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Your Sex Questions Answered | 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 d