Rebuilding Intimacy: Why Sexual Rehabilitation Belongs in Modern Medicine with Prof. Rafi Heruti
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Featured Publications & Research
Professor Heruti has authored numerous peer-reviewed publications covering:
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- Sexual rehabilitation after sp
- Neurological rehabilitation
- Sexuality following trauma and chronic illnessinal cord injury
- Rehabilitation medicine
- Disability and quality of life
Rebuilding Intimacy: Why Sexual Rehabilitation Belongs in Modern Medicine with Prof. Rafi Heruti
00:00 – 01:46 | Introduction of Prof. Rafi Heruti and the importance of sexual rehabilitation.
01:47 – 05:38 | Moving from general rehab to sexual rehab; discussing spinal cord injuries and Maslow’s hierarchy.
05:39 – 09:14 | Exploring the Biopsychosocial model and treating the “whole person.”
09:15 – 13:05 | Medical warning signs: Erectile dysfunction as an early indicator of cardiovascular disease.
13:06 – 16:12 | Shifting patient lifestyle and behavior before medical crises hit.
16:13 – 19:10 | Fleshing out biological, psychological, and social factors of sex.
19:11 – 23:02 | Aging and Andropause: Testosterone decline starting at age 35.
23:03 – 27:21 | The dangers of misuse of hormones (steroids) vs. targeted medical replacement therapy.
27:22 – 29:23 | The impact of pharmaceutical medications (like SSRI antidepressants) on sexual drive.
29:24 – 33:48 | Distinguishing Sex Therapy from complex Sexual Rehabilitation.
33:49 – 39:01 | Prof. Heruti’s work in Australia classifying athletes for the Paralympic movement.
39:02 – 42:54 | Moving from “patient” to “athlete”: Inspiring recovery stories (the Israeli combat pilot).
42:55 – 46:44 | Breaking down Surrogate Partner Therapy (SPT) and the clinical intimacy triangle.
46:45 – 51:29 | The modern isolation crisis in young men and why doctors must talk about sex.
51:30 – 56:09 | Moving away from “performance” and “penetration” to “pleasure” and “intimacy.”
56:10 – 1:00:19 | Lifelong sexual education from youth to the elderly.
1:00:20 – 1:03:19 | Prof. Heruti’s personal message on choosing well-being over career demands; closing thoughts.
Prof. Rafi Heruti (00:00)
Sexual health is a pillar of overall health. Sexuality will reflect quality of life. Sexual health is strongly connected to well-being.
Dr. Ron Ehrlich (00:17)
Hello and welcome to Unstress Health. My name is Dr. Ron Ehrlich. Well, sex. It’s an important part of our lives, and it’s something that we have covered before on my podcast, Ian Kerner. We’ll have links to that, of course, but he’s written many books.
But today we are talking about sexual rehabilitation. My guest today is Professor Raphael Rafi Haruti, a specialist in physical medicine and rehabilitation and a leader in the field.
Of sexual rehabilitation, particularly surrounding trauma, post-traumatic stress, or any other traumatic events. He’s based in Tel Aviv and at the Ruth Hilla Rehabilitation Hospital and affiliated with Tel Aviv University.
Rafi has spent many years working with people recovering from spinal cord injury, trauma, stroke, and chronic illness. And through his work, he’s come to recognize that sexuality and intimacy.
So central to identity, relationships, and the quality of life are often overlooked in medicine. Now today we explore why sexual health belongs within rehabilitation. We explore the bio, psychosocial model in medicine, trauma and intimacy, and also we touch on the world of Para Olympic sport. I hope you enjoy this conversation I had with Professor Rafi Haruti.
Welcome to the show, Rafi.
Prof. Rafi Heruti (01:47)
Thank you for hosting me on.
Dr. Ron Ehrlich (01:50)
Rafi, your path into sexual rehabilitation, I mean, you trained as a rehabilitation physician. Can you tell us first how you came to realize that sexuality wasn’t was was one of the most neglected, and yet I think we’d all agree, essential aspects of recovery after injury or illness. How how did that how did you lead from rehabilitation physician to sexual rehabilitation focus?
Prof. Rafi Heruti (02:19)
So actually I think first of all it’s important to tell people what do what we do in rehabilitation because most people I don’t think they really know what is what rehabilitation deals with. Yes. And like in the medicine we we deal with saving organs.
You know, it can be a s saving a heart after a heart attack or saving a leg after diabetic causes or something like that. But in rehabilitation we don’t treat the organ.
We we treat the the old person per person. We focus on helping people regain function, regain quality of life and rebuild their lives. So if you understand the the concept of rehabilitation, you can understand that that sexual health it’s it’s is a crucial part of this quality of life model and of course we’ll give examples when we continue this conversation.
So so so as a young as a young physician training in rehabilitation, I I had I was working mainly with spinal cord patients. Spinal cord patients it’s usually young men, much more men than women. Usually after a big trauma, which is usually car accidents and you know, doing my doing training you have to stay long night nights at the hospital and you have time to talk with them.
You have time to talk with them. I was young then, I was in my late twenties, and you know those people, they lost the the ability to move, no mobility, they are confined to wheelchair, they don’t have no control on the like incontinence no control on the you in the first f
Dr. Ron Ehrlich (04:13)
Yes, basically.
Prof. Rafi Heruti (04:14)
Yeah. And and and w they they they wanted to talk with me about sex, about sexuality. And I was quite overwhelmed because you know why why why is it important when when you have such so many dramatic changes in your life? Those days, no Google, no AI.
I had to go the next day to read in the library and even in the the the the medical literature there was not a lot about sexuality. Like it was very, very neglected subject. Unfortunately until today it’s quite neglected. And I had to start and read and learn it by myself, lots of it by myself. And for my readings I understood how important it is.
How important it to talk with them about and at least to give them some knowledge, some hope, some some knowledge to know how to regain sexuality in the life because if I told you that in rehabilitation we help rebuild life. So how can we rebuild life without putting sexuality into it which is a very main aspect. Actually I I I I believe most of the listeners they know Maslow. Maslow was
Dr. Ron Ehrlich (05:39)
Maslow’s hierarchy of needs.
Prof. Rafi Heruti (05:42)
Yeah, yeah, excellent. So it’s almost eighty years old and in his hierarchy of needs, in the most important level you have oxygen, you have food, you have how do you say feces and and and urine that you must give.
And in in this level he puts sex as well, which means even then they understood that sex is a very crucial and important part of life, of our needs in our life. And when I talk about sexuality I don’t talk only about sex. Maybe we can discuss it later.
Dr. Ron Ehrlich (06:26)
Well, no, I think this is it’s it’s so interesting to use the comparison of incontinence, fe feces, urine incontinence ’cause these are functions that we give very little thought to. You know, I mean, we just assume this is what we do. I mean, obviously if people are constipated, they are more aware of it if they have diarrhea.
But but i not normal function of those everyday things is something we don’t give thought to and sexuality, well, is something we give thought to, but dysfunction of it is highlighted in all these areas during trauma, isn’t it? I mean this is a part of this highlights a whole range of things.
Prof. Rafi Heruti (07:10)
Yeah, yeah. Sexuality is actually one of the first things people lose after illness or injury. It’s not only trauma but but it’s you have to understand that unfortunately it’s it’s one of the last things medicine talks about. Yes. And and and and we can look at it through a very important model, I’m sure your listeners aware about because you talk about well being, it’s the bio psychosocial model.
Yes. Meaning that we we we treat we treat body, we treat mind, and we we we also have to treat relationship. We you cannot deal with one of them without talking about the others.
Dr. Ron Ehrlich (07:56)
Yes, well we’ve talked a great deal about relationships and its importance in in well being. In fact, we’ve often quoted the Harvard study, which is the longest study on well being and longevity, and they talk they identify relationships as the key to long ongoing ongoing well being.
Now, you know, if you’re fortunate enough to have a significant other and that relationship is a very intimate one, then sex obviously becomes an important expression of that. I want to talk about the biosocial/psychosocial model in a moment, but to msexuality in medicine, because you’ve said when you were younger, you had to go off and explore this because it played such a small part in medicine, and even today it still does.
Why should sexual health be recognised as a fundamental part of of rehabilitation medicine? I mean it is of of life. I think we can all agree that, you know, some form of sexuality is a is an important part of quality of life, and that means many different things to many different people, but rehabilitation medicine, medicine in general, where should sexuality sit in that model?
Prof. Rafi Heruti (09:15)
Because sexual health is pub i i i is to my opinion it is a pillar of overall health. sexuality will reflect quality of life. Sexual health is is is is strongly connected to well being because when we talk about sexual health we we address all parts in life that are again connected to to the biological parts, biological aspects and to all the other aspects.
And if we if we don’t relate to those aspects, we actually do half of the work. We don’t do the complete holistic work. So I can talk about it for on and on and on. But for me it’s like the basic of the basic of the basic. And I I I see it as something, you know,
I like how do you say it’s not only my work but it’s also my my my my aim to to make doctors ax access this knowledge to doctors so they can talk with it with their patients and sh so that they know how to talk with it in a very early phase, so that they know how to talk with it without embarrass the patients and without embarrass themselves.
Because talking about it will help in many, many, many areas. Let’s take an example like a cardiologist. did you know that erectile dysfunction, erectile dysfunction, usually in in young person, is a sign that i is the one of the first signs of atterosclerosis of of of of the closure of the small b blood vessels in the body.
And usually when you have erectile dysfunction, five years later, according to literature, according to cardiologic literature, five years later, much, much bigger vessels in the body will close or can be closed. So sometimes a rectal dysfunction is a sign of probably myocardial inf infarction or cerebral CVA, cerebrovascular accident.
So if I have a young patient like he’s forty years old, he smokes a little bit, he doesn’t do sport, he doesn’t heat eat very healthy, and he’s you know, quite he’s not sick, he’s not ill, but he comes and he asks for Viaga and he’s forty years old. So he will be a criminal if I will give him Viaga and we’re not discuss him about the risk.
Look, you can take Viaga, it will help you, your erection will be better. But in five years you are in a big, big, big risk to have a my myocardial infarction or or cerebovascular accident if you don’t change your lifestyle. You have to stop smoking, you have to start and do some sport and you have to you understand? So it’s all connected.
So that’s that is only one example from the the health the medicine field. So a cardiologist not not knowing this fact that if a patient if your patient asks for a yaga and you you you don’t know that it’s a an early sign of a bigger disease, you are a criminal. You must if you you want to give give medicine, you have to give medicine to the full picture, not only to a small part of it.
Dr. Ron Ehrlich (13:06)
Well, Rafa, you’ve you’ve gee, you’ve used you know, to I agree with you that we owe it to our patients to take a more holistic approach, but I’m guessing that that’s not the nor I mean, in my experience of forty plus years in healthcare, that holistic approach is most certainly not the normal way that people would approach it. I think they’d be reaching for the the prescription pattern, the Viagra very quickly.
Prof. Rafi Heruti (13:37)
I will give him the Vayaga. I will give him the Vayaga because giving him back a sex life and good direction it’s part of a quality of life. I didn’t say I will not give him, but I will give him the
Vayaga in in in in one condition that he will continue follow up and will continue understanding why I insist that he will stop smoking or or or at least lower the amount of smoking and why I insist I I want him to understand. I want him to change his lifestyle through understanding, not through forcing him not through waiting until he’s forty five and then he doesn’t have any choice but to change. So
Dr. Ron Ehrlich (14:25)
Do you think that the focus, I mean, you could be talking to him about his chance of getting a disease or a heart attack or sm a stroke, but do you think the fact that it’s manifested as erectile dysfunction is a is a great motivation for a lifestyle change?
Do you find that people who who that presents with are very motivated? I mean, men obviously are very motivated to change their lifestyle to protect.
Prof. Rafi Heruti (14:56)
You know that most of them are not. Until you are not in the threat, you will not change. I I I I know in Israel we know we have on the cigarette boxes, you have all those warning, you know, cigarettes smoking affects your your erectile dysfunction. So my patients say, So I will g buy another box which says it affects your pregnancy and I will never get pregnant.
Like they know how to suppress it and how to live, you know. We know how to to ignore those warnings, but if it will be in follow up in a professional field and and i i it will understand more than just what is written on the cigarette box, it might affect and I know from my experience it does help.
It does help, but you you have to learn how to to talk with the patient and and explain. It sh must come from the patient itself, from from his understanding. Yeah.
Dr. Ron Ehrlich (15:52)
you mentioned now the bios the biopsychosocial model in practice and and you’ve mentioned that it’s a combination of mind, body and relationship. I wonder if we could just flesh that out a little bit more. I mean, how those intersect and the effect this model has on your approach to working with patients?
Prof. Rafi Heruti (16:13)
So so sexuality will never be a purely purely biological or psychological or things related with relationships. So maybe I will explain explain what I mean when I when I talk about biological factors, I talk about hormones, I talk about nerves, circulation, circulation of blood vessels as I mentioned, and also important factor is medication.
And the side effects and and lifestyle as as we mentioned mentioned smoking, sport. But then we also mention the psychological factors. I mean how much stress do you have in your life if you had a past trauma, anxiety or personality, anxiety or self esteem, body image, all all those things are very very connected to sexuality.
And the last but not least is the social the social aspects which is partner communications or culture which culture I will I will use a culture approach. I will not talk to someone who is ultra orthodox the same like I talk from someone who is from Schenken, which is a very very liberal street in Tel Aviv.
I will talk differently and and the expectations the so suc success successful sorry for my English successful treatment will usually require addressing all the three aspects and if you don’t deal with three aspects so it’s not a complete holistic approach because sexual function happens in the body
Dr. Ron Ehrlich (17:42)
Okay.
Prof. Rafi Heruti (18:10)
But sexuality actually happens in the whole person. So it’s a different a diff different way to look at it.
Dr. Ron Ehrlich (18:24)
Yeah, yeah. So so I I
Prof. Rafi Heruti (18:26)
There’s a difference between sexual function and sexuality.
Dr. Ron Ehrlich (18:31)
Yeah, yeah. The the interesting the hormone effect, because I mean breaking this bodily approach down before we get into the mind and relationship. But hormones are an interesting one, aren’t they?
Because we are exposed environmentally to so many endocrine disrupting chemicals that the you know, there there’s something in the word endocrine disrupting that is linked very intimately to hormones in general, but sex hormones in particular. What what what aspect what what do you how do you see that impacting people’s sexuality?
Prof. Rafi Heruti (19:11)
So so when I do an intake, an interview to a new patient, I will always always when I talk with him I will I will try to think w where where the body, where the mind and where the relationship are are concerned. And if I think there’s there’s a risk that that there might be hormonal aspects, I will do a blood test. And we we see it more and more.
We see it no more and more. Not not only because of the chemicals, but because of modern medicine. Human beings were not at were not supposed to live until their seventies and eighties.
They were supposed to die when they were forty after their son knew how to hunt the lion and and protect them. And today we live long lives and but but the the body stops to to to produce hormones. Like in women it happens abruptly when she’s forty, fifty, you know, with the the menstrual cycle starting, but also in men.
Nobody kn not a lot of people know that even men have andopause, which is the equivalent of the menopause. But we do it gradually. But you know on when do we start to lower the production of testosterone, which is the main sexual hormone, male sexual hormone, you know when it starts to go down
Dr. Ron Ehrlich (20:33)
I, I probably go on. I’m I know I’m not gonna like what you’re about to say, but go on, give it to me.
Prof. Rafi Heruti (20:41)
Thirty five. Thirty five.
When a male is thirty five the the the testicles start gradually lower the production of the testosterone. But but we do it very slowly so it’s about one percent a year. One percent a year sounds very very very slow slow, but if you are sixty five so it’s already thirty percent lower than what you used to have. Yeah.
So you will usually ask a blood test even when you fifty or when I suspect that there might be another problem and not only the natural decrease. This is a natural physiological decrease but you can also as you said have other diseases that might affect. But through a thorough intake storytelling I can know when to suspect that it is medical or when it is in the brain.
When it’s it is connected to maybe depression, anxiety or or other aspects. And then I will decide with my knowledge when to do those blood tests. But we see a lot in the older age, not very, very old, fifty, sixty, it’s not old.
That they will have a less amount of testosterone, which is very, very easily fixed. Very, very easily fixed. Like if someone has diabetes and he doesn’t have insulin, we will give him insulin from outer sources. The same with testosterone.
Dr. Ron Ehrlich (22:11)
Can take testosterone as a supplement?
Prof. Rafi Heruti (22:14)
You can take testosterone not as a supplement, it’s it’s a a medication like insulin. I mean in you won’t you wouldn’t call insulin a supplement, would you? So it’s a medication and it needs lots of young people take it for building the body and then they can b do big damage to the body if they take it you know, with without recipe without prescription or without follow up and
Dr. Ron Ehrlich (22:23)
No you wouldn’t, no.
Prof. Rafi Heruti (22:44)
Mm. Okay. So it’s a supplement.
Dr. Ron Ehrlich (22:49)
A lot of people who are in the weightlifting game, bodybuilding game, I’m sure, over perhaps are are likely or possible to overdo the the pus that that use of testosterone. Is that
Prof. Rafi Heruti (23:03)
Not only dystroxia, also steroids they take for it’s also steroids are also a hormone, if you talk about hormones.
Dr. Ron Ehrlich (23:11)
Right. And and the effect of that on their sexuality? Do they become hypersexual on all of these hormones or does it have the opposite effect?
Prof. Rafi Heruti (23:21)
Usually, it will have eventually it will have the opposite effect.
Dr. Ron Ehrlich (23:25)
Right, right. So so w I know that when blood tests we did a programme on men’s health many years ago with Dr. Rob King and he introduced me to the idea that I should be having testosterone checked regularly on my blood profiles, but as I reflected on my history of blood tests from the age of thirty or twenties,
I I I it was never even included in the panel. Is that should that be part of an an ordinary panel for Men and women, I mean, I’m guessing women’s progesterone and oestrogen levels are similarly affected.
Prof. Rafi Heruti (24:02)
In women they they won’t take testosterone because we don’t st we still don’t know how to to understand the results in women. But women also have testosterone but in a much, much, much lower levels, although they don’t have testicles, they produce him produce it in other organs like adrenals or ovaries, you know, but a very, very small amount because testosterone is not only a sex hormone for a for libido, for desire.
It also it is also important for building bones and preventing osteoporosis. It’s all it’s it’s important in in well being in in well being in your in in your mood. It can help with with your mood. It’s important in the immune system. So if if someone lacks testosterone I will not give it to him only
Because I want him to have more sex and more frequency of sex. I will look at the the the whole picture. With women the the blood test will will usually include other hormones such as Sogan and Progoster and and and in women it’s much more developed the the hormone therapy for the the menopause period.
Dr. Ron Ehrlich (25:19)
You you mentioned you mentioned that incorrect prescription or use of testosterone will eventually have the opposite effect on a person’s libido, a male libido. What does the effect of hormone replacement therapy for women have on their sex on their sexual on their libido and sexual health?
Prof. Rafi Heruti (25:41)
Well, it’s a very tricky question. Okay. Because you know men and women are completely different. Many yeah, you’ve heard about it. And we’ve we we had lots of work suggesting that the brain, even the brain has a lot of difference, and you know men are much more physical and women are much more emotional.
Dr. Ron Ehrlich (25:48)
I’ve heard that.
Prof. Rafi Heruti (26:10)
Most of the time the these are really true journalisation. You see it also in in in in in reality. So with men you will give him testosterone and and and you will feel you you will see a dramatic effect on his libido and on his life. With women, if you don’t deal with also with the emotional aspect, sometimes you will fix the hormone levels and nothing will happen.
So many women, especially in the States now they try to combine testosterone in the treatment of women and they have medications to improve a sec a libido in women that the the FDA has approved and cost a fortune by the way, and then they take it and they don’t understand why it doesn’t help. Huh.
Because not everything is medical, not everything is okay, you have this woman is low, take hormone, now it’s good finish. It’s not working like this. And it’s again, the biopsychosocial. You can’t just take care of the biological aspect and and and hope that now everything will be lovey dovey and good and
Dr. Ron Ehrlich (27:22)
But Rafi Rafi, you you’ve just described Western medicine’s approach to healthcare, which has resulted in a two and a half trillion dollar industry in pharmaceuticals because that’s exactly the way most medicine approaches the pharmaceutical solution to a problem. and this this is why this is why this program’s on. This is all about championing a holistic or or biopsychosocial approach.
To healthcare. the the other thing is of course medication because that’s so common. I mean, one in w one example in Australia is one in six Australians are on antidepressants, and I believe antidepressants would certainly have an impact on sexual health. What w is that your experience? What
Prof. Rafi Heruti (28:14)
Yeah, show them the the SSRIs, SSIs, the sortonine re uptake, whatever inhibit inhibitory, usually will cause will will will lower libido. and it’s also difficult because sometimes when some one someone takes it for depression or for anx for anxiety, you have to understand if it’s the the cause of that it the cause that for it it tak for for this reason it takes the medication if it’s the depression or the anxiety that lowers the l desire or maybe it’s the drug.
So you have the the disease that can affect but also the treatment that you give for the same disease can affect. And then you also al always have to play with it. So today we have a a newer generation that that have less side effects
And we have to play with this medication and to see when when the what the patient can achieve the best. When we give him a medication and we don’t harm him. That we don’t cause harm.
Dr. Ron Ehrlich (29:24)
Yeah, there now sex therapy versus sexual rehabilitation. I mean, could you explain how those two approaches differ?
Prof. Rafi Heruti (29:34)
yeah. Sex therapy will often deal with it’s very important qu question because sex therapy will often deal with relationship, with the dynamics, with communication, with desire differences, things that I mentioned before. But sex sexual rehabilitation you must have much more knowledge.
Not every sex therapist can deal with sexual rehabilitation, most of sexual rehabilitation will have the knowledge in sex therapy before they will indwell in sexual rehabilitation because you have to have knowledge on the neurological diseases and the impact on on the body and on the
sexuality, chronic disease, the medication side effects, the physical limitations that your patient has and it will combine the sexual rehabilitation will actually combine the medical knowledge but with psychology some psychology or or sexual sexology is more precise and with the functional adaptation.
So and if you don’t have this knowledge you you you don’t you cannot really do full sexual rehabilitation. In sexual rehabilitation actually we walk at the intersection of medicine, psychology and relationship. It’s all of them together.
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Dr Ron Ehrlich (31:07)
I imagine that I imagine the sex therapist deals with in that biopsychosocial model the relationship aspect of it, the perhaps the mind aspect of it, but not having the medical background to fully appreciate the biological impact as well would be important.
Prof. Rafi Heruti (32:36)
So if they have someone i with a spinal cord, you have to understand how it affects the body. And you have to understand that spinal cord, even though it sounds that it’s only body because it’s a big trauma, it also affects the the mind.
It also also affects the mind because your body image now is very, very damaged. You know, I was one eighty and now I’m one twenty on a wheelchair. It’s completely different. And and of course that can affect relationship. And it’s not only a spinal cord, traumatic brain injury. It’s much more complicated than spinal cord because it wi within spinal cord patients, the brain is not affected. So you have who to work with.
And with traumatic brain injury, sometimes the work is with the the spouse, with the family more more than with the patient himself, especially in the beginning when you cannot really communicate very good with the patient.
Dr. Ron Ehrlich (33:40)
Yes, wow that’s amazing.
Prof. Rafi Heruti (33:41)
And just a small glimpse because each one of the subjects that we mention, you know, it’s a it’s it’s a it’s a world world of its own.
Dr. Ron Ehrlich (33:49)
Yeah. Yeah, I I know that and we want to talk about your involvement in in classifying Paralympic sports. I know that’s what you know, that’s a part of your professional life and personal life as well.
Classifying that, but classifying trauma, classifying disability, I mean, my goodness, the range must be well, it’s a huge range of wha how we classify not for Paralympics, but in terms of actual patient experience, how we classify, quantify trauma and disability is an interesting challenge ’cause there there must be a a range, an incredible range.
Prof. Rafi Heruti (34:31)
Yeah so so actually I’m here in Australia because I was invited by the Australian Paralympic Committee to classify in the the an swimming competition for for disabled and and classification is is a a a very important and crucial field within the the the Paralympic movement within disabled sports because you want people to to to compete with people that have the same or similar functional ability.
So usually it involves two classifiers. One like me, which is medical and it knows the medical feel very good, he knows the impairments, the disabilities, the effect of the impairment on function and can measure it. And the other one is a technical classifier.
In swimming after I do my my my my examination my physical assessment, we will go with the swimmer to the swimming pool and then we will see him in in in swimming and the technical classifier will perform a thaw assessment in the water n and we both look if what we’ve seen on the bench is similar to what we see in the water. The third part the third part will be in doing the compete competition itself when we observe
Because some swimmers won’t show their best doing the medical assessment and the physical assessment and suddenly when we watch them in the competition, boom, you know, they fire themselves and they can be ruled out from the c from a competition. It’s like taking drugs in sport. but to your question, we we can measure function. We can measure function, it’s not something easy, it’s I do it for many, many years.
And well but we will measure the function according to the impairment of the patient. So if the pati the the it’s not a patient, it’s an athlete. Now we change my heart, it’s it’s an athlete, it’s not a patient anymore. So we will group it the pa the athletes according to the functional ability and we evaluate different things. So if it’s a spinal cord or someone who has a nerve injury, I will
I will measure the strength. I can measure measure measure the strength in many many muscle groups that are important in swimming. If it’s someone with CP cerebral palsy or someone that the attack impairments that affect coordination, we have a special coordination test. I can evaluate coordination and measure it and get points.
if it’s someone that has problems in range movement like outro gul gulposis, I can measure the range of every of every movement and see how much he has and how much is lost and again I can put it on a table of points and know the total function. And sometimes it’s someone who lose parts of the limbs and we know according to biomechanic studies
How important is each each part of the limb? And we can give score according to what percentage of this limb that he lost. And and and so the w the whole p person according to what he lost, we have the remaining points and you have to remember that some will have few problems. They can have you can have a a a cerebral pulsy person who became spinal cord, we who became paralyzed and then we can
use different few tests and but we will i will lose only for the lowest. You cannot lose twice. You cannot have below zero. So it’s not easy. It’s not easy and every every assessment can be one and a half to two hours for each athlete. And we are subject to criticism from the athlete themselves when they want to be in a lower class, which increases the chances chances to win.
But also from the other countries that think he has to be in a higher class because he endangers their athletes. So it’s
Dr. Ron Ehrlich (39:02)
Rafi on a on a personal level, I mean you said something there which I thought was incredibly inspired. You know, we’re not talking about a patient, we’re talking about an athlete. Now to somebody who has s had an injury or sustained or has a disability or trauma that has caused a disability, to move from being a patient to an athlete, just that word alone, must have a huge impact on their biopsychosocial.
Health, but for you as a as a practitioner who sees the person coming in on the first day for rehabilitation, and then here you are in the Olympics dealing with people who have not only come to terms with it, but have moved from being a patient to an athlete. That’s quite a range for you as a person to must be very empowering to see these people. Some very inspiring stories. Do you have any that come to mind?
Prof. Rafi Heruti (39:59)
This is why I really loved my involvement in the Paralympics sports, Paralympic movement and I do it actually voluntarily because in in the Paralympic sports this is the the I I constantly see this incr incredible adaptability of the human body. You know when you see them in the beginning you you don’t believe what they can do eventually. And I add patience.
that I as a young doctor that I had to accept them, you know, like a what we call almost total loss, you know, not functioning. And then a few years later I went with them to the Paralympics. I served as a team physician for like a few Paralympics in in the past. And one of them even was a pilot in the Israeli army, was a combat pilot in the Israeli army that was injured and became paralyzed.
When I told him look, this is your injury, it’s D twelve, whatever D twelve, he said so I understand. It’s from F fifteen to d D twelve. And then he became from F fifteen is the pilot.
Dr. Ron Ehrlich (41:10)
Yes, I know. But D twelve is
Prof. Rafi Heruti (41:16)
Few years later he got the gold medal in the Athens Paralympic for sailing. Only a few like six or seven years later. So this for me it’s like it’s a wow. It’s a big
Dr. Ron Ehrlich (41:29)
Rafi, what was the D twelve? You mentioned he went from F six to
Prof. Rafi Heruti (41:32)
D twelve is the vertebra that was injured. I told him you are paralyzed between the b below the vertebra called D twelve, which is a thoracic vertebra, the lowest one. So he was paralyzed in the lower limbs.
Dr. Ron Ehrlich (41:47)
Yeah. Yeah. Wow.
Prof. Rafi Heruti (41:49)
So that’s a real story.
Dr. Ron Ehrlich (41:51)
That is a real story and that must be you you there must be so many people that come to see you as an initial rehabilitation case who you wish you had the Para Olympic team sitting behind you saying, I know you feel life is is over, but these people are here to tell you it’s not.
Prof. Rafi Heruti (42:11)
So we involve them. I ask them, please come and visit, please come and give you the inspiration talk. Or I show they have do those talks on the YouTube and I s show the patient, look, watch it, we can talk about it tomorrow and it really helps that they see this is i they can be like this within a year.
That the the injury is not the end of life. It’s just the beginning of a new life. And it’s not an not necessarily worse life because sometimes some of my patients will say no it opened many things in me and I I understand life better so it’s not even not always necessarily bad.
Dr. Ron Ehrlich (42:55)
Now one thing that I we we talked about this when we b before when we first met. You I me you mentioned the word surrogacy to me and I thought that is a very revolutionary approach, I imagine, professionally, although I suspect on a personal level many people explore this approach and give it other wor other names.
But within the context of sexual rehabilitation, can you talk to us a little bit about surrogacy and how
That is used and what it is what it is and how it’s used.
Prof. Rafi Heruti (43:29)
So we call it SPT Sourgate Partner Therapy. And actually it’s not very revolutionary because it is used since the seventies of last century, so it’s more than fifty years. But unfortunately not many use it. In Israel we are one of the pioneers in this field. The clinic where I work we use the Sourgate Partner Therapy and it’s a Sourgate, it can be men or woman that actually they play the role of a partner that the patient doesn’t have.
Okay? But they play the role of the partner not only for the not only for sex but mostly for social skills. We talk about patients that their social skills are very low. So the therapy doesn’t start in bed like many people outs in the outside world think that the Sourgat partner therapy will do sex with the patients and teaches him how to do sex, it’s wrong.
That’s wrong, it’s not true. It it starts in a coffee shop, they meet in a blind date. The the the Sourgate can say no, I i it doesn’t suit me. The patient can say no, it doesn’t suit me. It’s not it’s not a must and they know how to they they they they learn how to build relations.
And the sour gate is only part of a triangle. We see a triangle on one corner it’s the patient, other corner is the sour gate, but but the therapist, the sexual therapist, he decides how will it continue, and it will continue according to to the anxiety level of the patient. So if the patient has a very high anxiety, we will the next meeting will still be in the coffee shop.
They will learn how to go to the cinema and what to talk about or how to walk hand in hand on the beach and what to talk about. Because sometimes they don’t know how to to communicate. Sometimes going into the room, the room in the clinic where the where they where they practice intimacy can be even in the tenth or fifteenth appointment.
So we build it very, very gradually and it’s a it’s it’s like learning how to swim. Through YouTube and never go inside the water or jumping into the water and start to swim. And it’s a a a kind of therapy that r I call it the whole soys of the sexual therapy, because it’s also very expensive, but but but it changes lives of people. It actually changes lives of people.
And I see people in the beginning of the therapy and in the end and you see their completely different, even the body stature, even the confidence that they gain, even their communication and the way they look, the way they look, they they start to take care of themselves, you know, and they don’t neglect the their appearance.
So but this is a very you know it’s a very broad subject, a very fascinating subject I believe.
Dr. Ron Ehrlich (46:45)
I mean, when we talk about a bio-psychosocial model of body, mind and relationships, and we reflect on our modern world where people are spending more and more time connecting with people all around the world, but not really connecting with them at all, spending a lot of time in their room.
I mean, I heard one statistic recently that in America young men between the age of twenty or thirty are spend less time outside than prisoners in jails. You know, so they spend less time outside. So the foundation for a bioso psychosocial health is really compromised, putting even aside bodily traumas and injuries, isn’t it? I mean, we’re starting from a low base society wise.
Prof. Rafi Heruti (47:42)
yeah, yeah, I think you’re right, you know, and and young people today they communicate much less and much better than than what we did, you know. We as kids we and we went to play outside, we had to talk, we had to fight and as i it’s it’s exactly like you said. Today they can fight with a computer.
They talk through writing on WhatsApp and and it’s a big problem, you know, a and we see it. We see more and more patients that don’t that that the main problem is communication. As I mentioned, social skills. But can I a can I ask you a question? Sure.
So I I actually when you you asked me to to be in this podcast, I didn’t know this podcast because I’m not from Australia and I listened and and I I’m curious because I I heard in your podcast lots of conversations about health and stress and holistic health and I I I am curious to know how often sexuality comes up as part of overall well being. Because you know for me it’s very crucial but
Dr. Ron Ehrlich (48:53)
Well well, thank you for that question. And I agree w I mean, I’ve done a program or two on sexual health. Ian Kerner, who is a very well known author from America, who’s written books like He Comes First, She Comes First, and that sexual scripts of romance, th those kind of books.
I’ve done programs, but you are right, and it may well be a reflection of why me sexuality isn’t part of mainstream medicine because people are maybe not as as keen to discuss it as as perhaps they should be because it’s such a central part of everybody’s life.
But having said that, Rafi, as soon as we met just last week over dinner, my you know I one of the first things I said to you was to correct the very problem you’ve just identified I’d love to have you on to talk about sex because we haven’t talked about it often enough.
Prof. Rafi Heruti (49:57)
Okay and I meant that when you talk with experts not from the sex field, like with the cardiologist or with does it come up even if they are not expert in the field? Does it come it comes even yeah.
Dr. Ron Ehrlich (50:05)
Stay good. Up in passing, I mean the subjective erectile dysfunction has come up and and that’s related to we’ve done programmes on PTSD and and I want to talk to you about that as well. But PTSD and and trauma and its impact on that. We’ve done we’ve skirted around about it with in terms of fertility as it’s as a discussion.
We’ve t flirted around it in terms of digital nutrition as a discussion, but you know, this is a very important point for me, Rafi, and thank you for it. but I will definitely include questions about what is the impact of this on people’s sex lives a lot more a lot more often, and and thanks for calling me out on that.
Prof. Rafi Heruti (51:07)
I’m glad to hear that it will be a more prominent subject. But not only not only sexual function. I talk about sexuality in the board board, you know also the psychological or also the mind, relationships, etc. And I hope the listeners understand what an important field it is and how important it to discuss to talk about it.
Dr. Ron Ehrlich (51:30)
Well, it’s an interesting one too, because for example, ten years ago I had prostate cancer and I had a prostatectomy. And one of the one of the side effects of a prostatectomy is the potential for nerve damage and a permanent erectile dysfunction.
And I know that in my own practice, which was a dental practice, and I’m not an expert on erectile dysfunction or prostate health, but but it was an interesting opening to discuss issues around it with with men who I had come into contact with that I was reluctant to discuss in the past.
So so that’s a very and and prostate health and prostatectomy in particular raises some very important questions for couples in general and and men in particular, doesn’t it? Because so much of sex for men and women, I guess, is penis centric and this challenges that focus. What are your thoughts on that?
Prof. Rafi Heruti (52:36)
It’s very important what what you ask but because also I hear from many patients posted patients that the the urologist that didn’t give them the side effects of the operation they didn’t know the nerves and they tell them look I saved your life what do you want and and then they need a process process of sexual rehabilitation but then the process if if they lose lose direction completely of we have ways to regain direction.
But but the main the main process will will regard the myth that sexuality equals to performance. Okay and sexuality doesn’t equal to performance because in reality sexuality is about connection about pleasure, about communication and you don’t need an erection for those aspects.
So we try to to move to shift to to shift people from concentrate concentrating on performance to intimacy. and if they understand that intimacy and pleasure they they are the focus so then things often improves. So so they must understand that sexuality works better or best when they stop being in performance.
Yes. So actually we take direction out, we move pleasure in, and concurrently I can I will try to to to help them with gaining erection because I don’t I don’t even argue with him that that penetration is a very pleasurable position but it’s not the only position and it’s only a position. Sex is not about penetration and performance.
Dr. Ron Ehrlich (54:50)
Yes, I love that. It’s not a not about penetration and performance, it’s about intimacy and pleasure. And that’s quite a focus. because this gets to the heart of of sexuality as we develop as as young people. you know, I mean I didn’t my parents didn’t talk to me a lot about it. I mean, I d I doubt whether I don’t think many people’s parents did and
Prof. Rafi Heruti (55:11)
Mine as well?
Dr. Ron Ehrlich (55:18)
you know, I I I remember my my daughter who’s now thirty nine, but when she was about ten or twelve had learnt th she once asked us what’s the what’s ps number six what’s sixty nine, mum, dad, what’s sixty nine? you know, w can you explain it to me?
Prof. Rafi Heruti (55:37)
It’s a number of a house.
Dr. Ron Ehrlich (55:41)
Yeah, she wasn’t going to accept that. But but but then I did say to her, it’s a sexual position. Did you want to hear more? And she said, No, no, that’s fine. I didn’t want to hear any more. And she she dropped the subject, but but really that kind of how do we talk to her, how do we prepare our our children to have a healthier approach to to sexuality? I mean, beyond, I guess it’s away from this performance. yeah.
Prof. Rafi Heruti (56:10)
Yeah, but but then we we differentiate between sexual education, sexual counselling and sexual therapy and in sexual therapy we have sexual rehabilitation. So we go down to sexual education, which is also very sad. I don’t know how what’s how it is in in Australia, but sexual education in Israel it’s usually until you are four years old.
And you know there’s a difference between a boy and a girl and a boy has a penis and a girl has a vagina and you shouldn’t touch and you can play but you don’t take your and then it finishes. And sexual education should be continued in every age.
In every age it it of course it should be adapted to the age and to the goals in this age, like the talk with your daughter when she was sixteen or seventeen or whatever. But sexual education we give e even for elderly. Yeah. Even for old patients.
Very old patients that they think, okay, it’s not correct that I’m doing sex, I’m old, it’s and but if you liked it when you’re sixteen, you will liked it where you will like it when you’re sixty and ninety. So this is also sexual education.
Dr. Ron Ehrlich (57:27)
Yeah, yeah. And I think the the as we get older, perhaps, the importance of intimacy and and you mentioned after thirty five years old, I think that’s probably a you know, not a not a bad place to start. Probably twenty is not a bad place to start. Probably, you know, about the focus being more on intimacy than on performance.
Prof. Rafi Heruti (57:51)
yeah, and this is what we this is a crucial part in the sex therapy. When we when we have patients for sex therapy and sex therapy, most of sex therapy is not spinal cords and traumatic brain inju injuries and post traumatic as I said.
Ninety percent of them are regular people, you know, it’s a young person with a premature ejaculation, a young woman who has vaginis, which which is in involuntary involuntarily contraction of the muscle of the vagina. So the main aspects is i the beginning of the therapy will always include the sex education as well.
Dr. Ron Ehrlich (58:32)
Mm. Hm. I I think it’s so interesting to talk about this biopsychosocial model because if we were talking about any any any condition, cancer, hearty cardiovascular disease, all every condition fits into this model, really, doesn’t it? Because the things that affect it positively affect sexual health positively, and the things which affect it negatively have the same impact.
Prof. Rafi Heruti (59:01)
Absolutely yes. And actually the biosychosocial model i it didn’t start in in in the sex field. It started in a rehabilitation field many, many years ago by a a psychiatrist called Engel and many many other fields adopted it. So it was adopted in the sex sex therapy field but also in the social work fields, in psychology. So we are we are not I talk about it but it’s not only mine.
Dr. Ron Ehrlich (59:33)
No no no
Prof. Rafi Heruti (59:35)
We and it should be adopted adapt adapted in all medicine fields, to my opinion.
Dr. Ron Ehrlich (59:41)
I you it’s music to my ears to hear you say that, Rafi, because we’ve done so many programs on an integrative functional or holistic approach to many, many conditions. Listen, I just want to take a step back. I wanna ask you this last question, because taking a step back from your role in rehabilitation and sexual rehabilitation in Paralympic sport as a professor, as an educator, we are all individuals.
On a health journey in this modern world, what do you think the biggest challenge is for us as individuals on that journey?
Prof. Rafi Heruti (1:00:20)
Can you elaborate on this question? Focusing on my answer.
Dr. Ron Ehrlich (1:00:24)
Well well my question
No, you don’t I just want you to focus on, you know, you as an individual are trying to be as healthy as you can, knowing everything you know in in health. What do you think your message to people in general would be? What’s the biggest challenge for us in our modern world today? What do you think?
Prof. Rafi Heruti (1:00:50)
To improve our quality of life, always improve our quality of life a a good example will be that if you have a very good income and you walk and walk to improve your income, but you don’t put in your in your health, you neglect your your health or you neglect your leisure time, you don’t go on vacations, you don’t you neglect your relationship and you’re on the verge of a divorce maybe.
So you are bringing b doing a big big mistake. So you should every time and then stop and say, Do I need this very, very high income? Or maybe I can do better with a lower income, but focus on the other fields in that in my life that are more important. My body, my mind, my relationship. So you have to stop and focus on yourself to give yourself those answers.
And actually me myself I was working in a very, very demanding job in hospital until recently, until a year ago. I was big manager, you know, with many, many doctors under under me.
And even though I was very close to my pension time five years before I left it all to focus on my well being. and it took me about two years to reach this decision with a lot of help, but I did it and I’m very glad that I did it. So I give me out I give you also an example for my personal life.
Dr. Ron Ehrlich (1:02:23)
Well, Rafi, that’s a great note for us to finish on and a great message for you to share. And I want to thank you for all the work you’ve done and are doing and for sharing your knowledge and wisdom with us here today.
Prof. Rafi Heruti (1:02:36)
Thank you one for hosting me. It was I loved it. I I don’t do it a lot in English and it was a nice experience for me as well.
Dr. Ron Ehrlich (1:02:44)
Well, sex is part of everybody’s life in one form or another and and it’s certainly an important part, but when we’re faced with the injury, trauma, stress, post-traumatic stress, i it is affected and it is has a a tremendous impact on our lives.
But starting a conversation and realizing what is important and how one can approach this is a very important first step. And I’ll have links to some of the resources that Rafi has shared. and we will do other programs on this issue from different perspectives.
I’d refer you back to that program I did with Ian Kerner, who has written some wonderful books like He Comes First, no, She Comes First, He Comes First, and all about sex scripts. We’ll have links to that. That was a great conversation. And I would also encourage you to join our unstressed health community because after all,
Addressing the five stressors and the five pillars lays down a very an optimal foundation for a healthier you and that will impact in all sorts of different ways. I hope this finds you well. Until next time, this is Dr. Ron Ehrlich.
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