改善男女性健康与泌尿系统健康 | 蕾娜·马利克博士

所以他们会先和伴侣亲近，然后 arousal 就会随之而来，接着就会想，哦，对了，我喜欢这样。

And so they'll start just being close with them and then arousal will come and then, oh, yeah, you know, I like this.

所以欲望是在之后才出现的。

So then the desire comes after.

这很正常。

And that's normal.

这完全没问题。

That's totally fine.

所以你需要把这一点理清楚。

So you want to kind of parse that out.

对于男性，你可以问：你晚上会有勃起吗？

And then for men, you can ask, are you getting erections at night?

因为这能告诉我们你的器官在夜间与白天的功能差异，而白天还涉及心理因素。

Because that will tell us the function of your organ at night versus during the day where you have also psychogenic components.

对吧？

Right?

你真的会过度纠结于勃起问题。

You can really get in your head about erections.

当你在卧室里遇到表现问题时，就会陷入恶性循环。

When you have a problem in the bedroom with performance, it becomes a vicious cycle.

对吧？

Right?

所以下次当你压力很大的时候，问题又出现了。

So you have a problem the next time you're really stressed.

你没有全身心投入。

You're not present.

你在性行为中无法专注当下。

You're not mindful in the moment with sex.

你心里想着：天啊，我能表现好吗？

And you're thinking about, oh my god, am I gonna perform okay?

我能表现好吗？

Am I gonna perform okay?

然后它又无法正常表现了。

And then it doesn't perform again.

情况越来越糟。

And you're just it's getting worse and worse.

焦虑感飙升，而这实际上正是导致你性功能障碍的原因。

And the anxiety is through the roof and that's actually causing your sexual dysfunction.

所以我认为，首先需要识别出这些问题。

So I think it's important first to identify those issues.

然后关于血流，我们通常可以通过询问你还有哪些其他合并症来评估。

And then also for blood flow, a lot of times we can assess based on, well, what other comorbidities do you have?

你是否还有其他正在影响你血流的问题？

Do you have other issues ongoing that may be affecting your blood flow?

最常见的包括高血压、糖尿病、心脏病，以及吸烟。

Most common, high blood pressure, diabetes, heart disease, and if you smoke.

所有这些都会影响生殖器的血流。

All of those things will affect blood flow to the genitals.

因此这会指向

And so that will point

我们走向负面。

us Negatively.

负面。

Negatively.

所以这会引导我们关注血管性问题。

So that will point us to a more vascular issue.

荷尔蒙问题对性欲非常重要。

Hormonal issues are very important for desire.

至于勃起功能，只有百分之三的勃起功能障碍与荷尔蒙有关。

And as far as sexual function in terms of erections, there's only three percent of erectile dysfunction that's related to hormones.

所以它是

So it's

实际上，但那更多是纯粹的勃起功能，对吧。

actually But that's more pure erectile function Correct.

与欲望相反吗？

As opposed to desire?

欲望是心理性的，或者主要由睾酮激素调节，无论是男性还是女性。

Desire psychological or is predominantly modulated by the hormone testosterone for both men and women.

事实上，很多人不知道这一点，但女性体内的睾酮含量实际上比雌激素还高。

In fact, a lot of people don't know this, but women have more testosterone in their bodies than they actually have estrogen.

因此，睾酮对男性和女性的多种功能都非常重要。

So testosterone is very important for both men and women for a variety of reasons.

因此，与患者进行这一讨论将帮助你确定治疗时需要关注的方向。

And so using that discussion with the patient will help you kind of identify where you're headed in terms of what you need to focus on for treatment.

有一些方法可以评估血流情况。

There are certain things you can use to assess blood flow.

你可以对阴茎和阴蒂进行多普勒超声检查，以判断血流是否良好。

You can do Doppler ultrasounds of the penis as well as the clitoris to see if there is good blood flow.

你可以评估峰值收缩期流速，这能告诉你是否存在动脉灌注问题；而舒张末期流速则能告诉你是否存在静脉回流问题。

You can assess the peak systolic velocity, which will tell you if there's a problem with arterial inflow, versus the end diastolic velocity, which will tell you if there's a problem with venous outflow.

因此，这可以评估这些方面。

And so that can assess those things.

有一些检查可以评估神经功能，尽管它们很少进行，因为大多数情况下我们可以通过临床评估来判断。

There are some tests you can do for nerve function, although they're very uncommonly done because mostly we can kind of get that through a clinical report.

不幸的是，如果你有神经问题，有时取决于其病因。

And unfortunately, if you're having nerve problems, sometimes it depends on what's causing them.

但有时这些问题是很难逆转的。

But sometimes they can be very difficult to reverse.

这确实是个问题。

And that's kind of a problem.

我们知道，随着年龄增长，人的感觉会减弱。

We know that as people age, their sensation becomes less.

因此，仅通过衰老，神经和感受器就会变得不那么敏感。

So just through aging, nerves, the receptors become less sensitive.

所以，你通常会对与年轻时相同的刺激产生更少的反应。

And so you will generally have less responsiveness to the same sensations you did when you were younger.

因此，这与所有这些因素相互交织。

And so that kind of overlays all of this.

所以这很复杂，但很大程度上取决于你与患者之间的对话，或者你需要深入探究发生了什么，认真思考每一个方面，以及你的关系和生活中正在发生的事情，比如压力和焦虑，它们是如何发挥作用的？

So it's complex, but really a lot of it comes from the discussion you have with your patient or you kind of really doing a deep dive in what's going on, like really thinking about each of those aspects and also what's going on in your relationship and what's going on in your life, stress, anxiety, like how are those playing a role?

我想短暂休息一下，感谢我们的赞助商 Athletic Greens。

I'd like to take a quick break and acknowledge one of our sponsors, Athletic Greens.

Athletic Greens，现在称为 AG1，是一种包含维生素、矿物质和益生菌的饮品，能满足你所有的基础营养需求。

Athletic Greens, now called AG1, is a vitamin mineral probiotic drink that covers all of your foundational nutritional needs.

我从2012年开始服用 Athletic Greens，因此很高兴他们赞助了这个播客。

I've been taking Athletic Greens since 2012, so I'm delighted that they're sponsoring the podcast.

我开始服用 Athletic Greens 的原因，也是我至今仍每天一到两次服用的原因，是因为它能为我提供肠道健康所需的益生菌。

The reason I started taking Athletic Greens and the reason I still take Athletic Greens once or usually twice a day is that it gets me the probiotics that I need for gut health.

我们的肠道非常重要。

Our gut is very important.

肠道中定植着肠道微生物群，它们与大脑、免疫系统以及我们身体的几乎所有生物系统进行沟通，显著影响我们的短期和长期健康。

It's populated by gut microbiota that communicate with the brain, the immune system, and basically all the biological systems of our body to strongly impact our immediate and long term health.

Athletic Greens中的益生菌对微生物群健康至关重要且最优。

And those probiotics in Athletic Greens are optimal and vital for microbiota health.

此外，Athletic Greens含有多种适应原、维生素和矿物质，确保我所有的基础营养需求得到满足，而且味道很棒。

In addition, Athletic Greens contains a number of adaptogens, vitamins, and minerals that make sure that all of my foundational nutritional needs are met and it tastes great.

如果你想尝试Athletic Greens，可以访问athleticgreens.com/huberman，他们会赠送你五份免费的旅行装，让你在外出、开车、乘飞机时也能轻松冲泡Athletic Greens。

If you'd like to try Athletic Greens, you can go to athleticgreens.com/huberman and they'll give you five free travel packs that make it really easy to mix up Athletic Greens while you're on the road, in the car, on the plane, etcetera.

他们还会赠送你一年份的维生素D3K2。

And they'll give you a year's supply of vitamin D3K2.

再次提醒，访问athleticgreens.com/huberman即可获得五份免费旅行装和一年份的维生素D3K2。

Again, that's athleticgreens.com/huberman to get the five free travel packs and the year's supply of vitamin D3K2.

天啊，这里有太多内容需要梳理了。

Gosh, lots there to unpack.

我很高兴你提到了关系本身，因为有很多因素会影响性唤起和新鲜感。

And I'm glad you mentioned the relationship itself, because there are all sorts of things that can impact the arousal response novelty.

并不是每个人都有稳定的伴侣关系。

Not everyone's in a committed relationship.

无论人们是否频繁自慰至射精或高潮，或是否观看色情内容，我们都会深入探讨这些问题。

Whether or not people are engaging in a lot of masturbation to the point of ejaculation or climax or not, pornography, etcetera, we will get into that.

这是一个广阔的探索领域。

It's a vast space to explore.

在继续之前，我想确保大家知道如何找到优秀的盆底治疗师，以及如何找到出色的泌尿科医生，来完成我们之前讨论过的检查和可能的治疗。

Before we go any further, I want to make sure, however, that we cue people to where and how they could find a really good, let's say pelvic floor therapist, and where they could find a really great urologist to do the sorts of exams and perhaps the sorts of treatments that we've talked about.

因为至少据我所知，很多人听这个播客的目的，是想了解身体机制如何运作，以及当出现问题时该如何解决。

Because at least as far as I understand, much of what people want to learn on this podcast is how things work and what happens when things break down, also but how to resolve those issues.

假设有人想检查自己的盆底，弄清楚那里发生了什么。

So let's say somebody wants to check out their pelvic floor, figure out what's going on there.

他们可能有症状，也可能没有。

Maybe they're having issues, maybe they're not.

无论男女，他们该去哪里？

If they are male or female, where do they go?

网上有没有一个可靠的资源列表，能帮他们找到所在地区最优秀的专业人士？

Is there a place online that has a great list of some of the best ones in one's area?

可以通过远程医疗进行吗？

Can it be done over telemedicine?

那么，该如何操作呢？

You know, how does one go about that?

是的，关于你的盆底，最好找一位专门研究盆底的医生进行评估。

Yeah, so in terms of your pelvic floor, it's good to get assessed by a physician who specializes in pelvic floor.

这可能是泌尿科医生、妇科医生，或者是专门从事盆底健康康复的物理医学与康复科医生。

Now, that could be a urologist, that could be a gynecologist, or even a physical medicine rehabilitation doctor that specializes in pelvic floor health.

通常来说，如果是女性，在泌尿科应寻找那些获得女性盆底医学与重建手术认证的医生。

So typically, you'll see in urology, you'll look for people who are board certified in female pelvic medicine and reconstructive surgery if you're a woman.

如果是男性，可以关注性医学领域。

If you're a man, maybe sexual medicine.

擅长性医学的医生会是一个不错的选择。

Someone who specializes in sexual medicine would be a good place to look.

对于妇科医生，同样要寻找那些对此领域感兴趣并擅长盆底管理的医生。

For gynecologists, again, want to look at someone who has interest in this area, who does manage pelvic floor.

至于盆底物理康复方面，至少在我接受培训的时候，全国大约只有20位PM&R医生专门从事这一领域。

And then in terms of pelvic floor physical medicine rehabilitation, at least when I was in training, there was about 20 PM and R doctors around the country who really focused on this.

所以这方面的医生并不多。

So it's not a lot of people.

如果你能找到一位盆底物理治疗师，而且附近就有，那也非常好。

If you can go to a pelvic floor physical therapist and you have one near you, that's great as well.

你一定要确保两点：第一，他们具备盆底物理治疗的认证；第二，他们有处理过你这种性别的患者的经验。

You do want to make sure that, one, they do are certified in pelvic floor physical therapy and that they have taken care of your gender.

所以如果你是男性，就要找一位真正治疗过男性的医生，因为很多盆底物理治疗师主要治疗女性患者。

So if you have male anatomy, then you want to go to someone who's actually seen men because a lot of the pelvic floor physical therapists tend to treat a lot of women.

这基本上就是我通常告诉我的患者的建议。

And so that's kind of what I tell my patients generally speaking.

至少据我所知，目前还没有一个特别完善的资源库，也许我们可以查一查，看看能不能找到一个。

There's no, at least to my knowledge, no great resource, and maybe we'll look that up and see if we can find one.

这非常有帮助。

That's very helpful.

谢谢。

Thank you.

因为再次回到我们对话开始时我说的，我认为在寻求与生殖器相关问题的帮助时，很多人感到羞耻，或者至少不清楚该怎么做，对吧？

Because again, going back to what I said at the beginning of our conversation, I think there's a lot of shame or at least a lack of clarity as to how one gets help for issues that relate to the genitals, right?

因为如果你头痛或者眼睛有问题，你知道该去哪里。

Because if you have a headache or you're having an eye issue, I mean, you sort of know where to go.

是的。

Yeah.

希望你的头痛不需要看神经科医生，但也许需要。

And hopefully your headache doesn't warrant going to a neurologist, but it might.

眼睛问题通常是去看眼科医生或验光师，对吧？

Eye stuff tends to be ophthalmologists, optometrists, right?

是的。

Yeah.

所以我认为我们很少听到关于如何获取这些病症的最佳医疗服务的信息。

So I don't think we hear often enough about where to access the best quality care for these things.

谢谢您提到这一点。

So thank you for that.

在思考性功能障碍时，如果我们能大致平行地讨论男性性功能障碍和女性性功能障碍，我会很高兴。

In thinking about sexual dysfunction, I'd like to have that conversation more or less in parallel if we can, around male sexual dysfunction and female sexual dysfunction.

在我们开始之前，我想确保我建立的这种平行结构是正确的，正如人们常说的那样。

And I want to make sure that before we do that, that I'm creating the correct parallel construction, as they say.

男性的勃起功能障碍显然是性功能障碍的一种形式。

Erectile dysfunction in males is clearly a form of sexual dysfunction.

女性中与勃起功能障碍相对应的是什么？

What is the parallel to erectile dysfunction in females?

是阴道润滑不足以及阴道无法放松以实现无痛性交吗？

Is it lack of vaginal lubrication and lack of relaxation of the vagina to have non painful intercourse?

我的意思是，关于这两者进行平行讨论真的可能吗？

I mean, is it even possible to have a parallel conversation about these two things?

所以情况是不同的。

So it's different.

在某些情况下，它们是同源结构，对吧？

In some circumstances, are homologues, right?

所以阴茎是阴蒂的同源结构。

So the penis is the homologue of the clitoris.

因此，阴蒂本质上与阴茎一样，都是海绵状的勃起组织。

So the clitoris is essentially the same sort of spongy erectile tissue that you see in the penis.

它在性兴奋时会勃起，并且实际上深入骨盆内部。

It gets erect with arousal and it actually extends very deep into the pelvis.

所以它不仅仅是一个小小的器官，实际上相当长。

So it's not just a small little organ, it's actually quite long.

在男性中，由于可以看到，所以会出现勃起功能障碍。

And so you can, in men you can have erectile dysfunction because you can see it.

但在女性中，可能会出现性高潮困难。

But in women, you may have difficulty with orgasm.

这并不是完全对应的，但女性性高潮困难是多因素的，我们可以深入探讨。

And it's not exactly a parallel, but difficulty orgasming in women is multifactorial, and we can get into that.

但我认为它们是不同的。

But I think they're different.

而且我认为性功能障碍在两性中的表现也不同。

And I think also sexual dysfunction presents differently in both genders.

所以当谈到男性时，他们看到的性唤起的唯一视觉表现就是勃起。

So when you talk about men, they're very, the one visual they see of arousal is erections.

因此，你的心理会深深认为：如果我没有勃起，我就没有被唤起，对吧？

And so it becomes very ingrained in your psyche that if I don't have an erection, I'm not aroused, right?

但有很多原因可能导致你无法勃起，我们之前已经提到过一些。

But there's a lot of reasons that you might not have an erection that we've sort of touched on.

比如血管问题、激素问题、神经问题、心理因素，以及你正在服用的其他药物。

Vascular problems, hormonal problems, neurologic problems, psychogenic issues, and other medications you're taking.

因此，有许多因素会影响勃起功能。

So there are issues that can affect erectile function.

所以，这可能是你感觉性欲低下的原因之一，因为你的唤起感消失了。

And so that can be part of it where you might feel like you have low desire because your arousal is not there.

这就有点让人困惑了。

And that becomes a little bit confusing.

对于女性来说，她们可以通过评估润滑程度、性交是否疼痛以及是否能获得高潮来判断。

For women, what they can assess is their level of lubrication if sex hurts and if they get an orgasm.

因此，这些就是你可以用来观察的方式。

And so those are kind of the ways you can look at it.

谢谢你详细解释了这些。

Thank you for fleshing all of that out.

多年前，我研究过性分化，特别是激素在性分化中的作用。

Years ago, I worked on sexual differentiation, and in particular, role of hormones in sexual differentiation.

正如你所描述的，我们之所以了解这些，是因为我们被这样教导，而且我认为人们至今普遍认同，如果观察阴茎和阴蒂的胚胎起源，它们本质上是同源结构。

And indeed, as you described, we learned because we were taught, and I think people still generally agree that if one looks at the embryological origins of the penis and the clitoris, they are essentially analogous structures.

而且，许多男性生殖器的发育过程实际上涉及女性生殖器官及其相关结构——如苗勒管等——的退化和消失。

And that a lot of male genital development involves literally the regression, the disappearance of the female sexual genitalia and associated organs, Mullerian ducts and things like that.

而本应发育为卵巢的结构则会变成睾丸，等等。

And what would become the ovaries become the testes, etcetera, etcetera.

这些是解剖学上的对应关系。

Those are anatomical parallels.

但你刚才为我们非常清晰地描述了与性功能和性障碍相关的功能对应关系。

But what you just described for us very beautifully is the sort of functional parallels as it relates to sexual function and dysfunction.

因此，我希望借助这个框架，我们能更快地解决一些问题，因为这里有很多内容需要探讨。

So, I'm hoping you with that framing that we can knock down a few of these pins in a little less time, because there's a lot to tackle here.

首先，我想谈谈荷尔蒙问题。

First off, I'd like to address the hormonal issues.

你提到仅有百分之三的勃起功能障碍，以及由此延伸，女性性唤起障碍也是由荷尔蒙引起的，是这样吗？

You mentioned that only three percent of erectile dysfunction, and by extension, can we say also female issues with sexual arousal are hormonal in origin?

对吗？

Is that right?

关于性欲，是的。

So with desire, yes.

好的。

Okay.

它们总体上是荷尔蒙相关的。

They are hormonal in general.

至于 arousal，如果你以润滑度作为衡量标准，是的，你可以看到荷尔蒙会导致阴道润滑减少。

And arousal, in terms of lubrication, if you're using that as a barometer, yes, you can see less vaginal lubrication due to hormones.

我想说，额外有百分之三到百分之六的勃起功能障碍，最多到百分之六，是由荷尔蒙引起的。

And I guess I'd say three percent to six percent more, up to six percent we see of erectile dysfunction is hormonal.

这仅占所有勃起功能障碍中的一小部分。

It's a small percentage of the entirety of erectile dysfunction.

好的。

Okay.

所以我认为，在社交媒体、播客以及大众普遍认知的背景下，我们都已默认睾酮能提升男性和女性的性欲。

So I think in looking in the landscape of social media and podcasts, and just in the common mindset, we've all come to believe that testosterone is pro libido, it's pro desire in men and women.

现在人们也开始意识到，它对女性的性欲也有作用，当然在男性中更是如此。

I now people are starting to appreciate that it's pro desire in women as well, but certainly in men.

多巴胺也与性欲有关。

And that dopamine is also associated with desire.

公众普遍认为雌激素是抑制性欲或对男性不利的，这实际上是错误的。

And the general public tends to have this view of estrogen as being sort of anti libido or anti male, which is frankly false.

事实上，我曾在播客中与基尔·吉莱特医生讨论过这一点。

In fact, and I've covered this on the podcast with Doctor.

以及与彼得·阿蒂亚医生和另一位YouTube博主德里克——《更多盘子，更多日期》的作者——也谈过这一点。

Kyle Gillette and with Doctor.

他们经常提到，如果男性服用阿那曲唑等药物来抑制雌激素，以为只要提高睾酮、降低雌激素就行，结果往往会严重打击性欲，甚至完全摧毁它，这正促使人们逐渐但积极地改变对雌激素的看法。

Peter Attia and another fellow YouTuber, Derek from More Plates, More Dates has talked a lot about the fact that if men take drugs like an Astrozole to suppress their estrogen, thinking that, oh, it's all about having high testosterone, low estrogen, oftentimes they crush their libido, just abolish it, which has led to a slowly growing, but I think positive shift in how people are thinking about estrogen.

雌激素对大脑功能有益，对男性和女性的性欲也有益。

Estrogen is great for brain function, estrogen is great for libido in men and women.

没错。

Correct.

这修正了大多数人对男性性反应的认知。

And that is a revision of, I think how most people think of the male sexual response.

这更符合人们对女性性反应的理解——雌激素在女性性反应中起作用，这很合理。

It's more in keeping with how people think about the female sexual response, Oh, estrogen in the female sexual response, that makes sense.

但我们在这里试图澄清一些误解。

But what we're trying to do here is clarify some of the misconceptions.

现在，我提到多巴胺的原因是，据我理解，多巴胺参与了欲望反应。

Now, the reason I mentioned dopamine is that my understanding is that dopamine is involved in the, excuse me, the desire response.

我们将区分欲望——心理上的兴奋，与生殖器兴奋——生理上的兴奋。

We will distinguish desire, the psychological arousal from genital arousal, physical arousal.

而催乳素则与不应期相关，在此期间男性无法勃起，女性也可能无法达到高潮，等等。

And that prolactin is associated with the refractory period during which erection can't occur, another perhaps orgasm can't occur in females, etcetera.

但据我所知，情况也没那么简单。

But my understanding is that's also not that simple.

也许我们需要退一步，谈谈欲望和兴奋反应的生理基础。

And we need to take a step back perhaps and just talk about the physiological underpinnings of the desire and arousal response.

所以我来告诉你我当初学到的内容，然后你告诉我哪里错了。

So, I'll tell you what I was taught, and then you can tell me where it's wrong.

好的。

Sure.

希望如此。

I hope.

我学到的是，勃起反应和阴道润滑反应是由副交感神经系统产生的，也就是神经系统中放松、休息与消化的那部分。

I was taught that the erection response and the vaginal lubrication response is generated by the parasympathetic nervous system, the relaxed, the rest and digest aspect of the nervous system.

因此，有些人会出现心理性性功能障碍，比如缺乏勃起或阴道润滑。

Hence why some people can get psychogenic sexual issues of lack of erection or lack of vaginal lubrication.

但确实存在一些人，他们的警觉性很高，甚至——这有点争议——对某些人来说，某种攻击性、紧张感或兴奋感，也就是肾上腺素，反而能刺激勃起或阴道润滑。

But that there are individuals out there for whom a lot of alertness, maybe even, and this is a controversial thing, but for some people, even some sense of aggression or kind of edginess or excitement, adrenaline in other words, can stimulate erection or vaginal lubrication.

情况变得复杂了。

It gets tricky.

这和教科书上说的不一样。

It's not like the textbooks.

据我所知，这和我们在高中时学到的也不一样。

It's not like they taught us in high school, as far as I know.

我学到的是，男性和女性的性唤起反应是由副交感神经系统的放松状态启动的。

I was taught that the arousal response in males and females is initiated by a parasympathetic sort of relaxed tone.

随着性欲、性唤起以及性行为或自慰的进行，这一过程会逐渐转向交感神经系统，这与情感上的同情无关，而与唤起有关——此时会释放儿茶酚胺、多巴胺、去甲肾上腺素和肾上腺素（也称为肾上腺素和去甲肾上腺素）。

And that as sexual desire and arousal and sex or masturbation progresses, that it shifts more towards the sympathetic nervous system, which has nothing to do with emotional sympathy and has everything to do with arousal, the catecholamines, dopamine, norepinephrine, and epinephrine, also called adrenaline and noradrenaline are released.

而高潮反应——可能包括射精，也可能不包括，我们必须将这两者区分开——实际上是身体应激系统的一部分。

And that the climax response, which may or may not include ejaculation, we have to separate that out, is one that is really of the stress system of the body.

而在性行为后、射精后或高潮后的阶段，身体又会重新转向副交感神经系统。

And then in the post coital or post ejaculatory or post climax phase, then there's a shift back to the parasympathetic nervous system.

正是在这一阶段，枕边话、气味与味道以及其他分子的交换，通过催产素、加压素等物质促进伴侣间的依恋。

That's where the pillow talk and the exchange of odors and tastes and other molecules is known to enhance pair bonding through things like oxytocin, vasopressin, and so on.

我刚才所描述的，我明白，是极度简化的。

And what I just described is exceedingly oversimplified, I realize.

但生理机制是否大致如此呢？

But is that more or less how the physiology works?

是的。

Yeah.

我们在医学院学到的是‘点射模式’。

So the way we're taught in medical school is point and shoot.

所以，重点是副交感神经系统。

So point is the parasympathetic nervous system.

所有男性听众都会喜欢这一点。

All the male audience will like that one.

然后，你会转向交感神经系统。

And then, you you go on to the sympathetic nervous system.

但这说得通。

But it makes sense.

我认为你们听到关于这种攻击性或导致性唤起的因素的原因，是因为需要一个刺激，对吧？

And the reason that I think you're hearing about this aggression or these things that are leading to arousal is because there needs to be a stimulus, right?

一种视觉刺激、触觉刺激，或者某种你们接收到的刺激，会促使副交感神经系统释放一氧化氮。

A visual stimulus, a tactile stimulus, some sort of stimulus that you're getting that is then causing the release of nitric oxide from the parasympathetic nervous system.

对某些人来说，这种刺激可能是攻击性，或者类似的形式，对吧？

And that could be for some people aggression or, you know, some form of that, right?

你能给大家讲讲一氧化氮吗？因为当我们讨论增加血流的药物时，比如希爱力、伟哥，还有非处方药，像L-瓜氨酸、精氨酸，甚至西瓜，都会涉及这个话题，对吧？

Can you tell people about nitric oxide, because we'll get into this when we talk about drugs that increase blood flow, Cialis, Viagra, and also non prescription drugs, things like L citrulline, arginine, and watermelon for that matter, right?

所以我在网上看过。

So I read on the internet.

是的。

So, yeah.

换句话说，一氧化氮实际上是勃起的触发机制，勃起的启动关键。

So nitric oxide is essentially the ignition for what we say for erections, the ignition for erections.

我之所以更常谈论勃起，是因为当你查看数据时，确实有一篇论文研究过，当你搜索‘阴茎’这个词和‘阴蒂’这个词时，分别出现了多少篇文章。

I mean, if you the reason I talk about erections more often is when you look at the data, in fact, there was a paper on this where they looked at the number of articles that came up when you put in the word penis and the number of articles that came up when you put in the word clitoris.

结果是，关于阴茎的文章有五万篇，而关于阴蒂的只有两千篇。

And it was 50,000 about penis and 2,000 about the clitoris.

好的。

Okay.

我们之前其实已经详细讨论过这个话题了。

We have to we this was actually a major section of the comments.

对。

Yeah.

当我在Instagram上征集问题时。

When I asked for questions on Instagram.

还有评论里的留言，对了，这是为什么呢？

And comments on comments and yeah, how come?

为什么不呢？

Why not?

诸如此类。

Etcetera.

这是因为泌尿科和性健康领域一直由男性主导吗？

Is that because the urology and sexual health field was dominated by men?

这将是人们的默认假设。

That's going to be the presumption.

还是因为某种原因更容易研究？

Or is it because it's easier to study somehow?

或者，我的意思是，这里到底发生了什么？

Or, I mean, what's going on here?

是的。

Yeah.

我认为过去有很多这样的情况，比如弗洛伊德就认为女性的性反应价值较低。

I think there's been a lot of I mean, you can go back to like Freud where he thought that that the female sexual response was less valuable.

所以确实存在一些一些

And and so there are some some

原因：价值较低。

reasons Less valuable.

我想我不确定这是否是正确的

I guess I'm not I don't if that's the right

术语，但哦，不。

term, but Oh, no.

不。

No.

我没有质疑你的用词。

I'm not challenging your term.

我只是想说，我更关注的是男性性反应，而不是女性性反应，所以总体而言，医学领域男性确实更多。

I just meant I just was more about the male sexual response than the female sexual And so in general, yes, there were more men in medicine.

男性研究更多，也更容易研究。

There was more and it is easier to study.

你很难像研究男性阴茎反应那样轻易地研究阴蒂，因为你无法直观地观察到。

You can't say the clitoris quite as easy as you can study the male penis response because you can see it visually.

你可以注射药物并观察到勃起反应。

You can inject it and see an erection response.

我们对患有勃起功能障碍的人就是这么做的。

We do this for people who have erectile dysfunction.

他们会服用增加血流的药物，比如三联混合剂（Trimix）。

They'll take medications that increase blood flow like Trimix.

你将药物注射到阴茎中，然后就能看到勃起。

You'll inject it into the penis and you'll see an erection.

所以你实际上会用三联混合剂？

So you can actually Trimix?

Trimix。

Trimix.

有

There's

整个男性观众都愣住了：等等，你们往哪里注射？

The entire male audience just went, Wait, what do you inject into

阴茎？

the penis?

因此，我们用于治疗勃起功能障碍的腔内注射药物主要有三种品牌。

So there are three basically brand names of intracavonosal injections that we use for erectile dysfunction.

我听到注射这个词，就认为这反映了男性的一种自然反应。

I hear injection in this, and I like to think that it reflects a natural male response.

我有点震惊。

I sort of, I taken aback.

我不确定，也许那里还涉及骨盆底肌肉的收缩。

I don't know, maybe there's a pelvic floor contraction in there someplace.

听起来确实让人害怕。

So it is scary to hear about.

使用的针头非常细小。

It's a very small needle.

耐受性非常好。

It is very well tolerated.

我曾在诊室为患者注射，他们看完后会问我：‘完了？’

I've done it to patients in the office, and they look at me and say, You're done?

就像他们根本没感觉到，其实没想象中那么疼。

Like, they don't even, you know, it's not as painful as it seems.

当你无法勃起，且尝试过多种方法后，人们最终会愿意试一试。

And when you are not having erections and you've tried multiple things, people get to the point where they're willing to try that.

因此，它的效果非常好。

And so it is very effective.

它是目前治疗勃起功能障碍最有效的非手术疗法。

It is the most effective nonsurgical treatment we have for erectile dysfunction.

通常是一种、两种或三种药物。

And it's usually either one medication, two medications, or three.

所以你可以用前列地尔、胡椒碱，第三个是什么？

So you can have alprostadil, piperine, and what's the third one?

没关系。

That's okay.

我们可以查一下。

We can look

看一下。

at it.

有人会在评论里发出来。

Someone will put it in the comments.

好的。

Sure.

他们肯定会的。

Surely they will.

它的设计用途是什么？

What is it designed to do?

这是一种血管扩张剂吗？

Is a vasodilator of sorts?

它们的作用机制不同，但类似于我们常用的PDE5抑制剂。

So they work in different mechanisms, but similar to the medications that we have, PDE5 inhibitors.

PDE5抑制剂作用于勃起的连锁反应过程。

PDE5 inhibitors work in the erection cascade.

我们先从一氧化氮说起，然后慢慢讲清楚。

Basically what happens let's take it back to the nitric oxide thing and we'll get there.

一氧化氮本质上是由内皮细胞在受到视觉或触觉刺激后释放的，对吧？

So nitric oxide essentially is released by the endothelium in response to a visual tactile stimulating cue, right?

于是你的身体释放一氧化氮，进而触发勃起的连锁反应。

And so your body releases nitric oxide, which then sets off the cascade for the erection.

这一过程会释放cGMP，从而导致勃起，而磷酸二酯酶会分解cGMP。

And so that releases CGMP, which causes the erection, and it's degraded by phosphodiesterase.

因此，抑制磷酸二酯酶的药物，比如伟哥和希爱力，可以防止CGMP被分解，从而延长勃起时间。

And so medications that inhibit phosphodiesterase, like Viagra and Cialis tend to prevent the breakdown of that CGMP so you have longer lasting erections.

同样地，这些药物的作用机制也与此类似。

And so similarly, these medications work sort of similar to that.

其中一些药物的具体作用机制尚不明确，但它们通过增加CGMP或cAMP来发挥作用，而这些物质参与了上述级联反应。

Some of them, we don't know exactly how they work, but they work by increasing CGMP or CAMP that are involved in those cascades.

那L-瓜氨酸呢？

And what about L citrulline?

我听说L-瓜氨酸是一种非处方补充剂，它参与精氨酸代谢通路。

I hear about L citrulline use, it's an over the counter supplement and it's in the arginine pathway.

我的理解是，它的作用方式与希爱力、伟哥类似，但效果可能没那么强。

And my understanding is that it works similarly to things like Cialis Viagra, is perhaps not as potent.

我还想提醒一下，L-瓜氨酸可能会引发严重的口唇疱疹和口腔溃疡。

I also just Cautionary note out there, L citrulline can give people vicious cold sores and canker sores.

非常严重。

Vicious.

你在互联网上听说过这个。

You hear about this on the internet.

已经有大量令人不适的图片证实了这一点，你绝对不想去搜索，而且并不是每个人都能很好地耐受。

It's been verified by grotesque images that you do not want to Google for and not everyone tolerates it well.

这些物质实际上是通过增加一氧化氮来起作用的。

So these actually work by increasing nitric oxide.

所以它们并不属于这条通路的下游环节。

So they're not in this they're not later down the pathway.

它们实际上是增加了一氧化氮的可用性。

They're actually increasing the availability of nitric oxide.

L-精氨酸是更直接的途径，但其生物利用度非常低。

So L arginine is the more direct pathway, but it's very low bioavailability.

L-瓜氨酸会转化为L-精氨酸，但它在血液中的持续时间要长得多，这就是为什么人们更倾向于使用L-瓜氨酸。

L citrulline converts to L arginine, but it lasts much longer in the bloodstream, which is why people tend to use L citrulline.

在性医学领域，这些补充剂虽然有一些研究证明其有效，但补充剂行业本身没有任何监管。

Now, you know, in sexual medicine, these supplements, while there has been some studies on them and they are effective, there's no regulation on the supplement industry.

所以我们能推荐它们，但无法确定补充剂的内容真的如瓶身所标示的那样。

So we can recommend them, but we just can't say that for sure that the supplement is exactly what's said on the bottle.

我们看到很多研究，比如我读过一篇关于褪黑素的，发现实际含量与瓶身标注的差异可达400%。

We see lots of studies where they'll say, you know, I read one about melatonin and there's a variation of melatonin from like what's on the bottle to 400% times more.

这就是我们作为医生所面临的困境。

And so that's kind of the struggle that we as medical doctors have.

我知道我们常因此被批评，说我们不谈补充剂，但真正的问题在于如何找到高质量的补充剂。

And I know we get a lot of slack for it that we don't talk about supplements, but it's really the challenge there is like finding the quality supplement.

一个很好的网站是examine.com，我和它没有任何关系，只是我经常提到它，这个网站提供了人类研究的参考文献，并展示了大量有效性证据。

A great site is, which I have no relationship to, except that I mention them all the time, is examine.com, which has references to human studies and where there's a lot of efficacy shown.

我们接下来会讨论一些副作用问题。

We'll get into some side effect issues.

我们无法针对品牌质量进行评价，但感谢你提到这一点。

Can't address quality by brand issues, but thanks for mentioning that.

服用西地那非（即他达拉非）或伟哥治疗勃起功能障碍的男性中，有多少比例能获得改善？

What percentage of males who take Cialis, aka Tadalafil, or Viagra for erectile dysfunction get relief from that?

因为你提到男性中只有百分之三的勃起问题源于荷尔蒙，但有多大比例可能是由血流问题引起的？

Because you mentioned only three percent of erectile issues in males are hormonal in origin, but what percentage are likely to be blood flow related in origin?

很大一部分勃起问题与血流有关。

So a large percentage are blood flow related.

但这并不意味着药物对每个人都会有效。

That doesn't mean that the medication will be effective for everyone.

如果你看大部分情况，它们都是血管性的，对吧？

If you look at the large percentage are vascular in nature, right?

随着男性年龄增长，这是最主要的原因。

That's the number one cause as men age.

我们知道，大约52%的40岁以上男性会有勃起功能障碍，并且这个比例会随着年龄增长而继续上升。

So we know that about fifty percent of fifty two percent of men over the age of 40 will have erectile dysfunction, and that continues to increase as you age.

所以，50岁的男性中有50%，60岁的男性中有60%，以此类推。

So fifty percent of 50 year olds, sixty percent of 60 year olds, and so on and so forth.

因此，这种情况非常非常普遍。

So it's very, very common.

研究中的成功率大约在百分之六十到七十之间。

And the success rate in the studies is about sixty percent to seventy percent.

因此，当你给某人开药时，他们会获得足以进行插入性性交的持续勃起，这正是我们在研究和与患者交流时讨论勃起功能障碍的标准，成功率大约在百分之六十到七十之间。

So when you give someone a medication, they will have sustained erections that are sufficient for penetrative intercourse, which is the way we kind of discuss erectile dysfunction in studies and in you know, with patients is about sixty percent to seventy percent.

并不是每个人都能成功，但并非所有失败都是因为药物无效。

So not everyone will have success, but not all of that is because the medication doesn't work.

有时人们没有正确服用药物。

Sometimes people are not taking them correctly.

有些人需要尝试不同的剂量。

Some people need to try different doses.

但还有一个问题，那就是你的大脑仍然在活跃运作。

And then there's still this issue of your brain is still active.

因此，如果你感到焦虑，或者生活中有其他问题或压力，这会影响你产生勃起的能力。

And so if you're having anxiety or you're having other issues or stress in your life, that can have an effect on your ability to create erection.

所以这其中涉及很多因素。

So there's lots of factors that go into it.

但总的来说，它们是有效的，效果相当好，而且耐受性也不错。

But generally speaking, they are effective and they do work quite well and they're tolerated pretty well.

百分之六十到七十可不是一个小数目。

And sixty to seventy percent is not a small number.

这是一个相当可观的比例。

That's a significant number.

这明显占了大多数。

That's the majority by a significant margin.

西地那非、他达拉非、L-瓜氨酸用于女性是否有依据？

Is there a basis for the use of Cialis, Tadalafil, Viagra, L citrulline in females?

是的，这方面的数据不多，但如果你推测是血流问题导致她们在性高潮方面有困难，确实可以尝试超适应症用药。

So yeah, there's not a lot of data on this, but certainly, you know, if you have surmised that there is a blood flow issue and they're having difficulties with orgasm, it's certainly something you can try off label.

当然，有些人会尝试这些药物，看看是否能改善女性的性功能。

And certainly people do try these medications off label to see if they improve sexual function for women.

但关于这些药物在女性身上的研究，还没有大量严谨的随机对照试验。

But there's not a whole bunch of robust, you know, randomized controlled trial studies on women with these medications.

稍后我们会专门讨论前列腺健康，但我想先在这里注明一点：如今，低剂量的西地那非（他达拉非）使用量正在增加。

A little bit later, we will talk about prostate health specifically, but I'm just going to make a note here that nowadays there's increasing use of low dosage CialisTadalafil.

我在线上查到的信息是，治疗勃起功能障碍的西地那非（他达拉非）剂量通常在15到20毫克之间。

Rather than what I found online was that the erectile dysfunction treatment dosage of Cialis Tadalafil is somewhere in the fifteen to twenty milligram range.

我们这里讨论的是每天服用2.5到5毫克的西地那非（他达拉非）以维护前列腺健康。

What we're talking about here is daily use of two point five to five milligrams of Cialis tadalafil for prostate health.

我在为这一期内容做研究时了解到，他达拉非（西地那非）最初其实是被开发用于治疗前列腺健康问题，目的是通过增加前列腺的血流来改善前列腺健康，而非用于治疗勃起功能障碍。

And I learned in researching for this episode that Tadalafil, Cialis, was actually developed as a drug for the treatment of prostate health, to essentially increase blood flow of the prostate to increase prostate health, not for the treatment of erectile dysfunction.

我觉得这一点相当有趣，现在越来越多的人开始使用这种用法。

So, found that to be somewhat interesting and a lot of people are now starting to use that.

我还了解到，如果深入挖掘网络信息，会发现现在越来越多的人开始联合使用低剂量西地那非和阿扑吗啡——这是一种促多巴胺类药物。

I also learned that if you dive into the guts of the internet, one can find that now there's a growing use of combined low dosage Cialis and Apomorphine, which is a pro dopaminergic agent.

我们稍后会再回到多巴胺这个话题。

And we'll get back to dopamine a little bit later.

但女性每日服用低剂量（如2.5至5毫克）的西地那非（他达拉非）是否有任何依据？

But is there any basis for low dosage, say two point five to five milligram daily use of Cialis tadalafil in females?

是的。

Yes.

那么，我们来谈谈男性和女性的情况吧。

So, well, let's talk about it for males and females.

我认为低剂量每日服用西地那非对男性的勃起功能非常有效，即使

I think low dose daily Cialis is excellent for erectile function in men even

这真的正确吗？抱歉打断一下，但对于没有勃起功能障碍的男性也有效吗？

Is that true even, sorry to interrupt, but is that true even for men that are not experiencing erectile dysfunction?

这并不是它的适应症，但有一种观点认为，它能增加该区域的血流。

It's not indicated for that purpose, but there's a thought that, you know, it's increasing blood flow to the area.

因此，我 personally 曾用它来帮助患有盆腔疼痛的男性改善血流。

So people, I've personally used it for men who have pelvic pain to help with increasing blood flow.

你也可以将其用作预防手段。

You can also use it potentially as a preventative.

所以有些人认为，它能增加血流，从而预防因年龄增长或其他血管问题导致的勃起组织纤维化。

So some people have, you know, kind of thought, okay, it's increasing blood flow, it's preventing fibrosis of that erectile tissue that can happen with age or other vascular problems.

因此，它也可能对这种情况有益。

So it may be beneficial for that as well.

不过，再次说明，这是超适应症使用，我们通常不推荐。

Although again, that's off label and not something that we generally promote.

至于女性，同样地，它可以帮助改善血流。

As far as for women, there's, you know, again, it can help with blood flow.

所以，如果你遇到有性功能障碍的女性，并且有血管问题的迹象，比如患有糖尿病、高血压或吸烟，那么尝试使用并观察效果是完全合理的。

So if you're having issues, so if you have a female who's having sexual dysfunction and she's got signs of vascular problems, like she's got diabetes, high blood pressure, she smokes, then yes, it's certainly reasonable to try and see how they do.

通常建议至少进行四周的疗程，以观察这些药物是否有效。

Usually wanna give at least a four week trial to see if there's any benefit with those medications.

很好，谢谢你的解答。

Great, thank you for that.

为什么我经常收到二十多岁和三十多岁男性关于勃起功能障碍的咨询？

Why is it that I get so many questions about erectile dysfunction from males who are in their 20s and 30s?

因为到目前为止你所说的内容主要针对的是40岁及以上的男性。

Because everything you said up until now was mainly focused on men 40 years and older.

是因为缺乏体育锻炼，还是尼古丁使用过度？

Is it from lack of physical activity, overuse of nicotine?

顺便说一下，据我们所知，电子烟和吸烟对男性和女性的勃起功能及整体性健康都有害，因为尼古丁是一种血管收缩剂。

By the way, vaping, as far as we know, vaping and smoking bad for erectile function and perhaps sexual health in males and females generally because nicotine is a vasoconstrictor.

尼古丁确实有一些益处，我曾在一期关于尼古丁对老年人神经认知益处的节目中提到过，但它确实是一种血管收缩剂。

Nicotine does have certain benefits, and I covered this in an episode on nicotine, neurocognitive benefits in the elderly in particular, but it is a vasoconstrictor.

所以，这与我们正在讨论的性唤起机制是背道而驰的。

So, it runs against all of the sexual arousal stuff that we're talking about.

但好吧，我们假设这位二十多岁或三十多岁的男性睡眠充足，每晚睡六到八小时，经常锻炼，也没有在健身房里对骨盆底造成损伤。

But okay, let's assume that male in their 20s or 30s is sleeping enough, know, six to eight hours a night, is exercising, isn't doing anything to punish their pelvic floor in the gym.

你知道，他们不会在做仰卧起坐时交叉双腿做凯格尔运动，或者在吸气时做仰卧起坐。

You know, they're not doing legs cross Kegels while doing crunches or something while inhaling on the crunch.

顺便说一句，朋友们，刚才那是个小测验，考察之前讲过的内容。

That was a quiz by the way, folks, for earlier topics covered.

我们再假设他们饮食相当健康。

Let's assume they're, you know, eating pretty well.

他们吃的大部分食物都是非加工或轻度加工的。

Majority of their foods are coming from non processed or minimally processed foods.

他们每天都会进行一点冥想。

They're doing a little meditation each day.

他们保持着健康的人际关系。

They're engaging in hopefully healthy relationships.

他们不会疯狂地自慰看色情内容。

They're not masturbating like crazy to porn.

我们再假设他们没有服用任何SSRI类药物。

And let's assume that they are not on any SSRI.

为什么所有这些二十多岁、三十多岁的人都在网上主要找你？

Why are all these 20 and 30 year olds on the internet asking mainly you?

他们主要来找你。

They mainly run to you.

同时也给我发私信，咨询他们的勃起问题。

But also to my direct messages about their erectile issues.

所以我要说，我在诊所见过很多年轻男性，他们经常有骨盆底功能障碍。

So I will say I have seen a lot of young men in my clinic, and I will say that they very often have pelvic floor dysfunction.

即使他们做了所有正确的事情，但我们也生活在一个充满压力的社会里，你可以尝试各种方法来减轻压力。

So even though they're doing all the right things, they do have I mean, we're in a stressful society, so you can try all the things to decrease your stress.

但很多人长时间坐着，尤其是在疫情期间。

But a lot of us are sitting long periods of time, especially during COVID.

我的意思是，人们一坐就是好几个月，对吧？

I mean, people sat for months, right?

好几年，就只是坐在家里的电脑前。

Years, like just sitting at their home computer.

所以每天锻炼一小时并不能抵消一整天久坐的影响。

And so exercising one hour is not going to offset the day full of sitting.

所有这些因素都会影响骨盆底功能。

And so all of those things can affect pelvic floor function.

因此，我的观点是，这可能是更常见的原因。

So my theory is that that's probably the more common cause.

所以多走动。

So walk more.

是的。

Yeah.

我已

I've

实际上，听说过站立式办公桌，是的。

actually Or use heard standing desk, yeah.

对，是的。

Yep, yeah.

多走动，用站立式办公桌。

Walk more standing desk.

好的，那么我猜这存在某种心理因素的反馈循环。

Okay, so, and then my guess is that there's some psychogenic feedback loop.

绝对如此。

Absolutely.

这其实就是极客说法，意思是事情没有像他们希望的那样顺利，于是他们为此感到压力，而压力又让情况变得更糟。

Which is just nerd speak for things aren't working as well as they would like, then they're stressing about it and the stress is making things worse.

完全正确。

Absolutely.

而且，你知道，你提到人们不再自慰或看色情内容，但很多人是通过色情内容了解性知识的。

And, you know, you mentioned that people are not masturbating or using porn, but a lot of people learn about sex through porn.

不管好坏，我们无法否认，这确实不是什么好事，但如今它触手可及。

Whether it's good or bad, we can't you know, it's not a great thing, but, like, that's accessible now.

我们小时候，得去找一台录像机。

When we were growing up, you had to find a VCR.

还得找一个没人会闯进来的安静房间。

You had to find a quiet room that no one was gonna walk in.

我年纪够大，还记得隔壁家的孩子——我就不点名了——但那孩子有色情杂志。

I'm old enough to remember when the kid down the street, I won't mention him by last name, but yeah, the kid down the street, you know, had porno magazines.

是的，或者杂志。

Yeah, or magazines.

当时那里其实还有一个这类杂志的藏匿点，天哪，我不该说具体在哪儿，就是我长大的那个镇上，孩子们会把它们藏在停车场的特定位置。

And then there was actually a library of these, goodness, I shouldn't say where they were, in the town I grew up in where kids would stash them in specific locations in parking lots.

然后男孩们会骑自行车、滑滑板或者步行过去，轮流观看这些杂志。

And then boys would bike or skateboard over or walk over, and then they would like take turns, excuse me, looking at them.

但这实际上引出了一个更重要的观点，那就是观看色情内容与对着色情内容自慰是不同的，而后者又与对着色情内容自慰到射精不同，对吧？

But that actually is to raise perhaps a more important point, which is that looking at pornography is different than masturbating to pornography, which is also different than masturbating to pornography to the point of ejaculation, right?

因为我经常收到很多人关于他们色情成瘾问题的咨询。

Because I also get a lot of questions from people about their porn addiction issues.

现在有一种越来越流行的观点认为，过度使用——也就是说，不仅仅是观看，而是对着色情内容自慰到射精——正在导致人们减少寻求和培养健康、真实的性互动。

And there's a growing theory out there that overuse, that meaning not just looking at, but masturbating to pornography to the point of ejaculation is creating a deficit of seeking out and cultivating healthy real world sexual interactions.

是的。

Yeah.

所以在深入讨论这一点之前，我想先说：如果你对着色情内容自慰，但你拥有正常、健康的人际关系，工作顺利，有一个很棒的伴侣，生活一切顺利，那没什么问题。

So I start want this before I get into that is to say that if you're masturbating to porn and you have normal, healthy relationships and you're going to work and you're have a great, you know, partner and everything's great in your life, it's okay.

羞耻感才是一个真正的问题。

Like, shame is a real problem.

我认为他们是一起观看色情内容的。

And I think they're watching pornography together.

是的。

Yeah.

所以我认为，至少在文献中，他们并不使用‘色情成瘾’这个说法。

So I think, you know, I think it's important, though, that at least in the literature, they describe they don't describe porn addiction.

他们称之为问题性色情使用。

They call it problematic pornography use.

在这些研究中，只有大约百分之四的人被描述为如此。

And it's only described in about four percent of people in these studies.

所以这只是少数人的情况。

So it's it's a small subset of people.

我认为这种情况正变得越来越普遍，因为色情内容太容易获取了。

I think it's becoming more common because pornography is so accessible.

它会像其他任何成瘾一样激活多巴胺通路。

And it activates the dopamine pathways just like any other sort of addiction.

你观看色情内容。

You watch pornography.

你会产生多巴胺反应。

You get a dopamine response.

你的大脑随后会想：哦，我想再体验一次。

Your brain then says, oh, I want that again.

于是你会不断寻求更新颖、更激烈、不同类型色情内容，以获得同样的反应。

And you keep seeking more novel, more aggressive, different types of pornography to get that same response.

但并不是每个人都会这样。

But it doesn't happen to everybody.

而且我还想说，抱歉打断一下，多巴胺反应是一种与适应性行为相关的硬连线生物机制，包括——让我们先定义健康的性行为，因为我认为这方面因个人背景、宗教信仰等而有巨大差异。

And But also I would say, sorry to interrupt, but that the dopamine response as a hardwired biological mechanism for adaptive behaviors, including And let's just define healthy sexual behavior because I feel like there's such a range on that, depending on one's background, religious beliefs, etcetera.

每次我们在本播客中谈论性时，我都想指出，这至少涉及四件事。

Anytime we talk about sex on this podcast, I'd like to say that involves at least four things.

显然，必须是自愿的、符合年龄的、情境适当的、物种适当的。

Obviously consensual, age appropriate, context appropriate, species appropriate.

是的，完全正确。

Yes, absolutely.

绝对正确。

Absolutely.

很高兴你提到这一点。

I'm really glad you brought that up.

我以前听过你这么说，但这非常重要。

So I've heard you say that before, but it's very important.

所以我认为，确实存在一个广泛的谱系，很多人接触色情内容，但依然过着正常的生活。

And so I think, you know, there is a spectrum, a large spectrum of people who watch pornography, ejected to pornography, and have a normal life.

所以这没问题。

And so that's fine.

我认为，如果我们羞辱这些人，反而会制造问题。

I think that, you know, if we shame those people, we're creating problems.

对吧？

Right?

我们就会说，哦，你做这种事。

We say like, oh, you do that.

这太糟糕了。

That's horrible.

然后他们就在自己脑子里，对吧？

And then they're in their head, right?

然后他们因为羞耻感而在生活中制造问题。

And then they're causing problems in their life because of shame.

所以我认为，这种讨论中带有一丝文化上的羞耻感。

And so there's, I think there's a little bit of cultural shame that comes of this discussion.

如果我们说‘这会制造问题’，从长远来看这是个问题，因为并不是每个人都这样。

And it's a problem in the long term if we say that, oh, this is going to create problems because not everyone has.

有太多人观看色情内容却没有任何问题，他们与伴侣拥有正常、健康的性生活，这完全没问题。

There's so many people who watch pornography and have no problems, who have normal, healthy relationships, great sex with their partner, and it's fine.

他们很穷。

They're poor.

关系。

Relationships.

或者他们

Or they're

是的。

Yeah.

而且他们特别依赖自慰。

And they're relying on masturbation specifically.

对。

Right.

有没有数据能区分纯粹的想象幻想与视觉幻想，就它们对性健康的发展或抑制而言？

Are there any data that distinguish between just pure imagination fantasy versus visual fantasy as it relates to developing or inhibiting sexual health.

而这里我们讨论的是欲望层面。

And here we're talking about the desire aspect.

我们假设生理唤起已经得到处理。

Let's assume physical arousal is handled.

我不是在玩文字游戏。

No pun intended.

所以

So

我觉得关于年轻人，我想先回到这一点，然后再回答你的问题。

I think that the thing about young people, I wanna get back to that, then I'll answer your question.

但那些观看色情内容的年轻人，他们以为性就是这样的。

But the thing about young people who are watching pornography, that's what they think sex is supposed to be like.

他们没有接受过关于性是什么的教育。

They don't get an education about what sex is.

对吧？

Right?

没有人会跟孩子谈这些，比如：嘿，孩子们，性行为实际上是这样的。

No one has a conversation with their kids like, hey, guys, this is what happens when you have sex.

性行为应该持续多久。

This is how long it should take.

这就是前戏。

This is what foreplay is.

这并不正常。

And this is not normal.

这是制作出来的内容。

This is the production.

这是一种经过包装的产品，目的是激发你的欲望，理想情况下让你射精或达到高潮，对吧？

This is a produced product that's meant to arouse you and to give you ideally an ejaculation or an orgasm, right?

所以没有人会进行这样的对话。

So no one has that discussion.

那么转向亲密关系时，就会想：为什么我的伴侣不像色情片里的那个女人那样反应呢？

So then go to relationships like, why did my partner not react like that woman did on the porno, right?

或者，为什么我没有像色情片里的那个女人那样反应呢？

Or why did I not react like that woman did on the porno, right?

那为什么他不像色情片里那样有反应呢？

Well, why didn't he react when, you know, like they would in porn?

因为，再说一遍，我认为女性也在看色情内容。

Because, again, I think females are watching porn as well.

没错。

Exactly.

是的。

Yeah.

你知道，我认为你提出了一个非常关键的点，那就是羞耻感可能是双向的。

You know, so I think that you raise a really critical point, which is that the shame can extend both ways.

嗯。

Mhmm.

嗯。

Mhmm.

因此，我认为在这方面确实是个问题。

And so I think to that end, that's a problem.

而且因为色情内容如此容易获取，我认为我们需要展开讨论。

And because it's so accessible, I think we need to have conversations.

我觉得这需要开放。

I think it needs to be open.

我们必须谈论性。

We have to talk about sex.

这正是我做我所做之事的原因。

And that's kind of why I do what I do.

我们必须进行这些对话，让人们了解什么是正常的。

We have to have these conversations so people know what normal is.

谢谢你这么说。

Thank you for that.

我认为人们需要了解什么是正常的，以及正常范围是多少，同时保持我们之前提到的限制，因为我认为这些是普遍健康的限制，对吧？

I do think that people need to know what normal is and what the range on normal is, keeping the constraints that we talked about place earlier, because I do think those are universal healthy constraints, right?

自愿、年龄适宜、情境适宜、物种适宜。

Consensual, age appropriate, context appropriate, species appropriate.

当然。

Absolutely.

我问过想象中的纯粹想象引发的性唤起与视觉唤起之间的区别。

I asked whether or not imagined Pure imagination based arousal versus visual arousal.

对一些人来说，听到别人做爱的声音会非常具有性吸引力。

And for some people, the sounds of people having sex is extremely arousing.

如果你曾经住在像纽约这样的大城市——我曾在纽约度过几个夏天——你会经常听到这些声音，比住在人口稀疏地区的人听到的要多得多，你会听到别人做爱的声音。

If you ever lived in a major city like New York, which I've spent summers in New York, you hear a lot, you hear more often than you do in areas where people are living further apart, you hear people having sex.

是的。

Yeah.

这是听觉环境的一部分。

It's part of the auditory landscape.

没错。

Yep.

你们住得非常近。

You're very close together.

但确实，至少据我所知，目前还没有数据专门研究幻想、视觉和听觉刺激之间的差异，但我可以肯定地说，人会对某些事物产生习惯化。

But yes, so there's not exactly, at least to my knowledge, I don't know of the data that looks at fantasy versus visual versus auditory, but I will say that you can get habituated to certain things.

而且确实有数据显示，你可能会对观看某种特定类型的内容产生习惯性 arousal。

And there is that data that maybe you can get habituated to watching a certain type of thing to get aroused.

然后正常的事物就无法让你 arousal 了，对吧？

And then normal things do not get you aroused, right?

比如你可能经常看色情内容，结果在看到伴侣时反而难以产生 arousal 或性冲动。

Like you may watch pornography, and then you may have difficulty getting aroused or turned on when you see your partner.

你可能已经习惯了以某种特定方式自慰，对吧？

You may get used to masturbating a certain way, right?

所以如果你每次自慰时都使用某种振动刺激或特定的压力感，你就可能对这种刺激产生习惯。

So if you use certain vibratory stimulation or certain pressure sensation every single time you masturbate, you can get habituated to that.

而在进行插入式性行为时，你可能无法复制这种感觉。

And you may not be able to replicate that during penetrative intercourse.

所以我认为这非常重要。

And so I think that's really important.

我认为关键在于尝试改变你所做的事。

And I think the take home is to try and vary what you're doing.

自慰是一种健康、良好的自我探索方式。

Masturbation is a fine healthy way of self exploration.

同样，前提是不要过度自慰，避免逃避你的责任、家人、伴侣或朋友，对吧？

Again, with the caveat that as long as you're not masturbating to excess and avoiding your obligations or your family or your partners or your friends, right?

比如，你只是因为自慰有助于改善睡眠、提升情绪、减轻焦虑等好处而自慰，这些都很棒。

Like you are just masturbating for the benefits of maybe sleep improvement, mood boosting, reduction in anxiety, those things are great.

因此，我认为在这一点上，你只是需要用心去尝试变化方式。

And so I think with that being said, you just want to be thoughtful about varying it up.

我在其他播客做嘉宾时曾谈到过自慰的一个问题，主要是在男性自慰和可能涉及色情内容的背景下，当然也可能不涉及——根据关于成瘾的数据，很明显，每当在不需要太多努力的情况下产生大量多巴胺时，比如在互联网上打开色情内容，而不是约人约会、去约会。

One of the issues with masturbation that I've talked about when I was a guest on other podcasts, mainly in the context of male masturbation and perhaps with pornography, perhaps not, is that it's pretty clear based on the data surrounding addiction that anytime there are big increases in dopamine without a lot of effort required to generate that dopamine, like turning on pornography on the internet versus asking someone out on a date, going out on a date.

再次强调，我们讨论的是人类求偶仪式中的对话和过程，当然，在健康互动的背景下，这涉及获得相互同意等，对吧？

Again, we're talking about going through the conversations and the mating ritual that is the human mating ritual that of course, in the context of healthy interactions involves getting mutual consent and these kinds of things, right?

你可以想象，如果不带任何道德评判，不羞辱任何人，如果一个人只进行自慰，而没有发展出求爱和建立健康性关系的技能，那么色情内容和/或自慰可能会开始引发所谓的‘问题’，对吧？

That you could imagine how without placing any moral judgment on it, without shaming anybody, you could imagine that if somebody exclusively masturbated and didn't develop the skills of courtship and building healthy sexual relationships, that pornography and or masturbation could start to create quote unquote problems, right?

在这种情况下，一个人只在这些领域感到舒适。

Whereby somebody only felt comfortable in those domains.

我认为，这正是我最近听到越来越多的年轻人联系我时所表达的。

And I think that's what I'm hearing more and more about when it seems to be young men reach out.

确实如此。

Absolutely.

而且我觉得，你说得对，这确实是由于获取途径太容易了，对吧？

And I think you're, you know, it's definitely the ease of access, right?

但我认为，这在当今的年轻人中非常普遍。

But I think that's pervasive in the young society now.

你根本不需要真的去寻找伴侣。

Like, you don't have to actually go and find a mate.

你只需要打开一个应用，就能找人。

You can just go on an app and look for somebody.

对吧？

Right?

就像，现在

Like, there's

嗯，这确实是寻找伴侣的多种方式之一。

Well, that's many a form of finding a mate.

我的意思是，我成长的那个年代，根本没有智能手机之类的东西。

I mean, I I was weaned in the era when, you know, no smartphones or anything.

而且

And

没错。

No.

我的观点是，我们认为自己已经深深融入了科技世界，这也意味着我们之间的面对面交流减少了。

My point is I think that we've become very connected to technology in our world, which also means that we're having less conversations.

年轻一代的面对面交流更少，而在线交流更多。

The younger generation is having less conversations and more online conversations.

我认为这也是需要培养的一项技能。

And I think that's a skill that needs to be developed as well.

我认为这部分也在促成这一切。

And I think part of that is contributing to all this as well.