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Pearls & Perspectives: Sexual Health in MSM, with Joshua R. Gonzalez, MD
The conversation covers practical, case-based strategies for counseling MSM patients.
In this episode of Pearls and Perspectives, host Amy Pearlman, MD, is joined by Joshua R. Gonzalez, MD—a board-certified urologist and sexual medicine specialist based in Los Angeles, California—for a candid, inclusive conversation on sexual health in men who have sex with men (MSM) and how urologists can better meet the needs of this often-overlooked patient population.
Gonzalez shares how his fellowship under Irwin Goldstein, MD, helped him develop a broad, inclusive approach to sexual medicine, one that reflects the diversity of human experience across gender, orientation, and identity. Together, Pearlman and Gonzalez discuss how standard definitions of sexual dysfunction often rely on heteronormative models—especially around conditions like erectile dysfunction, premature ejaculation, and delayed ejaculation—and why a more nuanced clinical lens is necessary.
They dive into Gonzalez’s work as co-founder of Popstar Labs, a sexual wellness company launched during the pandemic to meet real patient needs—starting with a supplement aimed at increasing ejaculatory volume. Gonzalez explains how this came directly from patient feedback, particularly from *** men, who described how volume contributed to pleasure, identity, and confidence. They also explore how this interest intersects with broader themes in men’s health—like sexual aging, performance expectations, and the underappreciated role of ejaculation in orgasmic satisfaction.
The conversation covers practical, case-based strategies for counseling MSM patients: how to ask about types of sex in a culturally sensitive way, how anal sex or topping can influence erection requirements, and how tools like intracavernosal injections and at-home phenylephrine can be incorporated into individualized treatment plans. They also discuss delayed ejaculation, sounding, edging, pelvic floor dysfunction, and the use of physical therapy and Botox to address pain with bottoming.
Later, they turn to procedural care—specifically penile girth enhancement using hyaluronic acid fillers—and how sexual practices may affect timing and technique. Gonzalez shares safety pearls on sounding, anal toys, and erection rings, emphasizing harm reduction over judgment, and urging clinicians to meet patients where they are.
In his closing message, Gonzalez challenges urologists to move beyond assumptions and create space for patients of all identities to talk openly about their sex lives. “Meet people where they’re at,” he says, “and give them the tools to have better sex—safely and confidently.”
Pearls and Perspectives: Advancing Sexual Health Conversations for Men Who Have Sex with Men
Dr. Amy Pearlman, a board-certified urologist specializing in sexual, hormonal, and genitourinary health, recently sat down with her colleague and friend, Dr. Joshua Gonzalez, for a candid and wide-ranging discussion on sexual health in men who have sex with men (MSM). Dr. Gonzalez, based in Los Angeles, is also a board-certified urologist with fellowship training in sexual medicine, and is recognized for his inclusive practice that serves patients of all genders and sexual orientations.
Breaking the Heteronormative Mold in Urology
Historically, urology and sexual medicine have focused on heterosexual men, with definitions and treatments for conditions like erectile dysfunction and premature ejaculation based on vaginal intercourse. Dr. Gonzalez, who completed his fellowship in 2014 under Dr. Irwin Goldstein, was among the first LGBTQ+ fellows in the program and played a pivotal role in reframing patient conversations to be more inclusive.
“A lot of the metrics we use in sexual health are rooted in a heteronormative model,” Dr. Gonzalez explained. “Even intake forms and the way we ask about sexual activity can unintentionally exclude or make assumptions about patients’ identities and practices.”
Both Dr. Pearlman and Dr. Gonzalez now use open-ended, nonjudgmental questions to learn about their patients’ partners and sexual practices, allowing patients to introduce their own pronouns and identities. Their intake forms also include comprehensive options for gender identity and sexual orientation, ensuring patients feel seen and respected from the outset.
Entrepreneurship Sparked by Patient Needs
Dr. Gonzalez is the co-founder of Pop Star Labs, a sexual wellness company born from the unique concerns voiced by his MSM patients—specifically, the desire to increase ejaculatory volume for enhanced pleasure and confidence. Many patients sought natural solutions rather than prescription medications, but found little reliable information or safe products on the market.
“The inspiration for our initial product came directly from my MSM patients,” Dr. Gonzalez shared. “They wanted a supplement to increase ejaculate volume for sexual pleasure, not just fertility. We spent months researching ingredients, drawing from reproductive medicine literature, and created a formula we felt confident recommending.”
This patient-driven innovation has since expanded into a broader sexual wellness brand, with a focus on safety, efficacy, and inclusivity.
Addressing Sexual Health Concerns in MSM
Dr. Pearlman and Dr. Gonzalez explored a variety of sexual health issues relevant to MSM, highlighting the importance of tailoring care to individual practices and preferences:
Ejaculatory Volume: Many MSM patients express concerns about decreased ejaculatory volume, which can impact pleasure and confidence. Dr. Gonzalez noted that while urology has historically focused on reducing ejaculatory volume (e.g., as a side effect of prostate procedures), there is growing recognition of the need to address and optimize ejaculatory health for quality of life—not just fertility.
Erectile Dysfunction (ED): The physical demands of anal intercourse often require a firmer erection than vaginal sex. Dr. Gonzalez adapts traditional metrics like the Erection Hardness Score, aiming for a “4+” for patients who are the penetrating partner (“top”). Treatment strategies may include combination PDE5 inhibitor therapy, intracavernosal injections, and, in some cases, shockwave therapy.
Premature and Delayed Ejaculation: While premature ejaculation is common in all men, Dr. Gonzalez observes more MSM patients presenting with delayed ejaculation, often due to age, medication side effects (such as SSRIs), or psychological stressors. He employs a range of off-label treatments—including Wellbutrin, oxytocin, and, selectively, Adderall—emphasizing a trial-and-error approach and normalization of the issue.
Culturally Sensitive Communication and Harm Reduction
The conversation underscored the need for clinicians to use language that resonates with their patients. Dr. Gonzalez often mirrors the terminology his MSM patients use, such as “top,” “bottom,” “versatile,” and even colloquial terms like “[ __ ] ring” (for erection rings), to foster comfort and trust.
Harm reduction is a central theme in his practice:
Intracavernosal Injections: Patients prescribed injection therapy for ED are also taught how to self-administer phenylephrine at home as a rescue for prolonged erections, reducing the risk of emergency room visits and permanent damage.
Urethral Sounding and Anal Play: Rather than discouraging practices like sounding or anal play, Dr. Gonzalez educates patients on safe techniques—using smooth, flared-base devices, appropriate lubricants, and avoiding intoxication during these activities. He also addresses the importance of pelvic floor physical therapy for those experiencing pain with receptive anal sex.
Erection Rings: Dr. Gonzalez advises patients to avoid metal rings, use materials that can be easily removed, and listen to their bodies for signs of discomfort or swelling. He challenges the conventional wisdom of limiting use to 20–30 minutes, suggesting that a few hours is generally safe if patients remain vigilant.
Penile Girth Enhancement and Community Interest
With the advent of safer, minimally invasive procedures like hyaluronic acid injections (the “FalloFill” protocol), interest in penile girth enhancement has grown, particularly among MSM. Dr. Gonzalez notes that while interest in penis size is widespread, conversations about “size queens” and aesthetics are especially prominent in the *** community. He recommends a 10-day abstinence period after the procedure before resuming anal sex, acknowledging the increased pressure exerted during this activity.
Meeting Patients Where They Are
Dr. Gonzalez’s closing message to urology colleagues is clear:
“We are long overdue to meet patients where they are, without assumptions about their identities or sexual practices. Whether it’s MSM, straight men interested in anal play, or those exploring non-monogamy, our role is to provide inclusive, nonjudgmental care and empower patients to have better, safer sex.”
Key Takeaways
Use open-ended, inclusive questions and intake forms to understand patients’ sexual practices and identities.
Recognize and address the unique sexual health concerns of MSM, including ejaculatory volume, erectile function, and pleasure optimization.
Employ harm reduction strategies and patient education for practices like sounding, anal play, and erection ring use.
Normalize conversations about delayed and premature ejaculation, and consider creative, individualized treatment approaches.
Embrace patient-driven innovation and entrepreneurship in sexual medicine.
As Dr. Pearlman summarized, “Erectile dysfunction is so over. The new frontier in sexual medicine is ejaculatory health.” The conversation signals a broader shift in urology—one that values pleasure, inclusivity, and patient-centered care above outdated norms and assumptions[1].
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