Medical Whistleblower: What Your Doctor Doesn’t Know Is Hurting You | Dr Rachel Rubin
In a Nutshell
Dr. Rachel Rubin argues that medical training ignores women's sexual health, leaving most doctors unable to prescribe safe, effective hormone therapy or treat issues like painful sex and low libido. Vaginal estrogen cream used twice weekly prevents UTIs, improves arousal and orgasm, and costs almost nothing, yet over 75% of women never receive it due to outdated fears and lack of education. She stresses that understanding clitoral anatomy, pelvic floor function, and responsive versus spontaneous arousal, combined with open communication and scheduled intimacy, closes the orgasm gap and restores sexual satisfaction for both partners.
These notes were generated by AI and may contain inaccuracies.
Vaginal estrogen cream applied twice weekly inside the vagina reduces painful and dry sex, improves arousal and orgasm, and prevents death from urinary tract infections. This generic medication costs little yet remains underprescribed, with more than 75 percent of patients in large database collections not receiving prescriptions.
The majority of women do not orgasm during sex because they lack education that orgasm comes from the clitoris rather than penetration. Most women do not know where their clitoris is located. The word clitoris does not exist in the 2026 checklist for what an OB/GYN must learn in training.
Men focus on penis size, hardness, straightness, girth, and duration, yet none of these factors determine women's pleasure and satisfaction. Basic sexual health information is not taught, and women's sexual health, menstrual cycles, pregnancy, menopause, hormones, pain with sex, and libido receive insufficient attention despite available data.
Even the most affluent women receive inadequate care for hormone therapy, menopause, and sexual health. Melinda Gates required three doctors before obtaining proper hormone therapy. Oprah consulted five doctors who failed to recognize her heart palpitations as menopausal symptoms. Halle Berry received a genital herpes diagnosis when she actually had genitourinary syndrome of menopause.
Medical schools and residencies do not teach hormone therapy, menopause, or sexual health. The speaker learned nothing about these topics during training. Research exists but does not reach practicing physicians because no mechanism exists to disseminate findings into clinical practice.
Fear and misinformation about hormone therapy from 20 years ago created a lost art of prescribing. Physicians lack training on writing prescriptions, understanding hormone types, and evaluating safety, risks, and benefits. Unlike blood pressure management where physicians acknowledge training limitations, hormone therapy and women's health prompt strong opinions despite knowledge gaps.
Men's health follows shared decision-making discussing risks and benefits, but women's health lacks this approach. Physicians attempt to save face rather than admit lack of knowledge, and 10-minute appointments prevent nuanced conversations. Patients seeking care for orgasm or libido issues consult gynecologists who never received training on the clitoris, vulva, sexual health, sexual pain, libido, arousal, or orgasm.
During pelvic exams and Pap smears, physicians cover patients with sheets, hiding genitalia from view and failing to teach anatomy during the process. The speaker provides patients with mirrors during examinations, identifying the labia majora, labia minora, clitoris, and urethra.
Women lack language for their body parts and cannot see their own anatomy due to skin, bones, muscles, and nerves. Providing anatomical language enables women to advocate for desired care and select appropriate providers including physical therapists, mental health professionals, primary care physicians, and gynecologists.
The three most frequent questions concern hormones, pain with sex, and libido.
Physicians view hormones as dangerous and harmful despite their natural presence in the body. Testosterone is not exclusively a male hormone. Testosterone levels begin declining in women's 30s, preceding the estrogen drop at menopause.
Menopause functions as a castration event comparable to testicle removal, producing hot flashes, night sweats, osteoporosis, depression, low libido, erectile dysfunction, metabolic syndrome, and weight gain. Every woman over age 50 experiences estrogen dropping to essentially zero, affecting bone health, brain function, heart health, sexual health, and increasing UTI risk.
Testosterone decline in the 30s manifests as reduced libido, longer time to orgasm, decreased arousal, and reduced clitoral engorgement. The clitoris and penis function identically, both becoming erect through blood flow.
Birth control pills contain synthetic estrogen and progestin in amounts high enough to suppress ovulation. The ovaries cease producing their own hormones, including testosterone, which is not replaced by the pill. This mechanism explains libido reduction in some users.
Studies indicate up to 27 percent of birth control users report decreased libido. When side effects occur, alternative contraception methods that preserve more testosterone production should be considered.
All medications carry side effect risks. Informed consent requires disclosure of common, less common, and serious adverse effects. Sexual side effects often remain unstudied.
GLP-1 medications including Ozempic and Mounjaro lack published research on sexual health side effects in women. An unpublished survey of 1,000 women found 25 percent reported sexual side effects, with half experiencing reduced libido, arousal, or orgasm, and one-quarter reporting improvement.
Global consensus supports testosterone for libido in postmenopausal women, with additional data supporting benefits for premenopausal women including improved arousal, orgasm, satisfaction, and body image. The speaker prescribes FDA-approved male testosterone formulations at one-tenth male doses for female patients.
During menstruation, estrogen and progesterone reach lowest levels around 50. Estrogen rises in the follicular phase, triggering follicle development and ovulation. After ovulation, the remaining follicle shell produces progesterone during the luteal phase. Without fertilization, both hormones decline, triggering menstruation.
Estrogen is not zero when hormones are low in the beginning of the cycle; levels sit around 50. During ovulation, estrogen may reach 150, 200, or 300. During pregnancy, estrogen can rise as high as 3,000 or higher. When hormone therapy is given, it restores levels to approximately 50, 60, or 70, matching early-cycle levels rather than pregnancy-level amounts.
Testosterone is not shown on standard graphs of estrogen and progesterone but remains relatively stable throughout the cycle, with a believed peak during ovulation that supports libido at the time of potential conception.
Few conversations occur about normal versus abnormal menstrual cycles, including pain, irregularity, or volume of bleeding. Conditions discussed include PCOS (now called PMOS), a metabolic issue causing irregular periods, and endometriosis causing painful periods. Many medications can alter hormonal and sexual health.
Menopause is defined as ages 45 to 55, with an average age of 52. Perimenopause is the roughly 10-year period before menopause when hormonal changes begin, typically spanning ages 35 to 45. Changes can start even in the early 30s.
Symptoms include temperature changes, fatigue, memory issues, low libido, dry eyes, itchy ears, burning mouth, joint pain, irregular periods, pain with sex, and UTIs. Hormones play roles in bladder health and UTI prevention. Many symptoms are dismissed as "everything being blamed on hormones," yet hormonal factors are frequently overlooked.
When progesterone declines in perimenopause, sleep disruption and increased anxiety can occur. Some patients begin with progesterone support, though estrogen can also address many of these symptoms. Treatment is individualized; some receive progesterone, estrogen, testosterone, or combinations.
Testosterone often declines in the 30s. Most guidelines focus on menopause treatment after levels are flatlined, but conversations are evolving to include earlier perimenopause intervention.
Hormone therapy (formerly called hormone replacement therapy) involves restoring hormones for hot flashes, night sweats, and osteoporosis in the over-50 population experiencing declining estrogen and progesterone. Classic therapy combines estrogen and progesterone.
Estrogen supports bone health, hair, skin, and nails; reduces hot flashes; and improves sleep. However, unopposed estrogen thickens the uterine lining (endometrium), raising long-term risk of endometrial or uterine cancer. Progesterone balances this effect and protects the uterus.
In the late 1990s, observational studies suggested hormone therapy reduced heart disease during menopause. The NIH funded the Women's Health Initiative, studying thousands of women aged 50 to 79. The study was stopped early in the early 2000s, and a press conference announced that hormone therapy caused cardiovascular disease and breast cancer.
This led to a multi-billion-dollar industry collapsing overnight, with women told to discard their hormones. Prescribers noted their patients were not experiencing the claimed harms. Reanalysis showed the study did not support the publicized conclusions.
In 2025, the original study authors published that below age 70, the type of hormone therapy used (no longer common) carried no increased risk of cardiovascular disease or stroke. Only 1.7% of women who should be offered prescriptions currently receive them.
- Whole-body estrogen: addresses hot flashes, night sweats, and bone loss.
- Whole-body progesterone: protects the uterus (especially if present), aids sleep, and can reduce anxiety.
- Testosterone: primarily supported for libido improvement.
- Vaginal hormones: micro-doses of estrogen or DHEA applied vaginally to support bladder and vaginal tissues.
Vaginal hormones treat genital urinary syndrome of menopause (GSM), though the term applies to any hormonal changes affecting bladder and genitals. Benefits include relief from pain with sex, dryness, urinary frequency, urgency, leakage, and prevention of UTIs. The therapy is safe for breastfeeding women, nursing-home residents, and patients of any age. It is especially critical for older adults at risk of dying from UTIs.
Urinary tract infections occur when bacteria enter the bladder, causing pain, inflammation, and potentially kidney infections, urosepsis, or death if systemic. The vagina is normally acidic; estrogen and testosterone maintain healthy bacteria and suppress pathogenic bacteria. Hormonal decline alters the vaginal microbiome, allowing bad bacteria to proliferate. Sex can further disrupt the microbiome because ejaculate is not acidic.
Vaginal hormones restore acidity and prevent UTIs by more than half, according to research since the 1990s. No probiotic matches the effect of hormones on vaginal tissue acidity.
- Estradiol cream: inexpensive ($14 for 2.5 months via Mark Cuban pharmacy); applied by rubbing 1 gram into vaginal walls twice weekly.
- Vaginal tablet inserts: less messy alternative inserted twice weekly.
- Vaginal ring: inserted for three months; releases estradiol steadily; suitable for those with dexterity issues or forgetfulness.
- DHEA (Intrarosa): precursor converted locally to estrogen and testosterone; used nightly or twice weekly; melts at bedtime.
Vaginal application supports arousal, orgasm, and is described as more effective than Viagra for sexual function. It is available over-the-counter in the UK and requires a prescription in the United States.
Common advice such as peeing after sex and wiping front to back lacks strong data support. Cranberry pills require high sugar intake to be effective. Increased water intake helps modestly. Vaginal hormones remain the most effective preventive measure, reducing UTIs by more than 50% while also addressing frequency, urgency, leakage, dryness, and sexual pain. They are safe even after cancer, blood clots, or stroke.
Initiation depends on symptoms rather than a fixed age or menopausal stage. After childbirth and during breastfeeding, estrogen crashes to menopausal-range lows, producing hot flashes, night sweats, urinary symptoms, and libido changes (genital urinary syndrome of lactation). Vaginal hormones are safe during breastfeeding.
At ages 38–40 with new UTIs, painful sex, or libido changes, testosterone or vaginal hormones may help. At age 43 with sleep disruption, progesterone may be indicated. Therapy can begin in perimenopause or postmenopause based on individual symptoms and goals.
A patient in her 60s initially refused systemic hormone therapy due to family history concerns. She started with vaginal hormones alone, experiencing return of orgasms, arousal, reduced nighttime urination, less dryness, and no UTIs. After bone-density scan showed osteopenia and persistent hot flashes, she added systemic estrogen plus nighttime progesterone. Later adding testosterone improved libido within 4–6 months and restored cognitive function, enabling her to enroll in and finish at the top of law school.
The current model requires ovaries to fail completely and 12 months of symptoms before intervention. This contrasts with other organ systems where decline is addressed before total failure (e.g., glasses before blindness, dialysis before kidney failure). Hormone therapy is compared to birth control, which is routinely given in reproductive years as high-dose synthetic hormone therapy. Natural versus synthetic forms should be viewed on a continuum. "Not feeling like myself" (NFLM) is a common complaint often linked to hormonal changes, including musculoskeletal issues such as plantar fasciitis and frozen shoulder.
Prescription rates remain low: less than 9% of Medicare patients receive appropriate prescriptions, and more than 75% of patients in large databases are not offered treatment.
More than 75% of people in large database collections are not getting prescriptions for vaginal estrogen. Women are not getting access to generic medications that could save their lives and also really improve quality of life. Dryness causes people to stop having sex because of the pain, the dryness, and the irritation, when these issues are fixable.
One of the questions people come to Dr. Rachel Rubin about is pain during sex. Up to 75% of women will say at some point in their life that sex is painful. Published reports indicate that up to 75% of women experience painful intercourse at some point. Between 10 and 20% of US women suffer from persistent chronic pain during sex, and during menopause it climbs drastically with estimates ranging from 20 to almost half of women having pain during sex. This figure probably does not account for people who have stopped having sex because it is too painful.
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.
There are many different things that can cause pain with sex. You could have a problem with the tissue. The tissue of the vulva is very hormonally sensitive, so that tissue could be impacted by hormones. People can get eczema or autoimmune skin conditions on the vulva.
You may have a problem with your muscles. The vagina and the vulva are surrounded by big pelvic floor muscles. Just like you can get tight muscles in your neck and back, you can get tight muscles in your pelvis.
Nerves are involved in this area. If you have a back problem that causes sciatica pain running down your leg, you can have a back problem that actually causes pelvic pain. People experience penis pain or vulva pain because of problems in their spines.
Scar tissue inside the body from endometriosis can push and scar tissue from the inside, causing pain with sex.
OB/GYNs received almost no training in this area.
If experiencing pain during sex, try to see someone who has an active interest in this area. See a specialized gynecologist or a specialized urologist who has an interest in pelvic pain. You may need a couple of opinions. Just like getting quotes from plumbers, it is okay to see a few different people for this problem.
Dr. Rubin uses financial literacy as a framework for talking about good sex. The checking and savings accounts represent the basics everyone needs: education, nutrition, exercise, sleep, communication, and safety in the relationship. Communication is probably the most important thing. Can you talk about sex? Can you use words? Can you explore? Can you ask questions?
The 401k represents things for compounding growth and long-term support: hormones, seeing a doctor who optimizes everything properly, pelvic muscles in good condition, mental health, possibly working with a sex therapist, and bringing toys and devices into the bedroom.
Crypto represents things not to start with or rely on exclusively. This includes ads for injections, cosmetic procedures, or supplements that promise to make sex great again. If it looks too good to be true in ads, it probably will not fix underlying issues.
Great sex is within everybody's reach, but great sex looks different for different people.
Hormones play a fundamental role in sex, though they are not the whole story. Biological and physical blockers to great sex include hormone crashes and pelvic floor issues.
Everyone who has a pelvis has a pelvic floor. Men have a pelvic floor and women have a pelvic floor. It refers to the bones of the pelvis, including the hips and pelvis bone, which hold all organs in place. Genitals are attached to this pelvic floor, which is surrounded by thick big muscles.
Muscles contract and relax. Problems can occur with pelvic floor muscles just like with any other muscles. If you work out too much and get a sore trap or need physical therapy for a shoulder, a lot can go wrong with the pelvic floor.
Sex is a contact sport. Getting erections, having an orgasm, and allowing penetration requires healthy muscles because muscles must contract and relax in a sexual way. As blood flows through the area, it engorges the clitoris and penis, making them bigger and erect. Muscles must relax for penetration because tight muscles are painful, sore, and burn. Orgasm involves a series of muscle contractions that equate to pleasure and release, involving nerves and muscles.
If muscles are too tight and you cannot have penetration but want it, that can be bad sex. If orgasm is painful, weak, or impossible, it could be related to pelvic floor muscles. If arousal, the ability to engorge and lubricate, is diminished, that could be due to pelvic floor issues because of insufficient blood flow. If you are not feeling your genitals when watching something sexy or seeing someone attractive, there may be an issue with the brain-genital connection. Perfect wiring of nerves, hormones, and muscles is required.
People mess up their pelvic floor through surgery, having babies, and other reasons that change muscle health. When problems occur, there may be biological reasons.
Pelvic floor exercises are typically not done at the gym. Trained physical therapists help determine what is going on with the pelvic floor. For some people, it is about strengthening through contractions called Kegel exercises. For many people, it is about learning coordination. You can get an exam and work with a pelvic floor physical therapist.
About 20% of women say they cannot have an orgasm. This creates an orgasm gap, as 20% of men do not have orgasm problems. This parallels the pay gap where women are not paid as much as men. The majority of the problem is education. Women think orgasm comes from penetration, but that is not how most women orgasm.
The clitoris is how women orgasm. Penetration is not how most women orgasm. Just like rubbing your thigh over and over will not produce an orgasm, the clitoris is separate from the vagina.
The clitoris is a huge structure. Following the labia minora leads to the hood of the clitoris, also called a prepuce or foreskin. Pulling it back reveals the tip of the head of the clitoris, but that is just the tip of the iceberg. The clitoris extends all the way down to the butt bones. Under the microscope, it looks like a penis. It is made up of the same tissue as a penis and works exactly the way a penis does.
A whole field of medicine is devoted to the male penis, but urologists are not even taught how to examine a clitoris or where it is located. If the penis, a toy, a finger, or a device goes inside without activating the clitoris, which is mostly an internal structure, orgasm will not occur for most women.
The clitoris has a hood. About 23% of the time, the hood can get stuck to the head, which is called a clitoral adhesion. You should be able to pull back the hood to see the whole head, which looks like a mushroom with a rim around it, but in about a quarter of cases you cannot. Published data shows that removing these adhesions in an office-based simple procedure improves orgasm, arousal, and satisfaction in 60 to 70% of cases.
One in five women have a clitoral adhesion, and when solved, it improves sexual satisfaction by up to 60%. No one has ever examined women's clitorises in any exam or doctor's visit. Nobody is asking women about their orgasms or satisfaction. Women come in with pain or libido issues, but this part of the body is never examined. The reason is not because it should not be done, but because it has never been done before.
Vibration can help activate blood flow. For women, vibration on the outside can be extremely helpful because the clitoris is around that area. If a penis were entirely inside the body, the vibrator industry would be much larger because vibration would be needed to achieve what is normally done manually.
A wand device can help with trigger points. If there is pain in the muscles, this device can go inside, vibrate to help with engorgement, and get rid of tension in the muscles.
Men constantly ask about wanting their penises bigger, harder, straighter, girthier, and lasting longer, but none of that has anything to do with how women experience pleasure and satisfaction. The question should be how women experience pleasure, what their anatomy is like, how to activate the clitoris and arousal response, and what brain things need to happen to make women interested. What gets women excited is different than what gets men excited, and every partner is different.
More curiosity is needed. Partners never got told any of these things. Watching educational content together can help start conversations about what feels good, looking at body parts together, learning anatomical terms, and discovering where pleasure is experienced.
The clitoris has about 10,000 nerve endings. Direct stimulation can sometimes be too much. Some partners love it, some want more stimulation on the outside, and some need vibration.
Orgasm is a buildup and release of pleasure. This is often not happening during penetration. After orgasm, women experience a period where the tissue is very sensitive and they do not want it touched for a while, similar to men. However, women can bounce back faster and potentially have multiple orgasms, though not all women do.
The conversation should include whether multiple orgasms are something desired. When penetration happens during the sequence matters because men often orgasm and then stop. The clitoral orgasm could happen before the partner's orgasm, allowing sensitive tissue time to rest, followed by the partner's orgasm, and then potentially round two.
Many times women get nothing from penetrative sex in terms of the main pleasurable event, which comes from the clitoris. Some women get connection and closeness. Some women have extra nerve endings inside the vagina on the top of the vagina and in the cervix, so some women love penetration.
Many women ask for penetration mainly because they know that is when their partner has an orgasm and the encounter is done, allowing them to go to bed or read. The pleasure often comes from clitoral stimulation. Penetration is part of the whole menu rather than the whole story. Every woman's body is different.
Some women can orgasm from penetration. There is a theory that just as about 8% of men are premature ejaculators who orgasm in a minute or less, perhaps 8% of women are so sensitive that they orgasm very quickly from penetration. These would be the women who orgasm with penetration.
Porn has messed up perceptions of sex. Just as professional wrestling has manufactured perceptions of fighting and bodies, porn is manufactured because that is what the algorithm uses to get men excited. It does not reflect what women typically want.
Pornhub data shows roughly 65% of traffic is men. Independent surveys find similar gaps. Men's consumption is high: 75 to 90% of men aged 18 to 35 report viewing porn regularly, whereas only about 34% of women aged 18 to 35 report regular viewing. Porn websites cater to predominantly male demand.
Most young men learn about sex from porn websites and assume that is what women want. Women think they are broken because they are not having magical orgasms from penetration. Women come to doctors saying they are broken because they are not orgasming during sex, yet they have good orgasms with vibrators, hands, or shower heads on their clitorises, which is totally normal.
Teaching women that the clitoris and penis are the same thing and that activating the clitoris produces orgasm for women makes it clear they were normal the whole time.
Pornography can be great for relationships and connection when it is the right kind.
Pornography itself is not inherently bad. Watching people have sex, fall in love, and experience romance can create excitement and arousal. However, problems arise when porn replaces human interaction, when it becomes the only way someone can have good sex, or when it is used excessively.
Heterosexual women have shown massive interest in content like the HBO show "Heated Rivalry," which depicts a sexual relationship between two gay male hockey players. The show went viral and functions as porn for women.
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. Discovering that a partner is hiding porn use often triggers intense feelings of betrayal, rejection, and insecurity.
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 unrealistic expectations about body types, stamina, and performance, making real sex feel less stimulating.
The core issue is often deception and hiding rather than the porn itself. When partners are not honest about their porn use, it creates disconnection. Desensitization is another factor: repeated porn use can train the brain to experience pleasure in specific ways that may not translate to partnered sex.
If someone can only achieve arousal or orgasm through one specific method, position, or type of content, that may not translate into satisfying intimate sex with a partner.
Men and women often experience different types of arousal. Spontaneous arousal means wanting sex and being ready immediately. Responsive arousal means becoming interested once sexual activity or foreplay has begun.
Data shows men are highly spontaneous in their arousal at approximately 70%, while women show spontaneous arousal at 10-15%. Responsive arousal is 10-15% in men and 40-50% in women. Mixed style arousal is 15-20% in men and 35% in women.
This means women are more likely to become aroused once foreplay or sexual contact has started. The comparison to exercise is useful: some people are eager to go to the gym, while others only enjoy it once they begin.
People avoid discussing sex for the same reasons they avoid discussing money: it feels inappropriate, deeply personal, emasculating, and intrinsically linked to self-esteem. The subject is highly vulnerable.
One personal story involved a partner expressing that she did not like having sex. The conclusion drawn was that the speaker must not be good in bed. Years later, it became clear there was an undiagnosed physiological issue causing the discomfort. The partner had been protecting the speaker by not sharing the information.
A friend revealed a similar situation: his partner also said she did not like having sex, and they had not had sex in three months. Both men arrived at the same conclusion that something was wrong with them or their partners were simply not sexual people.
Lack of information leads to false, unchangeable conclusions about relationships. With better understanding of biology and sexual health, many painful situations could have been avoided or resolved differently. Teaching people to think about biology, talk about sexual health, and discuss genitals without shame would reduce hurt, shame, and guilt.
Men often feel disconnected from partners and struggle to find partners partly due to lack of curiosity about what their specific partner wants and needs. Women frequently look for partners who demonstrate genuine interest in their individual desires rather than generic assumptions about what women want.
A good relationship involves both people working together to optimize erotic love, support, connection, and lust for each other.
When asked what they get out of sex, people give approximately 200 different reasons. Everyone wants something different, and many do not even know what they want until they explore together.
Partners often have different preferences. One may want bondage while the other prefers gentle touch. Sex is inherently messy, awkward, smelly, and involves fluids and funny noises. It requires vulnerability and uncomfortable conversations.
Compromise is necessary, similar to buying a house. Not every desire can be perfectly met. If certain sexual activities are non-negotiable, people should seek relationships or communities where those interests are shared.
It is acceptable to have fantasies or kinks that one thinks about but does not want to act on. When someone has a fantasy or kink they are afraid to share, sex therapy can help because a third party makes the conversation less threatening.
Apps like Spicer allow couples to explore preferences by answering questions separately; if both agree on something, the app reveals the mutual interest. Conversations about sex should happen outside the bedroom, not during active sexual activity.
People rarely conduct "after action" reviews of their sexual encounters, asking what went well, what did not, and what they might try next.
Women often hide pain from their partners. Men often hide insecurities and frustrations, particularly around erectile dysfunction and sexual problems. Many people either stop having sex, stop talking about it, or settle for mediocre sex due to poor communication skills.
Statistics indicate that if a woman orgasms every time from penetration alone within five and a half minutes (the average male duration during penetrative sex), it is likely not genuine. Women typically require 13-15 minutes or more and need clitoral stimulation to orgasm. Penetration alone is rarely sufficient.
Women can have multiple orgasms while men typically have one. The current pattern of men having one orgasm and women having zero should shift toward women having multiple orgasms and men having one.
Orgasm first for women allows pelvic floor release and relaxation, making subsequent penetration more pleasurable. Making penetration the main event creates challenges; it can be part of the experience but does not need to be the central focus.
Chronic stress, mental burnout, overwork, and lack of sleep significantly reduce libido in both men and women. When people are burnt out, have no white space, or are constantly scrolling at bedtime, they are unlikely to feel excitement or desire for their partner.
Many people consume romance novels and media about sex but fail to communicate directly with their partners or intentionally create time and space for intimacy. In our overscheduled modern society, scheduling sex can be beneficial. When dating, people naturally scheduled potential sexual encounters by planning dates in advance, building anticipation and excitement throughout the week. This made the experience erotic and intentional.
Once living together, partners see each other at their best and worst, including cranky and tired states, making it difficult to generate the same level of excitement. The idea that sex should always be spontaneous is largely a myth perpetuated by films, similar to how WWF wrestling is not real. People who work intensely and see each other daily have little natural space for spontaneous intimacy. Vacation sex often works well because it creates dedicated time away from daily pressures.
Practical barriers include children staying up later than parents, lack of door locks, and concerns about noise. Scheduling sex can create performance pressure, with people worrying about finishing work and then needing to perform at a specific time.
Schedule intimate time around periods that naturally work rather than forcing it during high-stress windows. One approach is quarterly dates where partners block their calendars for an entire day once per quarter. This dedicated time is not necessarily for sex but for connection, such as walking, hiking, taking a bath, or getting a massage. The goal is to create space to remember why partners like each other beyond discussing children or logistics.
Greater investment in joyful connection leads to better sexual experiences overall.
Body image issues represent a major blocker to satisfying sex. Patients often invest enormous energy into wanting to be skinny rather than strong. People readily affirm that their overweight best friend deserves great sex, orgasms, intimacy, pleasure, and connection regardless of appearance or weight. However, when applying the same standard to themselves, individuals often believe they cannot be naked, cannot be happy, or do not deserve orgasms until reaching a certain weight.
The solution involves empowerment, communication, and education. Mindset work is critical. Learning about bodies, pleasure, joy, connection, and intimacy changes the narrative. Society is currently experiencing a sex recession with people having less sex than ever, prioritizing scrolling and AI chatbots over human connection. Reaching people through direct conversation is necessary to reverse this trend.
Biology matters significantly in women's sexual health, yet medical conversations often minimize biological factors in favor of psychosocial explanations. Women must advocate for themselves regarding biological aspects, and doctors require better training to address these issues. Patients should be asked directly about their experiences with medical providers, as there is often insufficient curiosity about what women experience differently.
Partners frequently need education on physiology alongside emotional check-ins. During extended medical consultations, partners may attend to hear descriptions, observe examinations, and receive a tour of body parts. This helps reframe situations, such as understanding that pain at the vaginal opening explains reluctance for sex rather than any deficiency in the partner.
Understanding a partner's medication side effects, such as antidepressants or hair loss treatments lowering libido, prevents misinterpretation as loss of attraction or love. Two things can be true simultaneously: medication affects libido, and the relationship remains intact. Understanding both one's own biology and a partner's biology is essential.
Education and communication form the fundamentals of healthy sexual relationships. Many people lacked proper education on these topics at the start of adulthood and struggled with honest communication with partners and themselves. Avoiding gaslighting oneself or one's partner improves all relationships, not only romantic ones.
These subjects remain highly sensitive, leading people to keep them secret or share only with closest friends rather than addressing them directly.
The long-term health of a relationship can be predicted by whether each challenge heals to 101% or 99%. Conflict is inevitable, but how it is handled determines whether the relationship strengthens or weakens. This depends entirely on communication. Teaching people to communicate effectively, including both speaking and listening with curiosity, would resolve many downstream challenges and misunderstandings.
Current communication patterns determine whether arguments arise in six months, a year, or two years. Key questions include whether a partner feels safe expressing problems, how problems are received even when they feel like blame, and whether both parties remain open-minded about solutions rather than arriving with predetermined answers.
After seven years in a relationship, reflection on what enables 50-year partnerships points to conflict resolution and communication as the core. This same principle applies across finance issues and sex issues discussed with experts.
Couples exist on a spectrum: some discuss sensitive topics immediately upon returning home at 6 p.m., while others avoid discussing anything and function like strangers, burying issues. Burying problems does not eliminate them; they reappear in unexpected ways. One example involved a couple together for 14 years who had a baby, stopped having sex, and ceased communication, becoming parallel lines drifting apart before later wondering what happened.
The fundamentals worth teaching include that conflict resolution matters, intimacy and vulnerability matter, biology matters, and science matters. When individuals demonstrate curiosity and understanding of new information, they can apply it to their own relationships and lives while caring about friends' experiences. Vulnerability and curiosity shown publicly benefit many others who recognize they could do the same.
Loving someone deeply yet avoiding communication about sensitive topics represents a contradiction. When vulnerability has been practiced, the typical reflection is wishing it had happened sooner.
Many men historically avoided conversations about sex, assuming their partner enjoyed it and that their partner assumed the same. Further into relationships, discrepancies in preferences become apparent. The phrase "happy wife, happy life" can lead men to assume silence means everything is fine. However, it takes two to tango, and expecting a partner to have all the words and knowledge is incorrect.
Third parties such as medical professionals or sex therapists can facilitate conversations because people often assume partners fully understand and can communicate about their own bodies, which is not always true. Showing curiosity about a partner's experience indicates an evolved approach needed in 2026 to break down barriers, leading to stronger relationships. Growth occurs during difficult moments.
Having the words means knowing how to initiate conversations, handle discussions, and receive potentially ego-bruising information. Doing this independently is difficult because people avoid hurting feelings, and blunt statements may not be appropriate. Couples therapists excel at holding space for these conversations.
Often there is no bad guy in relationship conflicts. A libido mismatch between partners does not involve an evil party, yet conflict still exists. The challenge involves loving someone and evolving together through such situations.
Empathy begins when recognizing there is no bad guy. Past intimacy challenges often triggered attempts to determine whether the problem was "me" or "you." With time and understanding, the realization emerged that it was neither—it was the couple against the problem rather than against each other. This reframe removes shame and blame, focusing the team on resolution.
Many people are hurting, with damaged relationships and compromised health. They experience less pleasure, joy, and quality of life than possible. Simple, evidence-based approaches—communication, connection, education, and basic medical care—can deliver substantial improvements in joy, health, relationships, and living. These outcomes are observed daily in clinical practice. The goal is for people to fight for and advocate for these improvements, with doctors showing up to help.
One area for personal improvement is practicing what is preached. Despite being addicted to and obsessed with the work, less time is spent lifting weights, avoiding phone scrolling to focus on children, and scheduling the quarterly partner dates recommended to others. Having information does not automatically make execution easy. The principle applies universally: easy to do, easy not to do.
The website rachelrubinmd.com serves as the primary resource, focusing on research, education, advocacy, and mentorship. The newsletter provides the latest studies, research participation opportunities, job postings, and clinician advocacy information. Courses are available, some free and others offering continuing medical education credits. Instagram represents the most active platform currently. Clinical practices operate in Washington, DC and Los Angeles. Sexual health is health, and quality of life matters.
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