Dr Rachel Rubin: "I'm Filled With Rage!" Your Doctor Was Never Taught About Women's Bodies!

24:13What changes for a woman? So there are so many symptoms to hormonal fluctuations. So for some people, it's temperature changes. For some people, it's fatigue. For some people, it's remembering things. For some people, it's low libido. Some people get dry eyes, itchy ears, burning mouth, joint pain. Some people get irregular periods. Some people get pain with sex. Some people get UTIs. I would love to talk about why hormones are so important for the bladder and UTI prevention. And so there are so many symptoms. And everyone says, oh, we're blaming everything on hormones. And the truth is, we haven't talked about hormones enough to actually start looking at this to figure out what is important and what is hormonally important.

24:52So when you start to lose progesterone when you arrive at perimenopause, what are the symptoms you feel? Are they different symptoms to decline in estrogen? So it's hard to know for sure, but some people think that is the progesterone. So your sleep starts to get a little crazy. Anxiety starts to go up. And so some people will start with progesterone as a support for, you know, sort of perimenopausal hormone therapy. but estrogen can also help with many of those symptoms. So it's not a one size fits all of whether we give people, everybody gets progesterone or everybody gets estrogen. Sometimes people just get testosterone because remember that falls in your thirties.

25:26So there's sometimes where we do all three and there's sometimes where we do just one or two. Now it's a very evolving conversation because most of the book answers, most of the guidelines really talk about menopause and how we treat people in this menopause when you're flatlined. Remember it's that castration event where everything's zero and then we add back hormones. So now we're starting to talk about perimenopause as a place to start giving women hormones. And that's a very important and evolving conversation that is happening. And so this conversation that's sort of raging on about HRT, about safety, about what age you should take it, who should take it, what form you should take it in, what's your perspective on that?

26:09And what do women need to know about that? Yeah, so it's important because... And what is HRT? Yeah, it's a great question. So hormone replacement therapy, which is a term that we used to use for hormones in menopause. It has a bunch of different names and everyone tries to change the marketing around it. But hormone therapy in general is this idea of giving back hormones when you have hot flashes, night sweats, osteoporosis, you know, sort of this over 50 crowd that has this declining estrogen and progesterone levels. And so typically classic hormone therapy is estrogen and progesterone. Now, again, taking just estrogen, estrogen grows things.

26:47It helps your bone health. It helps your hair, skin, and nails. It helps you not have hot flashes. It helps you sleep. It can also grow the lining of the uterus. And so if it gets thicker, thicker, thicker, there is worry over years that leads to endometrial or uterine cancer. So the endometrium is the lining of the uterus. So here I can. Okay. So this is a vagina. and then at the vagina is like a sock. At the very end of the sock is a tiny hole and that hole is the pinpoint opening of the cervix. And that hole, if you go through that tiny, tiny hole, it gets to the uterus. And the uterus is a cavity where we hold babies where the lining comes out.

27:27That's what period blood is, is the lining of the uterus here, which we'll call the endometrial lining. So progesterone is very important for this lining here. if the the lining of the uterus gets too thick with just estrogen that can lead to problems but if you match it with progesterone those problems go away so when we so if you just gave someone estrogen then the linings of the uterus would get so thick that that would cause a problem but if you give it to both hormones together it sort of balances it balances them out and so that's why you'll hear hormone therapy talked about estrogen and progesterone just like the birth control pill your partner was on was an estrogen and a progestin there was a combination okay got you And also the history is kind of important here of why your mothers and grandmothers weren't given access to this medication and the stigma behind it.

28:12In the late 90s, a lot of people were on hormone replacement therapies and they were seeing benefits. They actually were all these observational studies that showed, wow, the heart disease is less. And like this is during menopause. And a billion dollars went into the NIH to study this in women. And it was called the Women's Health Initiative. It was thousands and thousands of people age 50 to 79. They gave a hormone pill, like a birth control pill almost, to all of these women, and they followed them. And they stopped the study early in the early 2000s, and they did a press conference. And at this press conference, they said, we're shutting down the study early.

28:49Hormone therapy causes cardiovascular disease and breast cancer. And overnight, a multibillion-dollar industry went to nothing. Everyone was told, throw your hormones in the garbage. This is dangerous. What was crazy is those people who were prescribing hormone therapy were looking around saying, I don't understand. My patients aren't dying of heart disease. They're not getting extra breast cancers. Like, this doesn't make any sense. And when people actually looked at the study, it didn't say any of those things. It was wild how misinterpreted this study was. In fact, the same authors of this study back in the early 2000s published this year in 2025, actually, that below age 70, that type of hormone therapy, which we don't really use anymore, has no increased risk of cardiovascular disease or stroke.

29:35And yet now you have a generation of doctors who weren't taught how to do this. Only 1.7 % of women are getting prescriptions for hormone therapy who should be offered prescriptions. So it is a disaster. Only 1.7%. Only 1.7%. Oh, really? Wow. And so hormone therapy is not something that I'm saying every woman must have, but every woman should have access to the toolbox. I like to think about hormone therapy as really four buckets that we talk about. Hormone therapy is whole body estrogen, which helps with hot flashes, night sweats, bone loss. Progesterone, whole body progesterone therapy, which protects the uterus and is this yin-yang, especially if you have a uterus.

30:16but it helps with sleep and it can help with anxiety reduction in many of our patients. Not everybody, but a lot of them. The third thing is testosterone, which we talked about, which can help with libido. That's what we have the most evidence for. And then the fourth thing is vaginal hormones. Now, vaginal hormones are micro doses of estrogen or what we call DHEA vaginally that supports the bladder and the vagina. So it helps with pain with sex, dryness, urinary frequency, urinary urgency, leakage, and it prevents urinary tract infections massively. It is safe for your great-grandmother in the nursing home.

30:51It is safe for your wife who's breastfeeding. So if you know anyone in your life who is a woman who's having urinary frequency, urgency, leakage, urinary tract infections, pain with sex, dryness, there is a magical solution that is safe for everybody on earth that is microdosing these hormones vaginally. At any age. At any age at all. In fact, even more important for people who are older because they are dying of urinary tract infection. They're dying of it. It's one thing when a young person gets a urinary tract infection and they go to the urgent care and they get an antibiotic. Even they deserve prevention.

31:27And this prevents those problems in those people too. Again, what is this? So vaginal hormones. So this is a really important topic. It's called genitourinary syndrome of menopause or GSM. Say GSM loudly for your listeners. GSM. GSM. Genitourinary syndrome of menopause. genital, urinary, syndrome of menopause. But really, it's kind of a dumb name because it's any hormonal changes in your body can affect the bladder and the genitals. So UTI, what is a UTI and what's causing a UTI? Urinary tract infection? Yeah, very good. So urinary tract infections are when there is bacteria in the bladder and it can be a lot of bad bacteria that can grow and create inflammation.

32:13It causes bladder pain, pain with urination. It feels like razor blades. But it can also go into your bloodstream and cause fevers and chills and cause kidney infections. It can cause something called urosepsis, where you have to go to the intensive care unit and need antibiotics through an IV and it can kill you if you have an infection go through your whole body. And this gets worse and worse as you get older. Why is there a link between hormones and UTIs? Yeah, because what happens is the vagina is supposed to be acidic and healthy and hormones help keep it. It is the hormones, the estrogen and the testosterone that keep healthy bacteria growing in the vagina and suppress or lower the bad bacteria.

32:54So there really is a vagina microbiome. There is and there's no probiotic on earth that has proven to do what the vagina needs quite like hormones. Hormones make the tissue go from not acidic to quite acidic, and it is that acidic environment that protects it from infection. And so perimenopause and menopause or other situations happen, and it changes that microbiome so the good bacteria are lower and the bad bacteria start to grow, which can increase your risk of infections. And sex, right, sex is a contact sport. So you're bringing the outside environment into the inside environment. Ejaculate is also not acidic, and that can change the microbiome as well.

33:36And so we know women who are sexually active also have an increased risk of urinary tract infections. So again, like a plant needing water, vaginal hormones help support the vagina and the bladder to maintain that acidic environment. And research has been clear since the 1990s that using vaginal hormones prevent UTIs, urinary tract infections, by more than half. So what have we got here in front of me? All right. So there's a bunch of different ways you can give yourself vaginal hormones. The most common way is a cream. Now, this cream is$14 on Mark Cuban's pharmacy, and it lasts about two and a half months.

34:14Now, this cream that comes with an applicator, which you don't ever have to use if you don't want to. But what you can do is you want to use one gram of this cream. So this amount is one gram of this cream. We'll put it on this paper here to show you. one gram of this cream rubbed into the vagina. So you take it, you can take it on your fingers and rub it into the walls. Like if you put sunscreen on your face, you don't blob it on and walk out the door. You rub it in so it doesn't look all white and filmy. So you put it in, you take it with your finger and you put it in the vagina and you rub it into the walls of the vagina and you can rub it on the outer, this area as well at the opening.

34:52Let me try it. There you go. I don't have a vagina, but I open it. Oh my gosh. So you take the, what is this cream called? It's estradiol cream. Estradiol. Take it on your finger. You rub it inside the walls of the vagina like this. And just rub it in like you would rub sunscreen on your face. And if you do that twice a week, you can prevent death from urinary tract infections. You can help with urinary frequency, urinary urgency, leakage. You make sex not painful and dry. It helps with arousal and orgasm. It's literally better than Viagra. And this is over the counter in the UK. In the United States, you need a prescription.

35:25but it's as little as$14. If you use Mark Cuban's online website, it should be covered by your insurance. Now, some women hate creams. And so we have things that are not as messy as what you're showing right there. And we have little tablet inserts. So here is, it comes with an applicator. And so what a woman does is put this in her vagina and press a button and this little tablet. So instead of a cream, you could just put this little tablet in twice a week. And that does the same thing as the cream. Ah, okay. Okay, so it's a little less messy. So people tend to like the creams better. Now, if you really don't want to do anything twice a week, this is a ring that goes in the vagina and it can stay in there for three months.

36:06Now, this, it's sort of like a tampon. You can kind of put it in the vagina and the vagina does not feel it. By the way, the vagina is not very sensitive in terms of nerve endings. And so when women put tampons in, they don't feel them. When you put this ring in, you wouldn't feel it either and it would stay in for three months at a time. It's quite a big ring. Vagina can hold like a bowling ball of a baby can come out of a vagina. So it can actually withstand quite a lot of volume. And there's a chemical inside this ring that's going to diffuse. Estradiol that slowly diffuses estrogen for the ring.

36:37So that's nice for women who have dementia, who have very bad dexterity with their fingers. They're in a nursing home for someone who's on the go and they can't remember something twice a week. So our ADHD patients like things like that. And so there's just different. It's all the same stuff. It's just in different formulations. Now, the one different one, this is something called DHEA. Now, DHEA is the precursor hormone to estrogen and testosterone. And remember, I said the vulva, the vagina, the bladder need testosterone too. So this is a chemical that converts into estrogen and testosterone.

37:11And so DHEA is a supplement you can buy, you know, sort of in the supplement aisle. But if you put it locally in the vagina, this is an FDA approved product. It's called Intrarosa. and if you just put this in the vagina, it's meant for every night, but you can do it twice a week. It melts at bedtime when you wake up and it prevents UTIs. It helps with pain with sex. And just to be clear again, so you think a lot of people should be taking these things? I believe it's preventative. So I think, and we wrote guidelines by the American Urologic Association, why this is so important, how to do it. So many women have symptoms of urinary frequency, urgency, leakage, urinary tract infections, pain with sex, dryness.

37:52And this is a safe option for all of those women. Does that make sense? It does make sense. And one of the things that doctors sometimes tell their patients to take to help with the UTI situation is that. Okay, this is a disaster. So women get urinary tract infections a lot. And so what do we tell women? Pee after sex, wipe from front to back. Like that's not data driven, by the way. That's all a folktale. Like that's folklore. There is some data that cranberry pills can help with preventing UTIs, but the amount that you'd have to drink is very sugary and diabetes-inducing and it wouldn't taste that good.

38:32And so they do make pills, but it's a small, these things are small things that help. Drinking lots of water can help, but vaginal hormones, vaginal estrogen or vaginal DHEA, which we just showed a bunch of, prevent UTIs by more than half. They don't just prevent UTIs. They help with urinary frequency, urgency, leakage, pain with sex. They help your arousal. They help your orgasm. And they're safe for every age with every medical problem. If you've had cancer, blood clot, stroke, any problems at all, vaginal hormones are safe and could save your life. And so this is such an important topic. My partner's 33 years old now.

39:10She's not yet in the perimenopause stage, at what point does someone start taking HRT? Is it when they are in the menopause stage, which is defined as 12 consecutive months without your period? Is it when they're postmenopausal? Is it in perimenopause? Yeah, this is a very important question because it's not a one-size-fits-all. At this age, start this medicine. It's really when people start having symptoms. And so I'll give you an example. So say your partner gets pregnant, okay, and you decide to have a baby. Her estrogen is going to go to 10 ,000 for nine months. It's going to be super, super high.

39:44And the day she gives birth, it's going to crash to zero. So you go from super high hormones down to zero. And if she chooses to breastfeed or pump or do any of that, they stay extremely low in the menopausal range for the entire time you're breastfeeding. So when you are breastfeeding or pumping or doing anything and your periods don't come back, you're basically menopausal. And what are the symptoms then? So if you've just had a baby, you're breastfeeding. She may have hot flashes. She may have night sweats. She may, you know, have urinary frequency, urgency, leakage. There's all sorts of symptoms that come with that.

40:18Libido changes as well? Libido definitely changes. Pain with sex goes up. And so we call this the genitourinary syndrome of lactation. And so there's all sorts of hormonal changes that can happen at that time. So we see a big need for vaginal hormones in this patient population. It's safe for the breast milk. It's safe for the baby. It doesn't cause any problems, but it can really help with all of those symptoms. Now, say she is done having babies and now she's 38, 39, 40, and she is doing fine and she has regular periods and she has no symptoms and no problems. She may not need anything at all.

40:49But what if she starts getting a lot of urinary tract infections or having dry, scratchy, painful sex or her libido just doesn't feel it sort of feels like back when it did on birth control pills, that may be an indication where she may benefit from whether it's testosterone or vaginal hormones or some kind of combination. What if she's 43 and her sleep starts to get really bad? And that may be an indication for progesterone. I have a patient who was having hot flashes and night sweats and brain fog and fatigue. I see her and she says, I will not take hormone therapy. It's not safe. My mother told me it causes cancer.

41:25at no point am I going to do this. I said, okay. We had a long conversation. I shared data and papers and we did a shared decision. We just worked with each other and I wasn't pushing anything on her, but ultimately she started with vaginal hormones. Her orgasms come back, her arousal gets back and she comes back to see me and says, Ruben, what are you doing here? I'm feeling much better. Like this is, you've given me my life again. I'm not peeing in the middle of the night, so I'm sleeping better. I don't have as much dryness. Sex is no longer painful. I haven't had a UTI in months. What else do you got?

41:55Well, she was still suffering with hot flashes and night sweats. She had a bone density scan, which showed osteopenia. And she was worried about osteoporosis because her mother died of osteoporosis fractures. Well, if she did whole body estrogen, she would prevent her risk of a fracture. She would make her hot flashes and night sweats go away, which would have benefit on how she sleeps and ultimately probably benefit on her whole vascular system. And so she started estrogen. And because she had a uterus, she took progesterone at night. And she said, well, my libido is still a bit low. We looked at her testosterone.

42:28We said testosterone will likely help with your libido, but it's going to take four to six months. So four to six months, she comes back to see me. Not only is her libido so much better, but she feels that she has the cognitive ability to enroll in law school. Like this woman literally decides that she wants to change the trajectory of her career and enrolls in law school. And her brain is working in like ways she hasn't seen it in so long. And she is competing against 22-year-olds in law school. And when I tell you she finished at the top of her class, she finished at the top of her class, whereas she said, I would have never even considered this opportunity if I hadn't been doing all of these things.

43:07So - And what age is she? Now she's in her 60s. And so that's why I'm so loud about these things Because what other organ in medicine do we let fail completely before we like do something about it? We don't make you go blind completely before we give you eyeglasses. We don't let your kidneys run out completely before we give you dialysis or medications to help your kidneys along. We don't let you go into full liver failure before you get the transplant. Like this idea of your ovaries have to fail and you have to suffer for 12 months before someone intervenes is insanity. But for some women, they do start HRT during the perimenopausal phase.

43:45And for some, they start it during menopausal, postmenopausal stage. And it's all depending on how you're feeling. It's all depending on how you're feeling and what you want, what your objectives are. Okay. But it's never too early to start necessarily. Not necessarily. So again, we give birth control all the time to people in their reproductive years. Birth control is just high dose fake hormone therapy, right? So we're giving women hormone therapy as young as in their teens, right, to help with different things and birth control. So if you think of it as all of it is some form of hormone therapy, it just depends.

44:16Are we using the natural form of hormone therapy? Are we using the synthetic hormone therapy? We have to get comfortable with hormones at all ages. And the thing that we see most commonly, Stephen, is sort of what we call NFLM, not feeling like myself. I love that statement because women are coming to the doctor every day saying, NFLM, I'm not feeling like myself, and they're getting dismissed. And the truth is there are often hormonal reasons why you may not be feeling like yourself. So for some people, it might be musculoskeletal pain. So we see plantar fasciitis and frozen shoulder, and we think of as those having underlying hormonal causes as well.

44:52So there's published data that less than 9 % of Medicare patients are getting prescriptions for this. More than 75 % of people in large database collections are not getting prescriptions for this. And so women are not getting access to generic medications that could save their lives and also really improve quality of life. I don't know about you, but dryness, people are not having sex anymore because of the pain, the dryness, the irritation when it's fixable. Xin chào mọi người. Chào mừng các bạn. I don't speak Vietnamese, but this show can because of AI video technology from our sponsor, Hey Jen.

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47:15Terms and conditions apply. And you'll also get 30 % off your first subscription order, exclusive Ketone IQ merch, and of course, your shot at these signed gloves. You said earlier that one of the questions people come to you about is pain during sex. Why are women experiencing pain during sex? What is going on there physiologically? Yeah, pain with sex is actually not rare at all. There are some published reports that up to 75 % of women will say at some point in their life sex is painful. So a really dumb question here. Sex is not supposed to be painful. Sex is not supposed to be painful. If sex is painful, you need to figure out why.

47:51You deserve a diagnosis. You deserve an answer. You deserve to understand exactly why sex is painful. You could have a problem with the tissue. So you could have a skin problem, which as we know, the tissue of the vulva is very hormonally sensitive. So that tissue could be impacted by hormones. It's skin. So people can get eczema. They can get autoimmune skin condition. So you may have a skin condition. You may have problem with your muscles. So remember, the vagina and the vulva are surrounded by these big pelvic floor muscles. And just like you can get tight muscles in your neck and in your back, you can get tight muscles in your pelvis.

48:27We also know there's nerves that are involved in this area. So if you have a back problem and you feel it running down your leg, right, that's called sciatica or sciatica pain, you can have a back problem that actually causes you to have pelvic pain. So we see people with penis pain or vulva pain because of problems in their spines. If you have scar tissue inside your body from endometriosis that's pushing and scarring this tissue from the inside, you may have pain with sex. And so there are many different things that can cause pain with sex. But remember I said your OBGYN got almost no training in this.

49:02So if I'm currently experiencing pain during sex as a woman, what advice would you give them? What should they do? Yeah, so I would really try to see someone who has an active interest in this. See a specialized gynecologist or a specialized urologist who has an interest in pelvic pain. And you may need a couple of opinions. Just like if you go to the first plumber, you want to get a couple quotes on who's going to do the best job. It's okay to see a few different people for this problem. And in terms of prevalence, up to 75 % of women, as you say, will experience painful intercourse at some point in their lives.

49:35Between 10 and 20 % of U.S. women suffer from persistent chronic pain during sex. And during menopause, it climbs drastically, with estimates ranging to 20 to almost half of women having pain during sex. And that probably doesn't even add to the people who stopped having sex because either they don't have a partner or because it's too painful to even consider it. And I think it's important to know that hormones play a fundamental role here. It's not the whole story, but it's a huge part of it. In different seasons of life, if a woman wanted to have the best sex of her life, what are the fundamental things you'd aim at to make sure she can have the best sex of her life?

50:14Yeah, so as a, you know, this is Diary of the CEO. So I love how you love the health topics, but obviously financial literacy is really important for you to help people. Because for some reason, people stink about talking about money and talking about sex. And yet we all want to be really great at both, right? We all want a lot of money and we all want to have great sex. And yet people stink at talking about it. They don't know the fundamentals. They don't know the basics. And so I actually use financial literacy sort of as a framework in how we talk about good sex. And so you've got your savings account and your checking account.

50:48Those are the basics. Everyone needs money in their checking and savings account, right? That's what everybody needs. So that's going to be your education, your nutrition, your exercise, your sleep, your communication, safety. Like, are you safe in your relationship? Like the basics. Are you doing the basic things you need to have great sex? You know, communication, it's probably the most important thing. Can you talk about it? Can you use words? Can you explore? Can you ask questions? So that's really important for great sex. Then there's the 401k, right? The 401k is something that we all want and should have access to, right?

51:21It's important for compounding growth and long-term support of your financial life. Think about hormones. Think about going to a doctor who's going to make sure that everything is optimized the way that it should be. Your pelvic muscles are in good condition. Your mental health is in good condition. Do you need a sex therapist? Do you want to bring toys into the bedroom and devices to have even more fun? That's kind of like the really important. Not everybody has access to it. Not everyone's going to do it, but I think it's really, really important for everyone to talk about. Then there's like crypto.

51:52OK, so crypto. That's not to say don't do crypto, but don't put all your money in crypto. Don't do everything and don't start with crypto. So that's going to be when you're watching, you're scrolling Instagram and you see these ads for do this injection, do this, you know, cosmetic procedure, do this supplement that's going to make sex great again. The truth is, if it looks too good to be true on TV and in the ads, like it probably isn't going to fix what if other things are struggling. So I think great sex is within everybody's reach. But I think your great sex is different than other people's great sex.

52:31So let's go through these slowly and one at a time. I kind of break it down into three categories, which is there's biological and physical blockers to great sex, which are some of the things we've talked about, hormone crashes, etc. You mentioned the pelvic floor. How is an issue with your pelvic floor going to impact your sex? And what is the pelvic floor? Why would you have an issue with it? What do you see in patients? Yeah, so everyone who has a pelvis has a pelvic floor. So men have a pelvic floor, women have a pelvic floor. It just means the bones of your pelvis, so your hips, right, and your pelvis bone, your butt bones, all of this is this big bony structure that holds all of your organs in place.

53:08And your genitals are attached to this pelvic floor. And the pelvic floor is surrounded by thick, big muscles. So if we look at the inside of the pelvic floor, it's these big, thick muscles. And muscles are just like your biceps, right? Like muscles are something that contract and relax. And there can be problems with muscles, right? Just like if you work out too much and you've got a sore trap and you got to go get it massaged and or you got to do physical therapy because your shoulder is hurting. A lot can go wrong with the pelvic floor. And so sex is a contact sport. So if you're going to get erections, if you're going to have an orgasm, if you're going to allow for penetration to happen, you have to have healthy muscles because you're asking your muscles to contract and relax in a sexual way.

53:55And so as blood is flowing through the area, blood is going to engorge the clitoris and it's going to get bigger and erect. It's going to engorge the penis. It's going to get bigger and erect. These muscles are going to have to relax so that you can have penetration because if they're too tight, Tight muscles are painful. They're sore. They burn. And so penetration can happen if you're relaxed. But then orgasm is a series of muscle contractions, which equates to pleasure and release, which is all has to do with the nerves and the muscles. Does that make sense? I'm trying to understand how the pelvic floor would give me bad sex and how I would know if the pelvic floor is the reason I'm currently having bad sex.

54:33Yeah. So if sex hurts, so if the muscles are too tight and you can't have penetration, but you want it, that can be bad sex. If orgasm is painful, weak, or impossible, it could have to do with the muscles. It's not always the muscles, but it could have to do with the muscles of the pelvic floor. If arousal, your ability to engorge and lubricate are diminished or less, that could be due to pelvic floor because you're not getting enough blood flow to the area. And so there are multiple different ways. And if you're not feeling your genitals, you watch something sexy on TV, and then you feel it in your genitals or you see someone attractive walking down the street, you feel it in your genitals.

55:11There's this brain genital connection. And sometimes that you see, you have to have perfect wiring and of your nerves, your hormones and your muscles. And so that could be affected by your pelvic floor. Now we do a lot to mess up our pelvic floor, by the way, people do surgery, people have babies, people, muscle health changes for many reasons. And so when you have problems, there may be biological reasons to these problems. Should we be going to the gym and like doing pelvic floor exercises to improve our sex lives? You typically don't do them at the gym. There are typically trained physical therapists who help you know what's going on with your pelvic floor.

55:47So for some people, it's to strengthen it and to do like almost contractions. We call them Kegel exercises. But for many people, it's just learned the coordination. And you can go and get an exam. You can go get an exam and work with a pelvic floor physical therapist. So some women, because we sometimes have them write in with questions, talk about the fact that they're not having orgasms. Is that normal or is that not normal as it relates to sexual contact? So about 20 percent of women will say that they can't have an orgasm. And the real question, I'm fascinated by this data because not 20 percent of men do not have orgasm problems.

56:24And so, again, if we go back to the financial literacy equation, we have a pay gap in this country, right? Women are not paid as much as men. Well, women are not orgasming as much as men. And so the data is very clear there. And I think the majority of problem is education. Women think that orgasm comes from penetration. Surely if the in and out penetration is happening, I should be able to have an orgasm. And the truth is that's not how most women orgasm. Some can. But the reason why women don't orgasm from penetration is because the clitoris is up here. So the clitoris is how women orgasm, right?

56:59Penetration is not how most women orgasm. Just like if you rub your thigh over and over again, you're not going to have an orgasm. Now, you could keep rubbing your thigh for the whole duration of this podcast. You still won't have an orgasm because it's close to your penis, but it's not actually your penis, which is where men have orgasms from. And so the clitoris, if you follow those labia minora, those inner wings, you get to the hood of the clitoris or a foreskin. We call it a prepuce. And that, if you pull it back, you see what is the tip of the head of the clitoris. But that's just the tip of the iceberg.

57:31The clitoris is this huge structure. My necklace is, of course, a gold clitoris. This huge structure that goes all the way down to your butt bones. It's a penis. Under the microscope, it looks like a penis. It is made up of the same tissue as a penis. It works exactly the way a penis does. It's just that we have a whole field of medicine devoted to the male penis. I'm a urologist. And no one is even taught how to examine a clitoris or where it is. So if the penis is going in here or a toy or a finger or a device, that is not activating the clitoris, which is a mostly internal structure. There's something called a clitoral adhesion, which people don't know about as well, which I've heard you talk about before.

58:11Yeah. What is that and how many people suffer with that? Yeah. So the clitoris has this hood to it. OK. And about 23 percent of the time, the hood can get stuck to the head. So, for example, I'm wearing a sleeve here. So you should be able to pull back the hood of the clitoris to see the whole head. It looks like a mushroom. You know how penises have like that almost like a mushroom rim around it? So the clitoris should have that too. But about 23 % of the time it gets stuck. So you actually cannot see the full head of the clitoris. It's called a clitoral adhesion. And so you should be able to pull it back.

58:44But about a quarter of the time you cannot. And we published data that if you remove these adhesions in an office-based, very simple procedure, we saw improvements in orgasm arousal and satisfaction up to 60 to 70 percent and so you have to understand one in five women yeah have a clitoral adhesion yeah and when solved improves their sexual satisfaction by up to 60 percent yes but no one's examined any woman in your life no one has ever examined their clitoris ever in any exam in any doctor's visit and nobody's asking women about their orgasm about their satisfaction where like they come in with pain or they come in with libido issues, but no one is examining this part of the body.

59:25And so it's this question of, is it because we haven't or because we shouldn't? It's because we haven't. We have never done this before. You pulled up the sex toys there. I think we were talking about orgasm. Yeah. So again, when you were talking about orgasm and how women experience pleasure, it's all buried inside the body. So if your penis was entirely inside your body, say you gained 500 pounds, okay? And your belly was so big, you couldn't hold on to your penis to do what it takes to have an orgasm. How would you orgasm? Probably. The vibrator industry would be a gajillion dollar industry instead of just a billion dollar industry because vibration can help activate this blood flow.

1:00:06And so for women, vibration on the outside can be extremely helpful because remember, the clitoris is kind of around this area. And so by putting vibrators on the outside, now inside you can also have pleasure, but not everyone experiences pleasure the same way. And so understanding devices and trying different things is really, really important. Oh, here we go. Okay, so this is vibrating now. So this one, this kind of device is interesting because it is a wand that can help just like with trigger points. So if you have pain in these muscles, this can go inside, vibrate to help with engorgement, but can also get rid of some of the tension in some of those muscles.

1:00:45As men, what are we getting wrong in heterosexual relationships when we're trying to arouse our partners, both in the context of using sex toys, but also without sex toys? What is it that we just don't understand? I think that men are constantly asking about they want their penises bigger, harder, straighter, girthier, lasting longer. And none of that has anything to do with how women experience pleasure and satisfaction in the bedroom. And so the question needs to be, how do women experience pleasure? What is their anatomy like? How can we activate the clitoris, the arousal response? What are the brain things that we need to do to make women interested?

1:01:26Right. What what gets women excited? Because it's different than what gets men excited. And your part, every partner is different in terms of what gets them excited. And I would love to see more curiosity. I wish everyone was as curious as you about what do we need to learn about women and how they behave and how they act and what they want. No. Yeah. So I'd like to implement it tonight. Communication. Right. It's that question. And also understanding that your partner never got told any of these things. And so this is where watching this podcast together could be really helpful to say, did you know that?

1:01:58Was it what do you like? Do you know? Like, can we look at your clitoris together? Like, do you know what these body parts are called? Where is it that you experience pleasure? Because some people find direct stimulation of their clitoris is too sensitive because we know the clitoris has like 10 ,000 nerve endings. So going directly over the clitoris can sometimes be too much. Some partners love it. Some partners want more stimulation on just the outside here. Some people need vibration. So that's another big problem. So she's going to orgasm at some point if this is sufficiently stimulated. So if there's sort of a buildup and release of pleasure, right, that's orgasm.

1:02:30And again, that is often not happening during penetration. And once she experiences that, what happens immediately after for her? Because I know from a man's perspective, if I orgasm, there's some kind of like decline in arousal. And I don't want you to touch it again. That's very similar in women. Okay, so it's the same in women. Except women can bounce back faster. Not all of them, but women can have multiple orgasms. So she orgasms. It's very, very sensitive. She doesn't want me to touch it for a while. Yeah. And then she potentially could bounce back faster. She could potentially. Some people do, some people don't.

1:03:01But that's the conversation of, is this something that is pleasurable? Is this something to try again? Is multiple orgasms something that you want to have or try to have? When does penetration happen during the dance? Because oftentimes men orgasm and then they're done, they roll over, go to sleep, whatever it is. Is the orgasm happening after your orgasm, before your orgasm? Is it happening before and after your orgasm? Because that could be a nice way to sandwich it of like there is giving the sensitive tissue some time to rest. Then your orgasm happens and then you potentially go for round two.

1:03:32So if the sensitive, pleasurable part is on the outside here on the clitoris, then what do they get from penetrative sex if the sort of main event is here in the clitoris? Many times nothing. Many times connection. Many times sort of this need for closeness and pleasure. Many times there are women who have extra nerve endings sort of inside the vagina, on the top of the vagina, in the cervix. So there are women who love penetration, but many women get the main event from the clitoris. And so it's part of the whole menu as opposed to penetration is the whole story. And I think every woman's body is different.

1:04:11And so kind of making these broad statements of every partner likes this. But many women are asking for penetration mainly because they're like, OK, that's when you have your orgasm, it's done. And then I can go to bed. I can read my book. I can do all these other things. but the pleasure often comes from that clitoral stimulation now some women can orgasm from i have a theory it's a really interesting theory that maybe your listeners can prove with science or help me prove with science so you know how there's men who premature ejaculate like who ejaculate very quickly yeah there are men who orgasm in a minute or less that's probably eight percent of men okay so we think men and women's bodies are very similar could we argue that eight percent of women will orgasm within a minute or less.

1:04:54So theoretically, it makes sense, right? I think those are the women who orgasm with penetration. They're so sensitive. Their nerves are so sensitive that penetration is very pleasurable. And then they have this magical orgasm and they do it very quickly. So it's good. It's often seen as like great in a woman and not great in men. And so I just have this theory that like there are women who have extra sensitive body parts. So, I mean, one of the things I've learned from everything you've said is just like how much porn has messed up our perception of sex. I mean, WWF has messed up our perception of, I don't know, like what people's bodies, like exercise, fighting, like it's all manufactured.

1:05:36And it's all manufactured because that's the algorithm that has been working to get men excited. and it doesn't like again it's that question of that curiosity of who's watching porn what do people want from porn what are they getting from porn because it's not what women want typically and it has really messed up people's perceptions of what is actually fun and pleasurable for the partner so seeing that curiosity of like what does my partner actually want you know you can have great sex without penetration and so the question is is what does great sex look like for you and your partner when i look at a website i've got some data here on a website like porn hub which is one of the leading porn websites, it says that roughly 65 % of their traffic is men.

1:06:18Independent surveys tracking any regular pornography use find a similar gap, but note that women's consumption is highly age-dependent. Men between the age of 18 and 35, 75 to 95 % of them report viewing porn regularly, whereas women age 18 to 35, only 34 % roughly report viewing porn regularly. And if we think about these systems as catering to demand, it means that porn websites are catering to predominantly male demand. And that explains why for most young men, we learn about sex from porn websites. Right. And then we assume that the woman looked like she was having fun and the man was doing this particular thing.

1:07:01And then we take that into our relationships. And I think this is where the misunderstanding begins. And the women think they're broken because they're not having magical orgasms from penetration. They come to see me all the time and say, I'm broken. You have to fix me. I'm not orgasming during sex. They have wildly good orgasms with a vibrator, with a hand, with a shower head, with whatever it is on their clitoris. And that's totally normal. Right. And then you show them the body parts. You said this is right. The clitoris and the penis are the same thing. You activate a penis for a man to orgasm.

1:07:29You activate a clitoris for a woman to orgasm. And once you teach them that, it makes perfect sense to them. Like they were normal the whole time. What do you think of pornography? I actually think pornography is great. For relationships, for connections. Potentially, the right point. Like, look, OK, let's look at something like Heated Rivalry. Have you heard of it? No. OK, Heated Rivalry is an HBO show that came out this year that is about two gay male hockey players. OK, it's based on a romance novel book from Canada. And HBO put it out there and it went viral in levels that the world has never seen before.

1:08:01And it is about two young men who fall in love, but there's a very sexual relationship between them. And heterosexual women have watched this 10 times over. Like they are addicted to this show. It's all over social media. It's this huge thing. It's essentially porn for women, right? It is women who are watching these pornographic episodes. And it's really important. They love it. It's supported. Everyone's talking about it. So I don't think porn in and of itself is bad. I think porn, you know, watching people have sex, watching people fall in love, watching people in romance, people like that.

1:08:32It gets them excited. It gets them aroused. But I think too much, if you are watching porn and not interacting with humans, if you are watching porn all the time, if you need to, if you can only watch porn to have good sex, like then that may not be the best, you know, and healthiest thing to do. I guess the question I was asking is, if you're in a relationship and one partner is using a lot of porn, won't that kill the sexual desire to be intimate with your partner? Yeah. It depends. It depends on the relationship and it depends on what each person needs in order to feel supported and connected.

1:09:05Right. I don't think we can say blanketly it's good or bad, right or wrong. I think if it is good or bad, right or wrong for that couple, then it's a problem because there are couples who like to watch porn together. There are couples where, oh, maybe someone has a much higher libido than the other person. So they said, okay, the high libido person can use porn. And then once a week, we'll circle together and we'll have a great experience together because it's not everyone's job to meet each other on the libido. The stat that I was looking at was a couple dozen studies, including a major matter analysis, show a consistent link between solo porn consumption and lower relationship and sexual satisfaction.

1:09:40The erosion of intimacy is usually driven by deception. finding out a partner is hiding porn usually triggers intense feelings of betrayal, rejection, insecurity, and heavy solo use can desensitize the brain's reward system leading to performance anxiety and erectile issues during real-life partner sex. It can also create highly unrealistic expectations regarding body types, stamina, and performance, making real sex feel less stimulating. Again, it was that deception. It's the hiding. If that ex of yours didn't tell you what was really going on and so you felt disconnected from that person because you didn't get that honest truth of what was going on but also the desensitization of it like it's never gonna you know i guess it depends on how you're using pornography it depends on how you use it so again that's the truth you're gonna kind of like train your brain to get pleasure in a certain way and then when you're with your partner one could argue that it's going to be quite difficult for them to replicate that particular way that you've pleasured you've learned to pleasure yourself Right.

1:10:38And that's a problem, right? If you're only able to do something in one way, in one position, watching one specific thing, that may not translate into great intimate sex with a partner. For the last couple of years, I've been working on something that I realized every podcaster listening to this, but actually probably every creator listening to this, might just need. Podcasting is difficult for many reasons. And one of them is that these hosting platforms don't give you much information. and also because they're so fragmented you kind of have to go through every single platform uploading it to youtube and then taking the same big old video file and uploading it to spotify's platform it takes huge amounts of time and that friction means most of us don't do it that is the problem we set out to solve and so we built something called flightcast which you can find at flightcast.com and today flightcast is also one of our show sponsors and some of the world's biggest podcasters are now using our platform to run their shows because it gives you an edge it It saves you time.

1:11:31It gives you analytics most people won't typically get. It allows you to use AI to be more informed on your show. And it has growth tools that other hosting platforms don't have. So podcasters that are using FlightCast have this unfair advantage. So go to flightcast.com slash DOAC now. I've done almost 700 interviews with some of the most interesting people in the world. And one of the things you learn, which is unexpected, is that vulnerability is the doorway to connection. And after sitting here for two, three hours with a guest, I feel a deep sense of connection to them. And as they leave, what I get them to do is to write a question in the diary of a CEO.

1:12:09We've taken all of the questions from the diary of a CEO. We have put the question here on this card with the name of the person that wrote it. So you can sit at home as I do with my fiance and my colleagues at work and other people in my life. Whenever we get a minute, we play the diary of a CEO conversation cards. And it is incredible what happens. These are great if you're in a romantic relationship and you want to connect your partner more. These are also great if you're in a team and you want to bond your team together. And I have to say they're also great for families that want to learn more about each other and that need a good excuse to spend some time in a digital world in the analog environment, connecting human to human.

1:12:47It is remarkable what the right question at the right time can do. Go to thediary.com and you can get these conversation cards right now. and there's different types of arousal right i was i heard from a sex expert i spoke to that men and women often have different types of arousal spontaneous and like reactive is it yep so there again this idea of like i want to have sex i'm ready to go versus i want to have sex because we've started having sex and we've started that process and now i can get into it sort of like exercise some people are like ready to go to the gym and exercise and other people like, I don't want to never want to exercise.

1:13:25But once they start getting going, oh, I know this is good for me. I should do this. This feels really good. And that's sex for a lot of people. But again, it's also a question of what kind of sex are you having? If you have sex the same way every single time and it's not that fun and it's not that interesting to your partner, are they going to look forward to it? Are they going to are they going to want it? Are they going to seek it out? And is that really low libido at all? Or is that sort of a product of like we just aren't talking about it, improving. If you had the same podcast guest on every single week and it was the same conversation every single week, it's not going to last you very long, right?

1:13:58You do different things. You try different things. Oh, what worked? What didn't work? How could we do this better? What does the algorithm want us to do now? No one's doing that in their sex lives. Like, like no one's even talking about it. Like, honey, what's working? What are we like? What's going on? I saw this thing like. Why? Why don't we talk about it? Because we don't talk about money either. We don't talk about sex because we're trying to be a pro. I don't know. Why do you think? I think that's a little bit of it, but I think the subjects are like deeply personal, emasculating, and so intrinsically linked to like self-esteem.

1:14:27It's vulnerable. Yeah, it's like super vulnerable. So, and if someone, I remember I had a partner turn around to me who, interestingly, was going through some of the issues that were undiagnosed. Turn around once upon a time and express that she didn't like having sex. And I didn't understand that as a 23, 22-year-old guy. yeah and so you kind of look yourself in the mirror and go oh shit like it's super it can be super emasculating it turned out that there was actually a physiological challenge she'd had yeah but we'd been in a relationship for a long time and she wasn't enjoying sex for because there was a physiological issue she didn't say anything to me yeah i didn't know and then the day she said something to me my i didn't know anything about sex so i just interpreted it as like damn i'm not good in your mind i must not be good in the bedroom or something um which is super like hurtful yeah And then that kind of breaks the relationship down.

1:15:15And it's all predicated on this like highly emotional, highly self-esteem linked, poorly educated subject, which destroys relationships. Destroys it. And that's such an important story, right? Because if you had had access to the information, she thought she was protecting you by not telling you that information. Do you know what's interesting? I went to one of my friends, one of my best friends, and said, my partner's just said this to me. Like, what does that mean? And he went to me, he goes, mine too. I was like, what? I was like, so you're not having sex with your partner? He goes, no. And by the way, I'm talking about 30-year-olds.

1:15:48He was like, no, we haven't had sex in three months. And I was like, what's the reason? And he said to me, she said she just doesn't like having sex. And I'm like, oh, okay, so that's the same in my relationship. My former ex-girlfriend said she just doesn't like having sex. And I can't tell you how ignorant and poor and insufficient the conclusions in such a situation we arrive at are. we're like, well, maybe there's something wrong with me. Maybe it's a sexuality challenge. Maybe it's a genetic thing. Maybe they were born and didn't want to have sex. We just don't know what it is. From doing this podcast and speaking to people like you, I'm like, oh my God, I just wish like five, 10 years ago when I had these conversations with my guy friends and also with the ex-partner that I'm referencing, I just wish I knew that it wasn't any of those things.

1:16:41It was something that could have been helped. What's so important is that you were able to learn and see and grow in this, right? A little bit of information gave you empathy for this partner where you took it on as a you problem. It became a you problem because it was both of you together, but it started with biology. And so if we actually taught people the biology or to think about biology or to be able to talk about sex, to talk about sexual health, to talk about genitals, to make them not private parts, how much better would your sexual upbringing really have been? How much less hurt and shame and guilt would you have felt?

1:17:19Because it actually wasn't you at all, right? It's the horrible conclusions you arrive at. And the conclusions you arrive at are often seen as both unchangeable. And therefore, in my situation back then, the conclusion was, well, this relationship's never going to work. Because the false conclusion we'd arrived at was not something we could change. change whereas when i hear about all of these different things we've talked about today i go oh my god there's so many other conclusions i could have arrived at or my friends could have arrived at that would have been fixable and therefore the relationship which was a perfectly great relationship with the person was therefore savable one of them is the thing we just talked about which is this idea that men and women have different types of arousal spontaneous and responsive and i was looking at some of the data on the variants which i think is very important for people to know.

1:18:05And it says that men are highly spontaneous in their arousal, which kind of means from my interpretation, please correct me if I'm wrong, that as a man, I can literally be, I can literally think about something and get aroused. And it's not to say that women can't, but the data suggests that men are more that way inclined. The data here says that their spontaneous rate in a man is about 70%, whereas in women, it's about 10 to 15%. It says the responsive rate which i guess is like i get aroused once the ship starts moving once we start foreplay once contact starts is 10 to 15 percent in men and in women in this particular report is 40 to 50 so that would suggest to me that women are much more likely to be aroused once you know foreplay or contact or the sexual actions have taken place i'm guessing and then the mixed style is 15 to 20 percent in men and 35 percent in women.

1:19:02Is that all accurate? It's accurate. And I think it really comes to this idea of your path to having a better understanding of that prior relationship was actually education and communication. Yes. If you had a better understanding of the biology, if she had a better understanding of the biology, if she were vulnerable enough to be real with you and honest with you up front, as opposed to kind of this bombshell that happened too late, all of that pain, all of that hurt probably would have looked different, right? It would have looked like the world would have looked very different. Now, that's what I'm fighting against, because I think that to your point, I think men are suffering.

1:19:41They're feeling disconnected from their partners. They're feeling a difficulty of even finding a partner. And part of that is because they lack that curiosity of like, what do they want? What do they need? What kind of communication helps me get to where I want to go with this person. And a lot of that is vulnerability and curiosity and interest. And I think that's what women often are looking for in partners is they're looking for someone who's going to give a crap about them enough to care what they specifically need and want, not what gender, what do women want and what is it like, like what specifically about this person in front of me, what does she need to feel that erotic love support connection lust and for the man too like what do you need to feel all of those things and what a good relationship is is when people work together to try to optimize that for everybody so what are the questions that you would ask your patients to ask their partner to start to tease out some of these things couples will come up to me when i'm at a restaurant or something and they'll come up together and they'll always they'll often say to me that the episode they watched together was about sex.

1:20:52So I literally have this image of this particular couple that came up to me when I was abroad and they said, we were just listening on the plane about your sex episode. So I'm like, they're listening now. Like, again, I think it's that basic thing of like, what does great sex mean for you? Okay. What, what do you want? Like what, what is a great time? What's something fun? Like, what is it about sex that you enjoy? When you ask people, what do they get out of sex? It's like 200 different reasons. Everyone wants something different and everyone doesn't always know what they want. And then having that ability, if you don't know what you want, is having that curiosity to explore together.

1:21:28So with that said, 200 different opinions on what good sex is, and this is kind of what I think you find in couples. And when I've sat with my partner before and said like, what arouses you during sex, what do you like? The two things can often be different. Totally. And so is this not a problem that one partner might say, I really want you to tie me up and da da da da da. And then the other partner might say I really want you to not tie me up and be really soft and gentle. And there's a bit of a dichotomy between these two sort of sex preferences which means no one's really ever getting what they want.

1:22:02Like how do you navigate that? When you go to buy a house you don't always get to choose what house you get unless you you know you build it yourself. Like there are compromises in life and and there is no all good or all bad. You're never going to find this is actually the problem with pornography. is you figure out the exact porn and the exact situation, or even worse with AI, like you're going to have a sex robot who's going to be able to do exactly what you want in the way that you want to do it. And people are afraid about what that means for intimacy and relationships and great sex going forward, because the truth is sex is messy.

1:22:31It's awkward. It's smelly. There's fluids. There's funny noises. There's like it's it's vulnerable. It's like really uncomfortable sometimes to like have these deep conversations. But isn't that why life exists? Like, Isn't that like the most fun part is when you can kind of have that with somebody else where they know all of you and they want to explore that with you? Now, if it's not the right relationship, it's not the right relationship, right? And figuring out if that is an important part of your life and it's a non-negotiable, then find the rooms where there are other people who do those things too.

1:23:04I mean, what you will find is that people have all sorts of agreements and relationship setups. And as a sex doctor, like the things I hear in a room like would, you know, are quite wild and you wouldn't even believe like people are doing. Well, I think people have multiple like there are people who have open relationships. So they have multiple partners or they have certain kinks. Right. So there are things that they really enjoy that maybe somebody would look at that and be like, oh, that's very strange. But there are other consenting people who also are comfortable and want to do those things.

1:23:35There are websites that deal with different erotica and different kinks and things like that. And there's also this idea of fantasy. It's also okay to have things that you think about, but that you don't actually want to partake in and that you use. On this point of fantasy, what if you have a, you probably have experience where someone's come to you and they have a fantasy, but they don't want to tell, or a kink, and they don't want to tell their partner because they're worried about the reaction. Yeah. This is where things like sex therapy become really helpful of how do you have a third party?

1:24:04Because again, when your doctor's telling you to do something or bringing something out, It's so much less scary than if you're doing it on your own. There are also different like apps and things like that where you can sort of dip a toe where you have there's one called Spicer, I believe, where you can sext each other in ways and they'll push questions. If you both agree, it'll tell each other that you both agree with things. So there's ways to dip a toe here and sort of be curious about it. But again, that's where watching things together or asking the questions. This should happen not when you're naked in the bedroom actively having sex.

1:24:35Like it's OK to have conversations about sex when you're not having sex. Right. Like you plan these podcasts before you actually sit down to record. Afterwards, you talk with your team. Hey, this is what I liked about it. Here's what I didn't like. Let's change this in the future. Let's never have Dr. Rachel Rubin on again. Right. Like these are the conversations you're going to have with your team. People don't do that about sex very often. Right. They don't actually do after action. What went well? What didn't go well? Do you ever want to try this? Like what would be fun here? Like there is often a lack of curiosity.

1:25:04And you're a sex doctor, right? But people come to you and sort of offload their sex lives to you. My job is so fun. I love my job. It's so fun because people will talk to me about their most full, like we do two hours and we talk about their lives in the context of their sexual health for two hours. And people never have those types of conversations, even with their partners. And it is incredibly vulnerable. It's incredibly important for people to see that and see, oh, that was actually really nice to talk about. I didn't know this, that, and the other thing about my body. And what do you find that men and women typically are hiding from their partners when they do confide in you?

1:25:44I think they don't tell their partners just about anything. Like, there's a lot they don't tell their partners, right? Is there a difference between men and women, what they're not saying? That's a great question. I would say that no one is talking about sex at all. Women are hiding their pain from their partners. men are hiding their um insecurities and their frustrations and there's a lot of shame around erectile dysfunction and sexual problems in men and so they a lot of people just either stop having sex or stop talking about it or sort of have a mediocre sex because they are not that great at talking about these things and i imagine your i mean my first reaction would be like oh you should tell them but i imagine that doesn't necessarily work i think it's a challenge like if you have had if you have been faking an orgasm for your entire relationship and women have been yeah many those statistics are quite clear like if you're only having penetration and your partner orgasms every time and it's a perfect orgasm every time i would say there's a high percentage that that's not real because the truth is is orgasm often takes a lot of arousal and like like again stop watch every header if a penis enters a vagina and they orgasm about five and a half minutes is on average how long men last, right?

1:26:56Like that's science. It's about five and a half minutes. Now, if you're longer, great job. If it's shorter, it's okay. It's all within the range of normal. Women, if penetration is happening, almost nobody orgasms in five and a half minutes. It's usually well over 13, 14, 15 minutes and penetration is usually not how that happens. Because again, if you're distracted while you're trying to stimulate your penis, it's going to take longer. Women need focus on the clitoris. So again, if your partner is orgasming every time within that five and a half minutes and it's like clockwork, I would call bullshit on a high percentage of it.

1:27:29So but a partner doesn't want to tell you, right? Like they're afraid to tell you because they're they want to make you happy, right? It's not that they're having bad sex. They just know that that's not what's going to get them to orgasm. And they want you to be happy and to feel supported. So that presents a pretty good case that the woman should orgasm first. I think so, because I think orgasm first will allow for pelvic floor release and relaxation, which will make penetration more pleasurable, enjoyable. I think women can have multiple orgasms. So there's a case to be made for before and after.

1:28:01Why are women having zero orgasms, men having one orgasm, when women could be having three orgasms and men have one orgasm? So I think we should be actively trying to change the orgasm gap and focus on the pleasure. And I think making penetration the main event is where the challenge. I think penetration can be part of the whole story, but doesn't necessarily always need to be the main event. On the physical blockers, you talked about some of them like anxiety. One of them that I think isn't talked about enough, especially in the modern world, is what they call like the dopamine drain, where you've got mental burnout or chronic stress, or we talked a little bit about depression.

1:28:35But I did notice that through my life, when I'm very, very overworked, shall I say, my libido is not the same. Yeah. And this is also the case for women as well. Do you have a lot of women come to you or couples come to you where this is quite clearly the problem? This sort of like dopamine drain. It's actually their stress and lifestyle. It could be the kids. It could be. Oh, it's a huge problem, right? It makes logical sense. Again, if we go back to the fundamentals of if you're not sleeping, if you're overworked, if you're burnt out, if you have no white space for yourself, why are you going to have all this excitement for your partner and all of these things?

1:29:11If we're scrolling all the time at bedtime or if we're watching porn all the time or we're reading romance novels all the time, but we're not talking to the partner that we're with or we're not creating that time and space, I think there's a big opportunity for people in our modern society, which is overscheduled, to schedule sex. I mean, they do this quite well. So when you were dating, right, and you would ask your date, you know, let's go out Saturday night, you were literally scheduling potential sex. You were like, I could get lucky. I'm going to plan for it all week. I'm going to get excited.

1:29:43I'm taking this person out. I'm like, it's going to be really fun and I'm going to do whatever it takes to sort of cross that finish line. So we were always scheduling sex and it was very erotic and fun when you're in your dating life. And now you live with a person and you sort of, they see you at your best, they see you at your worst, they see you at your crankiest and you're most tired. And so it's really hard to get that level of excitement when you're dealing with those, you know, sort of life circumstances. People will say that, you know, there's a spontaneity myth around sex, that it should be spontaneous.

1:30:14And that's kind of how we see it in films. Like they grab you in the hallway and you start kissing and whatever else. It's just not real. It's just the same as WWF. Like it's not real. And so that's the truth is like you, if you see your partner every day and you see your partner, you're high and you're low and the crankiest and all of these things, and you're all working like crazy, where is the space for that? Like, that's not how humans work. So creating, that's why vacation sex is always fun for people or they find time, you know, so again, if you've got kids and your kids are staying up later than you are and you don't have a lock on your door and you're worried about making noises and you don't want to be too loud, like how are you going to have great sex in that situation?

1:30:47One of the, I guess the challenges people might also bring up is that if you're scheduling sex, it puts a lot of performance pressure on you. If I know tonight at 8 p.m. I have to have sex because that's the time we scheduled this week, then like, oh gosh, I'm going to be finishing my work at 5, 6, 7. I need to get home. I need to have sex as well. So this is where you schedule it around a time that you know is going to work for you. So I tell people to do things like quarterly dates. So listen, I'm working in D.C. Everyone is very high powered with very busy jobs. I say one Friday a quarter you and your spouse can literally block your calendars.

1:31:22A quarter. A quarter. A quarter. Okay, that means you might have sex every week. You might have your late night sex, whenever you might have sex, whenever you have sex. But once a quarter, have a day where you just block it out and you have a spouse day or a partner day or whatever it looks like. And maybe do an act. It doesn't necessarily have to be a sex day, but you actually take time of your little mini vape. Maybe you go on a walk. Maybe you go on a hike. Maybe you take a bath. Maybe you get a massage. You kind of create space for you to actually say, oh, wait, we like each other. Oh, we like talking to each other.

1:31:52We don't have to just talk about the kids all the time. So again, the more you invest in each other and in a joyful way, the better sex you're going to have. What about self-esteem issues? You mentioned that as well, body image issues. How often do you see that being the blocker to great sex? It's a huge problem. Again, I wish that the energy that my female patients put into wanting to be skinny is enormous. And I wish that energy was put into wanting to be strong. But it's kind of funny because what people think about themselves versus what they think for their friends are very different. Your best friend, say they're overweight.

1:32:30Do they deserve great sex? Of course. Of course they do, right? Your best friend deserves great orgasms, great sex, no matter what they look like, no matter what they weigh. Everybody deserves intimacy, pleasure, and connection with someone that they can have intimacy, pleasure, and connection with. But for some reason, when we think of ourselves, oh, I can't be naked with this person. Oh, I can't be happy until I lose this much weight. I don't deserve an orgasm unless I am, you know, skinny. And that's a huge problem. So what do we do about it? I think it's empowerment. It's communication. It's explaining to people.

1:33:00I think that all of the mindset stuff that you do and you talk about is so important because, look, you changed your mind around your own situation with this ex of yours because you got education, right? You were able to see that it was more complicated than that. And I do think by educating people on bodies, on pleasure, on joy, on connection, on intimacy, I actually think it changes the narrative. I think people, we're in a sex recession, okay? People are having less sex than ever. People are not connecting. People are scrolling and they're on their AI chatbots instead of like human connection.

1:33:33We're getting worse at this, not better. I just think that like we have to reach humans and we have to be able to talk about it to change the narrative. What is the most important thing we haven't talked about that we should have talked about as it relates to all the work that you do? I think the most important thing is that biology matters in women. And we often spend so much time talking about psychosocial issues, about emotions, and all of that is true. That is important to sexual health. But we minimize biology when it comes to women. And we have to let women advocate for themselves about the biology.

1:34:05And we need to train doctors to care about the biology. I would love to find out from all the women in your life and the women on your team like what experience like i would love for you to ask them their experiences with medical providers because i don't think we have that curiosity of like what are you experiencing that's different yeah i think that i yes i think that's gonna have to for me to have like a healthy relationship with my partner i think that's gonna have to be uh practice or like part of our you know we check in on our relationship etc but we don't really check in on the physiology biology yeah so super interesting so i spend two hours with people and there are times when the partner comes to that talk.

1:34:42And so they get to hear sort of what their partner is describing. They even see the exam and they get sort of a tour of their own partner's body parts. And so it is helpful sometimes to bring partners into those conversations, the biology conversations of like, she doesn't want to have sex with you, not because you're bad at sex. Look how painful it is right here at the opening of her vulva. It's like a sunburn. I touch it with a Q-tip and she's on fire. Like, what do you think your penis is doing. And it gives that ability to say, oh, it's not a me problem. How do I support her best knowing that this is the issue?

1:35:14So getting partners to understand the biology is extremely helpful. Or say you have a man who's taking an antidepressant or a hair loss medication that can cause sexual dysfunction as well. Say you have a man who takes an antidepressant and it lowers his libido. Is it, oh, honey, you're not attracted to me anymore. You must not love me. Or is it, I actually understand the biology that your libido is lower because of this antidepressant. and two things can be true. So I think understanding your partner's biology and your own biology is quite important. Yeah, I guess that's the crux of the conclusion really is that both education and communication are where it all begins.

1:35:50Which is the fundamentals, right? Yeah. And I think, gosh, if I had better education on these subjects, God, at the start of my adult life, and also I had like figured out how to communicate with my partner, maybe even also with yourself, and like to be a bit honest with yourself about how you're feeling not to gaslight yourself not to gaslight your partner just it just goes to show how better relationships would have been not just with your romantic partner but really with all the people in your lives and this is easier said than done like especially the communication part because these are very very sensitive subjects and so we we'd rather just shut up about them and keep them as these sort of like secrets that we whisper about with the closest people in our lives maybe our best friend and i just think generally one of the things i've come to learn from doing this podcast as well is that you know there was this quote i read it said you can predict the long-term health of a relationship by whether each challenge heals to 101 or 99 does your conflict make you stronger and what it's essentially saying is like conflict is guaranteed in life but the thing that's going to turn your conflict into a strengthened relationship or a weakened one is your how you deal with it like and that's all predicated on communication and so if we can just teach people how to communicate if we can become better communicators which is both a function of speaking and listening and i guess curiosity then all of these downstream challenges and misunderstandings would have a chance of being solved for and i think about this so often i often think okay how i'm communicating with my partner currently is really going to determine whether we have an argument in two years time or a year's time or six months time our strategy of communication does she feel safe expressing a problem how do i receive the problem even when it feels like i'm being blamed and vice versa and then are we open-minded about solutions or do we come with a bias around this is the solution this is what i think the correct answer will be i've spent a lot of time you know i'm like seven years into my relationship now almost so i spend a lot of time thinking okay like how do people go how do they build a relationship like 50 years and the crux of it seems to be conflict resolution slash communication that seems to be the crux of it and actually with finance issues that we talk about with finance experts or with sex issues the crux of it seems to be conflict resolution slash communication and i also know because i know lots of couples that we're all living on a different spectrum here some couples are like they come home at 6 p.m and all they want to do is talk about the most sensitive subjects and then you've got this other group of couples who almost don't talk about anything they're kind of like strangers that are like burying everything in the cupboard and they think burying it in the cupboard means that it's outside out of mind and it's not impacting anything but again you come to learn that any problem buried rears its head in unexpected ways and uh you know i think in one particular friend of mine who was in a relationship for 14 years had a baby they kind of stopped having sex didn't really talk about it they become like parallel lines that are drifting apart and they get you know several years later what happened what happened to our relationship well they never spoke about it so i think you understand this perfectly and for you to um see it in this you can help so many people because i think these are the fundamentals how do we teach young people and old people that conflict resolution is important in intimacy and vulnerability are important in biology is important science is important and we can do this i just taught you a few things that i know today and you under not only did you understand it but you were curious about it to ask further questions and you can now figure out how it works in your own relationship in your own life you're even caring enough about thinking about your friends lives and so if you've shown that this matters and this is important i just think how many people are going to benefit by your vulnerability and your curiosity and saying oh i could do that too yeah it's crazy isn't it that like if you love this person so much yet you don't often love them enough just to communicate about some of these like sensitive tricky subjects which is like craziness when you articulate it like that like i've been in relationships i just absolutely love this person but no i wouldn't i wouldn't raise x y and z subject it's just it's just too uncomfortable and the few times i guess i will ask that you have been vulnerable has it gone well or not well oh my gosh it's like the most important thing i just i always think why didn't i do this sooner yeah okay so to be even more honest i like didn't have conversations with my partner about sex at all like i just i assume she liked it i think she assumed I liked it and it wasn't until you get further into the relationship that you start going like wait I don't think this is how this person wants to have sex or I don't know I actually have to give her the credit because she's the one that started like pushing on the communication I think sometimes as men we just you know that old slightly toxic phrase happy wife happy life I think sometimes as men we just kind of assume that if no one's saying anything then everything's great but it takes two to tango and i think expecting your partner to have all the words and to know everything is the wrong answer that's where again that third party whether people come to see me together as a medical person or a sex therapist or a third party to help you have that conversation because i think we assume our partners know everything about their own bodies and can communicate about their own bodies and that's just not true even showing that curiosity makes you quite evolved, right?

1:41:29And I think that that's the energy that we need in 2026 is breaking down those barriers because it will lead to stronger relationships. It will lead to stronger partnerships. And it's those hard moments that you grow the most from. You need the words though, as you say. Yeah. When you say you need the words, what specifically do you mean by that? You need to know how to start the conversation, how to handle the conversation, how to receive a subject that might be a little bit offensive and might hurt your ego a little bit? Is this what you mean by like have the words? It's really hard to do that on your own because people don't want to hurt other people's feelings.

1:42:05And so just saying it as it is may not be the right approach either. That's where, again, couples therapists are very good at holding space for those different conversations. And I think one of the other problems here, Stephen, is many times there's no bad guy. Of course, when it's obvious someone cheats on someone, someone breaks trust, yes, there's a bad guy. But so often, you know, say someone has a higher libido than someone else. There's no bad guy. That person has a high libido and that person has a low libido. There's no evil bad guy, but there is still conflict. And so how do you deal with conflict when it's not a good guy, bad guy situation?

1:42:39And how do you love someone and evolve with them, right? Like, I think it's not easy. I think your point there, though, is actually where it starts often, which is this point of empathy. The minute you realize that there is no bad guy, just as you said it, I thought, oh my gosh yeah back when i had those intimacy challenges and that relationship it was a case of trying to figure out who the bad guy was i was like is it me is it a me problem is it a you problem that's kind of like what the brain jumps to but actually now that had time passed and we figured out what it was turns out that it was neither of us it was really the whole time not me against her or her against me it was me and her against the problem and that refrain i think removes the shame, the blame, and all that stuff that gets in the way and focuses you as a team on resolution and conflict resolution.

1:43:28Thank you. You know, you said that I will help people, but actually you're the one that's helping people. I'm just asking questions. I disagree. I think it's the simple, it's the vulnerability of watching others. It's the simple stuff that makes the biggest change. Why does this matter so much, Joe? I can see it in your face. because so many people are hurting relationships are hurting people's health is hurting people aren't having as much pleasure and joy and quality of life that they could be having using what we already know to be true simple things communication connection education basic medical care these things can bring so much joy health great relationships great living and I see it every day in my clinical practice.

1:44:15And I want that. I want that for every person out there. And I want them to fight for it. And I want them to advocate for it. And I want doctors to show up in a big way to help them. And I think we can do it. But I am so passionate about this because I see how much it's not being done. Dr. Rachel, we have a closing tradition where the last guest leaves a question for the next, not knowing who they're leaving it for. The question left for you is, what would be one thing you would like to do or improve in your life tomorrow

1:44:50i would like to get better about practicing what i preach because we always say the shoemakers kids don't wear shoes i am addicted and obsessed with what i do i love my work so much but i don't necessarily spend as much time lifting weights that I should or not scrolling on my phone and paying attention to my children that I should. I don't spend as much time, you know, scheduling those quarterly spouse dates that I tell other people to do. And so I think practicing what I preach is a huge opportunity for me. Well, that's refreshing to hear because none of us are perfect in that regard. So it's good to know that just having all the information doesn't necessarily mean it's easy to execute upon.

1:45:35Easy to do, easy not to do. Amen. Where do people go to find more from you? Do they go to your Instagram, your website, your YouTube channel? Where should they go? Yeah, our website is really fabulous. We are very big into research, education, advocacy, and mentorship. So rachelrubinmd.com, that would lead you to sign up for our newsletter, which is really an incredible source of education. We are sending you the latest and greatest in studies, research that you can be a part of, job opportunities and advocacy for clinicians. We have courses and teaching you how to do this, both free and ones that come with continuing medical education.

1:46:15I would say Instagram is the most popular for me right now, although we're trying to get louder. If only I had your skills, I would love to be louder on YouTube and other places. We do have a clinical practice both in Washington, D.C. and Los Angeles. And so if we can help in any way on the sexual health side, please reach out to us because sexual health is just health and your quality of life absolutely matters. I'll link all of that below. And I hope people sign up for your newsletter as well. That sounds really interesting. Thank you. Dr. Rachel Rubin, thank you so much for all of this. I think it's so telling that your conversations are often the most shared on the podcast and generally in podcasting because the subjects are so important to so many people's lives and they can relate to feeling not themselves as you say but there's very few people out there that have the credibility the experience with patients but also the ability to articulate it in a way that's highly accessible like you have so I know that you know we talked beforehand you don't necessarily love doing this but um it's a very very important worthy course because there's very few people that can speak to these subjects with it in the way that you can so please keep doing it so kind anybody who's listening now i highly recommend if there's somebody in your life that might want to listen to this conversation i think there's a reason why dr rachel's conversations are always the most shared um please do share it with them dr rachel thank you so much for your time thank you

1:48:11We'll be right back. In just 10 minutes, your dream technician will check your tire pressure, top off fluids, change your oil, and verify with Carfax exactly what your car really needs, all while keeping you in the driver's seat. Take five to stay in your car 10-minute oil change. Save up to 30 % on your next oil change to take five. $15 value. Valid to participating locations. Terms and conditions apply.