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A Urologist Answers Every Question We Have About Beau Is Afraid

Joaquin Phoenix in Beau Is Afraid, giant balls not pictured. Photo: A24

This piece was originally published in April. We are recirculating it now that Beau Is Afraid is available on digital. Warning: Spoilers ahead for the plot and ending of Beau Is Afraid.

How stunted is the titular man-child at the heart of Ari Aster’s Beau Is Afraid? So much so that, despite Joaquin Phoenix’s Beau being well into middle age, he apparently has never had an orgasm, neither with a partner nor by his own hand. And this is not an incidental detail. It’s actually a pivotal plot point: Like a lot of what’s wrong with Beau, his aversion to orgasm can be traced back to his mother (played at different ages by Zoe Lister-Jones and Patti LuPone), who’s told him that his father died of a heart attack at the moment of his conception — and wouldn’t you know, Beau has the exact same heart defect.

This lack of release has had consequences on our anxious anti-hero, not just emotionally, but also physically. Because of the decades’ worth of semen collecting inside of him, Beau canonically has enormous testicles. (We see them briefly, which is enough.)

As you have probably guessed, Beau Is Afraid takes place in a heightened reality that’s not meant to be read literally. Even so, Beau’s giant balls had me wondering about the real-world science at play. In need of an expert opinion, I called up Dr. Yaniv Larish, chief of urology at RWJBarnabas Health in Jersey City, who also works as a concierge urologist in Manhattan. His father, Naftali Larish, is a retired cinematographer and documentarian, so you could say he is doubly qualified to comment on these nuts.

What was your opinion of the movie as a filmgoer, rather than a doctor?
First of all, it’s such a pleasure to see a movie that’s not a superhero movie. The movie really takes you on a ride through what it’s like to have an anxiety attack to an extreme level with a psychotic break. It was actually humbling as a physician … I’m not a psychiatrist, right? I’m a urologist. Maybe that’s what a good movie does, is it lets you be empathetic towards someone who you have nothing to do with.

We’re told that Beau has made it into his late 40s without ever ejaculating. If a normal human male somehow did the same, would there be any adverse medical consequences?
Probably not. The real question is, is ejaculation beneficial? There have been a couple of studies showing that ejaculating more than five times a week is actually protective against prostate cancer. Go figure. It probably has to do with reducing inflammation within the prostate.

But your question was, can what we see on screen actually happen? I think it was more of a metaphorical tool. Here you have a guy who’s scared of everything, is anxious about the simplest acts, and yet the audience is told that he has massive balls. “You got big balls” — that’s a phrase that connotes bravery, testosterone, virility. This character is the exact opposite of all those things. So, I actually think it’s a beautiful literary tool that they’ve used grotesquely to subvert the audience’s expectations.

There are medical conditions that cause very large scrotums. There’s a condition called elephantiasis, which is really a lymphatic obstruction caused by a parasite called Wuchereria bancrofti. It’s a mosquito-borne illness where you can get these massively inflamed scrotums that are swollen with fluid, and can actually look like what we saw on screen.

Is there a treatment for that?
Shout out to my infectious disease professor in medical school, Christina Coyle, who will crucify me if I get this wrong. You have to get a drug called DEC, and the only entity that holds DEC is the CDC. Once that infection is resolved, the swelling is still there, so you have to remove excess skin, do skin grafts, all sorts of things. I actually did a couple of those cases in training, with one of my reconstructive mentors, Christopher Dixon — apt name for a urologist, right? It is not unusual for a patient like that to show up with their scrotum in a wheelbarrow. We don’t see it often in New York, because we don’t see Wuchereria bancrofti in New York all that often.

Have you come across any scientific literature about men who’ve gone their entire lives without ejaculating?
Not really.

Usually temptation takes over.
Yeah. If you think about it from a purely biological perspective, human beings, really all living creatures, are put on this world to do two things: eat and reproduce. That drive to reproduce exists in everyone. Whether they become asexual or they don’t have interest in sex, that’s a different story. But the physical aspect of ejaculation, I don’t think is going to be affected in that way.

The reason Beau doesn’t have sex is that he’s been told he has a congenital heart defect that also took the lives of his father and grandfather the moment they had an orgasm.
You can certainly have a cardiac event from sex. That is a thing. When you’re sexually excited, your heart starts pounding, oxygen demand goes up, and if you can’t supply that oxygen, you get a heart attack. Could you have an electrophysiological defect that causes an arrhythmia in the setting of exertion? Certainly. But to not have a diagnosis and only have it hovering over you like the sword of Damocles that if you ejaculate you’re going to die, that’s sort of a strange version.

In this case it seems that the climax, not the physical exertion, is the thing that would tip him over the edge.
Remember, in the movie, he’s lying on his back. And that’s not by accident. He’s not an alpha male. He’s not even the beta. He’s a zeta. You know what I mean?

The physiological changes that occur during sex are not just from the physical activity. The adrenaline is really what it is. That heart pounding, the flushing of the face, it’s from the heart responding to adrenaline and pumping faster. Some of it has to do with the movement. But I would venture that even laying on your back in the most passive way to reach orgasm, there’s a lot of physiological changes that are going to be strenuous for the heart.

Because Beau’s been saving up his semen all his life, when he finally does orgasm, his ejaculate is powerful enough to shoot through the condom. Is that possible?
No, that is not possible. It’s not like if you don’t ejaculate, the scrotum enlarges like that. That’s not really a thing. The sperm is actually not even stored in the testicles themselves. It’s stored in these storage pouches called the seminal vesicles, which are outside of the testicles, and they have finite space that they occupy. So, you can’t put more in there than what they can accommodate. No matter what you see in the movies.

You mentioned elephantiasis. Are there other conditions that could make one’s testicles swell up to an abnormal size?
Remember, he has bilateral swelling. Both sides. So, you have to start thinking about things that can cause that on both sides. The rare things would be bilateral testicular tumors. That’s sort of unlikely. Something called a hydrocele, which is not the testicle itself, it’s a sac filled with fluid that separates off of the testicle and fills with fluid. Those can get really large, and can be bilateral. My record is 2.5 liters of fluid drained from someone’s scrotum.

Yeah, 2.5 liters. What you saw on screen is an excess of three gallons. I’m not sure that’s all that realistic.

Do all of those conditions require medical intervention, or do some of them clear up on their own?
No, most of them require an intervention of some sort.

Okay, that’s good for readers to know.
A stitch in time saves nine. I mean, even small hydroceles require intervention. Testicular tumors obviously require intervention. There’s a reason why there are still surgeons in this world in the age of ChatGPT. Hopefully, one day not. I always tell patients, “The best patient is the one that doesn’t need me.”

What about if one finds a murderous penis in the attic, should they call a urologist?
I was thinking about that. I don’t think there are any representations of humongous monstrous penises with insect legs in nature, so one needs to think about it through the lens of metaphor. Maybe the metaphor is that masculinity chained up is dangerous. When it’s repressed, it takes a monstrous form. I’m not much of a philosopher. Nor am I a psychologist. I’m just a urologist.

This interview has been edited and condensed.

A Urologist Answers All Our Questions About Beau Is Afraid