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For so many reasons — shame, privacy, social discomfort — we don’t talk enough about sex as a public health issue. But it’s an important part of a healthy adult human life. So, we’re going to talk about sex. Abdul reflects on the forces that keep us from having a healthy, sex-positive perspective. Then he speaks with Emily Nagoski, New York Times Bestselling Author and Sex Educator about how to reframe and rebuild long term sexual relationships.

TRANSCRIPT

[AD BREAK] [music break] 

Dr. Abdul El-Sayed, narrating: Donald Trump threatens to cut off federal school funding over vaccine mandates. President Biden releases his 2025 federal budget. There are several important implications for American health care. A new study sheds light on the risks of microplastics. Oh, and a German man was vaccinated for Covid 217 times. He’s fine. This is America Dissected. I’m your host, Doctor Abdul El-Sayed. [music break] Dissectors, before I get started, a big thank you to all of you who shared your interest in earning CME credits through the pod. If you didn’t get a chance to share your CME needs with us, there’s still time. Head on over to AmericaDissectedcme.com. That’s America Dissected like the show title cme.com. All right, let’s get nerdy about getting dirty. Y’all know the drill. I usually start each episode with some personal or professional anecdote that I try to build out to a broader, evidence driven arc about a circumstance that’s ailing us all, and then introduce the interview. But I’m not taking anyone in my bedroom. Why? Because I was taught from a very young age that one ought not to talk about that in front of polite company. After all, sex is a shameful, dirty act, but also the physical act of showing love. And that’s exactly it. Sex is a quandary wrapped in a quagmire. We both call it making love and getting dirty. And I get that there are versions of it that are closer to each of those. But it’s still sex that’s both love and dirty. Make it make sense. So why do we think about making love as getting dirty? Let’s start with the evidence as we are want to do here. A study from 2017 found that Americans in their 20’s had sex about 80 times a year, compared to Americans in their 60s who did it about 20 times a year. But what’s interesting is that the kids these days are just having less sex. Millennials and zoomers are bedding less than their parent’s generation did. The Atlantic’s Kate Julien went as far as to call it a, quote “sex recession.” Must be all of our lattes and avo toasts, no? Or maybe it’s the housing crunch and student debt. Or maybe it’s online porn. All possible hypotheses except the lattes and avo toast, of course. Whatever it is, it means that the average adult is having 13% less sex than in the late 90s. In fact, another survey found that one in four American adults reports not having had sex in the last year. And that’s pretty consistent from what I hear from a number of folks these days. Mostly millennials like me, often in loving, committed, long term relationships, many with kids. Life gets hectic between work commitments, the struggle to keep up with various chores inside and outside the house, and the absolute libido killer that is the existence of children in your home. There’s just not time. And when there’s time, there’s not desire. And when there’s desire, there’s not space. And when there’s all three, there’s not the partner. And subordinating that most natural human act to the tyranny of our ever so busy lives is just one way capitalism steals our sex from us. The other? Well, there’s this irony. Society has never been more open about sex, but we’re having a lot less of it. And part of that, as we’ll discuss more later in the show, is that the sex were being sold. Yes, sold is exactly that. It’s a productized version of the thing, not the real thing you have with a real partner built on a real relationship, warts and all. We’ve talked a lot about social media on this show, and the way that it destroys so much of our confidence by showing us a highlight reel of other people’s lives on infinite scroll. That’s what modernity has done to sex. What’s that they say? Comparison is the thief of joy? If so, that’s the other way capitalism has become the thief of sex. Sex positivity isn’t about being exposed to the highlight reel picked and pruned version of sex that is so ubiquitous on our screens. It’s about embracing the sex we actually have. Doctor Emily Nagoski, our guest today, is a sex educator and New York Times bestselling author. She was riding high after the publication of her first book about women’s sexual health. And then let’s just say she found challenges of her own. And that forced her to reconsider all the ways we think about sex in long term relationships. Which inspired her to write another bestseller about it, as one does. Here’s my conversation with Doctor Emily Nagoski. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Emily Nagoski: Yes, I’m Emily Nagoski. I am a sex educator and author of Come as You Are and Come Together. 

Dr. Abdul El-Sayed: Well, I really appreciate you taking the time today because I think, um the subjects that you write on are so critical, fundamental to the human experience. But they’re not something that we talk enough about, or think enough about, frankly. And, you know, there’s all sorts of expectations and stigmas and, um norms and mores that I think leave folks, um unfulfilled quietly. And I um, you know, I see your work as about trying to address that, uh and to start with a public conversation. So I want to sort of jump in and tell me a little bit about what motivated uh your interest in, in, becoming a sex educator and writing, in particular, Come Together? 

Emily Nagoski: Yeah. I started as a sex educator. Oh, almost 30 years ago now, in the mid-nineties. I was a big nerd in high school, unsurprisingly, so when I got to college, I knew I was going to be going to grad school eventually for something. So I needed some volunteer work on my resume. So I uh, a guy on my floor was pre-med and said, hey, come be a peer health educator with me. And I thought, I like health. Why not? So, uh I did, I got trained to go into residence halls to talk about condoms, contraception and consent. And while I was getting a degree in psychology with minors in cognitive science and philosophy, uh the work I was doing as a sex educator and then as a sexual violence prevention educator and then as a sexual violence crisis responder. That work made me like who I am as a person in a way the brain stuff never could. Much as I love the brain stuff. I decided that sex education was the path I was going to choose. So, I went to grad school. I get a master’s degree in counseling. I was going to be a sex therapist about halfway through that degree, I realized I do not have the magical thing it takes to sit with people week after week can go, mm hmm. What was that like for you? I don’t have it. Um. But, I am a nerd, and I am a woman who likes to be in charge of things. So I continued on to get a PhD, and what is now the IU School of Public Health, concentrating in human sexuality. Uh. And ultimately got a job as the director of wellness education at Smith College, where I taught a course called Women’s Sexuality, which is a deliberately provocative name for a course at Smith College, because what’s a woman and what is sexuality? And at the end of the first semester teaching there uh, the last question on the final exam was. Just tell me one important thing, you get the two points, no matter what you say. Very important that you get the two points. Just one important thing you learned. And more than half of my students, 187 students, more than half of them wrote something like, I learned I’m normal. I’m normal. Just because I’m different from other women doesn’t mean I’m broken. I can trust my body because I know I’m normal. Um. And you may have had this experience of grading final exams, so, you know, it’s not usually like this. I was in my office grading with tears in my eyes. 

Dr. Abdul El-Sayed: Yeah, wow. 

Emily Nagoski: Feeling like something important had happened for my students, and I wanted to do it again. And bigger. And that’s the day I decided to write, Come as You Are, five and a half years later, Come as You Are gets published. And in the process of writing that book, I was so stressed that I lost all interest in actually having any sex with my husband. And then I finished the book, and it got better. And then I went on book tour, and it got worse. I would try to follow my own advice in Come as You Are, I talk about responsive desire and how, like, you set up a time, you put your body in the bed, you’ll let your skin touch your partner’s skin, and your body will wake up and go, oh, right. I really like this. I really like this person. And I would put my body in the bed and let my skin touch my partner’s skin, and I would cry and fall asleep. And I thought I need better advice than I gave in my own book. So I did what anyone would do. I went to Google Scholar and I looked at the peer reviewed research on couples who sustain a strong sexual connection over the long term. And what I found there contradicted the whole mainstream discourse about sex in long term relationships. Right. Because it was 2014. Deep in the conversation about is intimacy the enemy of the erotic? And you need distance to keep the spark alive? Or is intimacy the foundation of the erotic? And you need closeness to keep the spark alive. When you look at the research on couples who sustain a strong sexual connection over the long term, they do not talk about spark. 

Dr. Abdul El-Sayed: Hmm. 

Emily Nagoski: They don’t talk about desire and how much they want sex. They don’t talk about craving. They don’t talk about desire. They talk about pleasure. They talk about engaging in sexual behaviors that everybody involved enjoys. Which is a fundamental transformation of the way to think about how sex in a long term relationship works. It is not about– 

Dr. Abdul El-Sayed: Yeah. 

Emily Nagoski: –how much you want the sex, it’s about whether or not you like the sex that’s available to you in that relationship. I actually told my literary agent what I was learning and she was like, so would you consider writing another sex book? And that’s how that happened. 

Dr. Abdul El-Sayed: I really appreciate that, that insight. Um. Just to, to step back, like to understand the scope of this, what proportion of people in long term relationships have an unfulfilling sex life? Like how common is this? Because, you know, I think about, I’m uh I’ve been married now for nearly 18 years, and– 

Emily Nagoski: Congratulations. 

Dr. Abdul El-Sayed: I think about. Thank you. Um. And I think about a lot of my folks in my sort of relationship, peer group, people who, got into committed relationships at about the same time and distance and I, you know, think about the conversations I’ve shared with um, my, my friends. And it seems like there’s this sort of silent epidemic of unfulfilling sex lives. Um. When you look across the population, how common is that? 

Emily Nagoski: Very. And I’m going to give you the unsatisfying answer that I don’t provide numbers on things like this because it is impossible for me to say, like x percent of people experience blah, blah, blah, or couples have sex X frequency per whatever time period, because you can’t hear a number like that and not judge yourself against it and have an opinion about whether you’re okay or not based on other people’s sex lives. And those people’s sex lives don’t actually have anything to do with you and your sexuality, but it’s just impossible to receive those numbers without having those feelings. So I’ll say it’s really common. The most common thing is for it to come and go. Pardon the expression. For like the sexual connection to be really strong and then life gets in the way. 

Dr. Abdul El-Sayed: Yeah. 

Emily Nagoski: And the couples who sustain a strong sexual connection are not the ones who never lose track of each other. They are the ones who find their way back. And the reason they find their way back is because they have figured out that for them in their relationship, sex contributes something important. That they prioritize sex because it matters in their relationship that they cordoned off space, time, and energy to close the door on all the other things we could be doing with our lives, and God knows we are busy. And just like, roll around naked with lube and lick each other and have fun and giggle. 

Dr. Abdul El-Sayed: I really appreciate that point because I think some folks will listen to a conversation about sex and say, well, why are you not focused on the hard issues? You know, you know, I come here for hard hitting conversations about things like overdose and cancer and heart disease. But walk us through just how fundamental and foundational um having a sexual relationship is to thinking about your own joy fulfillment, but also your mental health. And, you know, that sort of stickiness, that glue that tends to keep people together. And, you know, when we talk about things like isolation and mental health, that stickiness of being together is kind of important. Um. And I’d love to hear your thoughts on the role that sex plays. Even beyond the self-evident joy and, um and and meaning of being able to have sex and enjoy that part of your humanity. 

Emily Nagoski: It’s self-evident to you. And there are plenty of people hearing this who are like, why, why, why would we even like, why? Why is it the thing I have to do? Why is this an expectation that the world has of me? Why would I do this? Um. And it’s actually a question that I started asking my workshops a couple decades ago. What is it that you want when you want sex and people’s sort of off the cuff, flippant answer is, well, orgasm. Um. But most people can do that on their own. And if you can’t, there’s whole books and workshops just about that. But most people can have an orgasm on their own. And so what is it that you want when you want sex with this other person present? Um. At this point, I’ve asked a few thousand people that question, and there’s four big themes. And the first one with isolation, you hit the nail on the head. The number one thing people say they want when they want sex is connection. Human beings have a lot of ways that they can experience connection with each other. For some people, sex is a fairly peripheral way that they experience connection, and for other people it is like the primary way. It is the most powerful channel for experiencing connection with another person. So connection is number one. The second thing people say they want when they want sex with another person is shared pleasure. There’s something specific, not just about like, you know, I put my body in the bed. I let my skin touch my partner’s skin, and I enjoy how it feels for my body to touch that other person’s body. I also want my partner to enjoy that sensation, and I want them to enjoy my pleasure. And I want to enjoy their pleasure. That shared pleasure is a specific thing that people want when they want sex with another person. Third, people want to be or feel wanted. And no wonder so many of us grow up being taught that the sexual parts of ourselves are dirty, dangerous, and disgusting. So to have a connection where those parts are not merely acceptable and sort of okay, but wanted, desirable. Yum. Give me more of that. Of course, that is the thing we want. Not to mention all the gendery messages about how being wantable as a sex object validates us in our identities. There’s the whole, there’s a whole chapter about the patriarchy. Don’t worry. Um. And the fourth most common theme is, a variable that I called freedom, which is this ability, like I said, to close the door on all our other responsibilities and obligations and roles and identities and functions in life and just disappear into the pleasurable things that are happening in this moment. It is incredibly nourishing for us to experience pleasure in our bodies, pleasures only available to us neurologically in uh an appropriate context. I’m a big polyvagal theory nerd. Um. Pleasure is mostly available to us when we’re in a ventral state, which is the safety and connection state, as opposed to the sympathetic activation fight or flight. Run for your life. Like when you’re being chased by a lion. That’s not a great time to be like, savoring pleasure. And when you’re in a dorsal shut down conservation state, literally, the way your brain functions shifts depending on your activation state. When you are feeling safe enough and connected enough, the nucleus accumbens, how nerdy should I get? 

Dr. Abdul El-Sayed: Get nerdy. That’s that’s what we do here. Okay. Get nerdy by getting dirty. 

Emily Nagoski: The nucleus accumb–

Dr. Abdul El-Sayed: There we go. 

Emily Nagoski: Yeah. Uh [laugh] that’s my whole life right there. Kent Berridge’s research is really crucial here. If people are like here are the– 

Dr. Abdul El-Sayed: By the way, we just– 

Emily Nagoski: –actual. 

Dr. Abdul El-Sayed: We just titled the podcast. [laughing] I’m sorry. [laughter]

Emily Nagoski: So I will. So one of the things, ideas in the book is the idea of this emotional floor plan that you need like to figure out what sort of space you’re in emotionally before you get into the lust space, because like, you get into that space so that it’s easy to get to lust. And for me, seeking curiosity, exploration is like the easiest place to be to get into the lust space. So when I was in grad school, I dated other grad students, as you do. And uh, we would we would talk about our research. And for me, talking about affective neuroscience, like water slide from conversation about affective neuroscience right into the lust space. So you had you had your finger up. 

Dr. Abdul El-Sayed: I wanted to ask, you know um, on that note, you know, I did want to sort of think a little bit about some of the concepts in the book, because I thought they’re really illuminating about how to how to engage with a space that tends to be closed off to a lot of people in the hustle and bustle of their life. And and you talk about this idea of a context for sex, and I think you just shared. 

Emily Nagoski: Right. 

Dr. Abdul El-Sayed: One for you. And almost you use, you use this analogy of a layout or a floor plan. Can you talk a little bit about that? What do you mean by that as as a way to think about sex? 

Emily Nagoski: Yeah. So I will say in advance it took me two chapters to to describe this. So um, it’s not going to be thorough what I’m about to say, but I will say that this is the idea that fixed it for me. So it’s really powerful, but it’s not easy. So um, first of all, can we just say it’s 2024 and we do not live in a world where there is one universally agreed upon theory of human emotion. There are at least three actively competing models of how human emotion works, and only one of them includes sex. Includes lust. Uh. So that’s the model I picked when I was trying to figure out what was going on with me, when I would like try I’d put my body in the bed. I love my partner. We have a great relationship. I know that, like, if I could just get there wherever there was, we would have like we would have a great, pleasurable, joyful, connected, loving sex. If I could just get there instead of crying and falling asleep. Uh. And so I turned to the affective neuroscience of the father of affective neuroscience, Jaak Panksepp, whose uh, book Archeology of Mind sort of changed everything. I tried to shoehorn it into Come as You Are and like, it wouldn’t fit. But, now I’ve got two chapters in Come Together. So uh, I took his model of seven primary process emotions, sort of the universal core mammalian emotions. And put it into this metaphor of a floor plan. So he says there are seven primary process emotions. Lust is one of them. And that’s the mammalian motivation system of courtship and mating. That’s one of the pleasure favorable spaces. There are three other pleasure favorable spaces. One of them is seeking, which is this curiosity exploration kind of space for some people it’s going to be intellectual like it is for me. For some people, it’s going to be like adventure out in the world. I know people who sold everything they own and, like, traveled around the world together for a year. Sounds like a nightmare to me. But they had they loved it. Things went wrong all the time, usually in places where neither of them spoke the language, and for them, the adventure and the problem solving and the excitement of it was like right next to the lust space. And they now have the babies to show for it. Another space–

Dr. Abdul El-Sayed: Adventure babies, I love that. 

Emily Nagoski: Adventure babies, exactly. It might be like cooking classes or going to art museums, but that like curiosity exploration space for some people, really close to the lust space. Maybe the most surprising for a lot of people is the Play space. Play is the universal mammalian motivational system for friendship. Play is any behavior that we engage in for its own sake, because everybody involved likes it and there is nothing at stake. Sex at its best is play with nothing at stake. So a context for me that makes it easy to enjoy sex is vacation. Honestly, that’s play sex because you can step away from all the all the dimensions of your life, where the stakes are high, parenting and work and all those other identities that we have and just connect and play separated from all of the places that are serious. Uh. So there are lots of different kinds of play, object play obviously. So with little kids, uh they start out being like, what is this, the exploring. What is the what is it, what is this object when they’re in the bathtub. What is this? And then they start to play with the water in the bathtub. And playing is what can I make this object do? They start splashing in the water. What can I make it do? Sex obviously can be a form of object play. Your partner’s genitals. What can I make this do? Whoa! This is fun and interesting. What can I make this do? Nothing at stake. No performance demands, no expectation. Just what happens when I try this? Is that good? Play. There’s story play. There’s rough and tumble play. The most important thing is that nobody has anything to lose. Nobody’s like, identity is on the line. Uh. And then the last of the pleasure favorable spaces is the care space, which is a vast attachment, is really important for humans because I’m sure [?] cephalopelvic pelvic disproportion and neoteny, human beings are born underbanked. And so uh, we attach very intensely and we carry that attachment into our adult lives. And for a lot of people feeling like they are cared for and like they can care for someone, I think of it as like the living room of the emotional floor plan, where you’re lying on the couch in front of a crackling fire, snuggling with your certain special someone. For a lot of people, that emotional experience of feeling held and cared for and having their needs met is very adjacent to the lust space. [music break]

[AD BREAK]

Dr. Abdul El-Sayed: So I really appreciate that because it helps us think a little bit about helping folks sort of slide into the mindset, if you will, of being able to find that space that’s pleasurable. And I want to just point to that because you said it, and I just want to make sure our listeners appreciate that, because that’s not the same thing as a spark or feeling desire. And I think when you think about sex as a adjacent to play or adjacent to care or adjacent to adventure or adjacent to intellectual uh engagement with somebody, you start to come to that connection piece in a, in a, in a much clearer way then this idea of I have to be carnally attracted to your body right now. And so I want to contrast that because, you know, you set up this argument really nicely contrasted to this idea of uh, what you call imperatives. Right? And these imperatives are our expectations about what something ought to be. And then you develop that into thinking a little bit about how we think about our own body and and sex and body positivity. Can you tell us a little bit about imperatives and how they operate sometimes to take away um that, that focus on on shared pleasure? 

Emily Nagoski: Yeah. I borrowed this language of imperatives from a book called Mediated Intimacy. It has three authors, and I can never remember all their names because long Covid drilled a hole in the place in my brain where new names live. Uh. But I know the first author is Meg-John Barker. So, they did an analysis of mainstream media, the TV and magazines and books about what the messages were that were being communicated explicitly and implicitly in the media. And they had they were just, like, imperative after imperative. So there’s the sex imperative itself, the imperative to be a sexual person who has and likes and wants lots of sex. The performance imperative is maybe my favorite in an ironic way, because the performance imperative is about being obliged, morally obliged, to constantly work on getting better at sex, like you’re an employee who wants a promotion. There’s the intercourse imperative because heterosexuality is just assumed, and penis and vagina sex is, I guess, the expectation. The whole point of having sex is to put the penis in the vagina. Oy. Uh. And the all of the beauty imperatives, the pretty imperative to have a body that looks a certain way and never, ever to simply welcome your body as it is, but always to work on it and try and change it, or else you have, like, given up on yourself rather than embracing yourself as you truly are. And for me, as I was writing the book and thinking about this contradiction between the mainstream conversation that like, how do you keep the spark alive versus what the research says, which is people who have great sex are not worried about spark. They are really interested in co-creating a life that makes pleasure easy to access. And uh, I interrupted myself. Um. Pleasure is only available in our brains when our brains are in a certain state. The nucleus accumbens shell has what Kent Berridge calls the affective keyboard, where when you’re in, like a relaxed, happy, safe, connected state of mind, 90% of the nucleus accumbens shell becomes devoted to approach motivation. So almost any stimulation will result in an ooh, ooh woo what’s that sort of response? When they do these studies in rats, they put a probe in the nucleus accumbens shell, they zap it and the rats in like a happy, I call it the rat spa. Um. In the research they just call it the home environment. So it’s a peaceful, calm, connected state. Almost anywhere that you zap on the nucleus accumbens shell, the rat goes woo, woo, what’s that? Whoa? And then when they put the rat into a different room where the lights are on really bright and there’s music on. Not even just loud, but a different volume. So the rat can’t even habituate to the sound. It’s a very stressful environment. Almost anywhere that you zap on the nucleus accumbens shell will result in ugh what the hell is that? This is defensive dig, this is a defensive digging gesture where the the rat is kicking up dust in the face of the predator. Uh. There’s videos of it on YouTube. You can totally. It works. It’s amazing. Um. But these are uh, avoidance responses. So even in response to the same stimulation, your response will be different depending on the state of mind you are in. This is your internal context, which is why it’s so important to think about, like what state of mind was I in when it was easy to transition into a sexy state of mind? Chances are you felt safe enough, you felt connected enough, you felt like the stakes were low enough. When people experience high desire, that doesn’t even necessarily mean that they experience high pleasure. Humans can want things. One of the primary, one of the motivations for sex is connection. But one of the ways we can want connection is suppose our connection is threatened. There’s an instability in our connection. And so sometimes we move toward sex as a way to repair the threat to the connection. Sometimes that will feel good, like make up sex. And sometimes it’s intense but doesn’t feel good, like breakup sex. Does that make sense? 

Dr. Abdul El-Sayed: Mmm. Yeah. And it’s. I appreciate you highlighting that the difference in the mental state going into the experience. And if I may, it kind of helps explain why it is that long lived couples tend to go through these dry spells because you don’t have that immediate novelty to, like, pull through the discomfort part of it. It’s, hey, like, this is comfortable and easy, and I’m constantly dealing with all of the other parts of a relationship or a life that you build together that may pull you out of some of those states, and then you’re sitting here thinking that somehow, you know, the novelty is what’s supposed to keep it going. And, you know, while rather than this being a reflection of a connection and a sense of safety and a sense of almost returning to um a space in your relationship together, uh rather than the sort of like carnal um excitement of a person to have sex with. Right. And– 

Emily Nagoski: Getting horny. 

Dr. Abdul El-Sayed: It’s interesting. Yes. 

Emily Nagoski: Yeah. 

Dr. Abdul El-Sayed: Yeah. And like, the interesting thing about it is that when you stop for a second and ask, like, what does it look like to have a mature sexual relationship? I think almost anybody would almost intuit this idea that, of course, after ten years or 20 years or 30 years, and the aging that comes with that it’s not going to feel like day one or two, right? 

Emily Nagoski: Yeah. 

Dr. Abdul El-Sayed: But you can mature it because there’s so much more safety in the relationship if you’ve matured that relationship. And it’s like finding that safety in the relationship that opens up and unlocks this kind of pleasure seeking sex rather than this kind of, you know, uh horny, you know, hormonally driven, um more objective, almost, uh sense of of of sexuality. 

Emily Nagoski: Yeah. 

Dr. Abdul El-Sayed: I want to I want to ask you, because you write a lot about sex positivity in the context of body positivity. And you have this construct where you differentiate between confidence and joy in your body. Can you talk a little bit about that? Because I thought that was really insightful. And, you know, so much of the the negative thought cycles that tend to disrupt sexuality and set up these imperatives are this like constantly comparing yourself to quote, “what you used to be.”

Emily Nagoski: Oh gosh yeah. 

Dr. Abdul El-Sayed: I’m not, you know, I don’t have X, I don’t have Y, and I and you know, so I felt like these like confidence and joy constructs are really helpful in terms of being able to break down and normalize that. Can can you share a little bit more about that? 

Emily Nagoski: Yeah. So for me confidence means knowing what is true, knowing what is true about your body and your sexuality and your relationship and your culture and your life history and your current life circumstances. Knowing what’s true even when it’s not what you wish were true, even when it’s not what you believe should “should” in heavy quotes be true. And joy is is the hard part. Because joy is loving what’s true about your body and your sexuality and your relationship and your life history and your current life circumstances. Knowing what’s true even if it’s not what you wish were true, and even when it’s not what you believe should be true. When you can know what is true in this moment about your sexuality and your relationship in your body. My definition of perfect sex. Well, it starts with the definition of normal sex. People love a definition. So normal sex for me is when everybody involved are peers who are glad to be there and free to leave with no one unwanted consequences, including no unwanted emotional consequences. No. But if you love me. No. If. Oh come on. No. But you said you would. And no one wanted pain obviously. Perfect sex is all of that. Glad to be there. Free to leave with no unwanted consequences. No one wanted pain. And everybody turns toward what’s happening in this moment with confidence and joy and compassion. And if you possibly can, a sense of play so that if, for example, somebody wants an erection and an erection isn’t happening, you turn toward the absence of an erection with confidence. You know what’s true, ya love what’s true, compassion and a sense of play. There are so many neat things you can do with a penis that is not erect, that you cannot do with a penis that is erect. It is a real opportunity for object play. But also you can just transition your attention to something else entirely different if you want to. As opposed to problematizing it, deciding there’s a dysfunction. This means something about this partner or that partner, or about the relation that there’s something wrong. Or it could just be this is what’s happening right here in the present moment. And we’re going to turn toward it with confidence and joy and compassion and a sense of play. 

Dr. Abdul El-Sayed: I, I really appreciate that because I think the, you know, the um, implicit expectation of what it’s going to be. And these imperatives about what it’s going to be. It’s they set up in a uh, a harder and harder to meet uh imperative that– 

Emily Nagoski: Yeah. 

Dr. Abdul El-Sayed: Um. When you, when you when you miss in the context of, you know, a busy life with, you know, kids. My goodness. Um and– 

Emily Nagoski: Kids. My goodness. 

Dr. Abdul El-Sayed: Yeah. 

Emily Nagoski: Exactly. [laughing]

Dr. Abdul El-Sayed: That it it almost it almost forces you. And especially if you’re like uh, you know, type A personality, forces a couple to be like, okay, what what should I fix? Right? 

Emily Nagoski: Yes. 

Dr. Abdul El-Sayed: And what you’re asking folks to do is to step back and say, stop trying to fix, but instead try to accept and enjoy. Um. And it’s almost like that, that fixing that need to fix it. To your point, it just changes a mindset about what sex ought to be. So now instead of asking, you know, it’s like, did I hit my PR today, right? Like, did I achieve my outcome, which is implicitly a threatening situation. It’s a test. Rather than did I enjoy my partner? And did we um, did we come, come out of this thing–

Emily Nagoski: Right. 

Dr. Abdul El-Sayed: Having, fulfilled what it was that we wanted as a celebration of our relationship and the joy that we share together. And–

Emily Nagoski: Right. 

Dr. Abdul El-Sayed: You know, it’s an interesting sort of question about this role of imperatives and this expectation of what bodies ought to do. I guess my my question to you, right, is, is that it seems like and you talk a bit about this in the book, that there is a sense of shame that sits under a lot of this. And I think the way that it gets constructed is that, you know, you know, a lot of cultural norms. And I think these are starting to change. But, you know, they’re they’re deep seated that sex is is implicitly dirty, it’s implicitly bad. It’s implicitly something negative. And the sex that you have– 

Emily Nagoski: Oh yes, sex is dirty, dangerous and disgusting. You should really save it for someone you love. 

Dr. Abdul El-Sayed: Right? You know, exactly. It’s like, this is the disgusting thing that you’re going to do with the person you love most. [laugh]. 

Emily Nagoski: Yeah. 

Dr. Abdul El-Sayed: But but then it’s like this idea that, like, in order to, to get past that implicit filth of sex, it has to be good enough sex. And then you almost set yourself up for this, this like notion of failure. And then there’s this shame that just ties all of it. It’s like I’m not doing the disgusting thing well enough. Um. Or–

Emily Nagoski: Yeah. 

Dr. Abdul El-Sayed: –we’re not sharing the disgusting thing. 

Emily Nagoski: Yup. 

Dr. Abdul El-Sayed: With enough, with enough, like, performative gusto. And the funny thing about it is. 

Emily Nagoski: Oh performative gusto. 

Dr. Abdul El-Sayed: In most long term relationships, it’s not like you’re doing this on a, on a camera. In most long term relationships, you might, um but, but, but I guess my point is that there is no usually there’s no audience. So who you are performing for?

Emily Nagoski: Who are you peforming for? [laughter]Yeah, exactly. Yeah. And we all have a script in our heads, not just about there’s a sort of like order of operations of like which behaviors come first, second, third, like which clothes come off when, who goes down on who when. Nina Hartley, the feminist sex porn star, uh her summary is head head two positions and a pop. Like there’s a script and it also was a script of who has the sex. We have an image in our mind of like, who is allowed to have and enjoy sex. Like we know what their bodies look like, we know what age they are, we know what their relationship structure is. And it’s all the a myth, right? It’s all just this like thing we have been fed by our culture and our family of origin, and none of it has anything to do with what actually happens in our lives. And yet there is this sort of phantom ideal sexual self that we’re supposed to be, and we are always comparing ourselves, who we truly are, against that fantasy fictional self. And when we feel that pressure to perform, we’re trying to pretend that we are that fantasy fictional self instead of being the self that we truly are. When you can have with confidence and joy, know who you truly are, love who you truly are. Believe that who you are is someone worth being as a sexual person. That the sexual relationship you have is a sexual relationship worth having, as opposed to trying to make it into somebody else’s idea of what it’s supposed to. 

Dr. Abdul El-Sayed: So basically what you’re saying is stop trying to have porn star sex. 

Emily Nagoski: Unless porn star sex is like who you truly are. 

Dr. Abdul El-Sayed: [laugh] Fair. 

Emily Nagoski: Maybe. 

Dr. Abdul El-Sayed: It could be. I appreciate the framework, though, because it’s like you’re creating a permission structure for people to have the sex that they have, and stop trying to compare the sex that you have to this this this notion of what a manufactured version of sex ought to be. I want to ask you, because I’ve, I’ve, I’ve, I’ve struggled with the way that we have started to think about sex positivity. And, and I think there’s an inherent contradiction in it. And I want to try this by you because you’ve thought a lot more about this and a lot smarter than I am. We talk about about sex positivity as being open to and engaging with, putting sex into more places than it is denied. I worry, though, that the version of sex that people put in those places is this manufactured version that sets up an expectation of what sex ought to be versus what sex actually is. And I think the that version of this, um tends to do more harm than good. So I want to ask, like, what do you think about that? And then how do we actually create a healthier sex positivity that does not then create this sort of idealized version of sex that then everyone–

Emily Nagoski: Yeah. 

Dr. Abdul El-Sayed: –is comparing themselves to and feeling like they’re falling short? 

Emily Nagoski: I think the idea of sex positivity has absolutely been co-opted by capitalism to sell us stuff, and the best way to sell us stuff is to make sure we feel like shit, because people who feel like shit buy more shit. 

Dr. Abdul El-Sayed: Wow. 

Emily Nagoski: Actually. 

Dr. Abdul El-Sayed: That that, so well said. So well said. Go ahead. Sorry. 

Emily Nagoski: A student of mine was actually the one who first was like people who feel like shit buy more shit. And I thought about it in the context of sexuality and it’s like all these products will solve your problems, and especially in the pursuit of, like, medical interventions for women’s sexual desire. Why is women’s lack of sexual desire such a problem? Well, it’s because in a misogynist cis hetero patriarchy where we have nevertheless come to the point where a woman has to agree to have sex with a man, she her desire is a necessary prerequisite. So we need a medication to make sure she wants the sex. 

Dr. Abdul El-Sayed: Wow. 

Emily Nagoski: So that cis hetero patriarchy can be reinforced. Hooray! Cool. But here’s the thing. What if she doesn’t like the sex that’s available in her relationship? What if a couple is having sex at a frequency that when, if if I told you the number, you’d be like, wow, that’s a pretty high frequency. But at least one of the partners does not enjoy any of the sex they are having. So for me. I define sex positivity as everybody gets to choose how and when they are touched. They get to choose how they feel about their bodies. Basic bodily autonomy. Um. When I say it out loud, it sounds like a political definition. And it’s not not political, but it honestly is just like the mammalian biology, pleasure is only available to us when we feel safe enough, when we feel connected enough, and that autonomy, when we don’t feel isolated, when we don’t feel trapped, that is the mindset where our brain is capable of interpreting a sensation as being pleasurable. And the did you know that people believe you more when what you say rhymes? 

Dr. Abdul El-Sayed: Hmm. 

Emily Nagoski: It I that’s a thing that I learned in the preparation for book tour with Come as You Are. So here’s the way I put it. Pleasure is the measure. Pleasure is the measure of sexual well being. 

Dr. Abdul El-Sayed: I love that. 

Emily Nagoski: It is not about how often you do it, definitely not how often. It’s not what you do or where or with whom, or how many times, or even how many orgasms you have. It’s whether or not you like the sex you are having, and if you like it, you’re already doing it right. It’s not about judging yourself against a standard. It’s not about reaching a benchmark. It’s do you like the sex? And if you don’t, of course you don’t want it. It’s not dysfunctional not to want sex you don’t like. There’s a therapist and researcher, Peggy Kleinplatz uh the way she puts it in the fairly devastating way is that it sometimes low desire is evidence of good judgment. 

Dr. Abdul El-Sayed: Hmm. Yeah it’s profound.

Emily Nagoski: And yet so simple. Right? Like, on the one hand, it is normal not to want sex you don’t like. And at the same time, the number one reason why couples seek sex therapy is a desire differential. One partner wants sex more than the other one. And that couple will go to therapy. And one partner will be like, I’ll be fine if we never have sex again. I used to be into it, but I feel like I’m done with sex forever. And if their therapist is Peggy Kleinplatz, she’ll say, well, tell me more about this sex you don’t want. And, do you suppose the sex they’re having is joyful, playful, connected, authentic, vulnerable, exploratory? Or is it, you know, dismal and disappointing sex by rote, sex where at least one person feels like they can’t show up as their authentic self, sex where they’re just doing it out of a sense of obligation, or they’re trying to pretend that they are someone that they are not. And that is when Peggy will say, well, you know, I rather like sex, but if that’s the sex I were having, I wouldn’t want it either. So what kind of sex is worth wanting? 

Dr. Abdul El-Sayed: Hmm. I really appreciate that. Um. That thought and I think it’s a good place to to end it. Our guest today uh was Doctor Emily Nagoski. She’s a sex educator and author of the books, Come as You Are and Come Together. I really appreciate you joining us to to get nerdy about getting dirty. And uh [laughter] it really was a um, a really, thoughtful and, I think, really important conversation. So thank you for what you do. And, thank you for sharing your wisdom with us here. 

Emily Nagoski: Thank you so much. [music break]

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. So there’s this guy I hate to have to talk about, but he is the former president and the presumptive Republican nominee for president once more. And so I’m sorry, but we have to. This is what he had to say a few weeks back. 

[clip of Donald Trump] And I will not give one penny to any school that has a vaccine mandate or a mask mandate. 

Dr. Abdul El-Sayed, narrating: There’s this debate among political pundits. Should you take him literally or seriously? Both. I take him both literally and seriously, because I’m old enough to remember when he said he was going to ban people like me from coming to this country because of how we pray. And then as soon as he was elected, finding myself protesting his attempt to do just that at an airport. So when he says he’s going to pull federal funding from all schools with vaccine mandates. Yeah. I’m worried. See, almost every school in America has a vaccine mandate. They’re required to enter kindergarten. Now, we’ve made them way too easy to bypass on quote, “philosophical grounds,” but to end them altogether, that’d be disastrous. And that’s because we’re already watching as the number of kindergartners going to kindergarten with vaccine waivers is growing amidst an increase in vaccine preventable diseases. Uh. Measles? But there’s another feature here. Even if he never gets elected, even using his platform to push anti-vax policies will have devastating knock on effects, whether it’s Trump wannabes running for school board or just parents deciding whether to vaccinate their kids. What he says creates a permission structure to continue to choose against vaccines and policies that protect them. God be with us in November. For his part, President Biden released his 2025 federal budget with several important implications for American health care. As we discussed last week, the president wants to increase the number of prescription drugs that Medicare could negotiate prices for from the current 20 to 50. And he wants to extend the cap on out-of-pocket prescription drug spending for Medicare beneficiaries to all privately insured people. He’s also proposing a small tax increase on individuals making more than $400,000 a year, from 3.8% to 5% to extend Medicare solvency over the next 25 years, and finally, to extend Medicaid coverage for vulnerable folks living in the nine states that have yet to extend Medicaid. He’s proposing a medicaid lite coverage plan that would offer that coverage to nearly 1.5 million more people. A new study published in the New England Journal of Medicine shows the emerging hazards of microplastics. The researchers followed people who had had small fat plaques removed from the arteries in their necks, the kinds that grow to cause strokes. They analyze those plaques for the presence of microplastics. And get this nearly 60% of them had evidence of microplastics described as the presence of quote, “jagged foreign bodies” under electron microscopy. Here’s the downright scary part. They followed those folks for the next three years and found that those with microplastics in their plaques were four and a half times as likely, four and a half times as likely to have a stroke, heart attack or die over that time period. The study isn’t causal, but that’s a serious effect measure. That’s the kind that should spur us to act. Look, microplastics aren’t inevitable. They’re a choice that corporations are making for us. In the end, they don’t really get recycled. What we’re learning is that they simply get ground down into microscopic particles that wind their way into our bodies. Microplastics like these have been identified in all sorts of human tissues, including fetal placentas. Get this, people who haven’t even lived in the world. So why are companies choosing them? To save money, but they may be costing lives. Congress, this might be one of those few truly bipartisan causes left. Let’s get to it. And now for this headline. 

[clip of unspecified news reporter] German man has puzzled scientists after he deliberately got more than 200 Covid 19 vaccinations. 

Dr. Abdul El-Sayed, narrating: That’s right. A 62 year old man from Magdeburg, Germany, purposely got vaccinated 217 times in the course of 29 months. I honestly don’t even know what to say here except for dude did his part. A bit a bit too much, I’d say. To be clear, nobody should do this. Just want to be clear about that. But also. Dude’s fine. No horns, no tail. Nope. Just fine. So to all those folks harping on about the vaccine risks. Apparently you can get this thing 217 times and be just fine. So there’s that. That’s it for today. On your way out. Don’t forget to rate and review the show. It really does go a long way. And if you haven’t told us about your CME needs yet, AmericanDissectedCME.com. Please do share. Also, if you love the show and want to rep us, drop by the Crooked Store for some America Dissected merch. And don’t forget to follow us at @CrookedMedia and me at @AbdulElSayed no dash on Instagram, TikTok, and the website formerly known as Twitter. [music break] American Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Charlotte Landes mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Druan, Sarah Geismer, and me, Doctor Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care, medical advice, and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and guests, and do not necessarily represent the views and opinions of Wayne County, Michigan Department of Health, Human and Veteran Services.