Naturopath and psychosexual therapist Daniel Robson and our Ambassador Lisa Costa-Bir discuss the delicate but often avoided topic of male sexual dysfunction. Daniel emphasises the importance of being able to hold a safe space for your patients who may have emotional, mental or relationship concerns impacting their sexual function and how to interweave male sexual health questions into a consultation in a meaningful way.
Daniel and Lisa explore some of the risk factors that can impact male sexual health, including mental health, diet and lifestyle habits, and relationships. They also cover the key therapeutic herbs, nutrients, and dietary interventions for sexual dysfunction, and when practitioners should refer.
Covered in this episode
[00:34] Welcoming Daniel Robson
[02:19] What does a sex therapist do?
[05:57] Navigating the topic of libido during a consultation
[10:58] Underlying drivers for sexual dysfunction
[13:32] Anxiety and mindfulness
[14:43] Pine bark for erectile dysfunction
[16:42] Saffron as an aphrodisiac and nervous system tonic
[17:47] Panax ginseng as a male tonic
[18:20] Tribulus for reduced sexual desire
[19:06] Using nerviness and adaptogens
[20:46] Nutrients- zinc and vitamin D
[23:07] Diet and nutrition - pistachios, excessive alcohol, and the Mediterranean diet
[27:04] Referring to a sex therapist
[29:02] Thanking Daniel and final remarks
- Understanding how to implement questioning around sexual dysfunction is critical and helps you build your confidence in holding a safe space for your patients. Start by managing your own feelings and beliefs surrounding the topic to understand and overcome any potential areas of embarrassment. Then listen, validate and empathise with your patient.
- No need to reach the male repro systems review of your consult to start talking to sexual dysfunction as other systems may be connected eg: cardiovascular, nervous, endocrine systems or metabolic issues
- Anxiety around performance and function is something that can be managed through shifting the focus to pleasure and mindfulness exercises.
- Think outside the box when considering herbs as all too often herbs are gender stereotyped but benefit may be found when you look a little deeper.
- Herbal and nutritional medicines for consideration include:
- Maritime pine bark: for its action on nitric oxide synthase and vasodilation
- L-arginine: complementary to above as a precursor for nitric oxide
- Saffron: traditionally used as an aphrodisiac and nervous system tonic
- Motherwort & passionflower: fast acting anxiolytics
- Withania: stress adaptation
- Zinc: in patents with testosterone insufficiency
- Vitamin D: deficiency has a link with hypogonadism therefore hormonal balance
- Dietary options include:
- Pistachios (and other nuts): as a good source of L-arginine
- Reduce alcohol intake: negative impacts on detoxification, cardiovascular and mental health
- Mediterranean diet: research shows an improvement in erectile function when (diabetic) men followed this diet
- Know when to refer or consider support for relationships and/or, psychological support
Resources and further reading
|Gould's Natural Medicine
HERB AND NUTRITIONAL SUPPORT ARTICLES
fx Medicine acknowledges the traditional custodians of country throughout Australia, where we live and work, and their connections to land, sea, and community. We pay our respect to their elders, past and present, and extend that respect to all Aboriginal and Torres Strait Islander people today.
Joining us today is Daniel Robson. Daniel is a naturopath and sex therapist who has been in clinical practice for the past 20 years. Daniel has a passion for sexual health, having completed a Master's in sexual and reproductive health in Psychosexual Therapy in 2021.
With Leah Hechtman, he co-authored the male reproductive system chapter in the second edition of "Clinical Naturopathic Medicine" and has experience presenting to a professional audience on the topic of natural medicines and sexuality. Daniel is also part of the collective who operate Goulds Natural Medicine, the historic and iconic Hobart Apothecary and Clinic.
Male sexual dysfunction is very common with an estimated 20 to 30% of men reporting at least one current sexual difficulty. Despite this high prevalence, I feel like men's health, and particularly sexual health, is a neglected area generally, but also in our industry. And I wonder if this is in part because practitioners often don't know or feel comfortable navigating what is still considered to be by some, a taboo topic. However, considering the distress sexual dysfunction can cause clients, it's a topic I really wanted to explore with you.
Welcome to fx Medicine, Daniel.
Daniel: Yeah. Thanks, Lisa.
Lisa: All right. So, let's get into it. Firstly, when I tell people I'm studying to be a sexologist, there's often this awkward, confused pause. So, can you outline what does a sex therapist or sexologist do, and how can they help clients? Because I often feel like there's some misconceptions in this area.
Daniel: Yeah, absolutely. I'm really familiar with that awkward pause as well, Lisa. So, yeah, I think that awkwardness can initially be because the misconceptions might be that sex therapy is like a hands-on type of therapy, which it isn't. So, I think that's one of the things that I like to clarify with people first is that the professional associations, the Society of Australian Sexologists, for example, of which I'm a member, they completely prohibit members engaging in practices of a sexual or sensual nature.
So, sex therapists are really a diverse group of health professionals. The unifying part of what we do is that we specifically work with people to assist with sexual difficulties, them and their partners. So, there's people from medicine, from nursing, counselling, social work, psychology, and physiotherapy backgrounds. And as I've learnt, more naturopaths coming into the scene as well. So, really a diverse group of people. And I think that's going to really inform how we practice. But I guess that unifying quality being that we're working often with psycho-education, counselling, behavioural type of homework techniques, working on communication within relationships as our primary focus. As we kind of consider well, there's a whole lot of physiological influences in sexual function, it's really those psychosocial aspects that are, I guess, core in really maintaining sexual difficulties.
Lisa: Absolutely. And I think that psychosocial aspect is really, really important because when patients are seeing someone that is qualified in that area, I feel like they're going to get a much better result. I think we really want to be able to hold that space well for patients. Particularly if there's a history of trauma or things like that, we don't want them to be further traumatised by seeing someone that's not qualified to hold that space well.
Daniel: Yeah. I think, following on from what you're just saying, really, I mean, I found myself I guess as a naturopath with an interest in particularly male health. And I guess being interested in male health meant that I started seeing a lot of clients with sexual problems as you'd expect, and particularly erectile dysfunction. And I found myself ill-equipped to deal with the dynamics that I was seeing in the room and I guess I just felt like I was really out of my depth. And I thought, "Okay, right-y-o, I really want to study more in this area and have those skills to be able to have more of the conversations that put the problem into a context."
The other element of that, of course, is that we are working with people's lifestyles and diet, and doing all the physiological stuff, but the reality is that sometimes people's function doesn't change, the erectile difficulty remains. And so how does this get incorporated into this person's sexual relationship, and still have it be a flourishing and enjoyable and pleasurable experience for everyone?
Lisa: Yeah. I think it's so important. I remember when I first started in private practice and I had a young man come in to see me, and he had issues with libido, and I didn't know how to hold that space properly for him. And I feel like I did a really terrible job because I didn't have that experience and the same kind of wisdom that I do now to navigate that.
So, how can practitioners comfortably navigate the topic of libido in a consultation? Because I do feel it's such an awkward subject for a lot of people. And as a clinic supervisor, I often see students feeling initially really uncomfortable about just navigating through questions about the reproductive system, let alone libido. And sometimes they say they feel like it's out of their scope. So, you know, where do you kind of go with this?
Daniel: I guess there's the, from the outset, I kind of figure that as holistic health practitioners, sexual health is part of our scope. But yeah, as we've sort of outlined earlier, I mean, there's a certain depth that we might go with clients that we would go if we have a more extensive background in that area than we would as a general health type of practitioner.
But I guess for me, it's really addressing or thinking about my own beliefs, and my own values, and how they relate to sex and sexuality. So, I think as therapists, we can do a lot just by listening, and being empathetic, and validating people. So, that's a big part of what we do. But we can only really do that if we're able to do that from a space of non-judgment and we're able to be present for our clients, which does necessitate us being able to hear what people are talking about, and not bring our own stuff into it.
So, I guess that's the first thing, and I guess apart from that though, a big part of the barrier within consultation is our own embarrassment I think, and like I say, it, comes back to how we manage that, and how we manage our beliefs around that, but also our perception of the embarrassment for the client. I think that also relates to how relevant we think the clinic questions are for our clients.
So, I guess when I can certainly relate to this feeling, it's where I think, "Well, gee, what's this got to do with what this person's coming in with, you know?" Like, I mean, and sometimes it doesn't have a lot, so maybe we'll be pretty rudimentary about how we deal with it. But I think for a lot of the times, we can find that most chronic health conditions, they're really quite likely to have some impact upon a person's sexual health, or their sexual relationship in some way or another.
So, I guess that's how I frame it up. If I'm seeing someone who's say, presenting with lower urinary tract symptoms, for example, we know are closely linked to sexual difficulties, or diabetes, or cardiovascular disease. Again, you know, these are sort of main risk factors. I'll kind of frame it up that way and just say, "Hey, you know, look, it's really common for people who experience X condition to have difficulties with sexual function. Is this something that you are dealing with? And then if it is, then is this something you want to talk about?" And just invite them to have that conversation, and we can explore it deeper. And if not, it kind of helps plant the seed for some time later. I can think about a number of clients where I've just put that into the conversation, and really that's not what they're coming in for. But then another consultation or two later, they're like, "Okay, I'm actually really ready to deal with this now, and I want to talk about it more." And that's cool. You know, I think we build up rapport with our clients, then we open up that door to be able to explore that further.
Lisa: Yeah. I love the way that you framed that. It was very professional, and it just slotted in really, really nicely too. Because I was going to ask where do you ask that question? Like, do you wait till you get to the male reproductive system, and then slot it in there? But I guess that you're just slotting it in where it fits right for the condition you're presented with.
Daniel: Yeah. Where it fits. I mean, look, I guess I do try to go with the flow in a consultation. I suppose that's something I've learnt to do more as I've become experienced as a clinician. But, of course, if it particularly is that primary complaint I'll bring it in earlier within the consultation. But yeah, in the systems review, it might just come up when I'm sort of moving through the reproductive system questions.
Lisa: Yeah. Because I usually put it in there if it's not a primary complaint. And I like the way that you asked it because I think that often clients are embarrassed to talk about it. Like, that's not necessarily something they'll put in their presenting complaints in the top three things, but when you ask, they're actually really relieved. And the majority will be like, "Yes, yes!” and they're happy to talk about it. And those that don't want to talk about it will generally say, "Oh, I don't want to talk about it," or, "It's not an issue." And then you just move on. But I think generally patients are really happy that you've asked because no one else has asked them.
Daniel: Absolutely. And yeah, chances are, if someone's sitting on that one, if we don't ask, there's a really good chance they won't tell us, or they might tell us just as we're about to finish, and we're already over time.
Daniel: That’s certainly been my experience.
Lisa: Okay. So, as we outlined in the beginning, sexual dysfunction is incredibly prevalent with up to 30% of males suffering from sexual dysfunction at any time. And then this number actually increases dramatically as men get older, so we're looking at 50 to 60%. So it's very, very prevalent, but not really talked about much. I'm really interested in what underlying drivers, risk factors are there for practitioners to be aware of with clients presenting with this sort of stuff.
Daniel: Really, any number of things can impact upon sexual function, like I mentioned earlier. But I guess the big ones with male sexual problems, one of the most common presentations, which is erectile difficulties would be cardiovascular health, and cardiovascular disease, and diabetes. I mean, that's a big one that we can do something about. And there's a fairly large contribution of lifestyle factors. So, diet, sedentary lifestyles, of course, smoking is a big one. So the kind of work that we're generally doing with clients around that sort of stuff is all really relevant in this space.
Medication side effects, that's a fairly big one. We probably encounter a lot more of that, particularly your antidepressants, SSRIs, that's a really common side effect. So, tricky one to deal with in many respects. But yeah, I guess that's one that we will encounter and we'll need to navigate around.
And then, of course, we've got all the stuff around mental health and say, depression, of course, is a pretty big contributor. I mean, you know, coming back to the treatment for depression, but also depression itself, there's a bidirectional relationship, causation, and also can be caused by sexual problems, particularly erectile dysfunction.
So, quite a lot of things. And then all the stuff that we sort of touched on earlier, our own beliefs and cognition, and our prior experiences, and, of course, experiences of trauma and our education, all that stuff can pile on in there, and impact upon how we are functioning.
Lisa: Yeah because where there's that anxiety, I guess, around it can really kind of compound things can’t it? That nervous system dysfunction, once I guess there's that one episode of erectile dysfunction, it seems like the brain kind of just goes into overdrive anytime. And I've read that anxiety can affect up to 25% of men. So it's really, really big.
I’m so interested in this mindfulness, because there's a lot of study going on with mindfulness and libido, and reducing anxiety with this sort of picture. And particularly in women, there's great research. I'm guessing, obviously from what you're saying, the same is true for men. You know how you said that practitioners can kind of do this, but does your patient need to see someone for specific mindfulness in this area, training, do you think?
Daniel: I think that's a really great question. I mean, I think if you're a naturopath who is seeing someone and you can identify that anxiety is a component of what's going on for them, and you've got good rapport, then I can see absolutely no reason why you can't. And certainly, if you've got a background or understanding of even just some simple mindfulness type of exercises, like, I mean, it wouldn't be unusual for me just to do a bit of breath awareness with the client at the very outset. Like, I can start from the very beginning. Let's just say, "Hey, you know, let's just learn a breath awareness type of mindfulness practice, and then build upon that as a skill down the track." But yeah, I think we can definitely start with at least some of the basics. It's just skill-building.
Lisa: Yeah, absolutely. I think so. Yeah.
Daniel: Yeah, absolutely. I guess that's where I started. So, I do use them and I still continue to, even when I'm doing sex therapy work. It's nice to be able to have something in that initial consultation while I'm still trying to get my head around what is going on to be able to give to someone if they're open to it, if they want it. Chances are if they're coming to see me, they know that's what they're likely to get. I certainly consider myself to be a herbalist-focused naturopath. So, I would use a lot of herbal medicines. I would often recommend pine bark extract. It's probably my number one. It will go into most of my herbal mixes. And that's based upon a number of studies using it for erectile dysfunction, using a proprietary product which isn't available in Australia.
But yeah, so I'd use the pine bark extract, and often in combination with L-arginine, and I find that can work quite well. So, I use it as a liquid extract mostly. But occasionally, I might sort of send people online to get a product if they don't want to take liquid. But I find the liquid extract works quite well.
Lisa: I just want to ask you about the pine bark extract. What are the actions of pine bark like for erectile dysfunction? How's that working?
Daniel: Yeah. Well, most people would probably know it as a cardiovascular herb. It does appear, or at least the claim is, that it increases the activity of nitric oxide synthase. So, it's working on that vasodilation pathway. And so, with the studies where they've kind of a used proprietary product, they're combining that with L-arginine. And L-arginine is a precursor to nitric oxide. So, you're kind of amping that up, and you're using something to facilitate that production of nitric oxide. So, that's the basis of it.
Daniel: Ah, yeah, so saffron is one I use a lot.
Lisa: My favorite.
Daniel: Yeah. Yeah, look, the research for it is a bit mixed, but at least in male sexual problems. There's a bit more support for it in female sexual difficulties. But yeah, it's got that traditional basis as an aphrodisiac and it's such a lovely nervous system tonic. I think particularly in the context of low mood, depression, anxiety, I really like to use it. It's also got those cardiovascular benefits and yeah, one study that was an open-label study, they used quite large doses of the saffron for erectile problems, and it showed an improvement, but there was another study done that didn't show any effects. But, so it's kind of a bit mixed, but from my experience, at least in the context of everything else, it seems to help.
Lisa: Oh, I'm so excited. Saffron is just the best. It just does almost everything.
Daniel: Yeah. Yeah. It does seem to do everything. I think we do use an extra amount of saffron in our clinic. Yeah. And definitely, yeah, those mixes almost always got it in there. Yeah.
Lisa: Yeah. Do you use much panax ginseng? Because I know it's so indicated as a male tonic, there is a little bit of research on there showing that in men, I know with erectile dysfunction, it seems to help with their libido.
Daniel: Yeah. Look, I do. Yeah, that will be the other, say if I was doing a herbal complex, and again, you know, I use a lot of liquids, it is often... I do individualised things, but often it'll be maritime pine, saffron, and panax ginseng.
Lisa: Yeah. You have your ones that work really well. Right?
Daniel: It’s kind of my fall back if I’m scratching my head and thinking, "Oh, well, okay. Yeah, I'll do my mix."
Lisa: What about Tribulus? Because I feel like it's not one I tend to use too much of in my clinic, but it's one that patients will often do themselves. It’s the one they look up on the internet and they're like, "Oh, Tribulus, I'm going to take this one."
Daniel: Yeah. Similarly, I don't have much of a relationship with Tribulus, but I'm familiar with the research that supports, at least to some extent, supports its use. So yeah, look, a lot of my clients will be taking it. And it would be on my list of possible things to try with, particularly in that context of low sexual desire. But yeah, look, I must admit it's not one that I recommend a lot, but I could certainly see why people would and certainly support that.
Lisa: Yeah. So, you use saffron from that nervous system kind of tonic aspect. I use a lot of passionflower for this sort of picture that we're talking about, too. What are your thoughts on any other nervines that you tend to use?
Daniel: In our clinic, we use a lot of motherwort, so I'd probably use it similarly to how you might use passionflower if anxiety was a pretty key presenting issue. I find that to be quite an effective anxiolytic and fairly quick acting for that purpose. I think I probably took a hit of it before this podcast, but, and also Withania or Ashwagandha, I think, is quite well indicated in this space as well. It's got that traditional use in males.
Lisa: It does.
Daniel: Not the research though, but there is quite a good study using in female sexual problems. And I think of course, as an adaptogen and anxiolytic, it's very well indicated. So yeah, it often gets recommended by me.
Lisa: Yeah. I think a lot of people think of Withania as being just a female tonic, but traditionally, it was such a male tonic, and there is quite good research for it for males too. So, yeah, it certainly is a good one.
Daniel: Yeah. And look, I think we can have this tendency to really gender our herbs. And I think that's why there's some good reasons for that. Like, sometimes, we do have some different bits, but as far as I think particularly when it comes to the stuff around sexual desire and yeah, interest a bit of all that sort of stuff, I think there's a lot more in common with males and females than what we think. So, yeah, I find that a lot of those remedies we might use are too gender-specific.
Daniel: Well, that's a great question. Yeah. It is pretty popular, isn't it?
I mean, there's a lot of reasons to use zinc, but I mean, I do recommend a lot, but more if it's a risk for deficiency, you know, based on a person's dietary intake, it'll come in. I don't do it as a standard male repro nutrient. The research that I'm familiar with, I mean, you’d think there should be a lot more research looking at it given its relationship to the reproductive system. But it's pretty limited to some specific conditions like renal failure. There's a study that gave zinc in testosterone deficiency secondary to renal failure, and that seemed to have a beneficial effect. So yeah, it could be indicated but I'm not flooding my patients with it.
Lisa: What about Vitamin D? Because I know there's Vitamin D receptors all over the male reproductive tract, but I feel, again, is it a good one? Tell me your secrets.
Daniel: Yeah, that's not much a secret. Again, it's more associations that I'm familiar with, with, again, hypogonadism and vitamin D deficiency. There's at least a couple of studies that show a relationship between low vitamin D and a higher prevalence of hypogonadism.
But again, like I think if it's deficient, then correct it. I don't think that really...I mean, I can fairly safely say with least with my clients, there's a good chance they'll be insufficient. So, I'll supplement them as a matter of course. But yeah, I think if you're sort of living in sort of more sunny climates, then you might, be more relevant just to screen for Vitamin D status before throwing supplements at them.
Lisa: Yeah, I agree. I'm always big on tests. I'm huge on testing before because not everyone is deficient. Yeah.
Daniel: Right. And people respond quite differently to supplementation as well. I mean, I think, yeah, we can fairly safely recommend moderate doses, but I also don't like to just overburden people with their shopping bags with supplements either.
Lisa: Yeah. Agree. I totally agree with that. Okay.
So, what about nutrition? Because again, it's something that I think patients want. They come and they want to implement dietary changes. I saw a really interesting, it's something I refer to all the time, but I don't know if it's too much, a 2011 study, which was examining intake of pistachios, and it was about a hundred grams. They got them, the male participants who had some sexual dysfunction, to consume these hundred grams of pistachios for lunch over a three-week period. And at the end of the three weeks, they observed an improvement in the erectile function parameters as well as lipid profile.
So, I get super excited about a study like that, but then the other part of my brain is like, “Oh, that was only three weeks, and can pistachios really do that?” Can they?
Daniel: I couldn't claim that they do, but I guess they're quite a decent source of L-arginine. So, there's a...
Lisa: So, that's what it is.
Daniel: …a good sort of nutritional reason. And, of course, we know that nuts are fantastic for cardiovascular health, and there's quite a lot of research, meta-analysis that demonstrate that, yeah, cardiovascular risk factors come right on down, and even a risk of death from myocardial infarction reduced by consuming nuts every day. But that's, of course, over a prolonged period as opposed to three weeks. Yeah, look, it's a lot of nuts. I think I would be hard-pressed to get people to eat that many every day forever.
But yeah, I definitely incorporate nuts as an initial recommendation because most people don't eat enough. And I do draw upon that cardiovascular benefit as being my main rationale. But yeah, I do get excited by studies like that too. It's nice to see, just food as medicine. But yeah, it might be too good to be true, but you know, it's not going to hurt. It's definitely nice to recommend.
Lisa: Yeah. What about alcohol? Because when I think back to that first male I ever had that had issues, he was drinking, like, 15 beers in one day after work sometimes, and smoking marijuana, and things like that. What sort of recommendations do you have around alcohol in situations like this?
Daniel: Yeah. The relationship with our colon sexual problems isn't super clear cut, but it does seem that those high levels of intake are likely to have detrimental impacts. And I think we can think of all manner of reasons why that would be. So, I think especially someone who's drinking 15 drinks a day would, you know, have an effect on their liver, and, of course, the impact on cardiovascular health and their mental health. At the same time alcohol can also be a part of people's rituals around sex, and, you know, having a glass of wine to wind down with a partner and…
So, my advice around it is really sort of moderate intake. Yeah, and I think that realistic intake around alcohol, I wouldn't see as being a problem or a contributor to a person's sexual problems. But definitely, that problematic intake would be a focus for intervention for sure.
Lisa: Lovely. So, anything else from a dietary perspective?
Daniel: Yeah, look, I guess the broader diet quality. We know the Mediterranean diet is associated with better sexual functioning, both males and females.
Lisa: Oh. I didn't know that.
Daniel: Yeah. More association, so, I guess you can always take that with the grain of salt. But I mean there's good reason for that, the cardiovascular health benefits of the Mediterranean diet. There was a study I think from memory where they looked at males with diabetes on a Mediterranean diet, followed them, I think for a couple of years, and that they were able to measure improvements in their erectile function over that time. But you could imagine all manner of things that are going on with that kind of intervention, and it's a long haul, but, yeah, definitely. So, my dietary advice really follows that and yeah, I'll work with people to get as close to a plant-based whole-food diet as possible.
Lisa: Lovely. Okay. So, I think as naturopaths and nutritionists, we've heard there's lots of great herbs and nutrients, but I think for us it's also a great area for collaboration and referrals in this area. I often refer to a sexologist also, because they're often psychiatrists as well. When should a naturopath or nutritionist refer to you, or someone like you?
Daniel: Well, yeah, that's a good question because we sort of covered that a bit earlier on, didn't we, when we looked at scope of practice. Look, I think once we're kind of moving into that space of I guess past the kind of basic psych-oeducation and counselling around sex, like, we can, you know, naturopaths of course, can, and they're wonderful at working on...We're wonderful at working on the lifestyle and diet and the herbs and all that stuff, and I guess those individual factors that could be at play in a person's sexual problem. But, of course, sex happens in a context, and often there are going to be sort of relationship impacts and responses. So, a person's partner is going to respond in some way or another that may help or may hinder the situation.
So, I think whenever you can sort of see those dynamics playing out, or you're thinking that, yeah, we really need to move into some deeper kind of behavioural type of type of interventions, and I'd be, yeah, referring to a sexologist, someone like myself, or, particularly if you encountered someone with a like with significant relationship conflict, and if you thinking of a relationship therapist and not necessarily someone like myself unless they've got relationship counselling backgrounds. And then, of course, people who have, you know, significant trauma background. And you'd be wanting someone who's well qualified in that space as well.
Lisa: Yeah. Amazing. Thank you. Thank you so much. I was so excited to talk to you, and I have learned so, so much. Key points...There are so many, but definitely pine bark extract, that's something I'm going to be trying in my patients for improving erectile dysfunction. I didn't know that one.
Saffron's one of my favourite herbs, but I didn't know about it for actually male sexual dysfunction. So I'm incredibly excited to try that one too. And I think probably most importantly for us to really reflect on our own kind of values and the baggage that we might bring in when asking our questions, and to be really aware of that too. Thank you.
Daniel: Thank you, Lisa. It was good fun.
Lisa: I really enjoyed it too. All right. Thank you everyone for listening today. Don't forget, you can find all the show notes, transcripts, and, and other resources from today's episode on the fx Medicine website. I'm Lisa Costa-Bir, and thank you for joining us. We'll see you next time.