Dr. Joshua Gonzalez
Podcast Transcript Season 1 Episode 3
Interviewer: Liz Goldwyn
Liz Goldwyn: Hello, welcome to The Sex Ed. I'm your host, Liz Goldwyn, founder of thesexed.com, your number one source for sex, health and consciousness education. Today, I'm talking to Dr. Joshua Gonzalez, MD, a urologist specializing in sexual medicine. Unlike most physicians who receive only eight hours of intake training on sexual health in med school, Dr. Gonzalez has devoted his career to studying and treating sexual dysfunction with a special concentration on LGBTQ+ issues. I visited Dr. Gonzalez at his private practice here in Los Angeles to talk about erectile dysfunction, premature ejaculation, birth control side effects, and a whole host of other medical mysteries that don't get discussed enough in polite company.
Liz Goldwyn: So I'm here with the very handsome Joshua Gonzalez, MD-
Dr. Joshua Gonzalez: You are going to make me blush.
Liz Goldwyn: He's wearing a really cool lab coat that says urology and sexual medicine on it.
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: Do you want to just tell us what you do?
Dr. Joshua Gonzalez: Sure. I'm a urologist by training, meaning that I did the same sort of residency training as any run-of-the-mill urologist.
Liz Goldwyn: What does a urologist do?
Dr. Joshua Gonzalez: So we handle the surgical side or the procedural side of problems that arise in the urinary tract. So that's anything having to do with the kidney, the bladder, the prostate. It's a pretty broad field. It can involve the management of incontinence, can be the management of kidney stones, certain cancers that arise in the urinary tract. But the other side of it has to do with the genital tract as well. So we manage issues with testicular pain and erectile dysfunction. And a lot of times are relied on to be ambassadors for men's health because men are notoriously bad at going to the physician. And we are in a unique position to address certain issues that come up in men's sexual and reproductive health.
So we do male infertility. As I mentioned, erectile dysfunction. We deal with low testosterone and hormonal management. So it's really, a pretty broad field. And in addition to that, I spent a year doing a fellowship in a field called sexual medicine, which focuses on the management of male and female sexual dysfunction, which is a unique field because urologists, historically when they do come up with sexual issues that they're trying to address, often focus solely on males. So sexual medicine was intentionally created to address sexual issues that come up in both men and women, and try to deal with it in a more comprehensive way than traditional urology or gynecology.
Liz Goldwyn: I was reading the paper that you wrote on oral birth control-
Dr. Joshua Gonzalez: Mm-hmm (affirmative).
Liz Goldwyn: ... and you seem very anti-pill.
Dr. Joshua Gonzalez: Mm-hmm (affirmative).
Liz Goldwyn: In the paper, you were talking about sexual liberation and feminism giving us the freedom to have birth control, that it's actually wreaked havoc on women's reproductive systems.
Dr. Joshua Gonzalez: I think that's the irony of the whole situation, is the pill, when it was initially developed, rightfully so, it was thought of as finally a woman being able to have the choice, whether or not she wanted to get pregnant or when she wanted to get pregnant and it was really the first time women were given that option. And so historically it's important. But the point of the blog post that I was writing is that the communication between physicians who, in my opinion, over-prescribe these medications to women about the potential negative effects that could have on their hormonal system and in their body in general, that conversation isn't really happening. And women aren't really being allowed to make fully informed decisions about the direction they want to go in with regard to their reproductive health.
The paper did come across sort of negatively towards birth control, but I do want to clarify, I'm not anti-contraception. I was just trying to point out that there are a lot of side effects that specifically oral contraceptive pills can have on women's reproductive tract.
Liz Goldwyn: Can you tell me what those are?
Dr. Joshua Gonzalez: Sure. The oral birth control pill is metabolized primarily in the liver. And this includes hundreds of different types of birth control pills out there, but basically oral contraceptive pills are metabolized by the liver. And one of the side effects of them passing through the liver to be metabolized is they increase a protein that is naturally occurring called sex hormone binding globulin, and everybody has it, men and women have it naturally, but when that protein is increased, it can cause problems. And the reason that it causes problems is that SHBG, its job is essentially to bind testosterone and make it inactive, sort of take it out of the usable amount of testosterone in the bloodstream. We have this occurring all the time, but when SHBG levels get really high, that means you have more protein circulating, which is going to bind more of your testosterone and mean that you have less testosterone that is usable by the body.
And the consequences of that in women who are on the birth control pill is they get atrophy or shrinkage or chronic inflammation or chronic irritation of areas in the genital tract that are very sensitive to androgens, which is the type of hormone that testosterone is. One of those areas is the vestibule, which is a thin rim of tissue at the opening of the vagina that is primarily made up of glands that secrete mucus that are important for lubrication and arousal and those glands get very irritated, very inflamed, become very painful and can often lead to issues surrounding sex. So that women start to experience pain or become less aroused or lubricate less when they are engaged in sexual activity. And it can start to cause issues not only in their sex life, but can affect in a chronic pain state. It can start to affect their life in general.
So the point of the article was to say, this isn't necessarily happening in every woman that is on a birth control pill, but before we hand these out like Halloween candy, we may want to have a conversation with the patients who are getting these pills, that this is a potential side effect of the medication.
Liz Goldwyn: What other side effects are that affect the hormones fertility and sense of smell. Obviously, if a pill makes your sexual experience less than ideal in the long run, you don't want that.
Dr. Joshua Gonzalez: Right. Are you talking about specifically the side effects of the pill?
Liz Goldwyn: Yeah.
Dr. Joshua Gonzalez: I don't even think we appreciate necessarily all of the side effects that the pills have. What I will say that's important to remember, and again, I don't think the average person knows how birth control pills work, but essentially they are pills made up of synthetic hormones that are not the same chemical structure as estradiol and progesterone which our body makes, but they're close enough that they essentially trick the ovary into believing that there is enough naturally occurring hormone circulating in the body. So the ovarian production of estradiol, progesterone, testosterone basically goes to zero. And the synthetic hormones that are in these pills do some of the job of what estradiol and progesterone do. But because their chemical makeup is different, they don't really affect the tissues and the cells of the body the way our natural testosterone, estradiol, progesterone would.
So we talked about the pain and the effects it can have on sex life, it can affect mood negatively. It can cause issues with anxiety, certainly affect libido. Hormones are very important parts of our everyday lives. And for some reason, I think because these three particular hormones have to do with sex and reproduction, we don't value them as much as some of the other hormones that our body makes like thyroid hormone or insulin. And so I try to-- when I see patients and I talk to them about hormonal issues related to these three particular hormones-- I tell them, I treat it very similarly as a doctor would treat having low thyroid or too much thyroid hormone or someone who has diabetes and doesn't have enough insulin. It's about replacing what your body doesn't have or is not currently making and restoring what the body is no longer doing appropriately.
Liz Goldwyn: And the pill can also affect not only your sense of smell, but the smell you give off. Did you know that strippers who are not on birth control make more tips?
Dr. Joshua Gonzalez: I did not know that. No.
Liz Goldwyn: Fun fact.
Dr. Joshua Gonzalez: (Both laugh) It's a fun fact.
Liz Goldwyn: And they say, I'm obviously not a scientist or a doctor, so it would have to get clinical backup for this but-
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: ...I think intuitively a woman has a sense of smell when picking a mate, that changes when you're on the pill.
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: I can speak from personal experience. I was on the pill for a long time and went off it a few years ago. And actually had a lot of female friends at the same time going off the pill and some friends in England where-- from what I know from my friends-- that there's a more holistic approach to alternatives to oral contraception. What alternatives can we women in the US get access to if we don't want to take hormones?
Dr. Joshua Gonzalez: One of the things that I discussed in the paper that you're referencing earlier was this idea of long acting reversible contraception.
Liz Goldwyn: Like an IUD, you mean?
Dr. Joshua Gonzalez: Yeah, so there's two types. There's sort of longer-acting hormone implants that are reversible. It can be removed or dissolve slowly over time or shots that you get of hormones that act for three, six months. The point that I made in the paper was that A-COG, which is the primary obstetrics and gynecology overseeing body in the US, has come out publicly and said within the last couple of years that these long-acting reversible contraceptive types are actually more effective at preventing unwanted pregnancies than more traditional treatments like the oral birth control pill.
Liz Goldwyn: But they're expensive. And I know a lot of people who've had really bad experiences with IUDs.
Dr. Joshua Gonzalez: Right. Anytime you're having something implanted, you're going to have some risk associated with that procedure. A lot of fear about things like IUDs is born out of old understandings of what an IUD is and complications that happened 20, 30 years ago. The implants themselves are very small. There's two types. There's a copper IUD and there's one that secretes a very low amount of progesterone that does not get absorbed systemically. And its function is to stabilize the endometrial lining. And yeah, everyone has heard a horror story about an IUD, but I think that they are overwhelmingly safe. They're reversible. They can be put in and last for five, 10 years, and they are not going to have the same potential effects as the oral birth control pill can have. And you want to just make sure that again, with anything, you're making an informed decision, that you talk to your doctor about the risks, that you go to someone that puts in IUDs regularly. Places like Planned Parenthood, implant IUDs all the time, very safely.
And again, a lot of the fear about IUDs is historically based. And I think the complication rate with IUDs now is significantly less than it was 20, 30 years ago.
Liz Goldwyn: So let's say we're an all natural woman and we don't want an IUD and we don't want to take birth control. What are our options? Condoms.
Dr. Joshua Gonzalez: Mm-hmm (affirmative).
Liz Goldwyn: And then I'd love for you to demystify the pullout method, which I think a lot of people, especially young people, talk about this. Can't get pregnant if... Why don't you give me the straight dope on the pullout method here?
Dr. Joshua Gonzalez: Sure. You mean about the inefficacy of the pullout method? (Both laugh)
Liz Goldwyn: Or the rhythm method, which I think people who are practicing to have a baby are very conscious-
Dr. Joshua Gonzalez: Sure.
Liz Goldwyn: ... of the rhythm method, but I think the average lay person or high school student or early twenties who's having sex. Talk to me about the pullout method.
Dr. Joshua Gonzalez: It's extremely unreliable. So, just to give a crude example, men in general are not great about stopping the act when they're in the heat of the moment, for the lack of a better phrase (laughs), and the ability to control one's ejaculation when having constant stimulation as occurs with intercourse is not terribly great. So as much as men would like to believe that they'll know when they're about to ejaculate and pull out in time, we just know historically that's not true. And the pregnancy rate is fairly high with the pullout method. The other thing is that you can have emissions prior to formal ejaculation or orgasm. And that can potentially, the risk again is fairly low, but could potentially lead to pregnancy. So it's not something that I even discuss as an option typically with patients of mine who are looking for reliable contraceptive methods.
Liz Goldwyn: So what about-- I hear this a lot, from a lot of different men, I think when I tell people I talk to all sorts of experts in sex therapy and medicine, I think most men across the board, no matter what age they are ask me to ask this question, which is, they can't either get hard with a condom on, or they can't stay hard with a condom on.
Dr. Joshua Gonzalez: Mm-hmm (affirmative).
Liz Goldwyn: So what do you suggest for that problem?
Dr. Joshua Gonzalez: Well, that's interesting because I think if you have a normal functioning penis, a condom shouldn't be preventing you from getting hard or keeping an erection. So-
Liz Goldwyn: And I think a lot of men, especially young men, tell women this too.
Dr. Joshua Gonzalez: Right, right. (Liz laughs) So I would say either they have some biological problem that's preventing that, or they just don't want to wear a condom. It does decrease your sensitivity but if you have a healthy amount of hormone circulating, if you have good blood flow to the penis and you're trapping the blood in the penis, then putting on a condom, especially the thickness that they're made at, I should say the thinness that they make them in now shouldn't decrease your sensitivity enough that you are losing your erection. And one sort of, I guess, example that would kind of prove that is that there are men who have issues controlling their ejaculation. You have a condition called premature ejaculation. One of the treatments for that is creating a barrier. So we tell them to put on condoms and it delays their ejaculatory time, but they don't necessarily lose their erection or we'll prescribe a topical anesthetic so that they completely numb the skin on their penis. Again, that decreases their sensitivity, but they're still able to maintain their erections for the most part.
So, yeah. I think if I saw a male patient who was saying I just can't maintain my erection with a condom, I would want to investigate that more to figure out if there's maybe some other issue going on biologically and, you know, not just an excuse to not wear a condom.
Liz Goldwyn: Or psychosomatic-
Dr. Joshua Gonzalez: True, yeah.
Liz Goldwyn: ... it could be a psychological issue.
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: I think we don't pay enough attention or give enough support to men in our society, for sure.
Dr. Joshua Gonzalez: Right.
Liz Goldwyn: And the kind of fears and insecurities that they face sexually as well. I think there's a lot of pressure and expectation-
Dr. Joshua Gonzalez: Right. And then-
Liz Goldwyn: ... and performance.
Dr. Joshua Gonzalez: ... they don't seek help. That's the other issue is that there isn't enough attention paid to male sexual health I think in general, and their anxieties that come up with performance. But a lot of times they're embarrassed because of that. They feel less manly if they're having issues with their erections or if they're having issues controlling their ejaculatory time. They're embarrassed. They've been in previous encounters where a partner mentioned something and then that anxiety and that fear it gets carried on to the next relationship. They'll go years without seeking help necessarily. So I think that's also a big problem.
Liz Goldwyn: Because we're not communicating about sex.
Dr. Joshua Gonzalez: Right.
Liz Goldwyn: We're just having it.
Dr. Joshua Gonzalez: Right. Yeah. (Both laugh)
Liz Goldwyn: What about antidepressants?
Dr. Joshua Gonzalez: Mm-hmm (affirmative).
Liz Goldwyn: Again, like the pill, I hear a lot of information that medication in general can really affect libido and performance.
Dr. Joshua Gonzalez: Yeah. So there's a class of medications called SSRIs; Lexapro and Prozac, and all those sorts of medications kind of fall under and they affect the serotonin system and the brain. And it is a well known fact that they negatively affect libido. So the sexual issues that come up with me with patients that are on these medications --antidepressants-- primarily has to do with libido. Sexual function in general, at least the way we think about it in sexual medicine, is sort of a balance between factors that are pro-sexuality and things that are inhibitory or negative towards sexuality. So, things that would be sort of excitatory or pro-sex would be the sex steroid hormones that I talked about, certain neurotransmitters like dopamine or norepinephrine, and then things that would negatively affect sexual appetite and erections and all that sort of stuff are things like serotonin. That would be one example of a neurotransmitter. So the SSRI class of antidepressants acts by maintaining serotonin in the synapses between our nerves in the brain. And when you have an abundance of serotonin, very often, it will negatively affect one's libido. So there are some-
Liz Goldwyn: Because you would think serotonin makes you happy, right?
Dr. Joshua Gonzalez: Right, right. Yes. Yes. But dopamine is thought traditionally to be important in our reward pathway and libido, sex and all that falls in the same reward pathway, the same thing as chocolate or anything else that brings us pleasure. And we have agents that actually block dopamine for patients who have an issue with this reward pathway. So one of the medication-- tell people to stop smoking, decreases dopamine in the brain and it's thought that that decrease in dopamine will then turn off the reward that they get from smoking cigarettes and allow them a better chance at stopping the smoking.
Liz Goldwyn: What's the top problem that you see in sexual medicine now?
Dr. Joshua Gonzalez: I would say it depends on whether the patient's male or female. I would say in men, it's a combination of erectile dysfunction and symptomatic low testosterone. In women, there's sort of two categories. Older female patients who are sort of peri-menopausal or post-menopausal.
Liz Goldwyn: Which is at what age?
Dr. Joshua Gonzalez: It depends. So, on average, it's around age 51, if you look at our national average, but women can start that process earlier. I've seen women in their late thirties that are starting to go through menopause and other women it occurs in their late fifties. So, that's one category of women; the older female patient, and then in younger female patients, a lot of times I see similar symptoms, but it's related primarily to history of birth control use. So it's interesting because we've talked a little bit about the oral contraceptive pill, but what it essentially does is creates a peri-menopausal/post-menopausal state in a young woman. The symptoms that are reported by both groups of women are very similar. Both will complain of pain with intercourse, recurrent UTIs, which is, they've probably seen a multitude of providers and they're not actual infections, but it's just sort of this chronic irritation in that area that can mimic an infection, issues with libido, all of those sorts of things.
And the management of the two groups of women is a little bit different, but it's interesting because they often present with the same symptoms. And you're talking about a woman who's in her early sixties and a woman who could be in her early twenties.
Liz Goldwyn: Mm-hmm (affirmative).
Dr. Joshua Gonzalez: And so it's interesting to see both symptomatically and sometimes even anatomically how similar they can be.
Liz Goldwyn: What do you think about pills like Yaz, which stop your period?
Dr. Joshua Gonzalez: I don't think there is anything inherently wrong with stopping your period. One of the IUDs that I mentioned secretes progesterone, and it stabilizes the endometrium and often women stop menstruating. So I don't have a problem with Yaz in that regard. The problem with Yaz is that it's still an oral birth control pill, and it will have the same effect or could have the same effect that I kind of already alluded to. I think historically when the pills were initially developed, the reason that they had the week of sugar pills was that it was thought to be unnatural, whatever that means, for women to not menstruate. So they created this cyclical way of taking pills so that no matter what a woman would always shed the lining of her uterus, so it would appear that things were occurring naturally.
I think that's a little bit based in misogynistic science. A woman doesn't necessarily have to shed the lining of her uterus for things to be natural. At the end of the day, we are changing our ability to reproduce. That in and of itself is, quote unquote, "unnatural." So, by doing that, I don't think that we have to try to mimic the way a woman menstruates to make ourselves feel better.
Liz Goldwyn: I was reading, again in your presentation at UCLA-
Dr. Joshua Gonzalez: Mm-hmm (affirmative).
Liz Goldwyn: ... that the average act of sexual intercourse lasts for 7.3 minutes.
Dr. Joshua Gonzalez: Yes.
Liz Goldwyn: How can we extend that? What can we do about that to get those minutes up? (Both laugh)
Dr. Joshua Gonzalez: If I could get seven minutes for some of my premature ejaculation patients, they would worship the ground I walked on. And I do point to that number a lot of times, it's interesting. People have a wide range of ideas of what is the amount of time you should be having sex before you ejaculate or have an orgasm.
Liz Goldwyn: By that 7.3 or we're talking about penetration?
Dr. Joshua Gonzalez: Exactly. Yeah. It's-
Liz Goldwyn: Not foreplay.
Dr. Joshua Gonzalez: Right. So, it's the-
Liz Goldwyn: Not oral sex.
Dr. Joshua Gonzalez: ... term itself, which we use as an objective metric, intra-vaginal ejaculatory latency time. That particular study that you're referring to, it was looking at heterosexual sex as well. And part of the issue with premature ejaculation in a non-heterosexual man is that all of our metrics are based on a vaginal penetration model, but to get back to your question-
Liz Goldwyn: I was going to ask you about that.
Dr. Joshua Gonzalez: Mm-hmm?
Liz Goldwyn: About what percentage of heterosexual versus homosexual male patients you see that have this issue of premature ejaculation?
Dr. Joshua Gonzalez: The numbers quoted are around 10% nationally. I haven't really in my practice seen it more prevalent in heterosexual versus homosexual men-
Liz Goldwyn: You see it in both?
Dr. Joshua Gonzalez: Right. Oh yeah. Yeah, it occurs in both. One of the problems I think with sexual medicine currently as it stands is that all of our metrics are based on a heterosexual model. Erectile dysfunction in terms of measuring the hardness of an erection, the erection hardness scale was developed during the Viagra trials. It's all based on vaginal penetration. And we know that to have anal sex, you have to be even more rigid than you would to penetrate vaginally. So with the erections, it becomes a little bit problematic when I am talking to homosexual men or men who have sex with men because the scale is one to four and four is what everyone wants to be, the perfect erection. But I often tell them, you know, if you're going to penetrate anally, you actually have to be sort of like a four-plus, right? It has to be fully, fully rigid.
I try my best to sort of modify the metrics that we do have when I'm talking to patients about it. And I make them aware that this is based on a model that doesn't necessarily apply to them, but this is the best thing that we have right now. And we're going to use this to help guide our treatment. But with premature ejaculation, it's the same thing. I just make patients who are not having vaginal sex just aware of that and tell them we're going to still shoot for that one minute mark, which is considered to have some sort of pathology to be categorized as premature. The definition is that you ejaculate in a minute or less. But to kind of circle back to how we initially brought this up, people have a very wide range of what they think is normal.
And I don't think that pornography necessarily helps that because young men oftentimes think like I should last 20, 30 minutes and they'll write that down on their intake form for me and circle early premature ejaculation. They'll write down it's 20 minutes, but that's still early. And so then I try to bring them down to earth and I say, "Well, the definition of a premature ejaculation is actually one minute." They're like, "Oh, wow. I guess I'm good then." But to answer your question, if we were going to try to think of ways to prolong that. Number one, it doesn't measure foreplay. So certainly extending foreplay is going to extend the amount of time that you can have sex. In terms of prolonging actual penetrative time, taking time to stop, maybe pull out, go back to doing some foreplay, restarting, that sort of stuff will certainly prolong it.
Liz Goldwyn: Cool.
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: Let's get that number up to at least 14. If not 28, 36, an hour and a half.
Dr. Joshua Gonzalez: Right. Right. Right.
Liz Goldwyn: It's interesting because in the class I'm taking it at UCLA with Dr. Walter Brackomins, there's some MDs and residents in the class who are not specializing in sex therapy. But one woman I was having conversation with the other day told me that in medical school, she was only given one day of how to take a patient's sexual history. That there's not a real focus-
Dr. Joshua Gonzalez: Oh, not at all.
Liz Goldwyn: ... on sexual medicine.
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: So are we doing a big disservice?
Dr. Joshua Gonzalez: Yes. So I think in medical training, when you go through medical school and when you're doing your sort of preclinical years and they're teaching you how to be a doctor and they're going over the physical exam and how to take appropriate history, sexual history, as part of the historical part of your evaluation of a patient is basically overlooked unless they're coming in with some sort of sexual complaint, a lot of times it just gets ignored. If that's not emphasized in your preclinical training, then oftentimes when you go into your clinical training, you're focusing on other things. You're focusing on, why are they having abdominal pain or what is this? Unless you have a really diligent medical student who is trying to be thorough and do well in that course, then they're probably not even going to ask about sexual history. And I think that just gets worse as we go on because we do become more focused, right?
Once you finish medical school, you then go into a specific specialty. So you start focusing on that specialty. Almost never does it have to do with sex. It just gets lost the farther we go into our training. And I think that is why there's such a need for specialists in the field of sexual medicine who can talk openly to their patients who approach the management of sexual function in a comprehensive way, realizing that it's oftentimes a combination of biology and psychology and maybe a musculoskeletal problem, and really sort of try to think out of the box and bring in colleagues and try to address these issues together. And I think that patients really want it. Just from personal experience, I saw a woman the other day who's post-menopausal is having a really hard time, depressed. She wants to have sex with her partner, but it's painful. It's affecting her libido. It's affecting her marriage and she's walking around constantly feeling irritated and having a burning sensation in her genitals.
And she had a doctor tell her, "Deal with it. You went through menopause. This is what it's like to be in menopause, and this is your life." And I just think that's the worst thing for a patient who's already suffering to hear-- from a doctor. It's one thing if she's hearing it from a friend or her partner or whatever, but to hear that from a physician it was just mind boggling to me, because there are things that we can do to improve her quality of life. And she's motivated, she's obviously motivated and looking for answers. But it's easier for physicians oftentime to ignore it or to excuse it as not something that's important and they'd rather focus on your blood pressure and your diabetes and your thyroid issues and all these sorts of things. And just have people accept that loss of sexuality is somehow a normal part of getting older. I think because they don't feel comfortable talking about it.
Liz Goldwyn: Which is exactly the problem-
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: ... that we don't feel comfortable talking about sex and especially in the establishment, within the medical community and even the psychological community. I find there's also still quite a heterosexual bias too, which is not up to date with a new generation.
Dr. Joshua Gonzalez: Yeah, it's exactly right.
Liz Goldwyn: We're having sex, all different kinds of way, and very comfortable with having sex all different kinds of way, but don't really have anywhere to go to get the information.
Dr. Joshua Gonzalez: Yeah, a large part of my practice is gay men or men who have sex with men. And they really appreciate that I can talk very candidly with them. There's no judgments about what kind of sex they're having. And a lot of times, especially if it's something like erectile dysfunction, they're not talking to their friends about it. They very often will not bring it up with a primary care doctor because either they feel uncomfortable or they know that their doctor is not going to feel comfortable talking to them about having anal sex. And so, when they come to see me, and I'm gay myself, that immediately takes off some of the stigma surrounding whatever they're coming to see me about because they know that they can talk openly about it.
And if they're in a relationship or they're single or they're in an open relationship, whatever it is that has nothing really to do with the problem that we're going to address. I approach them as I would any other patient and I think they really appreciate that. But you're right. I think one of my goals is to sort of bring sexual medicine into the 21st century with regards to how we treat or engage with non-heterosexual people.
Liz Goldwyn: I just have one more question-
Dr. Joshua Gonzalez: Mm-hmm?
Liz Goldwyn: ... which is about PrEP-
Dr. Joshua Gonzalez: Mm-hmm (affirmative).
Liz Goldwyn: ... the HIV-
Dr. Joshua Gonzalez: Oh, good question-
Liz Goldwyn: ... the HIV drug. Well, a lot of my friends, a lot of my very virile gay and bisexual friends. They actually asked me to ask about PrEP.
Dr. Joshua Gonzalez: Okay.
Liz Goldwyn: And its safety, its current use in the gay community as a preventative.
Dr. Joshua Gonzalez: Yep.
Liz Goldwyn: Does it work? How are people using it?
Dr. Joshua Gonzalez: Yeah, so PrEP is medication called Truvada that was initially developed as a treatment for HIV, then it was studied as a possible prevention from contracting HIV. And the studies are very promising. So in men who took PrEP regularly, it basically cut your risk of contracting HIV down to almost zero. I mean it was, like, less than 1%. So I think it's a very good medication. I think the dangers that you get into with something like PrEP --which can be very empowering for people and allow them to continue to be sexual without putting themselves at risk-- is that-- and I don't know that this is necessarily true but I've seen that in some of the younger patients that maybe didn't grow up with the exposure to HIV and the media and having seen one entire generation of gay men die from AIDS, that there is almost this cavalier attitude towards getting HIV because now they have this pill that will prevent them from contracting. And even if they do, it's so treatable now. It's lost its scariness.
And so they're not continuing to make smart decisions in terms of protecting themselves with condoms. This is not an excuse to not wear a condom anymore. It's meant to be used in conjunction with other safe sex practices.
Liz Goldwyn: Because it doesn't prevent you from getting other STDs, right?
Dr. Joshua Gonzalez: Not at all. And in fact, there is a rise in certain areas of the country of other types of venereal disease. So gonorrhea, chlamydia, syphilis are on the rise. And the thought is that it may be because people are not participating in safe sex practices because of either the loss of fear over the disease itself, or maybe they're on a prevention treatment. So I tend to favor PrEP as an adjunct to safe sex practices because I think anytime you can empower someone to protect themselves, it's a good thing. But I think you need to really counsel patients really well and say, "This is just another thing that we're adding to the level of protection so that you can be safe." And make sure that they know that they're supposed to continue to use condoms and that sort of thing.
And as far as I know, what I have read, it's a very safe treatment. It can cause some nausea and GI side effects and that sort of stuff. And in fact, you're only allowed to prescribe it unless you've gone through a certain type of training as a provider. And there does need to be follow-up where you're monitoring certain blood tests and regularly checking them for HIV and that sort of stuff. So it's not like a pill that gets handed out and goodbye, we'll see you later-
Liz Goldwyn: Although as we know with any prescription pill that's in high demand-
Dr. Joshua Gonzalez: Yeah.
Liz Goldwyn: ... it's very, very easy to get your hands on prescription pills-
Dr. Joshua Gonzalez: Yes.
Liz Goldwyn: ... if you want them without a prescription.
Dr. Joshua Gonzalez: That is true. Yes.
Liz Goldwyn: Especially something like PrEP.
Dr. Joshua Gonzalez: Yes. Yes. I think because there is a desire to really just get it in the hands of the patients in any way possible, because from a public health perspective, it will hopefully decrease the rate of HIV exposure in the general population but, yeah.
Liz Goldwyn: Well, I think that wraps us up for today.
Dr. Joshua Gonzalez: Well, thank you for this interview.
Liz Goldwyn: Yeah. Thank you.
Dr. Joshua Gonzalez: It’s been fun. I didn't know that stripper-- I’m gonna use that now. (Liz laughs)
Liz Goldwyn: You can find Dr. Gonzalez online at joshuagonzalezmd.com and on Twitter @SexMedLA. He's also a contributing writer to our website, thesexed.com, where he covers topics such as whether one bad boner means you've got a serious problem? Want to know the answer? Then you'll have to read the article.
Thanks for listening to The Sex Ed. If you enjoyed this episode, please subscribe, rate and review us wherever you listen to podcasts and be sure to visit us at thesexed.com. I'm your host Liz Goldwyn. This episode was produced by Idea Farmer in association with Fanny Co. and edited by Rob Abear. Alyssa Venetucci did our sound recording and Eddie Ryan was our line producer. Special thanks to Josh Beane. Lewis Lazar made all of our music, including the track you're listening to right now.
As always, The Sex Ed remains dedicated to expanding your orgasmic health and sexual consciousness. Thanks again for listening.