Diary Of A CEO Interview: Dr Rachel Rubin (Transcript)

And instead of doctors saying, “I don’t know,” they’re sort of saying, “No, no, you can’t have this,” because it’s easier than going into that nuance, which can take time.

I also think that people are going to their doctor — say you want to talk about your orgasm or your libido, okay? You go to your gynecologist. Of course my gynecologist should know everything there is to know about the clitoris, about orgasm, about hormones — that’s what they do. And the truth is, it’s not what they do, and they were never taught that.

The Clitoris: A Word Missing From Medical Training

STEVEN BARTLETT: And they were never taught about the clitoris.

DR. RACHEL RUBIN: The word clitoris today in 2026 does not exist in the checklist for what an OB-GYN has to learn in their training. The word doesn’t exist.

STEVEN BARTLETT: What is an OB-GYN for anyone that doesn’t know?

DR. RACHEL RUBIN: An OB-GYN is a doctor who specializes in obstetrics, so delivering babies, and gynecology. So your gynecologist has never been taught about the clitoris, about the vulva, about sexual health, about sexual pain, about libido, arousal, and orgasm. And so the ones who have taken it upon themselves to get extra training — they’re very few and far between. And so every day, women and men too are going to a doctor expecting answers on a topic that their doctor probably has never gotten training on.

Why This Conversation Is for Everyone

STEVEN BARTLETT: I do want to focus today’s conversation on women’s health. I want to preface all of this by saying that I’m going to be as dumb as I am on this subject. If you say something about the vagina and I don’t know what it means, I’m not going to pretend to know. I’m going to ask you what it means. And I say that because I sometimes think with these conversations, the host often is too shy to admit their ignorance. And I have lots of ignorance on this, but I also have lots of curiosity, and I want to fill those gaps. And that’s going to require me to be very, very dumb.

Also, my second reason why is because I have so many women in my life. If you just look at my company, my entire executive team are all women. And also, I’ve got my fiancée, my mom, my sister, and understanding the women in my life — one element of understanding them is understanding their health. Women’s health isn’t something that I was ever taught in school. It’s not like a lesson I had. So I also think this conversation is for men. Every man has very important women in their lives.

So my question to you is, if a woman has clicked on this conversation right now, what are they going to get from it? Let’s start with that first question.

DR. RACHEL RUBIN: So I think it’s really important because as men, we expect the women to know. Surely the woman knows about their menstrual cycle, about pregnancy, about postpartum, about menopause, about hormones. Surely my partner knows, or the woman in my life, my mom, my sister, my daughter — they know all of that, so I don’t have to. And the truth is they don’t know.

When the women in your life go to their doctor and they’re getting a pelvic exam, say they’re getting a pap smear, a doctor is looking at their genitalia, putting a speculum in, going inside the canal and looking around. We put a sheet over you like we are mechanics looking under the hood. So we put a sheet to keep you comfortable, to keep you modest, but we hide your genitalia from you and we don’t teach as we go.

So I became known because when I started my practice, I didn’t buy any fancy equipment. I bought two mirrors on Amazon and I give women a mirror. And as I’m examining them, I say to them, “This is your labia majora, this is your labia minora, this is your clitoris, this is your urethra, the tube that you pee through,” because women can’t see it. You’ve got skin, you’ve got bones, you’ve got muscles, you’ve got nerves, you’ve got all the organs that are on the inside. And women don’t have access to this language. Certainly men don’t have access to this language.

And so it’s that basic ability to give women language. You can learn about your body parts, you can learn how hormones work in your body, and you can learn basic medicine for you that becomes important for how you advocate for what you want, what you care about, and who you bring into your medical life. You may have a physical therapist, you may have a mental health person. You may have a primary care, a gynecologist. You may go on Instagram and get great information from people on Instagram.

And so that doctor that makes you feel like crap because they tell you something that you don’t agree with — find a different one, right? You have to advocate for yourself. And I find we are starting to empower women to do that, which is very challenging.

The Most Common Questions: Hormones, Pain, and Libido

STEVEN BARTLETT: What is the most popular question you get asked now that you’ve been on these podcasts and you’re out there and you’ve done millions and millions of views all over the place and on clips and so forth? What is the number one most popular question you get?

DR. RACHEL RUBIN: I’m asked a lot about hormones. People want to know about hormones. People want to know about pain with sex. And I think people want to know about libido. I think those are the three most common things that we talk about.

STEVEN BARTLETT: So let’s go in that order then. So let’s start with the subject of hormones. What is it about hormones that people are so desperate to understand?

DR. RACHEL RUBIN: So hormones are fascinating because we forgot to teach doctors anything about hormones, and what we have taught about them, they think it’s dangerous, they think they’re harmful, they think that it’s almost like this thing that is natural in your body is somehow dangerous once you get over a certain age. And that is all politics and bad interpretation of science.

Understanding Female Testosterone

STEVEN BARTLETT: I’ve got this graph here which shows female testosterone levels by age. And again, as someone that has started to understand more about female hormones, I was quite surprised because you think of testosterone as a male hormone.

The Impact of Testosterone on Women’s Health

DR. RACHEL RUBIN: Yeah, so that’s the biggest misconception, is that women don’t make testosterone. Testosterone is just a hormone. It’s not a male hormone, a female — it’s a hormone. It’s also not a menopausal hormone. We think of menopause as estrogen starts to drop, right? So menopause is a castration event. If I cut your testicles off right now, you would have hot flashes, night sweats, osteoporosis, depression, low libido, erectile dysfunction, metabolic syndrome. Your weight would go up, and you would be generally pretty unhappy.

It’s a big deal when we castrate people. And yet we don’t do it for men regularly unless there’s a very significant medical reason to do so. And yet every woman over the age of 50, her estrogen goes to essentially zero, and that affects bone health, it affects the brain, it affects the heart, it affects sexual health, it affects UTIs start to go up. And so it’s a whole body event that happens.

Now testosterone’s really interesting because it actually isn’t at menopause that you lose testosterone. It happens in your 30s. So if you look at this graph, right, you can see testosterone starts to precipitously drop in your 30s. So what do we see clinically? Sometimes nothing, but we have a lot of people who will start in their 30s, mid-30s, late 30s, start to say, “My libido’s not as high as it used to be. My orgasm takes a little bit longer. I don’t feel as aroused. My engorgement is not the same. My lubrication—” engorgement, engorgement of the clitoris. It’s the same as an erection, right? So the clitoris and the penis are the same. They get hard with blood flow. And so this happens in your 30s and no one’s paying attention because if you look at the graphs that we are taught in med school, they look more like this. So the books all talk about estrogen and progesterone. They don’t talk about testosterone very often.

And there’s also a lot of things we do to worsen this problem. When you play with hormones, there are consequences, sometimes good and sometimes bad, because we do so much to mess with our hormone levels. Birth control pills, the way that they work is changing hormone levels. Medications for acne, medications for hair loss that people are using can affect your testosterone levels. So birth control is wonderful, but there are side effects to birth control, just like there’s side effects to any medication. And so one of the side effects is it lowers testosterone. And so that can cause low libido, pain with sex, in a small subset of people who take it. So if you’re someone who does have side effects, then it’s worth having conversations about different forms of birth control which may not lower your testosterone as much. Does that make sense?

STEVEN BARTLETT: It does make sense. And it’s interesting. My partner’s talked about this before, my fiancée. She was on birth control for a long time, and she also had concurrently libido problems. Now, we don’t know whether it was the birth control, whether it was something else, but when she came off the birth control pills, her libido challenges also evaporated.

How Birth Control Affects Hormones

DR. RACHEL RUBIN: So can I explain? Because I think, again, knowing the basics and the fundamentals give women and men access to the information so they can make choices with what they want to do with it. Okay, so how do birth control pills work? When you take a combined birth control pill, it has a fake amount of estrogen and a fake amount of progestin in it, so high that it tricks your body into not ovulating. So when you have so much hormone around, your body says, “Oh, I don’t need to make my own because there’s plenty around.” And so the ovaries shut down. So your ovaries are no longer making their own hormones.

And this happens to men too — when you take high doses of testosterone, you become infertile because your testicles say, “Oh, I don’t need to produce sperm right now because there’s plenty of testosterone around.” And so birth control causes your ovaries to just stay quiet. They shut down for a bit, but your ovary does 3 things. It does estrogen, progesterone, and testosterone. It doesn’t add back testosterone. So her experience possibly was because she wasn’t making her own testosterone. And once she went off that birth control, her ovaries woke back up and make estrogen, progesterone, and testosterone, which to you equaled more pleasure.

Now, because we focus on the psychosocial, I’ll have a lot of people saying, “No, no, no, it’s all communication.” And all of that is important, don’t get me wrong, but the biology matters too. And we know there is a biological basis to sexual health for everybody.

STEVEN BARTLETT: I was just looking at some data and it said that in some studies, up to 27% of people on birth control report a decrease in their libido slash sex drive. Which is shocking because it varies in these studies — that’s almost like 1 in 3 people are experiencing it. How does one navigate that? Because birth control has tremendous upsides. So how do you navigate that?

DR. RACHEL RUBIN: I think that everything that we do, there’s the risk of doing something and the risk of not doing something. No drug is going to be without possible side effects. And so that’s where it becomes important to know what are the non-negotiables. Antidepressants is a perfect example. We know that they can help people, a lot of people. But we know there are sexual side effects like low libido, delayed orgasm. And so it has to do with informed consent, which means, Steven, if I’m going to give you a medicine, I want you to know the common side effects, the less common side effects, and then the disastrous side effects. That’s why on the commercials they talk about all the disastrous side effects, but often they don’t even research the sexual side effects. So for example, GLP-1s.

STEVEN BARTLETT: Okay, what’s a GLP-1?

GLP-1 Drugs and Sexual Health

DR. RACHEL RUBIN: The GLP-1s are the weight loss drugs that everybody’s talking about. Ozempic, Mounjaro — all the celebrities are on these injections that are making them lose tons of weight. We are starting to look at these drugs in women, but nobody’s looking at it for sexual health. Everyone’s looking at it for can you get pregnant, reproductive health. There is not a single published paper on sexual health side effects for women.

So we did a survey — it’s not published yet, but we presented it at a conference, at a medical conference. We surveyed 1,000 women online who have taken these medications, and about 25% report sexual side effects from these medications. Again, that’s not to say the medicines are good or bad, right or wrong, but there are side effects. Now, of those 25%, about 50% of those people said it lowered their sexual function, whether it’s libido, arousal, and orgasm. And about 25% said it made it better.

STEVEN BARTLETT: Carrying on this track about women’s hormone levels through time and through age and through life phases, what else do I need to know or understand about how important testosterone is?

DR. RACHEL RUBIN: So we know — we have global consensus actually — that testosterone helps for libido in postmenopausal women. Now there is also data in perimenopausal women as well, and that is clear data. It helps with libido, but it also helps with arousal. It helps with orgasm and satisfaction. It can also help with body image, which is a really cool thing.

In my clinic, I use FDA-approved testosterone for men, and I give it to them in doses appropriate — like 1/10 the dose for a man I give it to my female patients. And I see that over the 3 to 6 months of taking it, it clicks. Now, does that mean every woman on Earth needs it? No, we’re not there yet. But if you want to try it and you’re curious about it, then you should have access to physicians who understand how this works, and they know how to write the damn prescription.

Women’s Hormonal Journey Through Life Stages

STEVEN BARTLETT: There are 5 life stages on here. We have puberty, your fertile years, perimenopause, menopause, and then postmenopause. When you think about a woman’s hormonal journey through these different life stages, what is the sort of advice you would give them to make sure they’re hormonally healthy across every life stage? What are the basics? What are the tactics, strategies, medications that they should be thinking about? And I say this because I’ve got women in my life at every stage in this life phase at the moment. I’ve got my nieces in the sort of puberty era, I’ve got my fiancée in the fertile years, I’ve got my mom and grandparents in the perimenopause and postmenopause years as well.

DR. RACHEL RUBIN: Yeah. So if you look at your nieces, for example, when they were babies compared to now, there are changes happening. Their bodies are transforming because they’re getting a surge of hormones in their body, and that’s estrogen, progesterone, and testosterone. They’re cycling, which means they’re getting periods. So let’s talk about the menstrual cycle for a second. I think it’s helpful.

STEVEN BARTLETT: Okay.

DR. RACHEL RUBIN: So when women have their period, they bleed for a few days, right? And that’s when their hormones, their estrogen and their progesterone, is at its lowest. So hormones are at their lowest, and then the hormones start to increase. Your estrogen starts to go up. You don’t make progesterone yet in the beginning. Your estrogen starts to go up, and there’s a follicle in your ovary which has an egg, right? It’s going to pop out an egg. Ovulation is when the egg pops out. So you get this big surge of estrogen. And then when the egg pops out of the ovary — that’s what’s going to make a baby if it gets fertilized — there’s a shell of the egg, right? The egg has a shell, which makes progesterone. So the second half of the cycle, there’s progesterone around. First half of the cycle, no progesterone.

STEVEN BARTLETT: Hmm.

DR. RACHEL RUBIN: And so that second half of the cycle, the shell is making progesterone. And then when you don’t have fertilization, the shell starts to break down.

STEVEN BARTLETT: Okay.

DR. RACHEL RUBIN: And that natural breakdown is a drop in progesterone, which causes the lining of the uterus to shed and you get a period again. And so estrogen goes high in the beginning and then pops out an egg. Progesterone gets high in the second half, then they both fall and you have a period.

And so the hormones being low in the beginning — estrogen is not zero, it’s about 50. So when we talk about numbers, if you get your hormones checked, if they’re at their low, it’s like 50. But when you ovulate, your estrogen may be 150, 200, 300. And then when you’re pregnant, your estrogen may be as high as 3,000 or higher, right? It’s very many thousands. And so these hormones have actions in our bodies. And so the reason it’s important is because when we give back hormone therapy, are we giving back 10,000 like pregnancy? No, we’re giving back to be like 50, 60, 70 — the way that you are early in your cycle, kind of a thing.

Now testosterone’s not even on this graph that everybody gets taught of estrogen, then progesterone. But we do know testosterone is pretty stable through the cycle, although we do believe it peaks during ovulation, which makes sense because you want to have a baby, right? So evolution says, “Okay, you need to be horny around the time that you are going to ovulate,” and so your testosterone starts to go up.

Now, it’s really important because you’re probably not having a conversation with your nieces about their menstrual cycles, but it’s a problem because no one’s talking about it — if they’re painful, if they’re abnormal. We don’t have a lot of conversations around what is a normal amount of bleeding. We have so many people who have problems, whether it’s PCOS, which is now called PMOS, which is a metabolic issue that causes you to have irregular periods. There’s endometriosis where you have painful periods. There are so many medications we give to people that can alter their hormonal health and sexual health for that matter.

And then it all starts to get even more chaotic in perimenopause, which is again age 35 to 45. If menopause, we say, is 45 to 55 — that’s normal menopausal age, average age is 52 — and we think perimenopause is when things start to change for people about 10 years before, so that means 35 to 45. So how old are you? I don’t remember. 33.

STEVEN BARTLETT: 33. My partner’s 33.

DR. RACHEL RUBIN: All right, so 33. So this idea that “I’m too young” or “it’s too early” or “I’m not there yet” — the truth is things do start to change.

STEVEN BARTLETT: What changes for a woman?

Symptoms of Hormonal Fluctuations in Perimenopause

DR. RACHEL RUBIN: 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.

STEVEN BARTLETT: Some people get irregular periods.

DR. RACHEL RUBIN: 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.

The Role of Progesterone and HRT in Women’s Health

STEVEN BARTLETT: So 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?

DR. RACHEL RUBIN: 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 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 30s. So 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.

STEVEN BARTLETT: 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? What do women need to know about that?

DR. RACHEL RUBIN: Yeah, so it’s important because—

STEVEN BARTLETT: And what is HRT?

DR. RACHEL RUBIN: 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, 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. It 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— 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. That’s what period blood is, is the lining of the uterus here. Which we call the endometrial lining.

So progesterone is very important for this lining here. If 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.

STEVEN BARTLETT: So when we— so if you just gave someone estrogen, then the lining of the uterus would get so thick that that would cause a problem. But if you give both hormones together, it sort of balances—

DR. RACHEL RUBIN: It balances them out. And so that’s why you’ll hear hormone therapy talked about as estrogen and progesterone, just like the birth control pill your partner was on was an estrogen and a progestin. There was a combination.

The Women’s Health Initiative and the HRT Controversy

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. In the late ’90s, a lot of people were on hormone replacement therapies and they were seeing benefits. There were actually 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 they—

STEVEN BARTLETT: They—

DR. RACHEL RUBIN: 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 this study early. Hormone therapy causes cardiovascular disease and breast cancer.”

And overnight, a multi-billion 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.

And 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.

STEVEN BARTLETT: Only 1.7?

DR. RACHEL RUBIN: Only 1.7%.

STEVEN BARTLETT: Oh, really?

The Four Buckets of Hormone Therapy

DR. RACHEL RUBIN: 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 4 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, but 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 microdoses 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. It 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.

STEVEN BARTLETT: At any age.

DR. RACHEL RUBIN: At any age at all. In fact, even more important for people who are older because they are dying of urinary tract infections.

STEVEN BARTLETT: They’re dying of it.

DR. RACHEL RUBIN: 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. And this prevents those problems in those people too.

Genitourinary Syndrome of Menopause (GSM) and Vaginal Hormones

STEVEN BARTLETT: Again, what is this?

DR. RACHEL RUBIN: 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.

STEVEN BARTLETT: GSM.

DR. RACHEL RUBIN: GSM. Genitourinary 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.

STEVEN BARTLETT: So UTI, what is a UTI and what’s causing a UTI? Urinary tract infection?

DR. RACHEL RUBIN: 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. It 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.

STEVEN BARTLETT: Why is there a link between hormones and UTIs?

DR. RACHEL RUBIN: 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.

STEVEN BARTLETT: So there really is a vagina microbiome.

DR. RACHEL RUBIN: There is. And there’s no probiotic on earth that is 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. And 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.

Vaginal Hormone Products: A Practical Guide

STEVEN BARTLETT: So what have we got here in front of me?

DR. RACHEL RUBIN: 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 2 and a half months. Now this cream 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 1 gram of this cream. So this amount is 1 gram of this cream. We’ll put it on this paper here to show you 1 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 area as well at the opening.

STEVEN BARTLETT: Let me try. I don’t have a vagina, but— oh my gosh. So you take the— what is this cream called?

DR. RACHEL RUBIN: Estradiol cream.

STEVEN BARTLETT: Estradiol. Take it on your finger, you rub it inside the walls of the vagina, and just rub it in like you would rub sunscreen on your face.

DR. RACHEL RUBIN: 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, but 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. And we have little tablet inserts. So here is a— 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.

STEVEN BARTLETT: Ah, okay.

DR. RACHEL RUBIN: 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 3 months. Now, this— it’s sort of like a tampon. You can kind of put it in the vagina, and the vagina does 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 3 months at a time.

STEVEN BARTLETT: It’s quite a big ring.

DR. RACHEL RUBIN: 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.

STEVEN BARTLETT: And there’s a chemical inside this ring that’s going to diffuse—

Vaginal Hormones, UTIs, and When to Start HRT

DR. RACHEL RUBIN: — estradiol— that slowly diffuses estrogen for the ring. So 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. What’s DHEA? So this is a chemical that converts into estrogen and testosterone. And so DHEA is a supplement you can buy, 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.

STEVEN BARTLETT: And just to be clear again, so you think a lot of people should be taking these things?

DR. RACHEL RUBIN: 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, and this is a safe option for all of those women. Does that make sense?

STEVEN BARTLETT: 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—

DR. RACHEL RUBIN: 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. That’s not data-driven, by the way. That’s all a folk tale. 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. And 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.

When Should Women Start HRT?

STEVEN BARTLETT: My partner’s 33 years old now. She’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?

DR. RACHEL RUBIN: 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. Say your partner gets pregnant, okay? You decide to have a baby. Her estrogen is going to go to 10,000 for 9 months. It’s going to be super, super high. And 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.

STEVEN BARTLETT: And what are the symptoms then?

DR. RACHEL RUBIN: So if you’ve just had a baby, you’re breastfeeding, you may have hot flashes, she may have night sweats, she may have urinary frequency, urgency, leakage. There’s all sorts of symptoms that come with libido 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. But 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?

A Patient’s Transformative Journey

DR. RACHEL RUBIN: 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, at 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— 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, “Rubin, what are you doing here? I’m feeling much better. 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?”

Well, 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. We said testosterone will likely help with your libido, but it’s going to take 4 to 6 months.

So 4 to 6 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. 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 ways she hasn’t seen it in so long, and she’s 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.”

STEVEN BARTLETT: And what age is she?

DR. RACHEL RUBIN: She’s in— 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 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. This idea of your ovaries have to fail and you have to suffer for 12 months before someone intervenes is insanity.

STEVEN BARTLETT: But for some women, they do start HRT during the perimenopausal phase. And for some, they started during the menopausal, postmenopausal stage. And it’s all depending on how you’re feeling.

DR. RACHEL RUBIN: It’s all depending on how you’re feeling and what you want, what your objectives are.

STEVEN BARTLETT: Okay. But it’s never too early to start, necessarily.

DR. RACHEL RUBIN: 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, to help with different things in birth control. So if you think of it as all of it is some form of hormone therapy, it just depends. Are 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, Steven, 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 those as having underlying hormonal causes as well.

So 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.

Pain During Sex

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: 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.

STEVEN BARTLETT: So a really dumb question here: sex is not supposed to be painful?

Painful Sex, Pelvic Floor Health, and Female Orgasm

DR. RACHEL RUBIN: Sex is not supposed to be painful. If sex is painful, you need to figure out why. You deserve a diagnosis, you deserve an answer, you deserve to understand exactly why sex is painful.

You could have a problem with the tissue. 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 conditions. So you may have a skin condition, you may have a problem with your muscles.

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. We also know there are nerves that are involved in this area. So if you have a back problem and you feel it running down your leg, 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, many different things that can cause pain with sex. But remember I said your OB-GYN got almost no training in this.

STEVEN BARTLETT: So if I’m currently experiencing pain during sex as a woman, what advice would you give them? What should they do?

DR. RACHEL RUBIN: 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 of quotes on who’s going to do the best job. It’s okay to see a few different people for this problem.

STEVEN BARTLETT: And in terms of prevalence, up to 75% of women, as you say, will experience painful intercourse at some point in their lives. Between 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.

DR. RACHEL RUBIN: 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.

The Framework for Great Sex

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: Yeah, so this is Diary of a CEO, so I love how you love the health topics, but obviously financial literacy is really important to you, to help people, because for some reason people stink at 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.

So I actually use financial literacy as a framework in how we talk about good sex. You’ve got your savings account and your checking account. Those 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? Are you doing the basic things you need to have great sex? Communication is 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. It’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 shape. 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 crypto. Okay, 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 what you’re watching when you’re scrolling Instagram and you see these ads for, “Do this injection, do this 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, it probably isn’t going to fix things 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.

Understanding the Pelvic Floor

STEVEN BARTLETT: So let’s go through these slowly, one at a time. I kind of broke it down into 3 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?

DR. RACHEL RUBIN: Yeah, so everyone who has a pelvis has a pelvic floor. Men have a pelvic floor. Women have a pelvic floor. It just means the bones of your pelvis. So your hips, your pelvis bone, your butt bones — all of this is this big bony structure that holds all of your organs in place. And your genitals are attached to this pelvic floor. And the pelvic floor is surrounded by thick, big muscles.

If we look at the inside of the pelvic floor, it’s these big thick muscles. And muscles, just like your biceps, are something that contract and relax, and there can be problems with muscles. Just like if you work out too much and you’ve got a sore trap and you’ve got to go get it massaged, or you’ve got to do physical therapy because your shoulder is hurting. A lot can go wrong with the pelvic floor.

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. 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. Penetration can happen if you’re relaxed, but then orgasm is a series of muscle contractions, which equates to pleasure and release, which all has to do with the nerves and the muscles. Does that make sense?

STEVEN BARTLETT: 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.

DR. RACHEL RUBIN: Yeah. So if sex hurts, 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 — is diminished or less, that could be due to the pelvic floor because you’re not getting enough blood flow to the area.

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 and you feel it in your genitals — there’s this brain-genital connection. You have to have perfect wiring 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, muscle health changes for many reasons. And so when you have problems, there may be biological reasons to these problems.

STEVEN BARTLETT: Should we be going to the gym and doing pelvic floor exercises to improve our sex lives?

DR. RACHEL RUBIN: 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. So for some people, it’s to strengthen it and to do almost contractions — we call them Kegel exercises. But for many people, it’s just learning the coordination.

STEVEN BARTLETT: And you can go and get an exam?

DR. RACHEL RUBIN: You can go get an exam and work with — look for a physical therapist.

The Orgasm Gap and the Clitoris

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: So about 20% of women will say that they can’t have an orgasm. And the real question — I’m fascinated by this data because 20% of men do not have orgasm problems. And 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 the 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. The clitoris is how women orgasm. Penetration 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. You could keep rubbing your thigh for the whole duration of this podcast and 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 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. The clitoris is this huge structure. My necklace is of course a gold clitoris. This is a 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.

Clitoral Adhesions

STEVEN BARTLETT: There’s something called a clitoral adhesion which people don’t know about as well, which I’ve heard you talk about before. What is that, and how many people suffer with that?

DR. RACHEL RUBIN: Yeah, so the clitoris has this hood to it, okay? And about 23% of the time, the hood can get stuck to the head. 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 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, but in 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%. And so you’ve done —

STEVEN BARTLETT: 1 in 5 women, yeah, have a clitoral adhesion. Yeah. And when solved, improves their sexual satisfaction by up to 60%.

Understanding Female Pleasure and Anatomy

DR. RACHEL RUBIN: 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, infection where, like, they come in with pain or they come in with libido issues, but no one is examining this part of the body. And 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.

STEVEN BARTLETT: You pulled up the sex toys there. I think we were talking about orgasm.

DR. RACHEL RUBIN: 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 or— how would you orgasm?

STEVEN BARTLETT: Probably, I don’t know.

DR. RACHEL RUBIN: The vibrator industry would be a gajillion dollar industry instead of just a billion dollar industry because vibration can help activate this blood flow. And so for women, vibration on the outside can be extremely helpful because remember, the clitoris is kind of around 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.

STEVEN BARTLETT: Oh, here we go. Okay, so this is vibrating now.

DR. RACHEL RUBIN: 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.

What Men Get Wrong About Female Arousal

STEVEN BARTLETT: As 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?

DR. RACHEL RUBIN: 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, right? What gets women excited? Because it’s different than what gets men excited. And every partner’s different in terms of what gets them excited.

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. So what do I need to know? Yeah, so you need to know.

STEVEN BARTLETT: I’d like to implement it tonight.

DR. RACHEL RUBIN: 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? What do you like? Do you know, can we look at your clitoris together? 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.

STEVEN BARTLETT: Okay, so she’s going to orgasm at some point if this is sufficiently stimulated.

DR. RACHEL RUBIN: If there’s sort of a buildup and release of pleasure, right? That’s orgasm. And again, that is often not happening during penetration.

STEVEN BARTLETT: 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 decline in arousal, and I don’t want you to touch it again.

DR. RACHEL RUBIN: That’s very similar in women. Okay, so it’s the same, except women can bounce back faster. Not all of them, but women can have multiple orgasms.

STEVEN BARTLETT: So she orgasms, it’s very, very sensitive, she doesn’t want me to touch it for a while.

DR. RACHEL RUBIN: Yeah.

STEVEN BARTLETT: And then she potentially could bounce back faster.

DR. RACHEL RUBIN: She could potentially. Some people do, some people don’t. But 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 — giving the sensitive tissue some time to rest, then your orgasm happens, and then you potentially go for round two.

The Role of Penetrative Sex

STEVEN BARTLETT: So 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?

DR. RACHEL RUBIN: 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 being the whole story.

I think every woman’s body is different. And so kind of making these broad statements of every partner likes this — but many women are asking for penetration mainly because they’re like, “Okay, 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 penetration. 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, who ejaculate very quickly? There are men who orgasm in a minute or less. That’s probably like 8% of men. Okay. So if we think men and women’s bodies are very similar, could we argue that 8% of women will orgasm within a minute or less? 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 often seen as great in a woman and not great in men. And so I just have this theory that there are women who have extra sensitive body parts.

How Pornography Shapes Our Perception of Sex

STEVEN BARTLETT: So one of the things I’ve learned from everything you’ve said is just how much porn has messed up our perception of sex.

DR. RACHEL RUBIN: I mean, WWF has messed up our perception of what people’s bodies are like, exercise, fighting — it’s all manufactured, and it’s all manufactured because that’s the algorithm that has been working to get men excited. And it doesn’t — 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, “What does my partner actually want?” — you can have great sex without penetration. And so the question is, what does great sex look like for you and your partner?

STEVEN BARTLETT: When I look at a website — I’ve got some data here — on a website like Pornhub, which is one of the leading porn websites, it says that roughly 65% of their traffic is men. Independent 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, 75–95% 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’s the one — the woman looked like she was having fun, the man was doing this particular thing, and then we take that into our relationships. And I think this is where the misunderstanding begins.

DR. RACHEL RUBIN: 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 it’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, you 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.

STEVEN BARTLETT: What do you think of pornography?

DR. RACHEL RUBIN: I actually think pornography is great for relationships, potentially the right porn. Okay, let’s look at something like Heated Rivalry. Have you heard of it? No. Okay, Heated Rivalry is an HBO show that came out this year that is about two gay male hockey players. Okay? 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. And 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. 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. Watching people have sex, watching people fall in love, watching people in romance — people like that. It gets them excited. It gets them aroused. But if you are watching porn and not interacting with humans, if you are watching porn all the time, if you can only watch porn to have good sex — then that may not be the best and healthiest thing to do.

Pornography and Relationship Satisfaction

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: It depends. It depends on the relationship, and it depends on what each person needs in order to feel supported and connected, right? 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 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.

STEVEN BARTLETT: The stat that I was looking at was a couple dozen studies, including a major meta-analysis, show a consistent link between solo porn consumption and lower relationship and sexual satisfaction. The erosion of intimacy is usually driven by deception. Finding out a partner is hiding porn use usually triggers intense feelings of betrayal, rejection, and 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.

DR. RACHEL RUBIN: Again, it was that deception. It’s the hiding. 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.

STEVEN BARTLETT: But also the desensitization of it. It’s never going to — I guess it depends on how you’re using pornography.

DR. RACHEL RUBIN: It depends on how you use it. So again, that’s the truth.

STEVEN BARTLETT: You’re going to 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 learned to pleasure yourself, right?

The Psychology of Sexual Communication and Arousal

DR. RACHEL RUBIN: And that’s a problem, right? If you’re only able to do something in one way, in one position, with one— watching one specific thing, that may not translate into great intimate sex with a partner.

Spontaneous vs. Responsive Arousal

STEVEN BARTLETT: And there’s different types of arousal, right? I heard from a sex expert I spoke to that men and women often have different types of arousal, spontaneous and reactive, is it?

DR. RACHEL RUBIN: Yep, 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 ready to go to the gym and exercise, and other people like, I never want to exercise. But 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 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? You 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. 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—

STEVEN BARTLETT: Why? Why don’t we talk about it?

DR. RACHEL RUBIN: We don’t talk about money either. We don’t talk about sex because we’re trying to be appro— I don’t know, why do you think?

Why We Don’t Talk About Sex

STEVEN BARTLETT: I think that’s a little bit of it, but I think the subjects are deeply personal, emasculating, and so intrinsically linked to self-esteem. It’s vulnerable. It’s super vulnerable. So, 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 expressed that she didn’t like having sex. And I didn’t understand that as a 22, 23-year-old guy.

DR. RACHEL RUBIN: Yeah.

STEVEN BARTLETT: And so you kind of look yourself in the mirror and go, oh sh, it can be super emasculating. It turned out that there was actually a physiological challenge she’d had. But we’d been in a relationship for a long time and she wasn’t enjoying sex because there was a physiological issue. She didn’t say anything to me.

DR. RACHEL RUBIN: Yeah.

STEVEN BARTLETT: I didn’t know. And then the day she said something to me, I didn’t know anything about sex, so I just interpreted it as like, damn, I must not be good in the bedroom or something. Which is super colorful.

DR. RACHEL RUBIN: Yeah.

STEVEN BARTLETT: And then that kind of breaks the relationship down, and it’s all predicated on this highly emotional, highly self-esteem linked, poorly educated subject, which destroys relationships.

DR. RACHEL RUBIN: 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. You know what’s interesting?

The Cost of Ignorance in Relationships

STEVEN BARTLETT: I went to one of my friends, one of my best friends, and said, look, my partner’s just said this to me, what does that mean? And he said to me, “Mine too.” I was like, what? So you’re not having sex with your partner? He goes, no, we haven’t had sex in 3 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 has said she just doesn’t like having sex. And I can’t tell you how ignorant and poor and insufficient the conclusions we arrive at in such a situation 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 just 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 think, oh my God, I just wish 5, 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. It was something that could have been helped.

DR. RACHEL RUBIN: Yeah. 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? Because it actually wasn’t you at all, right?

Understanding the Data on Arousal Styles

STEVEN BARTLETT: 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.

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 variance, which I think is very important for people to know. 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 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 the 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% 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 foreplay or contact or the sexual actions have taken place. And then the mixed style is 15 to 20% in men and 35% in women. Is that all accurate?

DR. RACHEL RUBIN: 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, right? 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 upfront, as opposed to this bombshell that happened too late, all of that pain, all of that hurt probably would’ve looked different, right? The world would’ve looked very different.

Now that’s what I’m fighting against because I think that, to your point, men are suffering. They’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 — 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 do women want in general, but 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, 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.

Questions to Start the Conversation

STEVEN BARTLETT: 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 often say to me that the episode they watched together was about sex. So 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 to your sex episode.” So I’m like, they’re listening now.

DR. RACHEL RUBIN: Again, I think it’s that basic thing of like, what does great sex mean to you? What do you want? What is a great time? What’s something fun? What is it about sex that you enjoy? When you ask people what 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.

Navigating Different Sexual Preferences in Relationships

STEVEN BARTLETT: So 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, what arouses you during sex? What 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 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. How do you navigate that?

DR. RACHEL RUBIN: When you go to buy a house, you don’t always get to choose what house you get unless you build it yourself. There are compromises in life. 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 in the exact situation. Or even worse, with AI, 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, it’s awkward, it’s smelly, there’s fluids, there’s funny noises, it’s vulnerable. It’s really uncomfortable sometimes to have these deep conversations. But isn’t that why life exists? Isn’t that the most fun part, 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. 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. What you will find is that people have all sorts of agreements and relationship setups. And as a sex doctor, the things I hear in a room would, you know, are quite wild, and you wouldn’t even believe what people are doing.

There are people who have open relationships, so they have multiple partners, or they have certain kinks — things that they really enjoy that maybe somebody would look at and be like, “Oh, that’s very strange.” But there are other consenting people who also are comfortable and want to do those things. There 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.

Talking About Fantasies and Kinks With Your Partner

STEVEN BARTLETT: On this point of fantasy, what if someone has a fantasy or a kink, and they don’t want to tell their partner because they’re worried about the reaction?

DR. RACHEL RUBIN: Yeah, this is where things like sex therapy become really helpful — having a third party. Because 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 apps and things like that where you can sort of dip a toe. 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 are 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. It’s okay to have conversations about sex when you’re not having sex. 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.” These are the conversations you’re going to have with your team. People don’t do that about sex very often. They don’t actually do an after-action review — what went well, what didn’t go well, do you ever want to try this, what would be fun here. There is often a lack of curiosity.

STEVEN BARTLETT: And to be clear, you’re a sex doctor, right? People come to you and sort of offload their sex lives to you.

DR. RACHEL RUBIN: My job is so fun. I love my job. People will talk to me about their most — we do 2 hours and we talk about their lives in the context of their sexual health for 2 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 think, “Oh, that was actually really nice to talk about. I didn’t know this, that, and the other thing about my body.”

What People Hide From Their Partners

STEVEN BARTLETT: And what do you find that men and women typically are hiding from their partners when they do confide in you?

DR. RACHEL RUBIN: I think they don’t tell their partners just about anything. There’s a lot they don’t tell their partners.

STEVEN BARTLETT: Is there a difference between men and women in what they’re not saying?

DR. RACHEL RUBIN: That’s a great question. I would say that no one is talking about sex at all. Women are hiding their pain from partners. Men are hiding their insecurities and their frustrations, and there’s a lot of shame around erectile dysfunction and sexual problems in men. A lot of people just either stop having sex or stop talking about it, or sort of have mediocre sex because they are not that great at talking about these things.

STEVEN BARTLETT: And I imagine my first reaction would be, “Oh, you should tell them,” but I imagine that doesn’t necessarily work.

DR. RACHEL RUBIN: I think it’s a challenge. If you have been faking an orgasm for your entire relationship — and women have been. The statistics are quite clear. 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, orgasm often takes a lot of arousal. Again, stopwatch — if a penis enters a vagina and they orgasm, about 5 and a half minutes is on average how long men last. That’s science. It’s about 5 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 5 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 5 and a half minutes and it’s like clockwork, I would call bulls* on a high percentage of it. A partner doesn’t want to tell you because they’re afraid to. They want to make you happy. 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.

Closing the Orgasm Gap

STEVEN BARTLETT: So that presents a pretty good case that the woman should orgasm first.

DR. RACHEL RUBIN: I think so, because orgasm first will allow for pelvic floor release and relaxation, which will make penetration more pleasurable and enjoyable. I think women can have multiple orgasms, so there’s a case to be made for before and after. Why are women having zero orgasms and 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. Making penetration the main event is where the challenge lies — I think penetration can be part of the whole story, but doesn’t necessarily always need to be the main event.

Stress, Burnout, and Low Libido

STEVEN BARTLETT: 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 the dopamine drain, where you’ve got mental burnout or chronic stress, or we talked a little bit about depression. I did notice that through my life when I’m very, very overworked, my libido is not the same.

DR. RACHEL RUBIN: Yeah.

STEVEN BARTLETT: 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 dopamine drain — it’s actually their stress and lifestyle. It could be the kids, it could be—

DR. RACHEL RUBIN: Oh, it’s a huge problem. It makes logical sense. Again, if we go back to the fundamentals — 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? If we’re scrolling all the time at bedtime, or if we’re watching porn all the time, or 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.

When you were dating and you would ask your date, “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. I’m taking this person out. 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 they see you at your best, they see you at your worst, they see you at your crankiest and your most tired. And so it’s really hard to get that level of excitement when you’re dealing with those sort of life circumstances.

The Myth of Spontaneous Sex

STEVEN BARTLETT: People will say that there’s a spontaneity myth around sex — that it should be spontaneous. And that’s kind of how we see it in films, like they grab each other in the hallway and start kissing and whatever else.

DR. RACHEL RUBIN: It’s just not real. It’s just the same as WWF — it’s not real. If you see your partner every day, 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? That’s not how humans work. That’s why vacation sex is always fun for people, or they find time. 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 — how are you going to have great sex in that situation?

STEVEN BARTLETT: One of 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 PM I have to have sex because that’s the time we scheduled this week, then I’m going to be finishing my work at 5, 6, 7, I need to get home, and I need to have sex as well.

DR. RACHEL RUBIN: So this is where you schedule it around a time that you know is going to work for you. I tell people to do things like quarterly dates. I work in DC, everyone is very high-powered with very busy jobs. I say one Friday a quarter, you and your spouse can literally block your calendars.

STEVEN BARTLETT: A quarter?

DR. RACHEL RUBIN: A quarter. Because 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 it doesn’t necessarily have to be a sex day, but you actually take time — maybe you want to walk, maybe you want to hike, maybe take a bath, maybe get a massage. You kind of create space to actually say, “Oh wait, we like each other. We like talking to each other. We don’t have to just talk about the kids all the time.” The more you invest in each other in a joyful way, the better sex you’re going to have.

Self-Esteem, Body Image, and Sexual Confidence

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: It’s a huge problem. 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. Do they deserve great sex?

STEVEN BARTLETT: Of course.

DR. RACHEL RUBIN: 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, 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 skinny.” And that’s a huge problem.

STEVEN BARTLETT: So what do we do about it?

DR. RACHEL RUBIN: I think it’s empowerment. It’s communication. It’s explaining to people. I 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. 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 human connection. We’re getting worse at this, not better. I just think that we have to reach humans and we have to be able to talk about it and change the narrative.

The Most Important Thing: Biology Matters in Women

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: 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. We have to let women advocate for themselves about the biology, and 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 what experience— 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?

STEVEN BARTLETT: Yeah, I think that— yes, I think that’s going to have to— for me to have a healthy relationship with my partner, I think that’s going to have to be 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.

DR. RACHEL RUBIN: I spend 2 hours with people and there are times when the partner comes to that talk, and so they get to hear what their partner is describing. They even see the exam and they get a tour of their own partner’s body parts. And so it is helpful sometimes to bring partners into those conversations, the biology conversations.

“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. 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?” So 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, 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.” Two things can be true. So I think understanding your partner’s biology and your own biology is quite important.

Communication and Conflict Resolution: The Foundation of Relationships

STEVEN BARTLETT: Yeah, I guess that’s the crux of the conclusion really, is that both education and communication are where it all begins, which is the fundamentals, right? And I think, gosh, if I had better education on these subjects at the start of my adult life, and also if I had figured out how to communicate with my partner, and maybe even also with yourself, and to be a bit honest with yourself about how you’re feeling, not to gaslight yourself — 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, especially the communication part, because these are very, very sensitive subjects. And so we’d rather just shut up about them and keep them as these sort of secrets that we whisper about with the closest people in our lives, maybe our best friend.

I just think generally one of the things I’ve come to learn from doing this podcast is that 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, conflict is guaranteed in life, but the thing that’s going to turn your conflict into a strengthened relationship or a weakened one is how you deal with it. And that’s all predicated on communication.

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 curiosity — then all of these downstream challenges and misunderstandings would have a chance of being solved for.

And I think about this so often. How I’m communicating with my partner currently is really going to determine whether we have an argument in 2 years’ time or a year’s time or 6 months’ time. 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 what the correct answer will be?

I’ve spent a lot of time — I’m almost 7 years into my relationship now — thinking, how do people build a relationship that lasts 50 years? And the crux of it seems to be conflict resolution and communication. That seems to be the crux of it. And actually, with finance issues that we talk about with finance experts, and always with sex issues, the crux of it seems to be conflict resolution and communication.

I also know, because I know lots of couples, that we’re all living on a different spectrum here. Some couples could come home at 6 PM 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 burying everything in the cupboard. They think burying it in the cupboard means that it’s out of sight, out of mind, and it’s not impacting anything. But any problem buried rears its head in unexpected ways.

Thinking of 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 became like parallel lines drifting apart, and several years later — what happened? What happened to our relationship? Well, they never spoke about it.

DR. RACHEL RUBIN: I think you understand this perfectly, and for you to see it in this way, you can help so many people because I think these are the fundamentals. How do we teach young people and older people that conflict resolution is important, and intimacy and vulnerability are important, and biology is important, science is important, and we can do this.

I just taught you a few things that I know today, and not only did you understand it, but you were curious about it and asked further questions, and you can now figure out how it works in your own relationship, in your own life. You’re even caring enough to think about your friends’ lives. 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.”

STEVEN BARTLETT: Yeah, it’s crazy, isn’t it, that if you love this person so much, yet you don’t often love them enough just to communicate about some of these sensitive, tricky subjects. That’s like craziness when you articulate it like that. I’ve been in relationships where I just absolutely loved this person but no, I wouldn’t raise X, Y, and Z subject. It’s just too uncomfortable.

The Power of Vulnerability in Relationships

DR. RACHEL RUBIN: And the few times, I guess I will ask, that you have been vulnerable — has it gone well or not well?

STEVEN BARTLETT: Oh my gosh, it’s like the most important thing. I always think, why didn’t I do this sooner? To be even more honest, I didn’t have conversations with my partner about sex at all. I assumed she liked it, I think she assumed I liked it, and it wasn’t until you get further into a relationship that you start going, “Wait, I don’t think this is how this person wants to have sex.” Actually, I have to give her the credit because she’s the one that started pushing on the communication. I think sometimes as men we just — that old slightly toxic phrase, “happy wife, happy life” — I think sometimes as men we just assume that if no one’s saying anything, then everything’s great. But it takes two to tango.

DR. RACHEL RUBIN: 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 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? And I think that’s the energy that we need in 2026 — 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.

STEVEN BARTLETT: You need the words though, as you say.

DR. RACHEL RUBIN: Yeah.

STEVEN BARTLETT: 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, it might hurt your ego a little bit. Is this what you mean by “have the words”?

DR. RACHEL RUBIN: It’s really hard to do that on your own because people don’t want to hurt other people’s feelings. And 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, Steven, is that 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, 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. So how do you deal with conflict when it’s not a good guy, bad guy situation? And how do you love someone and evolve with them? I think it’s not easy.

There Is No Bad Guy: Reframing Intimacy Challenges as a Team

STEVEN BARTLETT: 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 in 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 what the brain jumps to.

But actually, now that time has 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.

Thank you. You said that I will help people, but actually you’re the one that’s helping people. I’m just asking questions.

DR. RACHEL RUBIN: I disagree. I think it’s the simple stuff, it’s the vulnerability of watching others. It’s the simple stuff that makes the biggest change.

STEVEN BARTLETT: Why does this matter so much, Jackie? I can see it in your face.

DR. RACHEL RUBIN: 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.

I see it every day in my clinical practice. And 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 all the— like, I see how much it’s not being done.

Closing Tradition: The Question Left for Dr. Rachel Rubin

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: I would like to get better about practicing what I preach because we always say the shoemaker’s 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 as I should, or not scrolling on my phone and paying attention to my children that I should. I don’t spend as much time 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.

STEVEN BARTLETT: 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.

DR. RACHEL RUBIN: Easy to do, easy not to do.

Where to Find Dr. Rachel Rubin

STEVEN BARTLETT: 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?

DR. RACHEL RUBIN: 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.

I 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.

STEVEN BARTLETT: 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, 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 — we talked beforehand — you don’t necessarily love doing this, but it’s a very, very important, worthy course because there’s very few people that can speak to these subjects in the way that you can. So please keep doing it.

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. Please do share it with them. Dr. Rachel, thank you so much for your time.

DR. RACHEL RUBIN: Thank you.

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