, what do we feel comfortable with?


Let me give you an example. So if we have a gentleman who is self stimulating once a month, and he's not troubled by it, and he finds that it's relieving, and he's enjoying his life, then there's no problem. If we have another gentleman who is self stimulating eight times a day, and it's not interfering with his activities of daily living, and he's not distressed, that still is normal.


Normal is self defined.


We can talk about his societal norms. What does society accept, and what is it? That's very dependent on a variety of conditions. We know in ancient Rome and Greece, same sex relationships were accepted and embraced, and it was a form of changing from infancy to adolescence to adulthood.


Georgie Kovacs: Really?


Dr Michael Krychman: Yes. Boys used to take an older male lover to teach him how to be intimate with a woman, and it was a transient occurrence. There are certain communities where same sex relationships are accepted, but in others, they're not so hot. Very often, sexuality is a function of the culture and a function of what's going on outside your four walls.

Georgie Kovacs: Does this mean we should ignore magazines telling us what a normal sex life is and imposing these norms on us?

Dr Michael Krychman: You're not alone, either, because everybody wants to be accepted or above average. I think your point is very well taken. All these data points that we see in the news or magazines are really large surveys. We can say, on average, the North American couple has sex X amount of times a year, or once a week is the is the average. But that doesn't translate into satisfaction. You can have sex twice a day and be unsatisfied. Or you can have sex once a month. And it's really a very emotional, wonderful experience.


It's this PRO, or patient reported outcome, that is really important. We in the Sexual Medicine arena try to move away from defining normal. Everybody has to really understand their own context in which they have sexual intimacy.

Georgie Kovacs: Can you define, then, when it is time to seek professional help to support a healthier sex life?

Dr Michael Krychman: I would go back to the fundamentals of partnership or relationships. Remember, we're always compromising. Everyday, we do something we don't really want to do in our relationship for the benefit of our partner, and vice versa. Sex is no different.


But for some reason, when it comes to sexual activity, we put it on this pedestal. We can't talk about it. We talk about, “You always like to go for Chinese food or burgers, and I would like pizza. You hope, at the end of the day, you go for the same amount of burgers and pizza.


When it comes to sex, we feel like we can't communicate. However, if something is troubling you and you're upset about something, it's good to share the burden. And it's good to communicate initially. Very often, humans can problem solve, and, as we said, their problems and they're episodic and they're temporary and they have easily fixes. And then they move on.


If something is persistent, I would say that is a really important issue and you're persistently having negative feelings about yourself and about your relationship, I think that's the appropriate time to get professional help.


Georgie Kovacs: Let’s get specific about libido, arousal and orgasms. Are they really that differentiated?


Dr Michael Krychman: Let's start off with libido. There's a whole variety of different facets of sexual desire, fantasies or sexual interest. So libido, interest, desire are all synonyms. And in the healthcare community, we've transitioned from desire and arousal and orgasm to be separate and distinct. Now, by definition, we include desire and arousal together.


And there's a big controversy. Spontaneous libido is you wake up, you're interested, and there's no stimulus. There's some researchers who say that there's always a stimulus. It's always reactive.


Then there's other people that say, reactive libido is when you start off as neutral. A lot of women really need permission to understand that they can start off as neutral, they can take sex or leave it. They're not interested. They're busy. They have a lot of work in the home, out of the home, family, children work, what have you, and sex isn't on their brain. But when it happens, it's nice. And those are when the right cues are there. Reactive libido is when I start off, I don't really want to do it. But once I'm in the mood, I realize this is good.


The best analogy I can give you is when I go to the gym. I don't wake up and say, “Yay, I want to go to the gym and go workout and it's gonna be amazing.” I couldn't care less if I go to the gym. I have 1,000,001 things to do. My buddy says, “Mike, go to the gym, you’ll work out, you'll feel better.” I don't really want to go, but I go nonetheless. I work out, sweat, and feel really good. The next morning when I wake up, I say only crazy people go to the gym, I'm so busy. Right?


So that means that sometimes you need arousal to convince you that your desire is there. By definition, desire is more thoughts, fantasies, wants, needs, and it could be spontaneous or reactive. Arousal is, there's a lot of physiological things that happen. Increased breathing, swelling of tissue, rapid breathing, what have you, you see the physiological response in terms of engagement.


And it's a continuum. It goes from desire to arousal to orgasm, which is what people call the ultimate release. You have ejaculation for men and you may even have ejaculation for women as well. And then you have resolution. So it's a continuum of sexual experience.


The important thing to remember is that you can get satisfaction at every stage. You don't have to go from point A all the way to orgasm to have sexual satisfaction. For some people, it's just being aroused, being close, being touched. And they feel very, very sexually aroused. Or they may have, you know, these tingling feelings. A lot of people culminate and want to have an orgasmic release. And that is also perfectly fine for different individuals.


The other issue to remember is how does the brain fit into this. You can have brain-body disconnect. When you are a woman, your brain could be really interested. I want to have sex. I'm really interested, and your genitals are not responding. And vice versa. Your genitals could be responding yet your brain could be turned off. Your body is reacting almost independently.


There was this concept of subjective arousal and genital arousal. Subjective arousal is in your brain where I'm aroused, I'm interested, I'm really very much interested in what's going on sexually. Genital arousal is the physiological response. My tissues are becoming engorged, I'm lubricating, I'm really feeling the increased blood flow or what have you. So just because you have one doesn't mean you won't have the other. They can be separate and distinct.

Georgie Kovacs: Can you talk about this false goal of always achieving orgasm?

Dr Michael Krychman: It's like the marathon runner who only focuses on the finish line. I think the important concept is the sexual journey. And when you become so focused on the goal, sometimes the goal becomes unreachable. And sometimes focusing on the goal of getting to the finish line prevents you from running the race because you're not focused on what's going on. You're monitoring your behavior.


The important concept of sexual intimacy is to focus on sexual pleasure and on the journey to orgasm. It's not a failure if you don't have an orgasmic release. There's always rewards from being sexually intimate.


So for women who are always in their head and always monitoring their response and their orgasm, they have a challenge to achieve it because they're monitoring. They have brain body disconnect.


It's kind of like when you are playing football. You’ve got to be on the field playing. You can't be on the bleachers monitoring the playing field.


So when you start monitoring your orgasm, you kind of disconnect all those hormones that are going on and neurotransmitters that are going on in order for you to have an orgasmic release. So the more you monitor, the less likely you're going to achieve your goal.

Georgie Kovacs: So for those of us who are in our heads, and I will admit I am one of them, what advice would you give?

Dr Michael Krychman: The important thing to remember is that women are still the primary caregivers. They're still the cooks, the cleaners, they work in the home, out of the home, they monitor Zoom calls. They are overwhelmed with a lot of things that are going on on a day to day basis, and you hit the nail right on the head, women deprioritize themselves.


I'm very much about practical suggestions. The first thing is, I always tell women don't feel guilty about taking care of yourself. And I think it's really important for women to take care of themselves. We're so busy taking care of everybody else that we don't take care of ourselves. Take 30 minutes. And if you want to just veg out and go for a walk or do yoga or read a book. Be good to yourself. We teach from the moment that we're born, share your toys, be good to your siblings. We don't teach women or men to be good to themselves, and to do good things for yourself.


The other thing is humans are typically nighttime sex people. We've got to learn how to disconnect from all the other pressures that are going on in our lives. That means, let's turn off anything that starts with an “I” - iPhone or iPad. Turn off computers and decompress. I always say no electronics in the bedroom.


I also think it's important to practice staying focused outside of the bedroom before you bring it into the bedroom. If you are already in your head outside of the bedroom, it's a natural extension. It's going to come there.


I know it sounds maybe a little corny but the best advice i have is to live authentically and live in the moment. Be mindful when you are cleaning the dishes, you clean the dishes, you feel the water, you feel the soap, you feel the warmth of the water. You know, it's a little bit more than stopping and smelling the roses. It's really staying focused in just five minutes a day of staying focused and staying in the moment. And then translate that into those activities during intimacy.


And we know there's been studies that have been done. Lori Brotto, a good colleague of mine, has done studies on mindfulness and sexual activity. And when you stay focused on your body, and your responses, and you're really thinking about your body, and how it's responding and the why.


Georgie Kovacs: When is it time to seek professional help for a sexual dysfunction?

Dr Michael Krychman: There’s an interplay of a lot of different hormones and neurotransmitters. It's not just estrogen and testosterone. I see a lot of women who've undergone cancer therapy, and they can't be on hormones, and they don't have one drop of estrogen and one drop of testosterone in their body, but they're having great sex. So there's alternative pathways.


If one area is deficient, sometimes other areas get more heightened. It's a multihit phenomenon. So think about it when you're 18. And you're thinking you're sassy and sexy, and no one can stop you and you don't have any kind of impact on your hormones, and everything is great, and you don't have any stress or fatigue. And then, you know, and then you go, and you're now in graduate school, and you have a little more stress to study. And that kind of adds a layer of more anxiety and impacts your hormones. And then you get married, and you have a kid and you have more responsibility.


These microaggressions are additive. So when you were 18 or 19, and on birth control pills, you could superimpose and supersede the lower testosterone. But as you get into your 30s, the lower testosterone may be much more impactful because you have all these other things that are kind of chipping away at your libido. So very often, it's an additive issue.


We know that there's medications, like antidepressant medications can influence desire and libido. We know birth control pills, where worldwide, over 300 million women are taking them. For some women, they may have lower testosterone, and it may influence their level of libido. But that's temporarily associated. So if you started the birth control pill, and six or seven weeks later, you have no libido, that may be associated with medication. So we're looking at medication, chronic medical conditions.


I have devoted most of my career to cancer patients. Whether it's chemotherapy, radiation, or surgery, we alter the anatomy and the sexual self esteem. How we view ourselves as sexual people, that also can certainly influence your response.


Also, we know the longer you're with somebody, the less sex you have. And that's just a natural progression of the human experience.It takes a lot of work. One of the fascinating things that I study is couples that have been married 25, 35, or 45 years, and are still chasing each other around the room and having great sex.

Georgie Kovacs: What have you learned about these couples who have been together for a long time and still have the spark in their sex life?


Dr Michael Krychman: They communicate very well, and they focus on novelty and the daily activities of novelty. They make sex fun. It's not the Saturday night special. Novelty is really important.


When communication breaks down, that's when you start having problems with sexual activity. Very often people will come to me as a sex therapist or counselor or medical doctor and they say, “We're not having sex, and we really want to have sex.” And I say, “Okay, let's start at the beginning.” And we find out that they don't want tospend time together because they don't talk. They don't eat dinner at the same table at the same table. And they don't communicate about emotional things. They're just really operational. Who's taking Tim, to me to soccer and Kelly to ballet. They don't talk about their emotional connectedness. There's no preamble to sexual activity. There's no touching. There's no holding. There's no kissing. There's no oral pleasure or manual pleasure. They just want to go right to the sexual activity. So I said, “Look, that's the end game. Sex is the end game. Let's build from the beginning and very often you'll find that somewhere along the road.” They have had some breakdown in communication or discussion.

Georgie Kovacs: Let’s talk about premature orgasm in women.


Dr Michael Krychman: A lot of these definitions are really self defined. Premature ejaculation is before the man wants to ejaculate. There may be a medical component, but again, we also have to look at the anxiety component as well.


It's the same thing as delayed orgasm for both men and women. And very often, there's this heightened sense of awareness, anxiety, and expectation. We have to realize that we need to set realistic expectations, and you hit it on the head when you were talking about a magazine. And they set unrealistic expectations, and they make people feel bad about themselves, when, in reality, it may not be a perpetuation of truth. I think it's really important to set goals and see what's realistic for you.


And people have different levels of frequency and different levels of satisfaction. And it's about navigating those when you're with a partner who has different levels than you. And again, compromise and communication is really important.

Georgie Kovacs: When does someone seek help for sexual dysfunction and what does that look like?

Dr Michael Krychman: I would say for all sexual health issues, my approach is from conservative to aggressive. So conservative is behavioral things. Bibliotherapy - reading books, talking about sex. Sex not becoming a taboo topic is actually something that will help your treatment. So there's a whole lot of exercises - date night spending time together, even walking on the beach holding hands, when you couldn't stand each other before getting back to the basics is really important.


Then we have nutraceuticals, herbs, and supplements that may be helpful. We also have hormones, estrogen, testosterone, a variety of other things that we can use. And then there's also advanced medications. There's two drugs that are approved for women. And again, they're not without side effects. But for some women, it's life changing.


I want people to realize that it’s like the depression model. You get one level treated by medicine, you get to level 10. By therapy alone, you get to level 10. But you add them together, you really get to level 20. So it's a combination effect. And you don't have to see a formalized counselor or therapist, it's just about doing the work.

Georgie Kovacs: Have you heard of the app Dipsea?

Dr Michael Krychman: I have not.

Georgie Kovacs: I want you to download it and check it out. It's a sexual storytelling app. They would recreate different scenes, and you can pick how intense you want the sex scene to be. And they do all sorts of types of women - women, men - men, men - women, whatever. The app also teaches you certain aspects of getting to know your body and walking you through the steps of getting in touch. And it is truly amazing.