Dr. Reena Malik, a urologist and sexual health educator, breaks down the foundational pillars of sexual health, the most common problems she sees in her practice, and the practical, evidence-based steps people can take to improve their sex lives and overall health.
Why People Are Having Less Sex
Young adults are having less sex than previous generations, driven by constant phone and social media use, dating app culture that promotes shallow connections, and a lack of real sex education.
Dopamine-heavy activities like short-form video, pornography, and social media scrolling make it harder for people to be mentally present during sex, turning it into a mechanical act rather than an intimate experience.
Rough sex, particularly choking, has become extremely common among young people, with around 60% of college-age women reporting being choked during sex, often not because they enjoy it but because they believe it is expected.
The Four Pillars of Sexual Health
Dr. Malik organizes sexual health into four pillars: fuel, strength, environment, and confidence. Neglecting any one of them undermines the others.
Fuel: Diet and Nutrition
The Mediterranean diet is the most studied and effective diet for sexual health, associated with a 22% lower risk of erectile dysfunction.
Specific foods that help include pistachios (100 g daily showed measurable improvement in erectile function), blueberries (around 20% improvement in erectile function), and foods rich in flavonoids like citrus fruits and lycopene-rich red fruits.
Fiber is critically underappreciated: it converts to short-chain fatty acids in the gut, which protect blood vessels and improve metabolic health, directly benefiting erectile function. Men should aim for 38 g per day, women 25 g.
Excess body fat increases aromatase, an enzyme that converts testosterone to estrogen, lowering testosterone and increasing the risk of sexual dysfunction.
Strength: Exercise and the Pelvic Floor
150 minutes of moderate cardiovascular exercise per week improves erectile function as much as Viagra. Even light walking programs in men with heart disease improved erectile function by 70%.
Resistance training of large muscle groups boosts testosterone and helps maintain muscle mass, which is linked to sustained erectile function and sexual desire. Men who maintain muscle through resistance exercise are three times less likely to develop erectile dysfunction.
The pelvic floor muscles are essential for orgasm (they contract rhythmically at 0.8-second intervals), ejaculation, urinary continence, and blood flow to the genitals. Tension or dysfunction in these muscles can cause erectile dysfunction, difficulty orgasming, premature ejaculation, pain during sex, urinary urgency, constipation, and back pain.
Kegel exercises are only appropriate for a healthy, normal pelvic floor. If the muscles are already tight, Kegels can make things worse. Relaxation techniques like diaphragmatic breathing, figure-four stretches, and yoga poses (happy baby, child’s pose) are needed instead. Severe cases require a pelvic floor physical therapist.
Environment: Stress, Sleep, Chemicals, and Social Circle
Chronic stress keeps cortisol elevated and testosterone suppressed, maintaining the body in a sympathetic nervous system state that prevents arousal. Small interventions like 20-second hugs and six-second kisses with a partner can help break stress loops.
Sleep deprivation has dramatic hormonal effects: men sleeping 5 hours per night instead of 8 see a 15% drop in testosterone after just one week, equivalent to 10 years of aging. Sleep apnea, which can be screened for by measuring neck circumference (over 17 inches for men, 16 for women), can reduce testosterone by as much as fixing it raises it by up to 200 ng/dL.
Endocrine-disrupting chemicals in plastic water bottles (phthalates, BPA), non-stick cookware, and microplastics in dust and synthetic fabrics can mimic estrogen and reduce testosterone. Practical steps include avoiding warming food in plastic, using glass or metal storage containers, choosing ceramic over non-stick cookware, and drinking from metal bottles.
Social environment matters: being around peers who normalize not having sex or who complain about their sex lives makes a person more likely to accept the same in their own life. Studies show that surrounding oneself with people who practice positive sexual behaviors increases safe sex practices by 46%.
Pornography is not inherently harmful; the issue is the individual’s relationship with it. Compulsive use to escape negative feelings or intense guilt about watching it are the main predictors of sexual dysfunction, not the amount consumed. Couples who watch porn together report higher relationship satisfaction.
Confidence: Knowledge, Communication, and Exploration
Confidence means understanding your partner’s anatomy, communicating openly, and being willing to explore. The clitoris is mostly internal, with bulbs and legs extending deep into the pelvis, and the G-spot area on the anterior vaginal wall allows internal stimulation of the clitoral body and the Skene’s glands (the female homologue of the prostate).
Sex toys can add novelty and help couples explore. Concerns about permanent desensitization from vibrators are unfounded; studies on construction workers using vibrating tools show any numbness is temporary.
Novelty does not require extreme changes. Small variations like a different room, a pillow under the hips, or a slight positional shift can introduce the mild challenge needed to enter a sexual flow state, where people become fully immersed and experience the best sex.
Sexual Performance and Orgasm
Performance anxiety creates a vicious cycle: worry about maintaining an erection activates the sympathetic nervous system, which prevents arousal, leading to failure and further anxiety. The recommended treatment is sensate focus, a graduated process of exploring non-genital touch, then genital touch without penetration, and finally reintroducing penetration only after arousal happens naturally without pressure.
Morning erections (nocturnal penile tumescence) are a sign of healthy blood flow, hormones, and nerve function. Young men have 3 to 5 erections per night, lasting up to 40 minutes each. Women experience the same phenomenon as nocturnal clitoral tumescence. These nighttime erections are the body’s way of maintaining genital health through regular blood flow. Without them, the spongy erectile tissue (corpora) develops fibrosis and the organ can shrink over time.
If a man can get erections from porn but not with a partner, the cause is usually psychological (no performance pressure when alone) or habituation to a specific type of stimulation (a very firm grip, for example) that a partner cannot replicate.
For women, only about 15% can orgasm from penetration alone; the vast majority need direct clitoral stimulation. Positions where the woman is on top give her more control over clitoral stimulation angle. The coital alignment technique, a rocking motion where the pubic bone rubs against the clitoris during penetration, has been shown to increase orgasm rates.
Squirting occurs in about 40% of women. The fluid comes from the urethra and contains both bladder fluid and secretions from the Skene’s glands. It is chemically different from urine (clear, odorless) though it does pass through the bladder. Evolutionary theories for why it exists include antibacterial protection against UTIs (the fluid contains PSA and zinc), a vestigial ovulation trigger, and a mate selection reward mechanism.
Erogenous zones are nearly universal across bodies: neck, nipples, lips, buttocks, and inner thighs. Slow caressing at 3 cm per second activates C-tactile afferent fibers that produce pleasure, while faster speeds (18 cm/s) are less effective. These fibers respond only to human touch, not gloves or devices, which is why human massage is irreplaceable.
Testosterone
Average testosterone levels in men have dropped about 25% since the late 1990s (from around 600 ng/dL to 450 ng/dL), driven by obesity, endocrine-disrupting chemicals, ultra-processed food, diabetes, and insulin resistance.
Testosterone declines about 1% per year after age 30 to 40, but not every man becomes hypogonadal. Symptoms of low testosterone include fatigue, brain fog, depression, low desire, erectile dysfunction, increased fat mass, and decreased muscle mass.
There is no direct correlation between testosterone level and fertility. High testosterone does not mean more fertile, and testosterone replacement therapy actually suppresses fertility: about 70% of men on TRT become infertile within 18 months, with sperm count drops visible as early as 10 weeks. Recovery can take up to 2 years.
Anabolic steroids (taken by bodybuilders for muscle growth) are not the same as testosterone replacement therapy. Anabolic steroid use carries a 15 times higher risk of premature heart failure and a 122 times higher risk of cardiac death.
TRT is only appropriate for men who are both symptomatic and biochemically low. If testosterone receptors are already saturated, adding more provides no additional benefit for mood, cognition, or sexual function, though it may continue to increase muscle mass.
Free testosterone (the 1% to 2% not bound to proteins) is often more informative than total testosterone, since SHBG levels vary widely between individuals and are affected by thyroid function, aging, and oral contraceptive use in women.
Penis Size, Enlargement, and Related Anxiety
More men want a longer penis than want to be taller. Average erect penis length is 5.3 to 5.5 inches, though men tend to estimate the average as 6 to 7 inches. Women on average say they want about 6 inches, but sex toy purchase data shows the most popular sizes are close to average (5.2 to 5.5 inches).
Small penis anxiety is widespread and often begins in childhood or adolescence. Men compare themselves to porn actors, who are genetic outliers.
The man with the largest medically verified penis (13 to 14 inches) reports that it makes sex difficult and uncomfortable for partners, illustrating that bigger is not better.
Penis shrinkage with age is not inevitable if blood flow is maintained through regular erections. Weight gain can make the penis appear smaller as the suprapubic fat pad enlarges.
Traction devices are the safest and most evidence-based enlargement method: 30 minutes twice daily for 3 to 6 months can yield about 2 cm of increased length. Results may not be permanent if the device is discontinued. These devices can also help correct curvature from Peyronie’s disease.
Jelqing (stretching the penis with the hands) is dangerous and has caused micro-tears leading to erectile dysfunction. Surgery for penile lengthening has very high complication rates and can result in permanent disfigurement.
Only about 15% of women orgasm from penetration alone. The vast majority need clitoral stimulation, which can be achieved with fingers, mouth, or toys. Average vaginal length is about 3.5 inches at rest, expanding to double that when aroused, easily accommodating an average penis.
GLP-1 Drugs and Sexual Health
Drugs like Ozempic improve metabolic health, which benefits sexual function through better blood flow, weight loss, and improved body image. The reduction in the suprapubic fat pad can make a penis appear longer (“Ozempic penis”).
However, because GLP-1 drugs act on the brain’s reward pathway, they may reduce desire not just for food but potentially for sex, gambling, shopping, alcohol, and smoking. This effect may go unnoticed because patients feel so good otherwise. If desire drops, dose adjustment may help.
How to Talk to Sex With Your Partner
Avoid bringing up sexual issues in the bedroom or right before or after sex. Instead, choose a calm, low-pressure setting like a walk or a car ride where you are side by side rather than face to face.
Start with something positive about the relationship, express curiosity rather than blame, and let your partner have input on when to have the conversation.
Men and women often frame sex differently: women tend to experience sex as an added demand when stressed, while men often use sex as their primary way of achieving intimacy and stress relief. Recognizing this difference is key to resolving desire mismatches.
Building intimacy throughout the day through affection, compliments, and small gestures creates the conditions for good sex, rather than treating sex as a scheduled task to complete.
Fantasies are nearly universal and often involve submission, voyeurism, multiple partners, or strangers. Fantasizing about something does not mean a person wants it in real life or is dissatisfied with their partner. Writing down private fantasies and optionally sharing one with a partner can be a low-pressure way to explore.
Men’s top communication taboos include performance anxiety and erectile dysfunction (linked to masculinity), expressing nonsexual emotional needs, setting boundaries or communicating rejection, and discussing unconventional fantasies. Women’s top taboos include asking for more foreplay or specific clitoral stimulation (fear of being labeled high-maintenance), discussing pain or discomfort, body image concerns, and explaining why they are not in the mood.
The Bigger Picture
People who have sex once a week live 49% longer than those who have sex once a year. For every 100 orgasms men have, life expectancy increases by about 13%. While causation is hard to establish, sex is a cardiovascular workout, a marker of good health, and a powerful antidote to loneliness, which the WHO has classified as a global epidemic as harmful as smoking 15 cigarettes a day.
Semen quality is a biomarker of overall health: men with poor semen parameters die younger in a dose-dependent manner, except when the cause is genetic.
Dr. Malik’s book, The Hard Truth: Everything Men Need to Know About Good Health, Great Sex, and Long Life, is due in September 2026 and covers these topics in depth.
