Link: https://youtu.be/MM-Qhlxf1pM

Duration: 107 min

Transcript: Download plain text

Short Summary

Dr. Rachel Rubin, a urologist specializing in women's sexual health with practices in Washington D.C. and Los Angeles, is interviewed across two segments (by Steven Bartlett, then by hosts Stephen and Jack) about the systemic under-treatment and under-education of women's sexual health. The wide-ranging conversations cover hormone therapy controversies, the clitoris's overlooked anatomy, the orgasm gap, the "spontaneity myth," and practical tools for couples to build lasting intimacy through education and communication.

Key Quotes

1. "And so I am filled with rage because people are limiting their ability to have great sex, great health because they aren't having access to all the information that they could." (00:00:32)
2. "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." (00:07:44)
3. "Only 1.7% of women have are getting prescriptions for hormone therapy who who should be offered prescriptions. So, it is a disaster." (00:28:49)
4. "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." (00:12:30)
5. "about 23% of the time, the hood can get stuck to the head." (00:58:16)

Detailed Summary

Dr. Rachel Rubin on Women's Sexual Health, Hormones, and Intimacy — Full Episode Summary

This multi-host episode features urologist Dr. Rachel Rubin, a sexual health physician with clinical practices in Washington D.C. and Los Angeles. Steven Bartlett opens the interview, followed by hosts Stephen (roughly 7 years into his relationship) and Jack, with a recurring thesis running through both segments: women's sexual function is under-taught, under-diagnosed, and under-treated, and lasting intimacy is built on education and communication, not spontaneity.

Hosts, Guest, and Episode Format

• The episode is structured in two segments: Steven Bartlett interviews Dr. Rubin first, then hosts Stephen and Jack continue the conversation with a focus on relationships and practical intimacy tools.
• Dr. Rachel Rubin is a urologist who specializes in women's sexual health and maintains practices in Washington D.C. and Los Angeles.
• Co-guests in the first segment include Dr. Emily Morse and other clinicians who break down how women's sexual health is under-taught, under-diagnosed, and under-treated.
• Dr. Rubin's content is cited by host Stephen as consistently the most-shared content on his podcast and across podcasting broadly.

OB/GYN Training Gaps and Systemic Under-Treatment

• As of 2026, the word "clitoris" does not appear in the OB/GYN training checklist, and gynecologists are not taught about the clitoris, vulva, sexual health, libido, arousal, or orgasm in standard training.
• Only about 1.7% of women who should receive hormone therapy actually receive it, and more than 75% of women in large database studies are not getting needed prescriptions.
• 10-minute appointment windows push doctors to say "no" rather than engage with complex sexual health needs, contributing to systemic under-treatment.
• Dr. Rubin frames this as a structural failure: training omissions, time pressure, and historical stigma combine to leave patients without options.

Vaginal Estrogen, UTIs, and Hormone Basics

• Rubbing 1 g of estradiol cream (approximately $14 on Mark Cuban's pharmacy, lasting about 2.5 months) into the vaginal walls twice a week reduces painful and dry sex, improves arousal and orgasm, and can help prevent fatal urinary tract infections.
• Research since the 1990s shows vaginal hormones cut UTIs by more than half, a finding backed by American Urological Association guidelines.
• Estrogen and testosterone keep the vagina acidic; menopause shifts the microbiome and raises infection risk, especially because ejaculate is not acidic.
• Common advice to "pee after sex" and "wipe front to back" is labeled folklore; cranberry pills have some supporting data, while juice equivalents are too sugary to count.
• DHEA (Intrarosa) is an FDA-approved vaginal insert that converts locally into estrogen and testosterone, expanding options beyond estradiol.

The WHI Controversy and Hormone Therapy Reputation

• The Women's Health Initiative (NIH-funded, roughly $1 billion, ages 50–79) was halted in the early 2000s at a press conference claiming hormone therapy caused cardiovascular disease and breast cancer, collapsing a multi-billion-dollar industry.
• Per Dr. Rubin, the original WHI data did not actually show those harms, and a 2025 reanalysis by the same authors concluded there was no increased cardiovascular or stroke risk under age 70.
• Celebrity examples illustrate access failures: Melinda Gates saw 3 doctors before getting hormone therapy; Oprah saw 5 doctors who missed her perimenopause-driven heart palpitations; Halle Berry was misdiagnosed with herpes when she actually had genitourinary syndrome of menopause.
• Hormone therapy is framed as four buckets: whole-body estrogen, whole-body progesterone, testosterone (best evidence for libido), and vaginal hormones, each with distinct indications.

Female Hormonal Life Stages and Symptoms

• Five hormonal stages define female physiology: puberty, fertile years, perimenopause, menopause, and post-menopause.
• Perimenopause typically runs 35–45, menopause 45–55, with the average menopause age at 52; symptoms include hot flashes, night sweats, fatigue, brain fog, low libido, dry eyes/ears/mouth, joint pain, painful sex, and UTIs.
• Testosterone begins dropping precipitously in women's 30s, not at menopause; signs include low libido, longer time to orgasm, reduced clitoral engorgement, and less lubrication.
• Estrogen levels vary dramatically across life: roughly 50 low-cycle, 150–300 at ovulation, up to about 3,000 in pregnancy, and around 10,000 sustained across 9 months of pregnancy.
• Combined birth control pills shut down ovarian production of estrogen, progesterone, and testosterone, with the latter not replaced; up to 27% of users (a range of 1 in 7 to roughly 1 in 3) report decreased libido.
• An unpublished survey of 1,000 women on GLP-1 drugs (Ozempic/Mounjaro) found about 25% reported sexual effects, with roughly 50% of those reporting worsened function and about 25% reporting improvement; formal studies have not been completed.

Painful Sex and Pelvic Floor Dysfunction

• Up to 75% of women experience painful sex at some point, and 10–20% of US women have chronic dyspareunia; estimates in menopause range from 20% to nearly 50%.
• Causes include hormonally sensitive vulvar skin, eczema, autoimmune skin conditions, tight pelvic floor muscles, referred nerve pain (sciatica-like), and endometriosis scar tissue.
• Pelvic floor muscles surround the hips, pelvis, and butt bones, and must contract and relax for erections, penetration, and orgasms; dysfunction signs include pain, weak/painful/impossible orgasms, and reduced engorgement.
• Treatment is typically pelvic-floor physical therapy (Kegel-style clinical work), not standard gym exercises, which can worsen dysfunction.

The Clitoris and the Orgasm Gap

• The clitoris is mostly internal, extends to the butt bones, is made of the same tissue as a penis, and has roughly 10,000 nerve endings; the visible tip is "the tip of the iceberg."
• Penetration alone often produces no orgasm for most women because the clitoris (located above the vaginal opening) is the primary orgasmic structure.
• Clitoral adhesions (hood stuck to the clitoris head) occur about 23% of the time, or roughly 1 in 5 women; a simple office-based procedure to remove them improved orgasm, arousal, and satisfaction by 60–70% in published data.
• About 20% of women report they cannot orgasm, a gap attributed mostly to education rather than dysfunction.
• The vibrator industry is estimated at about $1 billion; external vibration helps activate blood flow for an internally located organ.
• Men's focus on penis size, hardness, and longevity does not actually drive women's pleasure, countering a widespread male assumption.

Arousal Biology: Spontaneous vs. Responsive

• Men's spontaneous arousal is cited at approximately 70%, while women's spontaneous arousal is only about 10–15%.
• Responsive arousal flips the dynamic: men 10–15%, women 40–50%, with mixed-style arousal at 15–20% for men and 35% for women.
• Men can be aroused purely by thought, whereas women more often become aroused once foreplay or physical contact begins, a key biological literacy gap in relationships.

Orgasm Timing, Frequency, and Practical Sequencing

• Men last roughly 5.5 minutes from penetration to orgasm on average, while women typically need 13–15+ minutes from penetration alone and almost never reach orgasm in 5.5 minutes.
• Women can have about 3 orgasms in a session, while men typically have 1, framing the "orgasm gap" as something to actively close rather than accept.
• The recommended sequence is that women orgasm first, because orgasm releases the pelvic floor and makes penetration more pleasurable for both partners.
• Many women have faked orgasms, and claims of consistent orgasm from penetration alone are statistically suspect.

Pornography's Impact on Young Men and Relationships

• Pornhub traffic is roughly 65% men, and among 18–35-year-olds, 75–95% of men versus about 34% of women report regular porn viewing.
• Because platforms cater to male demand, most young men effectively learn sex from porn, bringing misconceptions into real relationships.
• A meta-analysis and roughly 24 studies link solo porn use to lower relationship and sexual satisfaction; hiding use triggers betrayal and rejection feelings, and heavy use can desensitize reward pathways, causing erectile issues and performance anxiety.
• Dr. Rubin rejects blanket judgments, noting couples who watch together or use porn to bridge libido differences.
• HBO's "Heated Rivalry" was cited as "essentially porn for women," with heterosexual women reportedly rewatching it multiple times.

The Spontaneity Myth and Scheduling Sex

• A "spontaneity myth," fueled by film portrayals likened to choreographed wrestling, ignores how over-scheduled modern life actually is.
• Dating already implicitly schedules sex through date-night planning; long-term cohabitation makes spontaneous excitement harder because partners see each other at their worst and most tired.
• Rigid scheduling can create performance pressure (for example, a fixed 8:00 p.m. appointment), so flexibility matters.
• The concrete recommendation: block one Friday per quarter on the calendar as a dedicated partner day, which often leads to more frequent intimacy the rest of the time.

Tools, Therapy, and Communication Practices

• The Spicer app lets couples sext and push questions, only revealing mutual agreement on kinks or interests if both opt in.
• Sex therapy and couples therapists serve as a third party to surface fantasies or kinks partners are afraid to disclose directly.
• Sexual health consultations last about 2 hours, sometimes with partners present for body tours to make biological issues legible.
• Conversations about sex and after-action reviews of what worked should happen outside the bedroom, not during sex.
• There are roughly 200 different reasons people want or avoid sex, and most people don't even know what they want, underscoring the need for explicit communication.

Conflict Resolution and the 101% Rule

• A central quote: "You can predict the long-term health of a relationship by whether each challenge heals to 101% or 99%."
• Effective conflict reframes the dynamic as "me and her against the problem" rather than "me against you," removing shame and blame.
• Many conflicts, such as libido mismatch, have no bad guy but still require resolution; men often wrongly assume silence means everything is fine.
• Better communication means speaking, listening, and curiosity, not just honesty, because direct honesty can hurt when not paired with care.
• Host Stephen admitted he went about a year without discussing sex in a past relationship until his partner pushed for openness, illustrating how silence compounds.

Cultural and Biological Barriers to Intimacy

• A "sex recession" is underway, with people scrolling and using AI chatbots in place of human connection.
• Antidepressants and hair-loss medications can lower libido and cause sexual dysfunction in men, often misread as lost attraction rather than biology.
• Body image and self-esteem are described as a huge blocker, with female patients directing energy toward being skinny rather than strong.
• Pornography and AI sex robots threaten intimacy because they let users avoid the messiness, vulnerability, and compromise of real partners.
• Dr. Rubin emphasizes that biology matters in women's sexual health and is often minimized in favor of psychosocial framing in clinical practice.

Key Treatment Recommendations and Clinical Details

• Perimenopausal indications for hormone therapy include UTIs, dry or painful sex, low libido, and disrupted sleep (the last signaling progesterone need).
• Testosterone for low libido typically takes 4–6 months to "click"; Dr. Rubin prescribes FDA-approved male testosterone at 1/10 the male dose.
• Vaginal hormones (estrogen or DHEA/Intrarosa) are described as safe at any age, including during breastfeeding and for cancer, clot, or stroke histories.
• A 3-month vaginal estradiol ring is suggested for patients with dementia, dexterity issues, or ADHD who cannot manage twice-weekly dosing.
• Case example: a 60-something woman with osteopenia and a family history of osteoporosis started estrogen + progesterone + testosterone, which resolved her hot flashes, night sweats, dryness, UTIs, and sleep/libido issues; she then enrolled in law school, competed against 22-year-olds, and finished top of her class.

Resources and Where to Find Dr. Rubin

• Primary resource: rachelrubinmd.com, which includes research, education, advocacy, mentorship, and a newsletter.
• Free and CME-credit sexual health courses are available through her platform.
• Instagram is her most active social platform for ongoing engagement.
• Dr. Rubin's stated "tomorrow improvement" is practicing what she preaches, including lifting weights, not scrolling past her kids, and actually scheduling the quarterly partner dates she recommends.
• Host Jack pushed back on the idea that the interview itself "helps," arguing that watching others' vulnerability is what actually drives change.