Dr. Rachel Rubin Urges Menopause Reform to Fix Sexual Health Gaps

Dr. Rachel Rubin呼吁推进更年期改革以弥补性健康缺口 医学培训不足与生理认知误区导致女性普遍面临且原本可治疗的器质性性功能障碍与疼痛。 Dr. Rachel Rubin指出了医学培训在女性性解剖学、激素疗法和盆底疾病方面存在的系统性不足。她探讨了性交疼痛、性欲低下和高潮困难的生理根源，包括阴蒂粘连和盆底肌张力过高。讨论还重点阐明了自发性性欲与反应性性欲的区别、色情制品对伴侣关系预期的影响，以及伴侣改善亲密沟通的实用策略。 泌尿与性医学专家 Rachel Rubin 指出，超过 75% 符合条件的女性从未获得阴道雌激素处方，这种低成本通用疗法不仅能消除性交疼痛与干涩，还能预防致命性尿路感染，但妇产科常规培训大纲甚至长期忽略阴蒂。 (0:00) 从 Melinda Gates 到 Halle Berry，即便顶级名流也常经历多次就医才获得正确诊断（如将绝经期泌尿生殖综合征误诊为生殖器疱疹），反映出医疗界对更年期与激素替代疗法（HRT）的系统性无知与培训断层。 (4:39) 女性体内的睾酮早在 30 岁中后期便开始大幅下滑，直接导致性欲与敏感度降低；同时高达 27% 服用避孕药的女性因自身卵巢激素分泌受抑而遭遇性欲骤降，但这类生物学诱因常被临床忽视。 (11:29) Rubin 博士将激素疗法细分为全身雌激素、全身黄体酮、睾酮及局部阴道激素四大类，并指出局部补充雌激素或 DHEA 能将复发性尿路感染发生率降低 50% 以上，远比喝蔓越莓汁等传统偏方有效且安全。 (31:17)

Dr. Rachel Rubin argues that systemic omissions in medical education leave physicians unequipped to treat female sexual pain, perimenopause, and hormone loss, leading to widespread misdiagnoses and untreated suffering. She contends that restoring women's sexual and urological health requires integrating evidence-based hormone therapy, clitoral and pelvic floor literacy, and destigmatized communication between partners. Systemic Training Gaps and HRT Stigma (4:39) Dr. Rubin highlights that standard obstetrics and gynecology training focuses heavily on obstetrics and surgical procedures while neglecting vulvar anatomy, sexual pain, and menopause care. Notably, the word "clitoris" remains omitted from the standard 2026 OB/GYN curriculum checklist. This educational void leads even affluent, high-profile patients—including Oprah Winfrey, Melinda Gates, and Halle Berry—to cycle through multiple clinicians or endure misdiagnoses, such as confusing the genitourinary syndrome of menopause with genital herpes, before obtaining competent care. Prescription practices collapsed following the early-2000s Women's Health Initiative (WHI) study, which was abruptly halted amid publicized warnings that hormone replacement therapy (HRT) elevated risks of breast cancer and cardiovascular disease. Dr. Rubin explains that subsequent re-analyses, including a 2025 publication by the study's original authors, affirmed that menopausal hormone therapy is safe and beneficial for women under 70. Nonetheless, an entire generation of doctors stopped learning menopause management, leaving over 75% of eligible symptomatic women—and more than 91% on Medicare—without prescriptions for low-cost, generic hormone therapies. Hormonal Declines and Targeted HRT Solutions (29:15) Female hormone levels follow distinct biological trajectories across the lifespan. While estrogen drops sharply around age 50, a woman's testosterone begins a precipitous decline in her mid-to-late 30s, often presenting as fatigue, brain fog, metabolic decline, and loss of desire. Estrogen also crashes from roughly 10,000 pg/mL during pregnancy to menopausal baselines during lactation. This hormone deprivation alters the vaginal microbiome and pH balance, driving the genitourinary syndrome of menopause (GSM), tissue dryness, and recurrent urinary tract infections (UTIs) that can escalate to life-threatening urosepsis in older demographics. To correct these deficits, Dr. Rubin categorizes hormone treatment into four distinct clinical buckets: systemic estrogen to prevent bone density loss and hot flashes; systemic progesterone to protect the uterine lining against cancer for women with an intact uterus; off-label micro-dosed testosterone to restore arousal and libido; and local vaginal hormones. Delivered directly via creams or suppositories, local estrogen or DHEA carries minimal systemic risk, remains safe for nursing mothers and cancer survivors, and reduces recurrent UTIs by over 50%. Anatomical Ignorance, Dyspareunia, and Clitoral Realities (56:04) Addressing the estimate that up to 75% of women experience pain during sex (dyspareunia) at some point, Dr. Rubin insists discomfort is never a normal component of aging. Pain typically originates from identifiable physical pathologies: hormone-deficient, thinned tissue; hypertonic, non-relaxing pelvic floor muscles; nerve impingements radiating from the spine; or structural conditions like endometriosis. Because traditional pelvic exams obscure the patient's view behind drapes, Dr. Rubin provides mirrors in her practice so patients can visually identify their anatomy and actively participate in their care. Compounding this physical pain is a pervasive "orgasm gap" where roughly 20% of women report an inability to climax. Dr. Rubin attributes this to cultural myths positioning penetrative intercourse as the primary event of sex. Anatomical data indicates that approximately 70% to 82% of women require clitoral stimulation to achieve orgasm, while only 18% to 30% climax from penetration alone. With approximately 10,000 sensory nerve endings concentrated in the glans and extensive erectile bodies extending internally beneath the pelvic bone, the clitoris requires focused, often indirect stimulation. Dr. Rubin notes that female arousal generally requires over 13 to 15 minutes, contrasting sharply with the 5.5-minute average duration of male penetrative intercourse. Overcoming Libido Drain and Communication Silences (73:01) Much of what couples diagnose as low libido is rooted in misunderstood arousal mechanics and lifestyle exhaustion. Dr. Rubin distinguishes spontaneous desire from responsive desire—where physical arousal occurs only after an activity has started, analogous to feeling motivated to exercise only after beginning a workout. Chronic overwork, digital screen scrolling, and sleep deprivation create a severe "dopamine drain" that deprioritizes sexual desire, making expectations of spontaneous intimacy unrealistic in busy households. To rebuild intimacy without performance anxiety, Dr. Rubin advises couples to schedule low-pressure quarterly partner days focused on non-sexual reconnection, such as shared walks or baths. She cautions against discussing sexual dissatisfaction while naked in bed, recommending neutral "after-action reviews" instead. Because clinical consults reveal that women frequently conceal physical pain to avoid bruising their partner's ego while men hide performance insecurities, open questions such as "What does great sex mean for you?" are essential to dismantle shame and the unrealistic expectations created by mainstream pornography. Dr. Rubin concludes that female sexual medicine is an integral component of general healthcare, demonstrating that evidence-based interventions can resolve chronic pain, recurrent infections, and relationship deterioration. However, broad progress remains contingent on reforming medical curricula, modernizing clinical guidelines, and overcoming persistent social taboos surrounding female anatomy.

泌尿科与性医学专家Rachel Rubin医生指出，现代医学体系在女性解剖教育与激素治疗上存在长期系统性缺失，导致数以千万计的女性在面对性交疼痛、尿路感染和更年期综合征时遭受误诊与忽视。她主张打破医学禁忌，普及循证激素疗法和以阴蒂为核心的性解剖知识，并重塑伴侣间的性沟通模式。 医学培训空白与女性健康误诊危机 (0:00) Rubin指出，现行医学教育对女性性解剖与性功能的关注严重匮乏。至2026年的妇产科专科住院医培训核心清单中，“阴蒂”一词仍未被列入标准学习要求；妇科培训普遍偏重产科分娩与基础外科手术，忽略外阴解剖、性疼痛和性高潮机制。这种盲区导致临床误诊屡见不鲜，即使是拥有顶尖医疗资源的公众人物也难以幸免：Melinda Gates历经3位医生才获得正确的激素处方，Oprah因围绝经期引发的心悸看了5位医生，而Halle Berry则将绝经期生殖泌尿综合征误诊为生殖器疱疹。 针对传统骨盆检查中使用布帘遮挡患者视线、剥夺患者知情权的惯例，Rubin在门诊中引入镜子辅助检查，引导患者直观认识大阴唇、小阴唇、阴蒂及尿道口。她认为，医疗体系缺乏的并非资金，而是对女性生理机制的专业训练和知识普及，致使超过75%亟需局部激素治疗的女性从未获得相应处方。 激素断崖式衰退与HRT的历史争议 (25:41) Rubin将女性绝经期形容为一种“生理性去势”。不同于男性睾酮缓慢下降的认知，女性体内的睾酮早在30岁中后期便开始显著滑坡，而雌激素则在50岁左右绝经期骤降。激素匮乏会诱发脑雾、严重焦虑、骨质疏松、关节疼痛甚至足底筋膜炎等全身症状。针对低性欲问题，全球医学共识已支持女性使用微量睾酮疗法，Rubin在临床中常超说明书开具相当于男性标准剂量十分之一的FDA批准睾酮制剂。 关于绝经期激素替代疗法（HRT）的污名化，源于2000年代初美国国家卫生研究院（NIH）耗资十亿美元的“妇女健康倡议”（WHI）试验。该研究因片面宣称激素显著增加乳腺癌和心脏病风险而紧急中止，引发全球恐慌，导致整整一代医生停止接受绝经期管理培训。然而，后续多项再分析及2025年WHI原始作者发表的更新数据显示，对于70岁以下女性，规范使用HRT是安全且具有明显健康获益的。Rubin提倡将激素管理分为四大工具箱：全身雌激素（缓解骨质流失与潮热）、全身孕激素（拮抗雌激素以保护子宫内膜、改善睡眠与焦虑）、睾酮（改善性欲）及局部阴道激素。 生殖泌尿综合征与性交疼痛根源 (31:17) 绝经期生殖泌尿综合征（GSM）指的是因激素下降引起的生殖道及膀胱组织萎缩病变。雌激素与睾酮对于维持阴道微生态的健康酸性屏障至关重要。一旦激素水平暴跌，局部酸性丧失，致病菌大量滋生，极易引发严重尿路感染（UTI），老年女性甚至可能因此并发危及生命的尿源性败血症。类似情况也见于产后哺乳期女性，因雌激素水平接近绝经范围而出现“哺乳期生殖泌尿综合征”。 Rubin批驳了饮用蔓越莓汁或性交后排尿等预防感染的民间偏方，指出其缺乏确凿临床证据，且高糖果汁可能增加代谢风险。相比之下，局部使用微量雌激素或DHEA乳膏可使UTI复发率降低50%以上，且几乎不被全身吸收，血栓或癌症康复者亦可安全使用。针对高达75%女性经历过的性交疼痛，Rubin强调疼痛绝非衰老的正常代价，其诱因主要包括激素匮乏导致的皮肤黏膜变薄、盆底肌痉挛高张力、脊髓神经受压放射痛以及子宫内膜异位症等结构性病变，患者理应寻求明确诊断。 阴蒂解剖认知与“高潮差距”解构 (56:04) 临床数据表明，仅有约18%至30%的女性能仅凭阴道插入达到性高潮，多达70%至82%的女性依赖阴蒂刺激；同时约20%的女性存在完全无法达到高潮的困境。Rubin指出，男女之间巨大的“高潮差距”源于对解剖结构的普遍无知：肉眼可见的阴蒂头部仅为冰山一角，其内部拥有庞大的勃起组织，并富集约10,000个神经末梢。过度直接刺激阴蒂头可能导致敏感不适，而主流色情作品却常误导大众以为单纯抽插便能轻易触发女性高潮。 Rubin提出了性健康的“理财模型”框架：第一层是基础账户（保障睡眠、营养、运动、安全感与基础沟通）；第二层是长期投资账户（合理使用激素、盆底物理治疗、性心理咨询及适度引入震动器具）；第三层则是高风险投机账户（应警惕未经医学验证的注射疗法和网络噱头广告）。她解释，盆底肌在性唤起时需要充分放松以接纳穿透，在高潮时则发生节律性收缩。借助外置震动棒或骨盆理疗杖，能够有效促进组织充血并释放肌筋膜紧张。 亲密沟通重塑与欲望机制实操法则 (73:01) 在性心理与伴侣关系层面，Rubin区分了“自发性欲望”与“反应性欲望”。许多人将性欲减退误判为感情破裂，实则是日复一日毫无新意的模式所致，其机制类似于健身——往往在行动开始后欲望才被唤起。现代人因高压工作、睡眠剥夺和睡前刷手机造成“多巴胺耗竭”，单方面苛求好莱坞式的即兴性爱并不切实际。她建议繁忙伴侣每季度固定安排一天不受干扰的专属约会日，专注散步、按摩等低压力的情感联结，而不强行设定性爱指标。 针对性沟通障碍，Rubin建议伴侣探讨核心问题：“对你而言，美妙的性爱意味着什么？”由于人群中对性满足的定义超过200种，双方必须摒弃理所当然的猜忌。关于性技巧，男性的平均插入持续时间约为5.5分钟，而女性常需要13至15分钟以上及直接阴蒂刺激；将女性高潮前置不仅能抚平生理时间差，还能通过高潮后骨盆肌肉的舒缓提升后续体验。此外，关于性幻想或特殊偏好的探讨，应转移至卧室之外的中立场合进行，并在事后展开非指责性的“行动后复盘”。 Rubin强调，性健康本质上是整体健康不可分割的一部分。本期对谈指出了现代医学长期漠视女性生理特质的历史教训，并展示了循证激素替代疗法与性解剖教育的救治价值。然而，GLP-1等新型减重药物对女性性功能的深层生理机制仍缺乏大规模同行评议研究；如何在保守的临床规程与更广泛的公众教育之间快速弥合知识鸿沟，仍是全社会亟待解决的挑战。

## Background 本期节目由知名商业与人物访谈频道《The Diary Of A CEO》（主持人 Steven Bartlett）于 2026 年 6 月 22 日在 YouTube 平台发布。节目邀请了美国著名泌尿外科及性医学专家蕾切尔·鲁宾医生（Dr. Rachel Rubin），深入揭示了现代医疗体系长期忽视女性身体与性健康的系统性危机，并围绕更年期激素管理、药物副作用、性交疼痛及高潮障碍等议题展开了深度医学科普。 ## TL;DR 鲁宾医生指出，主流医学教育长期剔除阴蒂解剖与女性性医学内容，导致逾 75% 饱受生殖泌尿综合征折磨的女性无法获得廉价且救命的阴道局部激素处方。节目深入剖析了女性体内睾酮自 30 岁断崖式下跌的生物学现实，揭示了避孕药、抗抑郁药对性欲的生理抑制，并彻底澄清了二十多年前妇女健康倡议（WHI）研究对激素替代疗法（HRT）的污名化误读。此外，她从解剖学视角拆解了高达 23% 女性存在的阴蒂粘连、盆底肌痉挛及尿路感染（UTI）防线机制，强调绝大多数高潮缺失并非女性身体“损坏”，而是源于穿透中心主义的认知偏差。整场对话颠覆了“自发性欲望”的神话，主张伴侣应将性痛与性欲差异视为纯粹的健康问题，通过坦诚沟通与科学医疗共同攻克难关。 ## Atmosphere & style 对谈在开篇即定下了极具冲击力与激进批判性的基调，鲁宾医生以“心中充满愤怒”的锋芒，毫无遮掩地向整个医疗体制的傲慢与失职发起挑战。主持人 Steven 则展现出罕见的坦诚与求知欲，不避讳自身在两性生理认知上的盲区与过往感情创伤，形成了平等、温和且彼此托底的深度信任场域。整期播客既有严谨硬核的医学循证与教具展示，又洋溢着饱满的人文共情与打破禁忌的释怀感，听感既振聋发聩又令人感到深层的被理解与治愈。 ## Bulletin - [00:00](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=0s) 阴道局部雌激素乳膏每周仅需使用两次，不仅能显著逆转干涩与性交痛、改善性唤起，还能降低50%以上的老年复发性尿路感染发生率，但临床数据库显示超过75%的适用女性从未获得该处方。 - [07:24](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=444s) 医学教育与临床规范长期边缘化女性解剖学：截至2026年，妇产科（OB/GYN）住院医培训考核清单中仍未纳入“阴蒂”，且约23%女性存在未被诊断的阴蒂粘连，经微创松解后满意度可提升60%-70%。 - [11:54](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=714s) 女性体内的睾酮并非在50岁绝经时才匮乏，而是自30岁左右起便经历断崖式暴跌；此外复方避孕药抑制排卵也会同步切断内源性睾酮分泌，导致约27%服药女性出现性欲低迷与唤起障碍。 - [01:26:02](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5162s) 异性性行为中男性平均射精潜伏期约为5.5分钟，而女性通常需要13至15分钟以上的持续阴蒂刺激，单纯依靠活塞式插入导致了巨大的人为“高潮差距”并诱发了普遍的假高潮。 ## Key takeaways - [07:24](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=444s) 性医学教育存在系统性缺失：妇产科核心侧重接生与传统器质性妇科病变，绝大多数医生从未受过关于外阴疼痛、性唤起及高潮机制的系统性受训。 - [11:54](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=714s) 更年期荷尔蒙断崖在生理上等同于“去势事件”，会对骨骼、心血管、大脑与泌尿生殖系统造成深远冲击，不能被轻描淡写为自然衰老而放任不管。 - [14:03](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=843s) 复方口服避孕药通过外源性雌孕激素反向抑制卵巢功能，在阻断排卵的同时也切断了天然睾酮分泌，是临床上常见的隐形性欲杀手。 - [17:19](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1039s) GLP-1受体激动剂（如Ozempic）等流行减肥药对女性性功能存在未被充分研究的副作用，调查显示约25%用药女性报告了性功能改变。 - [27:49](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1669s) 2000年代初WHI研究对激素替代疗法（HRT）的惊悚媒体解读严重误导了全球医疗界，最新循证医学已澄清70岁以下女性使用HRT并不会增加心血管疾病或中风风险。 - [29:46](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1786s) 现代HRT体系应被拆解为四大支柱：全身雌激素（防潮热/护骨）、全身孕激素（拮抗子宫内膜病变）、睾酮（提振性动力）以及局部微量阴道激素（修复组织与防感染）。 - [37:41](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2261s) 阴道局部激素（雌二醇或DHEA）几乎不参与全身血液循环，对于有血栓、中风或乳腺癌病史的群体同样安全，是击退反复尿路感染与性交痛的核心解法。 - [39:11](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2351s) 产后哺乳期因雌激素断崖式下跌，生理状态等同于“更年期绝经状态”，局部使用阴道激素可安全迅速缓解哺乳期生殖泌尿综合征。 - [47:27](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2847s) 性交疼痛绝非正常现象，75%女性一生中曾经历性痛，其根源往往涵盖黏膜萎缩、盆底肌痉挛、神经病变或子宫内膜异位症瘢痕，绝非一句“多放松”所能概括。 - [50:08](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3008s) 性健康资产配置金字塔模型：必须以生理认知、睡眠、营养与安全沟通为基底（储蓄账户），以激素优化与盆底理疗为核心（401k），切勿盲目从网红注射或催情保健品等投机手段起步（加密货币）。 - [56:04](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3364s) 阴蒂在组织学上是女性体内的勃起器官，纯粹轴向插入无法有效触及高潮中枢；约23%女性患有阴蒂粘连，简单的门诊微创分离即可大幅恢复敏感度。 - [01:18:01](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4681s) 两性在唤起模式上存在显著生物学差异：男性约70%属于自发性欲望，而女性40%-50%属于需经身体接触才激发的反应性欲望，不可将反应性误判为病理性冷淡。 - [01:26:02](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5162s) 异性性爱应践行“女性优先高潮”与“三明治法则”：女性率先达至高潮能促使盆底肌深度放松，使后续穿透更顺畅，并能最大化发挥女性多重高潮的生理潜能。 - [01:42:00](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6120s) 重构亲密关系沟通视角：性欲不匹配或房事障碍通常没有“坏人”，伴侣应将心态从“我对抗你”转变为“我们并肩作战对抗生理问题”。 ## Detailed walkthrough ### [00:00](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=0s) 比伟哥更有效却无人开药：女性性健康的系统性失职 鲁宾医生（Dr. Rachel Rubin）用一种极具画面感的方式切入话题：只需将一种廉价的通用雌激素乳膏涂抹在阴道内壁，“就像把防晒霜抹在脸上一样”，每周使用两次，就能彻底消除性生活中的干涩与剧烈疼痛，极大促进性唤起与高潮体验。从生理改善的角度来看，它“简直比伟哥（Viagra）还要管用”，更重要的是，从泌尿外科专家的角度来说，这款药物甚至能够有效预防老年女性因复发性尿路感染（UTIs）而导致的死亡。然而令人震惊的临床大数据显示，超过75%的潜在获益人群根本拿不到这张处方，大量女性就这样被生生剥夺了获取救命且能极大提升生活质量的廉价仿制药的机会。 面对诊室里络绎不绝的患者，鲁宾医生直言自己“心中充满了愤怒（I am filled with rage）”。无数女性走进行医室时满心自责与绝望，哭诉着说：“我坏掉了，你得修好我，我做爱时根本体验不到高潮。”但鲁宾医生指出，问题的根源根本不是女性的身体出了故障，而是整个社会的性教育彻底失败。绝大多数女性受错误观念误导，以为性高潮必须源于阴道插入；而生理现实是，绝大多数女性的高潮依赖于阴蒂刺激。残酷的讽刺在于，多数女性甚至不知道自己的阴蒂具体在什么位置；而即便到了2026年，“阴蒂”（clitoris）这个词依然没有被列入妇产科医生（OB/GYN）的执业培训考核清单中。 与女性性快感的普遍缺失形成鲜明对比的，是异性恋男性在卧室里的认知偏差。男性往往将全部注意力倾注在自己的生殖器上，整日焦虑于如何让阴茎“更大、更硬、更直、更粗、更持久”，然而在真实的性生理与心理层面，这些外在指标与女性能否获得愉悦感和高潮满足感几乎毫无关联。基础医学常识长期被尘封掩盖，从月经周期、怀孕、围绝经期，到激素变化、性交疼痛与性欲衰退，医学界与社会文化长期对女性性健康漠不关心——医生们之所以无法解决患者的痛苦，最核心的原因在于“整个医疗体系根本忘了去教你的医生”。 - **阴道局部雌激素乳膏**：每周局部涂抹两次，不仅能显著改善干涩、疼痛、性唤起及高潮，更能预防因尿路感染恶化导致的严重全身性并发症乃至死亡。 - **高潮鸿沟与处方缺口**：流行病学数据库显示，逾75%本应接受治疗的女性从未获得该类药物处方；大部分女性无法在插入式性交中获得高潮，真正的主导器官阴蒂长期被医学与公众教育边缘化。 --- ### [02:54](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=174s) 连顶级富豪都被误诊：被医疗体系辜负的女性群体 在正式深入医学探讨前，主持人史蒂文·巴特利特（Steven Bartlett）就鲁宾医生那句掷地有声的“我心中充满了愤怒”追问背后的系统性成因。鲁宾医生严肃地指出，当前的医疗体系在激素替代疗法（HRT）、绝经期管理以及性健康领域存在着系统性溃败，甚至形成了一种畸形的“人人平等”——即便你身处金字塔顶端、拥有全球最顶级的医疗资源，你依然无法幸免于难。 为了说明这种医疗困境有多么荒谬与普遍，鲁宾医生列举了多位全球知名女性的真实经历：梅琳达·盖茨（Melinda French Gates）不得不连续更换并看诊了三个医生，才终于为自己开出一张正确的激素替代疗法处方；传媒巨头奥普拉·温弗瑞（Oprah Winfrey）饱受严重心悸的折磨，辗转看了五个医生，却始终没有一位医生意识到这其实是围绝经期和绝经期的典型雌激素波动表现；著名影星哈莉·贝瑞（Halle Berry）拥有唾手可得的名医资源，却在出现严重外阴不适时被医生直接误诊为“生殖器疱疹”，而她实际患上的仅仅是极其常见的绝经期泌尿生殖综合征（GSM）。 这一系列令人啼笑皆非的名人遭遇揭示了严酷的现实：如果坐拥亿万财富的名流都无法从医生那里得到关于自身荷尔蒙与性健康的准确诊断与救治，普通女性的处境只会更加恶劣。医学教育自医学院和住院医师规培阶段起就留下了巨大的结构性空白，连鲁宾医生自己在早年的正规泌尿外科受训过程中也从未系统接触过这些知识。在女性性健康领域，医疗水准不仅没有与时俱进，反而由于历史偏见与信息脱节在退步。 ```mermaid flowchart TD accTitle: 医疗教育缺失导致女性健康困境 accDescr: 医学院课程缺失导致临床无法诊断，进而迫使患者求助无门或被误诊 subgraph Edu["医学教育缺失"] A["考核清单剔除阴蒂/性健康"] --> B["医生缺乏激素处方技能"] end subgraph Clinic["10分钟问诊现实"] B --> C["为顾全面子而武断说不"] C --> D["缺乏共同决策与风险评估"] end subgraph Patient["患者现实后果"] D --> E["75%以上未获救命与改善药物"] D --> F["严重症状被误诊（如误诊为疱疹）"] end ``` --- ### [05:00](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=300s) 男女医疗的双标与“失传的处方技艺” 造成女性医疗长期滞后的深层原因，既有科研人力投入的匮乏，更有两性健康在临床沟通上的巨大双标。医学研究不会因为发表了一篇论文就自动“下载”到全球医生的脑海中，科学证据的普及需要漫长的临床转化和言传身教。二十多年前针对激素替代疗法（HRT）的片面研究引发了全球范围内的恐慌与虚假信息浪潮，直接导致如何规范开具女性激素处方成了一门“失传的艺术”。如今的医生甚至根本不知道如何写一张激素处方，即便梅琳达·盖茨向绝经学会（The Menopause Society）捐赠了1000万美元用于科研，也无法瞬间填补一线医生对激素种类、安全性边界与获益机制认知的空白。 这种专业技能的断层直接滋生了严重的双重标准。在男性健康领域（如勃起功能障碍、低睾酮症），医生会坦诚地与男性患者进行“医患共同决策（shared decision-making）”，权衡利弊、讨论风险，绝不会居高临下地直接回绝“你不能用这个药”；然而面对女性的激素需求和性健康诉求时，许多医生尽管自己从未研读过最新循证数据，却表现出极其武断的主观偏见，动辄粗暴地告诫女性“你绝对不能碰激素”。 鲁宾医生分析认为，一线临床医生本身并非出于恶意，而是被僵化的体制和人性所困： - **缺乏专业受训**：绝大多数全科与专科医生从未在医学院或住院医时期上过女性性医学课，面对专业问询根本没有知识储备。 - **为了“顾全面子（save face）”**：许多医生难以坦然对患者承认“我不知道”，比起承认自身知识盲区，以权威姿态直接予以否定（“你不能用”）往往更容易下台阶。 - **10分钟快餐式问诊的弊端**：在现代医疗体制下，留给每个患者的问诊时间往往只有短促的10分钟。要在10分钟内像深度对谈一样厘清患者错综复杂的激素背景、性生活细节并制定定制化方案几乎是不可能的，说“不”成了最省事的高效托辞。 --- ### [07:24](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=444s) 妇产科医生培训清单里甚至没有“阴蒂” 针对公众普遍存在的认知误区，鲁宾医生进行了尖锐的剖析：当女性出现性欲减退、无法达到性高潮或性交疼痛时，最自然的反应就是预约妇产科医生（OB/GYN），理所当然地认为他们必然是外阴与女性高潮方面的权威。但冰冷的行业事实是，这根本不在他们的专业职能与受训范畴之内。 妇产科（OB/GYN）的专业核心实际上严格限定在产科（Obstetrics，即接生婴儿）与传统妇科疾病（Gynecology，如子宫肌瘤、卵巢囊肿、宫颈筛查及盆腔手术）上。整个规培考核清单中自始至终没有阴蒂的解剖细节，更谈不上针对外阴疾病、性健康、性唤起机制、性欲调节或性交疼痛诊疗的系统培训。绝大多数妇产科医生从未接受过一堂关于女性性快感的医学课程，只有极少数极具自驱力的医生自掏腰包、利用业余时间去寻找额外的继续教育。 这就导致每天成千上万的女性和男性满怀希望地走进诊室，向医生咨询自己的房事困扰与高潮障碍，换来的却是一堵无知的石墙——他们所求助的专业人士，在这一细分学科上的受训程度其实和普通大众一样匮乏。 ### [08:29](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=509s) 打破医学盲区：为什么男女都必须了解女性身体与解剖语言 主持人 Steven Bartlett 开诚布公地表示，在接下来的对话中他做好了“显得很无知”的准备。如果嘉宾谈及阴道的某个生理构造而他不明白，他绝不会不懂装懂，而是会直接追问到底。很多访谈主持人往往出于羞怯或面子不敢承认自己在该领域的盲点，但他不仅承认自己的无知，更抱有极强的好奇心去填补这些认知空白。他强调，这不仅关乎求知欲，更因为他的生活中充满了至关重要的女性——公司整个高管团队清一色是女性，生活里还有未婚妻、母亲与妹妹。在学校教育中，女性健康从未被当作一门正规课程讲授，但事实上每个男人生命中都有至少四位重要的女性，因此理解女性身体绝非“女性专属话题”，男人同样责无旁贷。当他问及如果一位女性点开这期节目能获得什么时，Rachel Rubin 医生指出，社会和男性往往默认“女性自然懂得自己的身体”——理所当然地以为女性天生明白月经周期、怀孕、产后、更年期和荷尔蒙变化，而现实恰恰相反，女性自己也从未被真正教导过。 Rubin 医生直言，当女性去医院做盆腔检查或宫颈抹片检查（Pap smear）时，医生往往会拿一块布单将患者下半身严密遮挡起来，“就像修车工在掀开引擎盖修车一样”。这种做法虽然打着“保护隐私、避免尴尬”的旗号，实质上却将女性与自己的生殖器官物理隔离开来，整个诊疗过程没有任何科普与教学。为此，Rubin 医生在创立自己的诊所时并没有斥巨资购置昂贵仪器，而是在亚马逊上买了两面镜子。在做身体检查时，她会递给患者一面镜子，指着具体部位逐一解释：“这是大阴唇，这是小阴唇，这是阴蒂，这是你排尿的尿道口。”皮肤、骨骼、肌肉、神经乃至内部器官，如果女性连这些基本的解剖学词汇都不曾拥有，就更不可能谈论和理解自身。Rubin 医生认为，赋予女性准确的生理语言，让她们了解自身器官如何构造、荷尔蒙如何运作，是女性在医疗体系中争取权益的前提。唯有掌握这些常识，女性才能清楚自己需要什么样的专业团队支持——无论是物理治疗师、心理咨询师、全科医生还是妇科医生；如果某位医生让患者感到被贬低或给出了不可信的结论，女性才有底气去更换医生、为自己的身体发声。 ### [11:29](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=689s) 被误解的睾酮：更年期与30岁断崖式下跌的荷尔蒙真相 当被问及在各大播客和全网数千万播放量的短视频中，公众问得最多的问题是什么时，Rubin 医生总结了三个最高频的核心焦点：荷尔蒙（Hormones）、性交疼痛（Pain with sex）以及性欲低下（Libido）。在探讨荷尔蒙时，她犀利地指出，现代医学教育几乎遗漏了对医生进行系统荷尔蒙知识的培训，甚至将人体原本天然存在的荷尔蒙妖魔化，误认为女性一旦过了某个年龄补充荷尔蒙就极其危险甚至致癌，这完全是拙劣的科学误读与政治博弈造成的后果。 很多人下意识认为睾酮（Testosterone）是“男性荷尔蒙”，然而睾酮本质上只是一种男女体内皆有的荷尔蒙，并非男性的专利。更年期常被简单理解为雌激素的断崖下跌，Rubin 医生将其生理本质比作一场“去势事件（Castration event）”：如果突然切除一个男性的睾丸，该男性会立刻经历潮热、盗汗、骨质疏松、抑郁、性欲丧失、勃起功能障碍（ED）、代谢综合征以及体重飙升，除非有重大医疗指征，医学界绝不会轻易对男性施行去势；但每一位年过50岁的女性，其体内的雌激素水平都会急剧下降至近乎归零，对骨骼、大脑、心脏、性功能以及泌尿道健康（尿路感染激增）造成全身性的剧烈冲击。更鲜为人知的是睾酮的衰退轨迹——女性体内的睾酮并非在50岁更年期才消失，而是在30岁左右就早早开始断崖式暴跌。临床上很多女性在30岁中后期便开始出现性欲减退、高潮延迟、性唤起困难、充血不足以及阴道润滑减少等现象： - **阴蒂充血（Engorgement）与男性勃起机制完全相同**：阴蒂与阴茎在组织学上是同源器官，均依赖血管扩张和血液充盈而坚硬膨胀。 - **医学院教学图表的致命盲区**：教科书在讲解女性周期时通篇只强调雌激素和孕激素，几乎从不讨论女性体内的睾酮变化。 - **睾酮下降的隐蔽性**：由于医学界对女性睾酮缺乏监测与关注，许多30多岁女性遭遇的性唤起与性满意度下降常被误诊为心理压力或纯粹的情感疏离。 ```mermaid flowchart TD accTitle: Female Hormone Decline Timeline accDescr: Diagram illustrating how testosterone drops in a woman's 30s while estrogen drops drastically at menopause around age 50. subgraph Phase1["30岁阶段：睾酮断崖期"] A["30-40岁女性"] --> B["游离及总睾酮水平骤降"] B --> C["阴蒂充血变慢 / 勃起功能减弱"] B --> D["性唤起迟缓、高潮延迟、性欲滑坡"] end subgraph Phase2["50岁阶段：全身去势期（更年期）"] E["50岁以上女性"] --> F["卵巢功能衰竭 / 雌激素趋近于零"] F --> G["骨质疏松 / 心血管风险增加"] F --> H["潮热盗汗 / 脑雾与情绪抑郁"] F --> I["生殖泌尿系统萎缩 / 尿路感染（UTI）频发"] end ``` ### [14:03](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=843s) 避孕药与性欲杀手：卵巢“休眠”对睾酮的抑制机制 荷尔蒙水平极其敏感，人为的药物干预往往会带来意想不到的连锁生理反应。除了痤疮药物和某些防脱发药物会压低睾酮外，使用最为广泛的复方口服避孕药（Birth control pills）也是抑制睾酮与性欲的隐形推手。Steven 分享了切身经历：他的未婚妻曾长期服用避孕药，期间一直饱受性欲低下的困扰；后来一旦停药，性欲问题便烟消云散。Rubin 医生从内分泌机理层面拆解了这一现象背后的生物学逻辑。 复方避孕药的核心成分是人工合成的高剂量雌激素与孕激素（Progestin）。当体内充斥着大量外源性合成激素时，大脑的下丘脑-垂体反馈系统会误认为体内激素极其充足，从而发出信号“关闭”卵巢的自主排卵功能。这就像男性大剂量外源性注射睾酮会导致睾丸萎缩、停止产生精子一样，女性服用避孕药会让卵巢完全处于“休眠”状态。然而，卵巢的核心功能是同时分泌三种关键荷尔蒙：雌激素、孕激素以及睾酮。口服避孕药只补充了外源性的雌激素和孕激素，却完全没有补回睾酮。一旦卵巢停摆，女性自身的天然睾酮来源便被切断，进而直接导致性欲丧失、性交疼痛或润滑障碍。当停用避孕药后，卵巢被重新唤醒，自身睾酮恢复分泌，性快感与性冲动自然得以回归。 虽然心理社会因素、伴侣沟通在性生活中不可或缺，但性功能同样具备坚实的生物学基础。数据显示，多达 27%（约四分之一到三分之一）服用避孕药的女性报告出现了不同程度的性欲滑坡。避孕药在防止意外怀孕方面具有不可否认的巨大价值，但医疗决策永远是一场“做与不做的风险权衡（Risk of doing something vs. risk of not doing something）”。女性必须知晓药物可能带来的睾酮抑制副作用，并在出现症状时主动与医生探讨其他对体内睾酮水平影响较小的避孕替代方案。 ### [17:19](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1039s) 药物的隐藏代价：抗抑郁药与 GLP-1 对性功能的影响 谈及药物治疗时，了解哪些收益与代价是“不可妥协的底线”至关重要。抗抑郁药是一个极具代表性的例子：这类药物确实帮助了无数人走出心理困境，但医学界同样清楚它们会带来性功能方面的副作用，例如性欲急剧下降和高潮延迟。这种现实凸显了“知情同意（informed consent）”的核心价值——医生开出处方时，必须向患者清晰说明常见副作用、罕见副作用以及可能出现的严重恶果。商业广告中总会不厌其烦地罗列各种极端风险，然而令人遗憾的是，科学研究却往往彻底忽略了对女性性健康副作用的评估。 以目前风靡全球的减重药物 GLP-1 受体激动剂（如 Ozempic、Mounjaro）为例，几乎所有名人和社交媒体都在谈论这类让人体重骤降的注射剂。科学界虽然开始关注这些药物对女性身体的影响，但目光几乎全盘局限在生殖领域，即“女性是否还能怀孕”，却没有任何一项已发表的正式论文去探究它们对女性性健康的影响。为此，鲁宾医生团队对 1,000 名在线服用此类药物的女性进行了一项问卷调查（已在医学学术会议上公布）： - 约有 25% 的女性报告使用 GLP-1 药物后出现了性功能方面的副作用。 - 在这 25% 出现副作用的人群中，约 50% 表示性功能明显下降（包括性欲减退、唤起障碍和难以达到性高潮）。 - 另外约有 25% 的人则表示性体验反而有所改善（可能得益于体态改变带来的自信提升）。 这并非要一棍子打死某种药物的优劣，而是强调女性在服药前完全有权利知晓这些真实存在的身体反应。 --- ### [18:48](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1128s) 睾酮在女性体内的关键角色与处方现状 当谈到女性在不同年龄与生命阶段的荷尔蒙变迁时，睾酮的重要性往往被大众严重低估。目前全球医学界已经达成明确共识：补充睾酮能够有效改善绝经后女性的性欲低下；不仅如此，针对围绝经期（Perimenopause）女性的研究数据也同样清晰有力。睾酮不仅能提升性欲，还能显著改善性唤起、帮助达到高潮、提升整体性满意度，甚至对改善身体意象（body image）有着极为积极的作用。 在临床实践中，由于缺乏专门针对女性剂量的获批产品，鲁宾医生直接使用美国 FDA 批准用于男性的睾酮制剂，按大约十分之一的男性剂量谨慎开给女性患者。在随访的 3 到 6 个月内，许多患者的身体状态宛如“齿轮重新咬合到位”。鲁宾医生指出，这并不意味着地球上的每个女人都必须服用睾酮，但如果一位女性感到需要、愿意尝试并心存好奇，医疗系统就应当为她提供懂得这一机理、并有能力“写下这张该死处方”的专业医生。 --- ### [19:52](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1192s) 拆解月经周期：荷尔蒙的升降起伏与正常基线 女性一生大致跨越五个荷尔蒙阶段：青春期、育龄期、围绝经期、绝经期以及绝经后期。当女孩步入青春期时，身体发生剧烈的生理蜕变，其核心驱动力便是体内雌激素、孕激素（黄体酮）和睾酮的周期性激增，月经周期由此开启。鲁宾医生以直观生动的方式梳理了月经周期的生理本质： ```mermaid flowchart TD accTitle: 月经周期荷尔蒙变化流程 accDescr: 展示月经周期的荷尔蒙水平起伏、卵泡发育及子宫内膜脱落过程 subgraph 卵泡期与排卵 ["周期的前半段：卵泡期至排卵"] A["月经期开始：雌激素处于低谷（约 50 pg/mL），无孕激素"] --> B["卵泡发育：雌激素持续攀升（峰值达 150-300 pg/mL）"] B --> C["排卵发生：成熟卵子破茧而出，睾酮出现生理高峰"] end subgraph 黄体期与月经 ["周期的后半段：黄体期至退化"] C --> D["卵泡外壳形成黄体：开始大量分泌孕激素"] D --> E{"是否成功受精？"} E -- "未受精" --> F["黄体萎缩退化：孕激素与雌激素急剧崩跌"] F --> G["子宫内膜剥落出血：迎来下一次月经"] E -- "受精怀孕" --> H["激素持续飙升：妊娠期雌激素可突破 3000 pg/mL 以上"] end ``` 在月经来潮并出血的几天里，体内的雌激素和孕激素处于整个周期的最低谷，此时雌激素水平大约在 50 pg/mL 左右（绝非归零）。随着卵巢中的卵泡逐渐发育，雌激素不断攀升；当排卵发生时，雌激素水平可达到 150、200 乃至 300 pg/mL。卵子排出后，遗留下的卵泡外壳（黄体）开始大量分泌孕激素，进入充满孕激素的周期后半段。如果卵子未被受精，这层外壳便自然萎缩退化，伴随孕激素水平断崖式下跌，子宫内膜脱落出血，形成下一次月经。而在怀孕期间，雌激素甚至可能飙升至 3,000 pg/mL 或更高。 理解这些数字的意义在于破除对激素疗法的误解：当医学上补充激素替代疗法时，绝非像怀孕那样给身体注入数千单位的高剂量，而仅仅是将体内激素维持在相当于月经周期早期 50、60 或 70 pg/mL 的生理基线水平。此外，常规教科书图表中常常忽略睾酮，但研究表明睾酮在排卵前后会出现一个小高峰——从演化生物学角度来看，这正是为了在受孕几率最高的时刻激发女性的性欲冲动。 - **经期健康的沉默危机**：社会普遍缺乏对异常出血量、痛经的科学讨论，许多罹患多囊卵巢综合征（PCOS / PMOS）和子宫内膜异位症的年轻女性长期在痛苦中沉默。 - **外界药物干预**：许多处方药在不知不觉中悄然打乱了育龄期女性脆弱的内分泌节律与性反应。 --- ### [23:33](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1413s) 围绝经期的真实面貌：远比预想来得更早 大众通常认为更年期发生在 45 至 55 岁（平均绝经年龄为 52 岁），因而 30 多岁的女性往往认为更年期离自己很遥远。然而，过渡期的“围绝经期（Perimenopause）”往往在最终绝经前 10 年左右就悄然开始，这意味着从 35 岁到 45 岁，荷尔蒙的大幅波动就已经开始在体内掀起波澜。 荷尔蒙剧烈起伏引发的生理症状繁杂而多样，但由于长期缺乏科普，许多女性被误诊甚至被指责为“把所有毛病都归咎于激素”： - **体温调节与神经症状**：体温异常波动、潮热、持续性疲惫、脑雾与记忆力下降、焦虑情绪暴增。 - **全身黏膜与感官异常**：干眼症、耳朵发痒、灼口综合征（burning mouth）、关节酸痛。 - **生殖与泌尿道改变**：月经周期紊乱、性交疼痛、顽固性复发尿路感染（UTI）——雌激素对维持膀胱上皮厚度与尿道防御力起着决定性作用。 随着围绝经期孕激素分泌首先开始不稳定，睡眠障碍和突发焦虑往往是最先浮现的信号，部分女性可优先通过补充孕激素获得缓解。然而，针对该阶段的干预绝不存在“千人一方”的套路：有的女性需要补充雌激素，有的需要单独补充在 30 岁后就自然断崖下跌的睾酮，有的则需要三者协同配合。传统指南大多僵化地将目光集中在“卵巢功能彻底枯竭、体内荷尔蒙归零”的真正绝经期，而将荷尔蒙疗法的干预节点提前至围绝经期，是当前妇科与性医学领域最具突破性、也最为重要的前沿进展。 --- ### [25:41](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1541s) 走进 HRT：重新定义更年期荷尔蒙治疗 随着对围绝经期和更年期身心健康的深入探讨，关于“激素替代疗法（HRT，Hormone Replacement Therapy）”的社会舆论与医学争议再次成为热点焦点。无论是关于其长远安全性、适宜启用的起始年龄、适用人群标准，还是剂型选择（口服、贴片、凝胶或局部用药），公众和医疗界都充斥着混淆不清的信息。 鲁宾医生指出，HRT 历史上是用于缓解绝经期女性因卵巢功能衰竭导致全身荷尔蒙归零的干预手段，但随着当代循证医学对激素受体生理学理解的深化，荷尔蒙疗法的定义、药物形态及其在维护女性认知、骨骼及心血管健康中的深远价值，正在经历一场颠覆性的重构。 ### [26:07](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1567s) 激素替代疗法（HRT）的本质：雌激素与孕激素的平衡 激素替代疗法（HRT）在市场上有着五花八门的商业包装和营销称谓，但剥离掉这些外壳，其核心理念非常纯粹：当 50 岁以上的人群遭遇潮热、盗汗、骨质疏松以及体内雌激素和孕激素水平断崖式下跌时，通过外源性补充把失去的激素“还给身体”。经典的激素治疗方案通常是雌激素与孕激素的组合拳。雌激素扮演着“生长促进剂”的角色，它不仅能维护骨骼健康，滋养头发、皮肤与指甲，消除潮热盗汗并改善睡眠，但它同样会刺激子宫内膜持续增厚；如果任由其无限增生，数年后发生子宫内膜癌（Endometrial Cancer）的风险便会大幅上升。 为了让听众更直观地理解，鲁宾医生用解剖结构打了个生动的比方：阴道就像一个承载的“插座”，在插座的最深处有一个针尖般大小的微小开口，即子宫颈口；穿过这个针尖小孔，便通向孕育胎儿的空腔——子宫。月经出血的本质，正是这层子宫内膜组织的周期性脱落。此时，孕激素的重要性便凸显出来：单用雌激素会导致内膜过厚并埋下病变隐患，而一旦引入孕激素与之形成制衡，内膜病变的风险就会被完全抵消。这正是激素治疗中雌孕激素常常“同进同退”的原因，其逻辑与女性服用的复方避孕药如出一辙。 - **雌激素的生理效益**：改善潮热与夜间盗汗、维护骨密度（预防骨质疏松）、滋养皮肤、毛发与指甲、提升睡眠质量。 - **子宫内膜保护机制**：具有完整子宫的女性单用雌激素会促使子宫内膜过度增生，必须联用孕激素进行拮抗平衡，以消除子宫内膜癌风险。 --- ### [27:49](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1669s) WHI 研究风波与历史误读：被耽误的一代女性 谈及为什么当今年轻人的母亲和祖母辈大多未能获得激素治疗，鲁宾医生揭开了一段沉重的医学历史与深深烙印的污名化根源。在 20 世纪 90 年代后期，激素替代疗法曾极为普及，大量观察性研究一致显示用药人群的心血管疾病风险显著降低。为了获得最严谨的科学证据，美国国家卫生研究院（NIH）耗资十亿美元启动了著名的“妇女健康倡议”（Women's Health Initiative, WHI）研究，追踪了数万名 50 至 79 岁服用激素药片的女性。然而在 2000 年代初，该研究被骤然叫停，主办方召开了一场震惊全球的新闻发布会，宣称“激素疗法会导致心血管疾病和乳腺癌”。 这声宣判几乎在一夜之间摧毁了一个价值数十亿美元的医疗领域，全世界的医生都在告诫患者“立刻把激素扔进垃圾桶，这东西致命”。临床一线的开药医生们面面相觑、困惑不已：“我的患者并没有死于心脏病，也没有突发乳腺癌，这完全不合逻辑。”随后医学界对数据的复盘揭示了荒谬的真相：原始数据根本无法支撑新闻发布会上的惊悚结论，研究结果被严重曲解。具有讽刺意味的是，当年 WHI 研究的原班作者在数十年后（包括 2025 年的最新论文）亲自澄清：对于 70 岁以下的女性，该类传统激素治疗根本不会增加心血管疾病或中风的风险。然而这场恐慌的恶果已无法挽回，整整一代医生在医学院里没有接受过规范的激素教育，导致如今本该接受激素治疗的女性中，仅有极少部分能拿到处方。 - **WHI 研究叫停的恶果**：将正常的医学随访演化为公众恐慌，导致全球范围内的停药潮与长达数十年的医疗断代。 - **最新循证共识**：70 岁以下女性使用激素治疗不会增加心血管疾病或中风风险。 - **处方鸿沟**：在所有存在临床适应证、应当获得处方的女性患者中，实际仅有 **1.7%** 的人成功拿到了激素治疗处方。 --- ### [29:46](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1786s) 激素治疗的四大支柱与绝经期泌尿生殖综合征（GSM） 鲁宾医生强调，自己并非主张每一位女性都必须无条件使用激素，而是呼吁每位女性都应当有权打开这个“医学工具箱”。现代内分泌与性医学将激素疗法拆解为清晰的“四大模块”： ```mermaid flowchart TD accTitle: 激素替代疗法的四大支柱 accDescr: 展示全身雌激素、全身孕激素、睾酮以及局部阴道激素四种治疗分类及其核心临床适应证。 subgraph Systemic ["全身性激素治疗"] A["全身雌激素"] --> A1["缓解潮热与盗汗"] A --> A2["预防骨质流失与骨折"] B["全身孕激素"] --> B1["保护子宫内膜"] B --> B2["改善睡眠与缓解焦虑"] C["睾酮补充"] --> C1["恢复性欲与性动力"] end subgraph Local ["局部微量激素治疗"] D["阴道局部激素<br/>(雌二醇/DHEA)"] --> D1["消除性交疼痛与干涩"] D --> D2["缓解尿频、尿急与漏尿"] D --> D3["预防致命性尿路感染 (UTI)"] end ``` 在第四个模块中，鲁宾医生着重引出了“绝经期泌尿生殖综合征”（Genitourinary Syndrome of Menopause，简称 GSM）的概念。她直言这个命名有些狭隘和愚蠢，因为事实上体内任何阶段的激素剧烈波动（包括哺乳期或长期服用某些药物）都可能重创膀胱与外阴道环境。阴道局部微量激素（雌二醇或 DHEA）不参与全身循环代谢，无论是住在养老院里九十岁高龄的曾祖母，还是正处于哺乳期的年轻产妇，都可以百分之百安全地使用。 - **第一支柱（全身雌激素）**：主攻潮热、盗汗及骨密度丢失。 - **第二支柱（全身孕激素）**：与雌激素呈“阴阳制衡”，核心在于阻断内膜恶变，同时对相当一部分患者具有改善睡眠质量和降低焦虑的附加收益。 - **第三支柱（睾酮）**：具有最坚实的循证医学证据支持，核心解决性欲低下问题。 - **第四支柱（阴道局部微量激素）**：通过局部黏膜微量给药，精准滋养膀胱和阴道组织，彻底击退干涩、性交痛、尿频尿急以及漏尿问题。 --- ### [31:41](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=1901s) 阴道微生态与尿路感染（UTI）的致命风险 许多人将尿路感染（UTI）轻视成一种单纯需要跑一趟急诊、吃几片抗生素的小毛病，但对年长女性而言，反复发作的 UTI 往往是致命的开端。细菌在膀胱内疯狂繁殖并引发重度炎性反应时，排尿的过程犹如“下咽剃须刀片”般剧痛难忍。更为凶险的是，细菌一旦逆行上行侵入血液循环，便会诱发高热、寒战、肾盂肾炎，甚至迅速恶化为尿源性脓毒血症（Urosepsis），将患者推入重症监护室（ICU）进行静脉强效抗生素抢救，伴随着极高的死亡率。 很多人未曾意识到激素与尿路感染之间存在着决定性的生物学屏障关系。健康的阴道黏膜必须依赖充足的雌激素与睾酮来维持其酸性环境。这种酸性微生态是益生菌（如乳酸杆菌）繁衍的温床，天然能够压制和清除致病菌；世上没有任何一款口服益生菌产品能复刻激素为阴道建立的物理与生化防御壁垒。一旦步入围绝经期或绝经期，激素匮乏导致阴道酸碱度失衡、黏膜萎缩，致病菌便会长驱直入。加之性生活属于“接触性运动”，不仅会将体外杂菌带入体内，弱碱性的精液亦会中和阴道原有的酸性环境，进一步放大了感染概率。自 20 世纪 90 年代以来的多项研究已明确证实：阴道局部补充激素就像干涸的植物得到了雨水灌溉，能够将尿路感染的复发率削减一半以上。 - **UTI 的临床危害**：从排尿时的“刀割样刺痛”到全身性感染，尿源性脓毒血症（Urosepsis）是老年女性致死的重要诱因之一。 - **阴道微生态核心机制**：雌激素与睾酮促使阴道上皮细胞合成糖原，维持局部强酸性环境，天然抵御有害致病菌。 - **性生活与 pH 波动**：性生活带入外源致病微生物，且精液呈碱性，极易打破更年期脆弱的阴道菌群平衡。 - **感染预防数据**：规范使用阴道局部激素，可使女性尿路感染的发生率**降低 50% 以上**。 --- ### [33:44](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2024s) 阴道局部激素的应用：比万艾可更神奇的日常解法 在节目录制现场，鲁宾医生向史蒂芬·巴特利特展示了多种具体用药用具，打破大众对激素治疗“高不可攀”或“操作繁琐”的误解。最主流的形式是雌二醇乳膏（Estradiol Cream）。医生挤出大约 1 克的乳膏置于纸上展示用量，并手把手指导使用细节：患者完全不需要依赖包装内附带的塑料推注器，直接用洗净的手指取药即可。涂抹的手法至关重要——必须像在脸上涂抹防晒霜一样，将药膏均匀轻柔地揉入阴道壁内部黏膜以及外阴道开口处，而不是堆积成一团黏腻的白斑。 鲁宾医生直言，只要每周坚持涂抹两次这 1 克的药膏，不仅能预防因尿路感染导致的死亡风险，还能根本性逆转尿频、尿急、漏尿与性交疼痛，极大地激发性唤起与性高潮质量，“它的综合疗效在女性身上甚至超越了男性的万艾可（Viagra）”。在英国，此类局部雌二醇制剂已获批为非处方药（OTC），而在美国虽然仍需医生处方，但在马克·库班（Mark Cuban）创办的平价在线药房（Cost Plus Drugs）上，一支足足可用两个半月的药膏仅售 14 美元，常规医疗保险亦基本全额覆盖。针对部分反感乳膏质地和黏腻感的女性，现代医学还开发了微型阴道片剂栓剂（Tablet Inserts），通过带有按钮的细巧给药器一键推入，干净利落且毫无异物残留感。 - **给药方法与剂量**：每次使用约 **1 克**雌二醇乳膏，用手指将其充分推开并揉入阴道黏膜内壁及外阴口，频率仅需**每周两次**。 - **治疗收益**：消除萎缩性干涩与性交痛、改善尿失禁与尿急、提升性唤起与高潮体验，筑牢尿路防感染屏障。 - **药物可及性与经济性**：英国可直接于药房柜台非处方（OTC）购买；美国通过马克·库班的平价药房仅需约 **14 美元**（单支可用 2.5 个月）。 - **剂型替代选择**：除传统乳膏外，还提供带推进按钮的极简微型阴道泡腾片/栓剂，满足对清爽度有更高要求的女性需求。 ### [35:32](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2132s) 局部阴道激素的多样化剂型与 DHEA 的独特机制 针对局部阴道激素给药，除了乳霜之外，临床上还有多种形态可供选择。例如一种极小的阴道阴道片剂，每周仅需塞入两次即可达到与乳霜相同的疗效，且避免了乳霜溢出带来的黏腻感。对于完全不希望每周记忆用药的女性，阴道缓释环则是一种更为省心的方案。这种环状装置放入阴道后可留存整整三个月，由于阴道内部的神经末梢分布并不敏感，女性在放入棉条时几乎毫无察觉，佩戴这种阴道环也同样不会感到异物感。面对主持人关于“这个环看起来体积不小”的疑虑，鲁宾医生风趣地指出，阴道是一个能够容纳并娩出如同保龄球大小婴儿的器官，其弹性和容积承受力极其可观。 阴道环内置有雌二醇（Estradiol），能够在三个月内持续缓慢释放激素。这种长效剂型对于患有认知障碍、手部关节不灵活无法完成精细操作的老年女性、生活在疗养院中的患者，或是经常处于奔波状态、生活节奏飞快的女性极其友好；尤其是注意力缺陷多动障碍（ADHD）的患者，无需每周两次惦记用药。尽管剂型千差万别，其核心成分的效用是一致的。 在此之外，还有一种机理独特的物质——脱氢表雄酮（DHEA）。DHEA 是雌激素和睾酮的前体激素。由于外阴、阴道和膀胱组织同样需要睾酮的滋养，经由阴道给药的 DHEA 能在局部细胞内转化为雌激素和睾酮。虽然市面上能在保健品货架买到口服 DHEA 补充剂，但作为阴道局部给药制剂，经 FDA 批准的处方药 Intrarosa（普拉睾酮）可以每晚睡前置入阴道深处，体温会使其自然融化吸收，患者也可以按需每周使用两次。它在预防尿路感染、消除性交疼痛方面展现出了显著疗效。 - **阴道片剂**：体积小巧，每周使用两次，比乳霜更清爽、不易弄脏衣物。 - **阴道缓释环**：单次放入可在体内留存 3 个月，缓慢恒速释放雌二醇，适合手部灵活性差、患有认知障碍或生活忙碌健忘的群体。 - **DHEA 阴道栓剂（Intrarosa）**：FDA 批准的局部前体药物，在阴道靶向组织内自行代谢转化为雌激素与睾酮，兼顾双重激素需求，显著缓解性痛与尿路问题。 ```mermaid flowchart TD accTitle: 局部阴道激素药物形态与机制 accDescr: 展示三种不同的阴道激素给药途径及其特点与应用人群 subgraph Formulations["局部阴道激素主要剂型"] A["阴道片剂<br/>(每周 2 次)"] B["阴道缓释环<br/>(单次留存 3 个月)"] C["DHEA 栓剂 (Intrarosa)<br/>(每晚或每周 2 次)"] end subgraph Mechanism["作用机制与特点"] A --> D["释放雌二醇，清爽无残留"] B --> E["缓慢恒释雌二醇，适合手部不便/高忙碌/ADHD人群"] C --> F["局部转化为雌激素与睾酮，双管齐下"] end subgraph Outcomes["临床获益"] D --> G["修复阴道黏膜"] E --> G F --> G G --> H["预防反复尿路感染 (UTI)"] G --> I["消除性交疼痛与干涩"] G --> J["改善尿频、尿急与漏尿"] end ``` --- ### [37:41](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2261s) 尿路感染的民间迷信与阴道激素的救命价值 许多医生面对饱受反复尿路感染（UTI）折磨的女性时，给出的往往是老生常谈的建议，例如“性生活后排尿”或“便后从前往后擦拭”。鲁宾医生直言不讳地指出，这简直是一场“灾难”，这些口口相传的说辞充其量只是缺乏严谨数据支持的“民间传说”（folklore），根本无法从源头解决病理机制。至于广为流传的蔓越莓汁，虽然某些高浓度蔓越莓提取胶囊在数据上显示有微弱的预防效果，但普通市售蔓越莓汁为了掩盖酸涩往往添加了极高的糖分，不仅难以下咽，甚至有诱发糖尿病的风险。多喝水固然有益，但在庞大的发病机制面前，这些手段的影响微乎其微。 真正具有决定性、循证医学证据充分的干预手段是阴道局部激素治疗（包括阴道雌激素和阴道 DHEA）。美国泌尿外科学会（AUA）已制定了相关临床指南，证实局部阴道激素能够将尿路感染的复发率降低一半以上（>50%）。它不仅能预防感染，还能全面改善尿频、尿急、压力性或急迫性尿失禁，彻底消除因阴道萎缩引发的性交刺痛与干涩，并显著提升女性的性唤起与性高潮质量。 更为关键的是其绝对安全性。局部阴道激素几乎不吸收入血液循环，因此适用于各个年龄段、患有各种基础疾病的女性。即便患者曾患有乳腺癌等癌症、经历过深静脉血栓或中风，使用局部阴道激素也极其安全，甚至能在预防因严重尿路感染引发的败血症方面发挥“救命”的作用。 - **常见迷信的破除**：性交后排尿、由前往后擦拭缺乏坚实的大样本临床证据；含糖蔓越莓饮料不仅疗效甚微，还会增加代谢负担。 - **核心临床证据**：阴道局部雌激素或 DHEA 可使尿路感染复发风险降低 50% 以上。 - **极高的全身安全性**：无全身循环负担，有癌症、血栓形成或中风病史的女性均可安全使用。 --- ### [39:11](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2351s) 激素替代疗法何时开始：从哺乳期到围绝经期的个体化评估 针对主持人提出的疑问——33 岁的伴侣尚未进入围绝经期，女性究竟该在停经满 12 个月的绝经期、绝经后期，还是在围绝经期开启激素替代治疗（HRT）？鲁宾医生指出，医学界绝对不能将年龄作为一刀切的硬性指标，用药的时机完全取决于患者何时开始出现症状。激素水平在女性一生中经历着剧烈的起伏，哺乳期便是一个被严重忽视的典型窗口。 在怀孕期间，女性体内的雌激素水平会飙升至平时的数倍（达到 10,000 左右的高位），但在分娩当日，体内雌激素会发生断崖式下跌，瞬间跌落至接近于零的谷底。如果产妇选择母乳喂养或吸奶，在整个哺乳期内，只要月经没有恢复，体内的激素水平就始终处于与绝经期完全一致的超低状态。这种状态在医学上被称为“哺乳期生殖泌尿综合征”（Genitourinary Syndrome of Lactation）。许多年轻的新晋母亲在此时会出现潮热、夜间盗汗、尿频、尿失禁、严重阴道干涩、性欲暴跌以及剧烈的性交疼痛。在此阶段局部使用阴道激素不仅对母乳和婴儿绝对安全，而且能迅速修复受损黏膜，将产妇从巨大的身心痛苦中拯救出来。 当女性度过育儿期，步入 38 岁至 40 岁左右，如果身体没有任何不适、月经周期规律，自然无需任何药物干预。然而，一旦出现反复尿路感染、性生活干涩刺痛、性欲如同当年服用口服避孕药时那般低迷，局部阴道激素或睾酮便可提上日程；若在 43 岁左右开始出现严重的睡眠障碍，微粉化孕酮则能带来显著的神经镇静和睡眠改善。 - **哺乳期的激素骤降**：分娩瞬间雌激素断崖式暴跌，哺乳阶段的内分泌环境在生理上等同于“绝经状态”。 - **哺乳期生殖泌尿综合征**：局部阴道激素是改善产后阴道干涩、性交疼痛与漏尿的极佳选择，且完全不影响哺乳安全性。 - **按需与症状驱动**：启动干预不看日历年龄，而是评估个体化症状（反复感染、睡眠骤降、性欲压抑等）。 --- ### [41:16](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2476s) 从痛不欲生到重返法学院：一位 60 岁女性的生命逆转 为了说明激素疗法如何彻底逆转生命质量，鲁宾医生分享了一位极具代表性的临床案例。这位年过六旬的女性初诊时饱受潮热、盗汗、脑雾与慢性疲劳的折磨，但受老一辈传统偏见的影响，她极为抗拒：“我绝不接受激素治疗，它不安全，我母亲生前一直警告我激素会致癌。”鲁宾医生并未强行推销，而是耐心地展示医学数据、学术论文，通过平等共享的医患决策模式，建议她先从安全性极高的局部阴道激素起步。 效果立竿见影：患者的阴道干涩与性痛彻底消失，性唤起和性高潮全面复苏，夜尿频繁的问题解决后睡眠质量大幅飞跃，且连续数月未再发生过一次尿路感染。重拾信心的患者主动找到鲁宾医生询问：“鲁宾，你到底对我做了什么？你把我的生活还给我了！你手里还有什么好方法？”此时，她依然残留着潮热、盗汗，且骨密度检查提示骨量减少（Osteopenia）；由于其母亲死于严重的骨质疏松性骨折，她对骨骼健康深感忧虑。 鲁宾医生为她量身定制了全身雌激素替代方案，并因其子宫完整而配伍了夜间口服微粉化孕酮，这不仅彻底消除了潮热盗汗、保护了心血管系统，更为骨骼筑起了防线。随后，面对依然低落的性欲，医生在检测后为她补充了小剂量睾酮。经过四到六个月的系统调理，患者不仅性欲全面恢复，更迎来了大脑认知功能的“重生”——她感觉大脑清晰敏锐，甚至作出了一个颠覆人生轨迹的决定：跨界报考法学院。最终，这位六十多岁的老人与一群二十出头的年轻学子同台竞技，以全班第一名的拔尖成绩毕业。 > “鲁宾，你到底对我做了什么？我感觉好多了，你把我的生命还给我了。我不用在半夜爬起来上厕所了，睡眠变好了，也不再干涩，性生活不再痛苦，好几个月都没得过一次尿路感染。你手里还有什么方案？” --- ### [43:14](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2594s) 拒绝让卵巢彻底衰竭：颠覆现代医学的迟滞思维 在谈到现代医学对女性衰老的处置态度时，鲁宾医生流露出了极大的愤慨。她尖锐地反问：在整个医学领域中，还有哪一个器官的衰竭，需要等到它“彻底功能丧失、患者苦熬满一年”之后，医生才被允许动手干预？临床上，眼科医生绝不会等到患者彻底双目失明才去验光配镜；肾内科医生绝不会等到肾功能完全衰竭才开始用药延缓或启动透析；肝病科医生更不会等到患者陷入终末期肝衰竭弥留之际才讨论治疗方案。 唯独在妇科内分泌领域，主流医学界竟荒谬地要求女性的卵巢必须彻底衰竭、连续 12 个月不来月经并忍受漫长的身心折磨，才准许被诊断为绝经并考虑干预。这种思维方式在鲁宾医生看来纯属“荒唐透顶”（insanity）。围绝经期本身就是一个充满激素剧烈波动的阶段，女性在围绝经期、绝经期或绝经后期均可根据主观感受和生活目标启动 HRT，根本没有所谓的“为时过早”。 鲁宾医生进一步犀利地类比：医学界长期毫无顾虑地给十几岁、二十几岁的年轻女孩开具口服避孕药，而复合口服避孕药本质上就是大剂量的“合成人工激素替代疗法”（high-dose fake hormone therapy）。既然主流医学能够对年轻女性使用高剂量的合成激素，为何面对中老年女性身体自然衰竭时，却对补充生理剂量的天然生物等同性激素（Bioidentical Hormones）推三阻四、充满道德与安全审判？医学的重心必须从被动等待器官崩溃，转向主动预防与提升生命质量。 ### [44:21](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2661s) 被忽视的“不再像自己”（NFLM）与激素治疗困境 在更年期及日常临床实践中，蕾切尔·鲁宾医生（Dr. Rachel Rubin）指出，医学界必须学会在各个年龄阶段坦然接纳并合理运用激素治疗。女性在走进诊室时最常吐露的一句心声是“NFLM”（Not Feeling Like Myself，即“我感觉自己不像自己了”）。然而令人沮丧的是，大多数医护人员往往对这种主诉轻描淡写或直接忽视。事实上，这种整体性的身心脱节往往根植于深层的激素失衡。例如许多中老年女性常出现的足底筋膜炎（plantar fasciitis）或肩周炎/五十肩（frozen shoulder）等骨骼肌肉疼痛，背后均与雌激素水平下滑有着直接的病理关联。 更为严峻的现实在于医疗体系对有效疗法的系统性剥夺。公开发表的数据显示，联邦医疗保险（Medicare）患者中，只有不到 9% 的人获得了相关激素处方；在大型医疗数据库中，超过 75% 的适用人群根本无法获取这种治疗。大量廉价且安全的仿制药本可以挽救生命并极大改善生活质量，却被拒之门外。成千上万的女性因阴道干涩、组织脆弱和摩擦剧痛而彻底放弃了性生活，但这种生理衰退本是完全可逆且极易解决的。 - **NFLM 现象**：女性常因难以名状的疲劳、情绪改变或骨骼肌肉疼痛求医，却常被判定为“心理作用”或自然衰老。 - **处方鸿沟**：在 Medicare 受益人中激素处方率不足 9%，庞大数据库显示逾 75% 的更年期女性未获得应有的低成本治疗。 - **隐形折磨**：由局部雌激素匮乏导致的干涩和灼痛是摧毁伴侣亲密关系的主要生理元凶之一。 --- ### [45:26](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2726s) 商业赞助：AI 跨语言传播与大脑代谢燃料 斯蒂芬·巴特利特（Steven Bartlett）插播了播客合作赞助商的相关信息： - **HeyGen**：利用 AI 视频与声音克隆技术打破语言壁垒。只需录制 15 秒个人视频，即可生成保留本人音色、情绪与口型节奏的超逼真 AI 分身，支持超过 175 种语言的本土化转播。目前全球已有 3,000 万用户及 85% 的财富 100 强企业在使用该技术，为《CEO日记》提供了多达 20 种语言版本的跨国传播支持。 - **Ketone-IQ**：由 UFC 综合格斗传奇选手乔恩·“骨头”·琼斯（Jon "Bones" Jones）与斯蒂芬联合持股的外源性酮体能量补剂。与咖啡因对中枢神经的短暂刺激不同，酮体直接作为大脑的高效替代燃料，提供平稳持久的专注力且不会引发能量骤降。节目同时介绍了由琼斯及其指导的奥运摔跤金牌选手盖布尔·史蒂夫森（Gable Steveson）亲笔签名的限量款拳套抽奖活动。 --- ### [47:27](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2847s) 性交疼痛绝非“正常现象”：生理成因与求医困境 当巴特利特询问性交疼痛的根源及女性是否必须忍受时，鲁宾医生给出了斩钉截铁的回答："Sex is not supposed to be painful."（性爱绝不应该伴随疼痛）。如果感到疼痛，患者理应得到明确的诊断与病因解释，而不是被一句“放轻松点”打发。性交疼痛的普遍程度远超公众想象，其背后的生理病理机制可以细分为多个维度： ```mermaid flowchart TD accTitle: 导致女性性交疼痛的生理机制分布 accDescr: 涵盖皮肤组织脆弱、肌肉过度紧绷、神经牵涉痛及盆腔内部疤痕黏连四大主要生理诱因 subgraph Causes["性交疼痛的主要生理诱因"] direction TB A["皮肤与黏膜病变<br/>(激素匮乏/湿疹/硬化性苔藓)"] B["骨盆底肌肉痉挛<br/>(盆底肌高张力/无法放松)"] C["神经病变与牵涉痛<br/>(脊柱病变/坐骨神经痛辐射)"] D["内部解剖结构黏连<br/>(子宫内膜异位症深层瘢痕)"] end Causes --> E["临床确诊与对症干预<br/>(激素替代 / 盆底物理治疗 / 手术)"] ``` 1. **组织与皮肤病变**：外阴前庭及阴道黏膜对性激素极度敏感。雌激素与睾酮下降会导致黏膜变薄变干；此外，湿疹及硬化性苔藓等外阴自身免疫性皮肤病也会带来剧烈灼痛。 2. **肌肉机能障碍**：阴道与外阴被厚实的骨盆底肌群包裹。与颈部或背部肌肉过度劳损类似，盆底肌在遭遇压力或炎症时会陷入长期痉挛，形成高张力性功能障碍。 3. **神经传导异常**：类似腰椎间盘问题引起的坐骨神经痛，脊柱神经受压或骨盆神经受损可直接向下辐射，在阴茎或外阴区域产生剧烈的神经性针刺痛。 4. **内部病灶与瘢痕**：子宫内膜异位症（endometriosis）等疾病会在盆腔内部形成深层粘连和硬化瘢痕，深部撞击会牵拉病灶引发剧痛。 在医疗现实中，由于绝大多数妇产科医生在规范化培训中几乎没有接受过性医学和性疼痛的专业训练，鲁宾医生建议患者必须寻求专注于盆底疼痛的专科妇科医生或泌尿外科医生。就像聘请水管工修缮管道需要多家比价一样，寻找能看懂外阴疼痛的医生也往往需要寻求多方意见（second opinions）。 - **极高的患病率**：文献统计，高达 75% 的女性一生中都曾经历过不同程度的性交疼痛。 - **慢性化趋势**：美国有 10% 至 20% 的女性长期承受着持续性慢性性交疼痛。 - **绝经期激增**：绝经后性痛发生率飙升至 20% 到近 50%，大量女性因剧痛彻底终止性生活，而激素缺乏在其中起到了核心推手的作用。 --- ### [50:08](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3008s) “性健康财务学”：打造极致性爱体验的三层金字塔 针对巴特利特提出“女性如何能在不同生命阶段获得极致性爱”的提问，鲁宾医生借用《CEO日记》受众最熟悉的商业逻辑，创新性地提出了性健康的“个人财务模型”。她幽默地指出，现代人往往既渴望腰缠万贯又渴望性福美满，但在现实中却最害怕开诚布公地谈论金钱与性。要实现顶级的性生活体验，必须像管理资产一样构建清晰的分层架构： ```mermaid flowchart TD accTitle: 鲁宾医生的性健康资产配置金字塔 accDescr: 展现活期储蓄、401k长线投资与加密货币投机三层比喻在性健康中的实际对应维度 subgraph Tier3["第三层：加密货币 (Crypto) - 营销噱头与投机"] C["网红注射项目 / 生殖整形 / 夸大宣传的催情保健品<br/>(高风险、本末倒置，切勿作为起点)"] end subgraph Tier2["第二层：401(k) 退休基金 - 复利成长与医疗优化"] B["激素水平精准优化 / 盆底肌康复 / 心理与性治疗 / 引入情趣玩具<br/>(长期复利支持，构筑核心生理与心理屏障)"] end subgraph Tier1["第一层：储蓄与支票账户 (Checking & Savings) - 基础底盘"] A["生理认知教育 / 充足睡眠 / 营养与运动 / 关系安全感 / 深度言语沟通<br/>(人人必需的基础日常支撑)"] end Tier1 --> Tier2 --> Tier3 ``` - **第一层：日常收支与储蓄账户（Checking & Savings Account）**：这是人人都必须拥有的生存根基。它对应着健康饮食、规律运动、优质睡眠、全面的性生理教育，以及伴侣关系中的安全感与透明沟通。能够用清晰的语言表达渴望、提出疑问和共同探索，是实现美好性爱不可动摇的底线。 - **第二层：401(k) 长期退休基金**：这是每个人都应尽力配置、用以产生长期复利支持的关键支柱。它包括主动寻求专业医疗帮助以优化体内激素平衡、确保骨盆底肌肉处于良好松弛与收缩状态、维护心理健康，必要时寻求性治疗师指导，或积极在卧室中引入情趣用品和辅助器械以拓宽快感维度。 - **第三层：加密货币（Crypto）**：鲁宾医生特别提醒，不要盲目否定这一层，但“绝对不能把你所有的资产都押在上面，更不能把它当作起点”。在性健康领域，这对应着社交媒体和电视广告上铺天盖地的局部填充注射、外阴美容手术或宣称能“一夜重燃激情”的神奇保健品。如果某些宣传听起来好得难以置信，且脱离了前两层的健康基底，它绝不可能解决真实的性功能障碍。 --- ### [52:34](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3154s) 骨盆底肌解构：被遗忘的深层核心肌肉 顺着上述生理障碍的脉络，巴特利特将话题引向具体生理结构的探究，要求鲁宾医生深入剖析经常被提及却鲜有人真正理解的“骨盆底”（Pelvic Floor）。 鲁宾医生澄清，骨盆底绝非女性独有的构造，男性与女性拥有完全相同的解剖学骨盆底。从结构上看，骨盆底是由骨盆骨、髋关节和坐骨所构成的坚固漏斗状骨性容器，其核心功能是承托体内的膀胱、肠道与生殖器官，人体的内外生殖器均附着其上。在这个骨架的内壁与底部，纵横交错着厚实强韧的骨盆底肌肉群。这些肌肉与手臂的二头肌、背部肌群或颈部肌肉具有完全一致的生理学特性，能收缩、能拉伸，但也极易发生慢性劳损、拉伤、痉挛或过度紧绷，进而直接扼杀正常的排尿、控便与性功能。 ### [53:27](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3207s) 盆底肌：性爱作为一项“身体对抗运动”的生理基础 骨骼肌的基本机制在于收缩与舒张，而盆底肌与二头肌、斜方肌并无二致——过度使用会导致酸痛紧绷，甚至需要按摩与物理治疗。Dr. Rachel Rubin 形象地指出：“性爱本质上是一项身体对抗运动（Sex is a contact sport）。”无论是男性勃起、女性阴蒂充血胀大，还是顺畅的阴道插入与高潮释放，都高度依赖健康的盆底肌群协同作业。当性兴奋唤起时，充血使阴茎或阴蒂挺立，此时盆底肌肉必须能够完全放松以容纳插入；如果盆底肌过度紧绷痉挛，插入就会引发强烈的疼痛、酸胀与灼烧感。而性高潮则是神经系统驱动下的一连串肌肉规律性收缩，带来极致的愉悦与张力释放。 很多女性并不知道自己的不良性体验其实源自盆底肌失调。Dr. Rachel Rubin 列举了盆底肌异常的几种典型表现：首先是性交疼痛与插入困难；其次是高潮变得疼痛、微弱或完全缺失；再者是唤起困难、充血不足和润滑不足，这往往是因为紧绷僵硬的肌群阻碍了局部血液流动。此外，当人们在电视上看到性感画面或在街上瞥见吸引人的人时，生殖器会产生本能的生理悸动——这种“脑-生殖器连接（Brain-genital connection）”需要神经通路、激素水平与盆底肌协同工作，任何一环受损都会切断感觉传递。外科手术、分娩创伤以及肌肉退行性病变，都是破坏盆底功能的常见生物学诱因。 面对主持人关于是否该去健身房练盆底肌的疑问，Dr. Rachel Rubin 特别纠正了大众误区：普通的健身房训练无法解决这一问题，甚至盲目做凯格尔运动（Kegel exercises）可能适得其反。对于许多肌肉过度紧张的患者，需要的不是盲目收缩强化，而是学会肌肉的放松与神经协调控制。正确的路径是寻求专业的盆底物理治疗师（Pelvic Floor Physical Therapist）进行详细的内部评估与针对性训练。 ```mermaid flowchart TD accTitle: 盆底肌在性反应中的生理机制与功能障碍 accDescr: 展示健康的充血与舒张机制如何导致高潮，以及紧绷痉挛如何导致疼痛与障碍 subgraph HealthyFlow ["健康性反应机制"] A["性刺激与神经唤起"] --> B["生殖区血流激增<br/>（阴蒂/阴茎充血勃起）"] B --> C["盆底肌自主放松<br/>（无痛顺畅插入）"] C --> D["节律性肌肉收缩<br/>（满意性高潮与张力释放）"] end subgraph DysfunctionalFlow ["盆底功能障碍表现"] E["盆底肌过度紧绷/痉挛"] --> F["阻碍血流输入<br/>（干涩、唤起不良）"] E --> G["通道无法舒展<br/>（性交剧烈疼痛、灼烧感）"] E --> H["神经肌肉失调<br/>（高潮微弱、疼痛或缺失）"] end ``` - **性高潮本质**：由神经触发的一系列盆底肌肉节律性收缩，带来快感与神经肌肉释放。 - **常见诱因**：盆底创伤、经阴道分娩、盆腔手术及慢性压力导致的肌肉张力亢进。 - **治疗途径**：不推荐盲目做抗阻凯格尔收缩，应由专业盆底物理治疗师进行生物反馈与协调性康复。 --- ### [56:04](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3364s) 性高潮差距与被误解的阴蒂解剖学 约有 20% 的女性表示自己从未或极少经历过性高潮，而男性中出现高潮障碍的比例远低于此。Dr. Rachel Rubin 将这种现象与社会经济中的“薪酬差距（Pay gap）”相提并论，指出男女之间存在着巨大的“高潮差距（Orgasm gap）”。造成这种鸿沟的首要原因并非女性生理构造存在缺陷，而是长期以来严重的解剖学教育缺失。绝大多数女性和伴侣根深蒂固地认为高潮应当自然而然地来自活塞式的阴道插入（Penetration），一旦无法通过插入达到高潮便陷入自我怀疑。 Dr. Rachel Rubin 用了一个极为生动的类比打破这一迷思：纯粹的阴道插入对于大多数女性而言，就像隔靴搔痒地“不断摩擦大腿”一样——哪怕你在整场播客录制期间不停地揉搓大腿，你也绝不可能因此达到性高潮，因为大腿虽然离生殖器很近，但它根本不是快感的核心激发器官。女性获得性高潮的真正中枢是阴蒂（Clitoris），绝大多数女性无法仅凭插入达到高潮，纯粹是因为阴蒂在解剖位置上处于阴道口上方，普通的轴向抽送很难对其施加有效刺激。 翻开小阴唇向上追踪，会看到覆盖在阴蒂表面的包皮（Prepuce/Hood）；退开包皮所露出的阴蒂头（Glans），仅仅是整座巨大器官的“冰山一角”。Dr. Rachel Rubin 指着自己脖子上的黄金阴蒂项链解释道，阴蒂是一个向下延伸至坐骨分支的庞大复合结构。在显微镜下观察，它的组织构成与男性的阴茎完全一致，本质上就是一座“内嵌在体内的阴茎”。然而现代医学为男性的阴茎设立了专门的男科学与泌尿外科分支，却几乎没有任何医学院系统性地教导医生如何定位和检查女性的阴蒂，这种体系化的无视直接导致了女性在卧室中的长年困惑。 - **高潮缺失率**：约 20% 的女性报告无法体验性高潮，而同等比例的男性并不存在此类器质性困扰。 - **解剖同源性**：阴蒂在显微镜下的海绵体组织与阴茎完全相同，具备充血挺拔的勃起机制。 - **医学教育盲区**：常规医学教育未将阴蒂检查纳入妇科或泌尿科标准查体流程。 --- ### [58:10](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3490s) 阴蒂粘连：被忽视的隐秘解剖病症 在阻碍女性快感的器质性因素中，“阴蒂粘连（Clitoral Adhesion）”是一种发生率惊人但极少被大众甚至临床医生所知的病症。Dr. Rachel Rubin 用自己的衣袖作比喻：正常情况下，阴蒂包皮应当能够自由向后滑动退缩，完整露出形状类似蘑菇冠状边缘的阴蒂头；然而在临床中，约有 23%（接近四分之一）的女性，其阴蒂包皮会与阴蒂头发生纤维化粘连，导致阴蒂头被死死卡住无法显露，局部极易积聚皮脂脱落物并引发慢性炎症和钝化。 面对主持人“每五个女人里就有一个出现粘连”的震惊追问，Dr. Rachel Rubin 引用了其团队发表的学术研究数据：在门诊环境下通过极简微创的操作松解分离这些粘连后，患者的性高潮质量、性唤起状态和整体性满意度改善幅度高达 60% 至 70%。如此高发且极易矫正的物理结构问题，在主流医学中却几乎处于完全隐形的状态。 造成这种局面的根本原因在于，几乎没有医生在常规盆腔检查中会翻开阴蒂包皮进行触诊与外观评估，更极少主动询问女性的性高潮与性满意度情况。女性即使带着性交疼痛或性欲低下的主诉求医，得到的也往往是轻描淡写的心理学解释。Dr. Rachel Rubin 直言，这种疏忽并非“我们经过医学权衡后不该做”，而纯粹是“医学界从未有人去做过”。 | 观察维度 | 阴蒂粘连（Clitoral Adhesion）现状 | |:--- |:--- | | **人群发生率** | 临床数据统计显示约为 **23%**（接近 1/4 的成年女性） | | **解剖特征** | 阴蒂包皮（Hood）与阴蒂头（Glans）粘合固定，无法退缩显露冠状边缘 | | **临床治疗** | 门诊即可完成的微创机械分离/松解术 | | **术后改善** | 患者的性唤起、性满意度及高潮功能可提升 **60% - 70%** | | **诊疗现状** | 常规妇科检查极少进行阴蒂专项查体，漏诊率极高 | --- ### [59:35](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3575s) 性玩具的医疗价值与男性对唤起的认知误区 由于女性的核心勃起与快感器官大部分深埋在骨盆内部，Dr. Rachel Rubin 提出了一个极具颠覆性的思考模型：设想男性的阴茎如果全部退缩进体内（例如体重达到500磅、下腹脂肪完全将其遮盖），无法通过手部直接握持刺激，“那么男人们会如何达到性高潮？”在那种情况下，振动棒行业绝不仅是一个价值十亿美元的市场，而是会变成“数万亿美元的超级产业”。外部震动能够穿透浅表组织，有效激活深层海绵体的血流与充血机制，因此外置振动器对女性来说绝非边缘化的情趣道具，而是至关重要的生理促反应工具。现场展示的骨盆理疗棒（Pelvic Wand）更具备物理治疗功能，深入阴道内部针对肌筋膜激痛点（Trigger points）进行震动放松，消除深层肌痉挛并促进血运。 针对异性恋关系中男性常常陷入的误区，Dr. Rachel Rubin 直言不讳地指出，男人们在探讨性能力时，往往极度焦虑于自身的生理参数——“想要阴茎更粗、更硬、更直、更长、持续时间更久”。然而从女性的生理机制来看，这些机械参数与女性体验快感和高潮几乎没有直接关系。男性真正应该探寻的是：女性的身体地图到底如何分布？阴蒂的立体解剖结构是怎样的？需要哪些脑部心理信号与情感铺垫才能点燃女性的性欲望？ Dr. Rachel Rubin 呼吁伴侣之间应当放下焦虑，建立起开放好奇的沟通机制，甚至建议伴侣们一起收听这期播客并展开坦诚对话。由于大部分女性自身也从未接受过科学的性解剖教育，伴侣间完全可以共同对照图谱探索彼此的身体：“我们可以一起看看你的阴蒂结构吗？你喜欢触碰哪个部位？”她特别提醒，阴蒂头部聚集了多达约 10,000 个密集的感觉神经末梢，其神经密度极高，许多女性直接接受强烈的外力直擦反而会感到刺痛或过敏不适，唯有通过充分的沟通、调试与多维探索，才能真正找到适合彼此的快感通路。 - **振动机制**：震动波能够深入软组织，促使内生海绵体充血膨胀，弥补纯物理接触的局限。 - **男性盲区**：过度将精力聚焦于阴茎的硬度、尺寸与抽插时长，忽视了神经心理唤起与阴蒂外部复合刺激。 - **高敏感度特征**：阴蒂含有约 10,000 个神经末梢，直接施压可能产生过度刺激或痛感，需讲究间接刺激与手法配合。 ### [01:02:15](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3735s) 阴蒂刺激与高潮体验：性高潮之后的生理反应与“三明治法则” 在谈及性刺激的手法时，Rachel Rubin 医生指出，由于阴蒂聚集了海量的神经末梢，直接按压或摩擦阴蒂头部有时会造成过度刺激而产生不适感。每位伴侣的偏好大相径庭：有人喜欢直截了当的触碰，有人则需要避开顶端、仅抚触外围区域，还有许多人必须依赖震动器具提供的高频刺激。Steven Bartlett 提问，只要给予足够的刺激，女性是否就会迎来高潮？Rubin 医生解释道，性高潮本质上是快感不断蓄积后的集中释放（"a build-up and release of pleasure"），而这一过程在单纯的穿透式性交中往往难以自然发生。 针对高潮发生后的身体反应，Steven 从男性生理角度提出疑问：男性射精后通常会出现明显的性唤起骤降，往往出于极度敏感而不愿再被触碰，女性是否也是如此？Rubin 医生证实，女性在高潮瞬间之后同样会经历组织高度敏感、暂时不希望被碰触的阶段；但两者的关键差异在于，女性恢复得往往更快，且具备多次性高潮的生理潜能。 ```mermaid flowchart TD accTitle: 伴侣性爱节奏协调与三明治模式 accDescr: 展示如何在性爱过程中合理安排阴蒂刺激、休息间隙、穿透与男性高潮的节奏流程 subgraph Phase1["第一阶段：唤起与前置高潮"] A["外围/阴蒂适度刺激与震动辅助"] --> B["女性达成第一次性高潮"] end subgraph Phase2["第二阶段：缓冲与过渡"] B --> C["高敏感期暂时休整"] C --> D["穿透性互动 / 满足男性高潮"] end subgraph Phase3["第三阶段：潜在第二轮"] D --> E["女性敏感度恢复"] E --> F["尝试第二轮刺激与多次高潮"] end ``` 这种生理差异为伴侣之间的互动顺序带来了丰富的可能性。Rubin 医生将性爱形容为一场“双人舞”：许多男性往往在自己射精后便宣告互动结束，倒头大睡；但伴侣完全可以通过沟通重新排布节奏。例如采用“三明治法则”（sandwiching）——先通过刺激让女性获得高潮，随后在其高度敏感的组织需要休息时进行穿透，待男性完成高潮或女性敏感度平复后，再视双方意愿决定是否开启第二轮。这种节奏安排不仅照顾了双方不同的不应期，也让互动更具包容性。 --- ### [01:03:35](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3815s) 穿透性性交的作用与高敏感假说：女性到底从中获得了什么？ 面对“既然绝大多数快感来源都在外部的阴蒂，女性究竟能从穿透性性交中获得什么”的疑问，Rubin 医生的回答十分坦诚：“很多时候什么也得不到，但很多时候收获的是深层的情感联结。”对许多女性而言，穿透满足的是对亲密、依偎与情感归属的渴望。当然，个体解剖结构存在差异，部分女性的阴道穹窿顶部及宫颈周围分布着较多神经末梢，因而能够纯粹从穿透中体会到强烈的肉体欢愉。然而，绝大多数女性的主要快感核心依旧在阴蒂，穿透应当被视作整套亲密体验“菜单”中的一道菜，而非涵盖全部的唯一主菜。Rubin 医生无奈地透露，现实中不少女性主动要求穿透，仅仅是出于“完成任务”的心态——因为她们知道只要男方射精，性事就会结束，自己便能去睡觉或看书。 ```mermaid flowchart LR accTitle: 男女性极速高潮的对照假说 accDescr: 对比男性早泄与女性穿透即高潮在解剖敏感度和文化评价上的差异 subgraph Male["男性群体（约 8%）"] M1["神经末梢极度敏感"] --> M2["1分钟内射精 / 早泄"] M2 --> M3["社会/医学评价：功能障碍"] end subgraph Female["女性群体（假说约 8%）"] F1["阴道与宫颈神经高敏感"] --> F2["仅凭穿透即可快速高潮"] F2 --> F3["社会/文化评价：完美天赋"] end ``` 针对少数仅凭穿透就能达到高潮的女性，Rubin 医生提出了一个颇具启发性的假说：医学界统计大约有 8% 的男性存在原发性早泄问题，能够在 1 分钟之内达到高潮；若男女生理结构具备同源对称性，完全有理由推论同样存在约 8% 的女性拥有天生超敏感的神经分布。这类女性仅凭单纯的阴道穿透就能迅速迎来“不可思议的高潮”。讽刺的是，同样的超高敏感度表现在男性身上往往被诊断为疾病，在女性身上却被外界奉为令人羡慕的“天赋”。 - 阴道神经末梢分布并不均等，主要集中在阴道外三分之一及少数特定区域（如部分人群的阴道上壁与宫颈附近）。 - 绝大多数女性若缺乏外在阴蒂刺激，单纯依靠活塞式穿透难以触发高潮反射。 --- ### [01:05:20](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3920s) 色情片对性观念的扭曲：男性导向的算法与女性的“自我怀疑” 两性对穿透快感的巨大误解，很大程度上源自现代成人色情工业的灌输。Rubin 医生尖锐地将色情片比作职业摔角联盟（WWF/WWE）：“它全都是人造的戏剧表演。”色情片的镜头调度与叙事机制完全由激发男性兴奋的算法和商业逻辑驱动，根本脱离了现实中女性真实的愉悦体验。这导致许多人从未思考过伴侣在现实中真正想要什么，更忽略了“完全不发生穿透也能拥有绝佳性爱”这一事实。 Steven 援引主流色情网站的数据指出： - 像 Pornhub 这样的头部平台上，约 65% 的访客为男性。 - 独立调研显示，18 至 35 岁的年轻男性中，有 75% 至 95% 承认经常观看色情片。 - 同一年龄段的女性中，仅有约 34% 保持规律观看习惯。 这种消费群体的严重失衡，意味着成人产业必然全力迎合男性幻想。大量年轻男性将色情片作为性启蒙教材，误以为片中女演员浮夸的穿透反应就是现实常态，并把这套模式生搬硬套进恋爱关系中。更严重的是，这种信息错位让无数女性陷入自我怀疑。Rubin 医生的门诊中充斥着哭诉自己“坏掉了”（"I'm broken. You have to fix me"）的女性患者，她们因无法在穿透中达到高潮而自卑，但实际上她们用手、震动棒甚至淋浴水流刺激阴蒂时都能顺畅地体会到美妙高潮。直到 Rubin 医生拿出解剖模型向她们解释阴茎与阴蒂在胚胎发育上的同源性——“让男性高潮需要激活阴茎，让女性高潮同样需要激活阴蒂”——患者们才如释重负，意识到自己自始至终都是完全健康的正常人。 --- ### [01:07:38](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4058s) 健康的色情作品与亲密关系：欺瞒才是破坏信任的元凶 谈及色情制品的价值，Rubin 医生的态度非常开明。她认为色情本身并非洪水猛兽，问题在于作品的形式与摄入的模式。她以近年来引发巨大社会反响的冰球题材小说及影视作品《热烈竞争》（*Heated Rivalry*）为例——该剧讲述两名青年男子之间的浪漫情感与密集的亲密互动，尽管实质上具有鲜明的成人色情属性，却在异性恋女性群体中引发了前所未有的狂热追捧与多轮反复观看。这证明女性同样拥有强烈的视觉与心理情欲需求，只是更偏向于包含情感拉扯、浪漫张力与相互吸引的叙事模式。 当讨论转向“伴侣一方过度沉迷色情是否会摧毁现实性欲”时，Rubin 医生指出不能一概而论。在成熟的关系中，色情片甚至可以作为调剂工具，例如双方共同观看，或者作为性欲不匹配时的调节方案（性欲旺盛的一方通过色情自行解决，双方定期约定高质量的真实互动，不必强求步调时时一致）。 ```mermaid flowchart TD accTitle: 隐瞒性色情消费对亲密关系的破坏循环 accDescr: 说明秘密消费色情片如何通过生理耐受与信任破裂双重途径恶化伴侣关系 P1["单方面隐瞒、秘密消费色情片"] --> P2A["欺骗与背叛感曝光"] P1 --> P2B["多巴胺奖赏回路受损与过度脱敏"] P2A --> P3A["伴侣产生严重不安全感与被拒绝感"] P2B --> P3B["现实互动中表现焦虑 / 勃起障碍"] P3A --> P4["情感联结断裂与性满意度暴跌"] P3B --> P4 ``` Steven 补充了多项元分析研究的结论：长期单独、秘密消费色情制品与较低的关系满意度及性满意度呈现高度正相关。其核心破坏力主要表现在以下方面： - **欺骗与背叛**：伴侣一旦发现对方在暗中隐瞒色情使用，极易触发剧烈的背叛感、被排斥感与容貌焦虑。 - **神经回路脱敏**：重度单人消费会钝化大脑的多巴胺奖赏系统，导致面对真实伴侣时出现表现焦虑乃至勃起功能障碍。 - **不切实际的锚定**：过度脱离现实的体型、持久力与场景呈现，会让日常真实的性生活显得平淡乏味。 对此 Rubin 医生深表认同，并强调核心症结永远在于“隐瞒与欺骗”（deception）。只要互动建立在坦诚沟通的基础之上，性爱的方式与工具并无绝对优劣；一旦丧失了开诚布公的透明度，伴侣之间的亲密联结便会从根本上瓦解。 ### [01:10:19](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4219s) 色情脱敏与单一快感模式对真实亲密的伤害 双方继续探讨了色情内容对大脑机制的重塑。主持人指出，色情内容会带来一种脱敏效应（desensitization），具体危害往往取决于一个人使用它的方式。如果一个人长期依赖特定画面的刺激来自慰，大脑实际上是在接受定向训练，逐渐习惯于只能通过某种极其特定的路径来获得快感。当这个人回到现实中与真实的伴侣相处时，伴侣几乎不可能完美复现那种刻板而强烈的刺激方式。 鲁宾医生对此完全赞同。她强调，这正是许多人面临的核心问题：如果你只能在某一个特定姿势下、看着某一段特定情节的视频才能达到高潮，这种高度机械化和条件反射式的快感模式，根本无法转化为与真实伴侣之间充满温存与互动的高质量亲密关系。 --- ### [01:10:53](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4253s) 脆弱感是通往深度连结的入口（赞助中插） 主持人在此插播了节目的赞助信息。首先是他针对创作者痛点历时数年开发的播客托管与增长平台 Flight School（flightcast.com/doac）。该平台旨在解决创作者在 YouTube、Spotify 等不同平台间重复上传超大视频文件的繁琐摩擦，利用 AI 工具提供深层数据分析与增长赋能。随后，主持人分享了自己主持近 700 场深度访谈后的深刻感悟——“脆弱感是通往连结的大门”（vulnerability is the doorway to connection）。每次与嘉宾促膝长谈两三个小时后，嘉宾离场前都会在日记本中留下一道直击心灵的问题。制作团队将这些问题制作成了《CEO日记》对话卡片（The Diary of a CEO Conversation Cards，可在 the-diary.com 获取），主持人经常与未婚妻、同事和家人一起抽取探讨。他感慨道，在高度数字化的时代，一个恰逢其时的问题往往能让人在实体世界中重新找回人与人之间真实的灵魂共鸣。 --- ### [01:13:01](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4381s) 自发性欲望与反应性欲望：性爱为何越来越无趣？ 广告结束后，主持人将话题引向性兴奋机制的差异，提到曾有性学专家向他解释过男性和女性在唤起模式上的不同：自发性欲望（Spontaneous Desire）与反应性/唤起后欲望（Responsive Desire）。鲁宾医生对此予以证实并展开剖析：前者是一种“我现在就想做爱、已经准备就绪”的主动状态；而后者则是“我们开始接触、身体逐渐进入过程之后，我才被唤醒并投入其中”。 鲁宾医生用健身打了个非常生动的比方：有些人天生像健身狂热分子，时刻跃跃欲试想冲进健身房；但还有很多人根本不想去锻炼，可是一旦他们换上衣服开始活动身体，就会意识到“这对我很好，感觉棒极了，我应该继续做下去”——对很多人而言，性生活也是完全相同的逻辑。但她犀利地指出，问题的关键还在于两个人究竟在进行怎样的性生活。如果每次性爱都是千篇一律的姿势、节奏与套路，既无趣味也无法满足对方的需求，伴侣又怎么可能对此充满期待与渴望？很多时候，这根本不是什么生理性的“低性欲”，而是因为性爱已经索然无味，且双方从未就此开诚布公地复盘与改进。她幽默地调侃，就像做一个播客，如果每周请同一个嘉宾、聊完全相同的话题，节目早就办不下去了；做内容的人懂得不断复盘“什么是有效的、什么是无效的、算法现在偏好什么”，但在床笫之间，几乎没有伴侣会坦率询问：“亲爱的，刚才感觉怎么样？我们喜欢什么？有什么需要调整的？” ```mermaid flowchart TD accTitle: 欲望类型的演进路径 accDescr: 展现自发性欲望与反应性欲望的不同启动机制以及良好沟通对长期欲望的维持作用。 subgraph Types["唤起模式分类"] A["自发性欲望 (Spontaneous)"] -->|"内在自驱 / 随时就绪"| C["进入亲密互动"] B["反应性欲望 (Responsive)"] -->|"需要前奏与物理刺激启动"| C end subgraph Dynamics["长期性关系维系"] C --> D{"性爱体验质量"} D -->|"千篇一律 / 缺乏沟通"| E["丧失期待 / 表现为'伪低性欲'"] D -->|"尝试新方式 / 坦诚复盘"| F["正向反馈 / 渴望下一次亲密"] end ``` --- ### [01:14:15](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4455s) 沉默与误解如何摧毁亲密关系：Steven 的切身之痛 当被问及“为什么人们无法在性事上坦诚沟通”时，鲁宾医生认为，这与人们羞于谈论金钱类似，背后是深层的禁忌感。主持人结合自身经历补充道，性是一个极其私人、容易让男性自尊受挫（emasculating）且与自我价值感深度绑定的脆弱话题。 主持人动情地分享了自己 22、23 岁时的一段切肤之痛：当时交往很久的伴侣突然对他说，自己“根本不喜欢做爱”。年轻的他完全不知道女方其实正承受着未被诊断出的生理疾病折磨，听到这句话后他看着镜子深感羞辱，满脑子都是“天哪，一定是我在床上表现太差了”。那种自尊受挫的痛苦不仅深深刺痛了他，也最终导致了感情的破裂。而女方之所以隐瞒真实的生理不适，竟然是以为不说出来是在“保护他的男性自尊”。更荒谬的是，当他痛苦地向最好的朋友倾诉时，这位同样 30 岁左右的好友竟然回答：“我女朋友也是这样，我们已经整整 3 个月没有性生活了，她说她就是天生不喜欢性。”两个年轻男人只能得出极其愚蠢且匮乏的结论：“也许是我的问题，也许是她的性取向问题，或者她是天生基因里就没有性欲。” 主持人感慨，正是因为缺乏正确的医学与生理教育，人们在面临性困境时往往会草率得出“不可逆转”的荒谬结论，进而判定“这段关系彻底没救了”，最终毁掉了一段原本极其美好、完全可以挽救的亲密关系。鲁宾医生感慨地表示，这段经历极具普遍意义： - 伴侣出于保护对方自尊的沉默，反而造成了更大的猜忌与裂痕。 - 只要掌握哪怕一点点生理学常识，伴侣之间就会产生巨大的同理心，明白这不是“谁不行”的能力问题，而是一个始于生物学层面的健康问题。 - 如果全社会能够像谈论普通健康一样坦然讨论生殖器官与性健康，不再将它们视作见不得人的“私密部位”，人们在成长过程中就能免受无数羞耻、内疚与心碎的折磨。 ### [01:18:01](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4681s) 自发性欲望与反应性欲望的男女差异 对话从男女在性唤起模式上的生物学统计差异展开。Steven 援引了一组关键的研究数据并做出解读：男性通常偏向“自发性欲望”（spontaneous desire），即字面意义上的“光是脑子里想到某件事就能唤起”；相比之下，女性更偏向“反应性欲望”（responsive desire），也就是一旦“船开动了”、前戏开展或身体接触发生之后，性欲才会被激发。 ```mermaid flowchart TD accTitle: 性唤起模式男女对比 accDescr: 对比男性和女性在自发性、反应性及混合型性唤起模式中的比例分布 subgraph M["男性唤起模式分布"] M1["自发性欲望: 约 70%"] M2["反应性欲望: 10% - 15%"] M3["混合型欲望: 15% - 20%"] end subgraph W["女性唤起模式分布"] W1["自发性欲望: 10% - 15%"] W2["反应性欲望: 40% - 50%"] W3["混合型欲望: 约 35%"] end ``` Rachel Rubin 医生对这组数据的准确性表示高度认同。她指出，理解这背后的生物学事实是改善亲密关系的关键。很多伴侣之间爆发的痛苦与断联，本质上是因为彼此缺乏基本的生理教育与坦诚沟通。很多男性处于痛苦和孤立中，无法与伴侣建立联结，甚至找不到伴侣，原因往往在于他们缺乏真正的好奇心——不去探索眼前这个具体的伴侣到底想要什么、需要什么。女性在关系中寻找的，正是那种“真正在意并关心她具体需求”的伴侣，而不是泛泛地琢磨“女人想要什么”。一段健康的关系，是双方协同合作，为彼此优化那种色情之爱、支持感、联结与欲望。 - 男性自发性性欲占比高达约 70%，而女性仅有 10% 至 15%。 - 女性反应性性欲占比达 40% 至 50%，男性仅有 10% 至 15%。 - 混合型（兼具自发与反应）在男性中占 15% 至 20%，女性中占约 35%。 ### [01:20:38](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4838s) 伴侣应该问的最核心问题与偏好分歧的妥协 当 Steven 提到常有听众情侣在餐厅或飞机上偶遇他，并表示最喜欢一起听关于性话题的播客时，他询问 Rubin 医生：伴侣之间到底该如何开启这类对话？Rubin 医生直言，最基础也最核心的问题非常简单：“对你来说，美妙的性爱意味着什么？”当被问及能从性中获得什么时，人们通常能列出两百种截然不同的理由。由于每个人想要的不同，甚至连自己都不清楚要什么，保持共同探索的好奇心就尤为关键。 Steven 随即抛出一个现实难题：如果两人深入沟通后，发现彼此的性唤起方式完全相反怎么办？比如一方希望“被绑起来，来点刺激的”，而另一方却只想要“极致温柔、缓慢而轻柔”，这种喜好的鸿沟是否意味着谁也无法满足？Rubin 医生用买房做比喻：“去买房时，除非你自己建，否则不可能完全由着心意挑出一套百分之百契合的房子，生活处处需要妥协。” Rubin 医生进一步直指现代色情内容和 AI 潜藏的危机：色情片让人沉溺于量身定做的精准刺激，未来甚至可能出现完全迎合个人需求的 AI 性爱机器人，但这对真正的亲密关系是危险的。因为真实的性“本身就是混乱的、尴尬的、有气味的、有体液的、会发出滑稽声响的”，且充满脆弱与不适。然而，能够与一个人在知晓彼此全部真实一面的前提下共同探索，正是人际亲密中最美妙、最有趣的部分。对于无法调和的非原则性或原则性差异，人们也会选择不同的模式，包括知情同意的开放式关系，或是仅将某些特殊癖好保留在纯粹的幻想层面，而不必非要在现实中执行。 ### [01:23:50](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5030s) 如何跨越性癖与幻想的羞耻：沟通工具与日常复盘 针对很多人有隐秘幻想（kinks/fantasies）却因恐惧伴侣反应而不敢启齿的现象，Rubin 医生建议借助第三方力量或数字工具来破冰： - **性治疗（Sex Therapy）**：让专业的性心理医生作为中立第三方引出话题，远比一个人单打独斗开口要轻松得多。 - **互动应用测试**：例如像 *Spicer* 这样的伴侣应用，双方在各自手机上匿名勾选感兴趣的亲密玩法或问题，系统只会在双方同时勾选“同意”时向彼此揭晓匹配项，以此循序渐进地试探边界。 Rubin 医生特别强调了一个极为关键的沟通原则：**谈论性的最佳时机，绝不是双方赤身裸体躺在床上正准备发生性行为的时候**。就像制作播客会在录制前后与团队开复盘会（“今天哪里做得好，哪里不理想，下次做哪些调整，以后别再请某位嘉宾了”）一样，性爱也需要健康、冷静的“事后行动复盘”（after action review）。伴侣双方可以在日常生活场景下平等讨论：“上次我们尝试的那个感觉如何？有没有什么是你很喜欢或者不喜欢的？以后还想不想再试试？” ### [01:25:07](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5107s) 诊室里的秘密：伴侣间到底在隐瞒什么 谈及自己的性医学专科工作，Rubin 医生充满了由衷的热爱：“我的工作太有趣了，我超级喜欢我的工作！”在她的诊所里，初诊往往会花上整整两个小时，全面深入地梳理患者整个人生维度下的性健康状况。绝大多数人哪怕跟自己的枕边人，也从未有过如此深度且毫无保留的倾诉。这种极度脆弱的表达，能让患者第一次卸下重担，真正认识自己的身体。 当 Steven 追问“男性和女性在向你倾诉时，通常对伴侣隐瞒了什么？两者的隐瞒有何不同”时，Rubin 医生的回答揭示了一个严峻的普遍现状：绝大多数伴侣根本完全不谈论性。而在这层沉默之中，存在着明显的性别差异——其中最触目惊心的是，女性在性生活中一直在向伴侣隐瞒自己的身体疼痛。 ### [01:26:02](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5162s) 假高潮的真相与被颠覆的“高潮顺序” 伴侣之间在性生活中的隐瞒极其普遍。男性往往在深重的羞耻感中隐藏对勃起功能障碍（ED）的焦虑与挫败感，而女性则常常在整个恋爱或婚姻关系中伪装高潮。医学与科学统计数据揭示了一个残酷的时间错配：在异性性行为中，从阴茎进入阴道开始计算，男性平均射精潜伏期约为 5.5 分钟；而女性若仅通过活塞式抽插，极少有人能在 5.5 分钟内达到高潮，女性通常需要至少 13 到 15 分钟专注且持续的阴蒂刺激。如果女性伴侣每次都在男性的这 5.5 分钟内像上了发条一样准时高潮，Dr. Rachel Rubin 直言“其中有极高比例是在演戏”。女性之所以伪装，并不是因为性体验糟糕，而是出于保护伴侣的自尊心，希望对方开心并感到被认可。 这种生理现实让传统的性爱步骤显得极不合理。Dr. Rachel Rubin 明确主张：在异性性交中，理应让女性先达到高潮。女性先体验到高潮，能够促使盆底肌群充分放松与释放压力，从而让接下来的抽插渗透更顺畅、更愉悦。更重要的是，女性具有多重高潮的生理潜能，完全可以在前戏获得一次高潮，在后续过程中继续体验快感。当下社会存在的“高潮差距”（Orgasm Gap）让男性次次高潮、女性颗粒无收，而打破这一困局的核心就是不再把阴道抽插当作性爱的“唯一重头戏”，抽插只是整体亲密拼图中的一部分，而非主宰一切的终点。 ```mermaid flowchart TD accTitle: Orgasm Gap and Solution Workflow accDescr: 展示异性性行为中时间错配导致的高潮差距以及让女性优先高潮的生理解决方案。 subgraph Problem["生理时间错配与伪装现状"] A["男性抽插潜伏期<br/>平均约 5.5 分钟"] -.-> C["严重时间错配"] B["女性阴蒂专注刺激<br/>通常需要 13-15+ 分钟"] -.-> C C --> D["女性伪装高潮以迎合伴侣<br/>造成持久的『高潮差距』"] end subgraph Solution["优化路径：打破抽插中心主义"] E["前戏聚焦阴蒂刺激<br/>确保女性率先达到高潮"] F["女性盆底肌肉释放与深度放松"] G["抽插渗透过程更舒适欢愉<br/>开启潜在多重高潮体验"] E --> F --> G end Problem ==> Solution ``` - **平均生理潜伏期**：科学研究显示，男性从进入到射精的平均时长约为 5.5 分钟，短于或长于此均属于正常生理谱系。 - **女性高潮所需时间**：女性通常需要 13 至 15 分钟以上的专注阴蒂刺激才能触发高潮，抽插伴随的注意力分散会使这一过程更长。 - **高潮差距（Orgasm Gap）**：女性常在伴侣获得一次高潮时经历零高潮，而女性生理上具备在单次性爱中经历多次高潮的能力。 --- ### [01:28:26](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5306s) 多巴胺耗竭与戳破“自发性冲动”的神话 现代社会快节奏的生活方式正在造成严重的“多巴胺耗竭”（Dopamine Drain）。长期的精神内耗、慢性压力、过度劳累以及缺乏充足睡眠，直接抑制了人的性欲。如果一个人毫无喘息的白昼空间，睡前持续刷手机、频繁消费色情内容或沉迷言情小说，却忽视了眼前活生生的伴侣，性冲动的消失在生理上是完全可预测的。流行文化中常将性爱描绘成突如其来、在走廊激情拥吻的浪漫桥段，Dr. Rachel Rubin 将这种“自发性神话”嘲讽为如同“职业摔角（WWF）一样脱离现实”。在现实生活中，朝夕相处、互相见证过最疲倦暴躁模样的同居伴侣，根本不可能凭空涌现出如同电影般野生的激情。 这也是度假时的性生活往往更美满的原因：伴侣摆脱了家务、加班与孩子的噪音干扰。针对“按日程安排性爱会导致表现焦虑”的顾虑，Dr. Rachel Rubin 提出了极为落地的处方。正如恋爱约会期人们会提前几天定在周六晚外出、满心期待并精心打扮一样，规划性爱本质上是成年人的情趣管理。她在华盛顿特区接触过大量高压高管客户，推荐的黄金法则之一是“季度伴侣日”（Quarterly Dates）： - **季度专属日程**：每个季度挑出一个周五，双方提前在日程表上完全封锁时间，将其定义为专属的伴侣日。 - **卸除单次绩效压力**：这并不意味着当天必须执行机械化的性交，可以是一起徒步、泡澡、按摩或深入交谈，重拾“原来我们依然喜欢彼此”的纯粹联结。 - **投资情感土壤**：当伴侣间的日常对话不再局限于孩子和家务账单，愉悦与爱意得到灌溉，性生活的品质便会自然回归。 --- ### [01:32:04](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5524s) 身体羞耻、性萧条与重塑亲密话语权 阻碍优质性爱的另一大无形高墙是自我认同障碍与身材焦虑。女性往往将巨额的心理能量消耗在“想要变瘦”的执念中，而非追求身体的“健康与力量”。在这方面存在着极其荒谬的双重标准：当人们看待超重的好友时，会毫无保留地认为“无论体型与体重如何，她都绝对配得上美好的性爱与极致的高潮”；但一旦面对镜子中的自己，内心便充斥着惩罚性的苛责，认为自己不瘦就不配脱光衣服、不配享受高潮。 这种身体自卑加剧了当前广泛蔓延的“性萧条”（Sex Recession）。现代人发生性关系的频率降至历史低点，宁愿长时间滑手机屏幕或沉迷于 AI 聊天机器人，也不愿进行真实的肉体与情感交互。Dr. Rachel Rubin 强调，走出性萧条必须依靠科学认知带来的去羞耻化（Empowerment）与彻底的坦诚沟通。当人们获得关于身体结构、神经机制与性反应周期的正规医学教育，才能解构原本笼罩在性爱上的狭隘预设，将性从压抑和冷漠中拯救出来，重新找回人类独有的温存与纯粹欢愉。 ### [01:33:51](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5631s) 女性生理机制被长期忽视与伴侣共同诊疗的价值 雷切尔·鲁宾医生（Dr. Rachel Rubin）指出，医学界和公众在探讨女性性健康时，往往将绝大部分精力耗费在心理社会因素（psychosocial issues）和情绪层面。尽管心理与情感不可或缺，但这种倾向往往导致女性真实的“生理机能”（biology）被极度淡化甚至彻底忽视。她强调，女性必须学会为自己的身体生理发声，医学界也必须重新受训去重视女性的生理机制。鲁宾医生甚至现场向主持人史蒂文·巴特利特（Steven Bartlett）提议，去问问身边所有的女性朋友和团队女员工，了解她们在就医时究竟遭遇了何种缺乏好奇心与同理心的冷落。 针对这种生理维度的缺失，鲁宾医生分享了她在临床中独特的诊疗方式：她会为每位患者预留长达整整两个小时的问诊时间，并极力鼓励伴侣一同参与。很多时候，伴侣不仅能亲耳听到对方的真实痛苦，还能直观观摩检查过程，如同经历了一场对自己伴侣身体构造的“深度导览”。鲁宾医生常常直接向伴侣展示事实：“她不愿与你亲热，并不是因为你床上技术糟糕，你看她外阴开口处的组织，娇嫩得如同重度晒伤；我仅仅用一根医用棉签轻轻触碰，她就如同置身火海，疼得跳起来。试想一下，你的阴茎进入时会带给她怎样的折磨？”这种直观的生理认知，瞬间击碎了伴侣的自我防御（“这不是关于我的自尊问题”），从而转向“我该如何全力支持她”。同理，鲁宾医生也列举了男性服用抗抑郁药或防脱发药物导致性欲低下的反向案例——若伴侣理解药理机制，就不会胡思乱想判定为“你不爱我了”。理解生理真相，往往是消除亲密关系内耗的第一步。 ```mermaid flowchart TD accTitle: 伴侣对性功能障碍认知的转变机制 accDescr: 展示从心理归因到理解生理机能的认知转变过程 subgraph 传统误区["传统心理化归因（加剧隔阂）"] A["性欲下降 / 拒绝同房"] --> B{"误判为情感与能力危机"} B --> C["伴侣自尊受挫：'你是不是不爱我了？'"] B --> D["自我否定：'一定是我床上技术太差'"] end subgraph 循证生理视角["引入生理机能认知（促成理解与支持）"] E["身体检查与药理机制解析"] --> F{"辨析客观生理病因"} F --> G["局部病理：如前庭部充血疼痛如同晒伤"] F --> H["药物副作用：如抗抑郁药、生发药抑制性欲"] G & H --> I["解除心理归咎：'这并非感情破裂，而是需要治疗的生理病症'"] I --> J["携手共情与科学治疗"] end ``` ### [01:35:46](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5746s) 沟通与冲突修复：决定关系走向 99% 还是 101% 的分水岭 史蒂文深刻认同这一观点，并指出一切的核心归宿在于“教育”与“沟通”。他感慨如果自己在成年之初就能获得充分的性生理教育，并掌握与伴侣乃至与自我坦诚沟通的技能，不仅恋爱关系会截然不同，整个人际网络都将受益匪浅。然而现实中，性与身体是极度敏感脆弱的话题，大多数人宁愿保持沉默，将困惑当成只在深夜与闺蜜窃窃私语的秘密，甚至在痛苦中对自己和伴侣进行情感欺瞒（gaslighting）。 谈及亲密关系的本质，史蒂文引用了一句令他印象深刻的名言：“衡量一段关系长期健康程度的标准，在于每次冲突之后，你们是修复到了 101% 还是滑落到了 99%。”冲突在生命中不可避免，关键在于如何处理——是让矛盾成为强化关系的淬火剂，还是任其成为削弱信任的裂缝。这完全取决于双方的沟通策略： - **表达安全感**：伴侣在表达真实诉求或遭遇问题时，内心是否感到足够安全而不必恐惧被苛责； - **倾听与接纳**：在面对看似指责的反馈时，自己能否放下防御心态去认真倾听； - **探寻解决路径**：双方是否带着开放与好奇的态度共同寻找方案，而非固守预设立场。 史蒂文以自己近 7 年的感情经历反思道，无论是夫妻间常见的金钱矛盾还是性生活危机，其底色都是“冲突解决与沟通能力”。他观察到身边的伴侣呈现两个极端：一类人下午 6 点回家就能毫无保留地探讨最敏感情感议题；另一类人却像住在同一屋檐下的陌生人，把所有问题“塞进壁橱”。史蒂文提到一位相处 14 年并育有孩子的朋友，因产后停止性生活且常年避而不谈，最终两人沦为渐行渐远的平行线，多年后只能茫然发问“我们的婚姻究竟怎么了”。 ### [01:39:08](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5948s) 走出“假装风平浪静”：为何需要第三方专业介入与恰当的语言 鲁宾医生对史蒂文的洞察给予了极高评价，称赞他在节目中展现出的好奇心、脆弱感与求知欲正在激励更多人去正视这门科学。面对鲁宾医生的夸赞，史蒂文坦露了更深层的脆弱：人们口口声声说深爱对方，却往往因为害怕尴尬和不适，不敢就最敏感、最棘手的问题展开交流。鲁宾医生追问他过往展示脆弱时的体验，史蒂文由衷感叹：“那是做过的最重要的事情，事后我总在想‘我为什么没有早点迈出这一步？’”。 史蒂文诚实地反思了自己过去的盲区：在关系的最初一年里，他从未与伴侣主动讨论过性生活细节，彼此单方面盲目预设“既然她没抱怨，那肯定很享受”。直到伴侣主动打破沉默推动沟通，他才如梦初醒。他指出男性群体中普遍流行一种略带毒性的处世哲学——所谓的“老婆高兴，日子舒坦”（Happy wife, happy life），导致许多男性潜意识里误以为“只要没人发火抗议，一切就风平浪静”。但事实上，“一个巴掌拍不响”（It takes two to tango），表面的沉默往往掩盖了真实的隔阂。 鲁宾医生进一步阐明，苛求伴侣天生就拥有精准的医学词汇、能够清晰无碍地表达身体感受是完全不现实的。绝大多数人对自己身体的运作机制一无所知，更遑论将其组织成语言。正因如此，引入中立的第三方专业力量至关重要： - **性医学专家（Sexual Medicine Specialist）**：精准排查激素、外阴前庭神经及盆底肌等器质性病因； - **性治疗师（Sex Therapist）**：搭建安全、无评判的沟通桥梁，引导双方拆解羞耻感； - **寻找合适的“沟通词汇”**：帮助伴侣学习如何开启对话、如何接听那些刺耳甚至略带冒犯的敏感情绪，将防御姿态转化为探索与成长的契机。 ### [01:42:00](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6120s) 亲密关系中的认知重构：没有“坏人”，只有并肩面对问题 探讨伴侣间沟通技巧时，Steven Bartlett 提到，面对一些可能刺伤对方自尊的问题，单靠伴侣自己往往很难说出口，因为大家都不愿伤害对方的情感。Rachel Rubin 医生赞同这一点，指出直接全盘托出“事实”并不总是最好的方法，这正是伴侣治疗师（Couples Therapist）能够发挥关键作用的地方——他们能为这些棘手且脆弱的对话提供安全的包容空间。 Rubin 医生特别指出，许多亲密关系问题中最棘手的一点在于：很多时候其实根本没有“坏人”（There is no bad guy）。如果有人出轨、背叛信任，那确实存在明确的过错方；但在很多情况下，比如一方性欲较高、另一方性欲较低，两个人都没有做错任何事，他们只是生理和心理节律不同。即使没有恶人，冲突依然真实存在。核心挑战在于，当没有非黑即白的对错时，双方该如何妥善应对分歧，如何在共同生活和爱意中与对方一起演变和成长。 Steven 深有共鸣地反思了自己的过往经历。他坦言，过去在一段感情中遭遇亲密障碍时，大脑的第一反应就是寻找“到底谁是坏人”——“这是我的问题，还是她的问题？”但随着时间推移，当他们真正弄清楚问题根源后才顿悟：这既不是他的问题，也不是她的问题，这场矛盾从一开始就不该是“我对抗她”或“她对抗我”，而是“我和她并肩对抗这个问题”。这种视角的转变彻底消除了羞耻感（Shame）和指责（Blame），让伴侣能够作为统一战线的团队，把精力集中在解决冲突上。 ```mermaid flowchart TD accTitle: 亲密关系冲突认知重构 accDescr: 展示从传统的相互指责思维向团队协作对抗问题的思维模式转变过程。 subgraph Destructive["对抗模式（寻找过错方）"] A["性欲/亲密需求不一致"] --> B{"谁是坏人？"} B -->|"是我的错？"| C1["自责与羞耻感"] B -->|"是对方的错？"| C2["怨恨与互相指责"] C1 & C2 --> D["关系隔阂加深、冲突升级"] end subgraph Constructive["共情模式（团队作战）"] E["意识到双方皆无过错"] --> F["认知重构：我和你 vs 问题"] F --> G["消除羞辱感，开启脆弱而诚实的沟通"] G --> H["伴侣共同寻求解决方案 / 专业支持"] end ``` --- ### [01:43:30](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6210s) 为什么这项事业如此重要：改变因无知而造成的痛苦 当 Steven 感谢 Rubin 医生为大众带来的巨大帮助，并询问她为何对此抱有如此强烈的激情时，Rubin 医生神情凝重地道出了心声：因为现实中有太多人正在遭受不必要的痛苦。伴侣关系在破裂，身体健康在受损，很多人明明可以通过现有的医学常识和科学认知，过上更有快感、更具愉悦感和更高质量的生活，却因为信息闭塞而被剥夺了这些权利。 她强调，很多改变往往源于最基本、最简单的事物：诚实的沟通、真正的情感联结、科学的性健康教育，以及基础但规范的医疗支持。这些完全能够为个人带来巨大的喜悦和健康的亲密生活。她在日常临床实践中见证了太多患者在接受正确治疗后的蜕变，因此她渴望每个人都能为自己的健康挺身而出、自我倡导（Self-advocate），同时也呼吁更多医生以更宏观、更负责的姿态站出来提供支持。她内心的强烈使命感，正是来源于看到当下医疗体系中有太多本该做到的事依然是一片空白。 - **简单的改变拥有巨大的力量**：性健康并不是高深莫测的玄学，基础医疗护理、科普教育与真诚脆弱的沟通足以从根本上逆转生活质量。 - **临床现状的巨大缺口**：大量女性和伴侣在沉默中承受痛苦，Rubin 医生的愤怒与激情源于现实医疗系统对性健康的系统性忽视。 --- ### [01:44:37](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6277s) 节目的传统提问：行胜于言与自省 在节目尾声，Steven 提出了《CEO 日记》的固定传统问题——上一位受访嘉宾在不知道下一位是谁的情况下留下的一道思考题：**“明天你在自己的生活中最想做出改变或改善的一件事是什么？”** Rubin 医生真诚且坦率地回答：“我希望能更好地做到‘知行合一’（Practicing what I preach）。”她引用了那句老话“修鞋匠的孩子往往没有鞋穿”（The shoemaker's kids don't wear shoes）。她坦承自己对工作极度痴迷和投入，深爱自己的医学事业，但这也导致了个人生活的失衡： - 她没有像建议病人的那样留出足够的时间去坚持力量训练； - 有时会忍不住刷手机，未能把全部注意力放在陪伴自己的孩子身上； - 也没能严格执行自己反复建议其他伴侣去做的事——定期安排与配偶的专属约会（Quarterly spouse dates）。 Steven 对此深表理解，认为这种坦诚令人耳目一新，证明即使掌握了世界上最全面的医学知识，在现实日常中去严格执行也绝非易事。Rubin 医生对此精辟地总结道：“做起来容易的事情，不做同样很容易”（Easy to do, easy not to do）。 --- ### [01:45:42](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6342s) 资源获取与未来愿景：性健康就是整体健康 谈及大众如何获取更多科学知识与专业医疗服务，Rubin 医生介绍了她的核心平台与团队业务： - **官方网站与通讯**：访问 `rachelrubinmd.com` 可以订阅其团队的 Newsletter，内容涵盖最新的性医学研究成果、患者可参与的临床试验项目、医学从业者的倡导动态与工作机会。 - **专业教育课程**：平台提供针对临床医生的培训体系，包括免费基础课程以及具备继续医学教育学分认证（CME）的高级培训，以系统性培养下一代性健康医学人才。 - **社交媒体与诊所分布**：她目前在 Instagram 上最为活跃，同时正致力于通过 YouTube 等多渠道扩大科学发声；其实体临床诊所设立在华盛顿特区（Washington D.C.）和洛杉矶（Los Angeles）。 Rubin 医生在最后强调了贯穿她整个理念的核心信条：“**性健康就是健康本身，你的生活质量绝对至关重要**”（Sexual health is just health, and your quality of life absolutely matters）。 Steven 在致谢中总结道，Rubin 医生的对谈在播客中往往是转发量和传播度最高的内容，因为这些问题触碰到了无数人最隐秘却最核心的生命痛点，而当今医学界极度缺乏像她这样既具备扎实临床专科资历、又具备罕见沟通表达能力的倡导者。他诚挚呼吁听众将这期充满科学与共情的内容分享给身边正在困境中挣扎的人，让更多人重获身体的主导权与健康快乐的生活。 ## Notable quotes > [00:00](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=0s) I am filled with rage — Rachel Rubin > [47:27](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2847s) Sex is not supposed to be painful. — Rachel Rubin > [41:16](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=2476s) 鲁宾，你到底对我做了什么？我感觉好多了，你把我的生命还给我了。我不用在半夜爬起来上厕所了，睡眠变好了，也不再干涩，性生活不再痛苦，好几个月都没得过一次尿路感染。你手里还有什么方案？ — 患者（引述） > [53:27](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3207s) Sex is a contact sport — Rachel Rubin > [01:05:20](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=3920s) I'm broken. You have to fix me — 患者（引述） > [01:10:53](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4253s) vulnerability is the doorway to connection — Steven Bartlett > [01:20:38](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=4838s) 对你来说，美妙的性爱意味着什么？ — Rachel Rubin > [01:23:50](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5030s) 谈论性的最佳时机，绝不是双方赤身裸体躺在床上正准备发生性行为的时候 — Rachel Rubin > [01:35:46](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=5746s) 衡量一段关系长期健康程度的标准，在于每次冲突之后，你们是修复到了 101% 还是滑落到了 99% — Steven Bartlett > [01:42:00](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6120s) There is no bad guy — Rachel Rubin > [01:44:37](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6277s) Easy to do, easy not to do — Rachel Rubin > [01:45:42](https://www.youtube.com/watch?v=MM-Qhlxf1pM&t=6342s) Sexual health is just health, and your quality of life absolutely matters — Rachel Rubin ## Mentioned Dr. Rachel Rubin, Steven Bartlett, The Diary Of A CEO, Melinda French Gates, Oprah Winfrey, Halle Berry, Mark Cuban, Cost Plus Drugs, Jon "Bones" Jones, Gable Steveson, HeyGen, Ketone-IQ, Flight School, Intrarosa, Spicer, Pornhub, Heated Rivalry, The Menopause Society, NIH (National Institutes of Health), Women's Health Initiative (WHI), FDA, AUA (American Urological Association) ## Video description Women’s sex lives are being quietly destroyed, and their doctors don’t even know it… Sexual medicine specialist Dr Rachel Rubin reveals the hidden hormone crisis, how prescription drugs can impact sex, and the treatments most doctors aren't prescribing like Hormone Replacement Therapy. Dr Rachel Rubin is a board-certified urologist and sexual medicine specialist, and one of only 80 doctors in the US trained to treat both male and female sexual health. She recently played a pivotal role in the removal of the FDA's boxed warning on menopausal hormone therapy - one of the most significant healthcare policy changes affecting midlife women in decades. She is also the Founder of Rachel Rubin MD and Director-at-Large of the International Society for the Study of Women's Sexual Health. She explains: ◼️ Why most doctors fail women on sexual health, and how to build a team that won't ◼️ Why menopause is a whole-body hormone event, and the treatments that actually help ◼️ The physical barrier blocking orgasm in 1 in 4 women, and how to fix it ◼️ How a tight pelvic floor could be ruining your sex life ◼️ Why your sexual pain and low libido are physical problems your doctor keeps missing 00:00:00 Why Women's Healthcare Is Still Neglected 00:04:39 If Men Had These Symptoms, Would Medicine Be Better? 00:07:24 Why Even Gynaecologists Misunderstand The Clitoris 00:08:25 What You'll Learn From This Conversation 00:11:29 The Question Women Ask Most 00:11:54 Why Testosterone Matters For Women 00:14:03 How Birth Control Can Kill Libido 00:16:47 How GLP-1s And Antidepressants Affect Sex Drive 00:18:48 Should Women Take Testosterone? 00:19:52 Understanding The Menstrual Cycle 00:23:33 Why Perimenopause Starts Earlier Than You Think 00:25:41 What Is HRT And How Does It Work? 00:26:23 Does Estrogen Increase Cancer Risk? 00:27:49 Why HRT Got A Bad Reputation 00:29:46 The 4 Types Of HRT Explained 00:31:41 What Really Causes UTIs? 00:33:44 Vaginal Hormones Explained 00:37:41 Does Cranberry Juice Actually Help UTIs? 00:39:11 When Should You Start HRT? 00:41:16 A HRT Success Story 00:45:23 Ads 00:47:27 Is Pain During Sex Normal? 00:50:08 How To Have Better Sex 00:52:34 What Your Pelvic Floor Actually Does 00:54:28 Signs You Have Pelvic Floor Problems 00:56:04 Is It Normal Not To Orgasm? 00:58:10 What Is A Clitoral Adhesion? 00:59:35 How Sex Toys Can Improve Intimacy 01:00:47 What Men Get Wrong About Arousal 01:02:37 What Happens To Women After Orgasm? 01:03:35 Do Women Get Anything From Penetrative Sex? 01:05:20 How Porn Changed Our Expectations 01:07:38 What Healthy Porn Looks Like 01:08:52 How Porn Can Damage Relationships 01:10:52 Ads 01:13:01 Why You Should Change Up Your Sex Life 01:14:15 Why We Hide Our Sexual Struggles 01:17:56 Responsive Vs Spontaneous Desire Explained 01:20:38 The Question Every Couple Should Ask 01:21:31 What If You Want Different Things In Bed? 01:23:50 How To Tell Your Partner About Kinks 01:25:07 The Secrets People Hide From Their Partners 01:26:21 How To Tell If She's Faking Orgasms 01:28:26 How Stress And Dopamine Influence Libido 01:30:12 Should Sex Be Scheduled Or Spontaneous? 01:32:04 How Self-Esteem Affects Sex 01:33:43 The Most Important Thing We Missed 01:35:46 Better Communication, Better Sex 01:43:30 Why This Work Matters So Much 01:44:37 What Needs To Change In Your Own Life? Independent Fact Check: https://stevenbartlett.com/wp-content/uploads/2026/06/DOAC-Rachel-Rubin-Independent-Research-Further-Reading.pdf Follow Dr Rachel: Instagram - https://link.thediaryofaceo.com/AYkgAOV YouTube - https://link.thediaryofaceo.com/1TQZeri X - https://link.thediaryofaceo.com/FxZbK5x Website - https://link.thediaryofaceo.com/4ZKqH2l The Diary Of A CEO: ◼ Join DOAC circle here - https://doaccircle.com/ ◼ Buy The Diary Of A CEO book here - https://smarturl.it/DOACbook ◼ The 1% Diary is back - limited time only: https://bit.ly/3YFbJbt ◼ The Diary Of A CEO Conversation Cards: https://linkly.link/2hm7r ◼ Get email updates - https://bit.ly/diary-of-a-ceo-yt ◼ Follow Steven - https://g2ul0.app.link/gnGqL4IsKKb Sponsors: HeyGen - https://heygen.com/DOAC Flightcast - Check out https://www.flightcast.com/DOAC5 Ketone - Go to https://ketone.com/steven to enter to win! no purchase necessary, terms and conditions apply. [Source](https://www.youtube.com/watch?v=MM-Qhlxf1pM)

[0:00] Rachel Rubin: I am filled with rage [47:27] Rachel Rubin: Sex is not supposed to be painful. [41:16] 患者（引述）: 鲁宾，你到底对我做了什么？我感觉好多了，你把我的生命还给我了。我不用在半夜爬起来上厕所了，睡眠变好了，也不再干涩，性生活不再痛苦，好几个月都没得过一次尿路感染。你手里还有什么方案？ [53:27] Rachel Rubin: Sex is a contact sport [65:20] 患者（引述）: I'm broken. You have to fix me [70:53] Steven Bartlett: vulnerability is the doorway to connection [80:38] Rachel Rubin: 对你来说，美妙的性爱意味着什么？ [83:50] Rachel Rubin: 谈论性的最佳时机，绝不是双方赤身裸体躺在床上正准备发生性行为的时候 [95:46] Steven Bartlett: 衡量一段关系长期健康程度的标准，在于每次冲突之后，你们是修复到了 101% 还是滑落到了 99% [102:00] Rachel Rubin: There is no bad guy [104:37] Rachel Rubin: Easy to do, easy not to do [105:42] Rachel Rubin: Sexual health is just health, and your quality of life absolutely matters

[44:23] Dr. Rachel Rubin: not feeling like myself [50:08] Dr Rachel Rubin: Sex is not supposed to be painful. If sex is painful, you need to figure out why... You deserve a diagnosis. [56:04] Dr Rachel Rubin: Penetration is not how most women orgasm [65:20] Dr Rachel Rubin: WWF has messed up our perception of exercise fighting... it's all manufactured because that's the algorithm that has been working to get men excited. [82:11] Dr Rachel Rubin: When you go to buy a house, you don't always get to choose what house you get... there are compromises in life. [83:50] Dr Rachel Rubin: 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.' People don't do that about sex very often, right? They don't actually do after-action: What went well? What didn't go well? [95:46] Steven Bartlett: you can predict the long-term health of a relationship by whether each challenge heals to 101% or 99% [99:18] Steven Bartlett: happy wife, happy life [99:18] Steven Bartlett: me and her against the problem [103:30] Dr. Rachel Rubin: Sexual health is just health, and your quality of life absolutely matters.

[0:00] You rub it inside the walls of the [0:01] vagina, like that. [0:02] >> rub it in like you would rub sunscreen [0:04] on your face. And if you do that twice a [0:06] week, it makes sex not painful and dry. [0:08] It helps with arousal and orgasm. It's [0:10] literally better than Viagra. And it's [0:13] cheap. And I'm telling you all this as a [0:14] urologist that this cream can also help [0:16] prevent death from urinary tract [0:18] infections. But more than 75% of people [0:21] in large database collections are not [0:23] getting prescriptions for this. And so [0:25] women are not getting access to generic [0:27] medications that could save their lives [0:29] and also really improve quality of life. [0:32] And so I am filled with rage because [0:34] people are limiting their ability to [0:36] have great sex, great health because [0:38] they aren't having access to all the [0:39] information that they could. For [0:41] example, women are not orgasming as much [0:43] as men. The data is very clear there. [0:45] And women come to see me all the time as [0:46] I'm a sex doctor. And they say, "I'm [0:48] broken and you have to fix me. I'm not [0:49] orgasming during sex." And I think the [0:51] majority of problem is education. Women [0:54] think that orgasm comes from [0:55] penetration. But the clitoris is how [0:57] most women orgasm. And yet most women do [1:01] not know where their clitoris is. And in [1:03] fact, the word clitoris today in 2026 [1:06] does not exist in the checklist for what [1:09] an OBGYN has to learn in their training. [1:11] >> And as men, what are we getting wrong in [1:14] heterosexual relationships when we're [1:16] trying to arouse our partners? [1:18] >> Well, men are constantly asking about [1:20] they want their penises bigger, harder, [1:22] straighter, girthier, lasting longer. [1:25] But none of that has anything to do with [1:27] how women experience pleasure [music] [1:28] and satisfaction in the bedroom. So [1:30] that's why I'm so loud about these [1:31] things because no one is getting good [1:33] sex ed. Because the basic information is [1:35] not being shared. And we fundamentally [1:37] don't give a crap about women's sexual [1:39] health, about their menstrual cycles, [1:40] pregnancy, menopause, hormones, pain [1:42] with sex, libido. [music] [1:44] But we actually do have a lot of [1:45] information that we are not using [1:47] because everyone forgot to teach your [1:48] doctor. [1:49] >> And I want to focus today's conversation [1:50] on women's health cuz I have so many [1:52] questions and curiosities. [1:53] >> Right. [1:54] >> So let's start with the subject of [1:55] hormones. [1:56] >> This is going to be so [ __ ] good. [2:00] >> This is super interesting to me. My team [2:02] gave me this report to show me how many [2:03] of you that watch this show subscribe, [2:05] and some of you have told us, according [2:06] to this, that you are unsubscribed from [2:08] the channel randomly. So, favor to ask [2:10] all of you, please could you check right [2:12] now if you've hit the subscribe button [2:13] if you are regular viewer of the show [2:14] and you like what we do here. We're [2:16] approaching quite a significant landmark [2:18] on this show in terms of a subscriber [2:19] number. So, if there was one simple, [2:21] free thing that you could do to help us, [2:23] my team, everyone here, to keep this [2:25] show free, to keep it improving year [2:27] over year and week over week, it is just [2:29] to hit that subscribe button and to [2:30] double-check if you've hit it. Only [2:32] thing I'll ever ask of you. [2:33] Do we have a deal? [2:34] If you do it, I'll tell you what I'll [2:35] do. I'll make sure [2:37] every single week, every single month, [2:39] we fight harder and harder and harder [2:40] and harder to bring you the guests and [2:41] conversations that you want to hear. I [2:43] stayed true to that promise since the [2:44] very beginning of The Diary of a CEO, [2:45] and I will not let you down. Please help [2:48] us. Really appreciate it. Let's get on [2:50] with the show. [2:52] >> [music] [2:54] >> Dr. Rachel Rubin. [2:57] Before we started recording, you said a [2:58] line to me, which I found to be very [3:01] interesting. You said, "I'm filled with [3:04] rage." [3:06] Why are you filled with rage? [3:08] >> I am filled with rage because I do think [3:10] that people are limiting their ability [3:12] to have great sex, great relationships, [3:15] and great health because they aren't [3:17] having access to all the information [3:18] that they could, and they're going to [3:20] see doctors who actually don't know how [3:23] to help them with these problems. [3:25] >> And on the subject of women's health, [3:27] sexual health, hormones, etc., can you [3:29] give me the background context of the [3:32] disservice that's been done? I remember [3:33] you you were talking previously about [3:35] how even the most affluent women in the [3:37] world are being let down. [3:39] >> Yeah, I think this is the great [3:40] equalizer in the fact that no one is [3:43] getting good medical care here when it [3:45] comes to hormone therapy, menopause, and [3:47] sexual health. Melinda Gates just came [3:49] out and said she had to see three [3:50] doctors before she got proper hormone [3:52] therapy prescriptions. Oprah had to see [3:55] five doctors and still they didn't [3:57] understand that her heart palpitations [3:59] was from perimenopause and menopause. [4:01] How about Halle Berry, right, who has [4:03] access to all the doctors in the world [4:05] and she publicly came out and said she [4:07] was diagnosed with genital herpes when [4:09] she really just had the genitourinary [4:12] syndrome of menopause. The rich people [4:14] are not getting good information about [4:16] their bodies, about their hormonal [4:18] health, about their sexual health. So, [4:20] what are the rest of us doing? We don't [4:21] teach it in medical schools, we don't [4:23] teach it in residencies. I didn't learn [4:25] anything about it and so we are actually [4:27] getting worse at this, not better at [4:29] this. And so I'm full of rage because we [4:32] actually do have a lot of data and we do [4:34] have a lot of information that we are [4:35] not using because everyone forgot to [4:37] teach your doctor. [4:39] >> It's staggering to me that, you know, [4:42] those very affluent women that you've [4:44] mentioned still are being let down by a [4:46] medical system. Um, it also sort of begs [4:49] the question that if men were in that [4:51] situation, this probably wouldn't be the [4:53] case. And that's says something about [4:55] the research and the investment that's [4:57] gone into understanding women's health [4:58] relative to men's health. [5:00] >> It's a huge problem. We don't have [5:01] enough specialties of medicine that [5:03] focus on women's health and we don't [5:06] have enough like manpower behind us. We [5:08] can throw money at the situation, but [5:09] you need physical human beings to roll [5:12] up their sleeves and do this work. Like [5:14] doing research is challenging and you [5:16] need people to actually disseminate the [5:18] research and talk about the research and [5:20] you need the training to happen so it [5:21] has to trickle down. So, just because [5:23] someone wrote a paper doesn't mean it [5:25] automatically gets downloaded into every [5:27] doctor's brains. So, someone has to [5:29] teach someone how to do something. So, I [5:31] I lecture all the time. I do a lot of [5:33] trying to teach clinicians how to do [5:35] this. I travel all over to say, "Here's [5:37] how to write prescriptions." because [5:38] that's what it's going to take. There [5:40] was so much fear and misinformation 20 [5:43] years ago about hormone therapy that it [5:45] is a lost art. Doctors don't know how to [5:47] write the prescriptions. Nobody taught [5:49] them how. So, even if they see headlines [5:51] and Melinda Gates giving $10 million to [5:53] the Menopause Society, that's wonderful, [5:56] but it doesn't translate into them [5:58] knowing how to actually write the [5:59] prescription, knowing the difference [6:01] between the type of hormones, knowing [6:02] the safety, the risk, the benefits, [6:04] because they never had the class. For [6:06] example, I'm a urologist. If someone [6:08] comes in to me asking about their blood [6:10] pressure, I'm not going to pretend like [6:12] I know everything about their blood [6:13] pressure. I'm going to be very honest [6:14] that I have the limitations in my [6:16] training. But, for some reason with [6:18] hormone therapy and women's health, [6:20] every doctor you go see has strong [6:22] opinions and will tell women what they [6:24] can and cannot have with their bodies [6:26] even when they don't know the data. I [6:28] come from the men's health world. We [6:30] don't tell men you can't have this. You [6:32] can't do this. We we talk about shared [6:34] decision-making. We talk about risks. We [6:36] talk about benefits. For some reason we [6:37] don't do that enough in women's health. [6:39] >> Why? [6:39] >> I think part of it I don't think your [6:41] doctor is evil. I actually have a [6:43] thought about this. So, I think your [6:44] doctor wasn't trained. I think they're [6:46] trying to save face. And I think 10 [6:48] minutes is impossible to give good [6:50] medical care. I could never get to know [6:52] you fully in 10 minutes and really give [6:55] you great advice on your life that's [6:56] customized for you. It's almost like the [6:58] difference between a viral clip that [7:02] you're going to try to do from this [7:03] episode and the long-form nuanced [7:05] conversation that you're going to have. [7:07] You love the nuanced conversation. You [7:09] love spending those those 2 hours. And I [7:11] think patients want that, too. But, when [7:13] they go to the doctor, they're getting [7:14] the 10-minute version. And instead of [7:16] doctors saying I don't know, they're [7:18] sort of saying no no you can't have this [7:20] cuz it's easier than than sort of going [7:22] into that nuance, which can take time. I [7:24] also think that people are going to [7:26] their doctor, say say you want to talk [7:29] about your orgasm or your libido. Okay? [7:31] You go to your gynecologist. Of course, [7:33] my gynecologist should know everything [7:35] there is to know about the clitoris, [7:37] about orgasm, about hormones, about [7:38] That's what they do. And the truth is [7:40] it's not what they do. And it's they [7:41] were never taught that. And they [7:43] >> taught about the clitoris. [7:44] >> They were The word clitoris today in [7:45] 2026 does not exist in the checklist for [7:50] what an OB/GYN has to learn in their [7:51] training. The word doesn't exist. [7:53] >> What is an OB/GYN for anyone that [7:54] doesn't know? [7:55] >> An OB/GYN is a doctor who specializes in [7:58] obstetrics, so delivering babies, and [7:59] gynecology. So, your gynecologist has [8:02] never been taught about the clitoris, [8:05] about the vulva, about sexual health, [8:06] about sexual pain, about libido, [8:08] arousal, and orgasm. And so, the ones [8:10] who have taken it on their themselves to [8:12] get extra training, they're very few and [8:14] far between. And so, every day women, [8:17] and men too, are going to a doctor [8:19] expecting answers on a topic that their [8:23] doctor probably has never gotten [8:25] training on. [8:25] >> And I do want to focus today's [8:26] conversation on women's health. And I [8:28] want to preface all of this by saying [8:29] that I'm going to be as dumb as I am on [8:32] this subject. If you say something about [8:34] the vagina and I don't know what it [8:35] means, I'm not going to pretend to know. [8:37] I'm going to ask you what it means. And [8:38] I say that because I sometimes think [8:40] with these conversations [8:42] um the host [8:44] often [8:45] is too shy to admit their ignorance. And [8:48] I have lots of ignorance on this. But I [8:50] also have lots of curiosity, and I want [8:51] to fill those gaps. And that's going to [8:52] require me to be very, very [8:55] dumb. And also, my second reason why is [8:58] because I have so many women in my life. [9:00] Um if you just look at my company, my [9:01] entire executive team in my company are [9:03] all women. And also, I've got my fiance, [9:05] my mom, my sister. And understanding the [9:09] women in my life um one element of [9:11] understanding them is understanding [9:12] their health. Women's health isn't [9:14] something that I was ever taught in [9:15] school. It's not like a lesson I had. [9:16] So, I also think this conversation [9:19] is for men. Every man has um four [9:21] important women in their lives. So, my [9:23] question to you is if if a woman has [9:25] clicked on this conversation right now, [9:27] what are they going to get from it? [9:28] Let's start with that first question. [9:30] >> So, I think it's really important [9:32] because as men, we expect the women to [9:34] know. Surely the woman knows about their [9:36] menstrual cycle, about pregnancy, about [9:38] postpartum, about menopause, about [9:40] hormones. Surely my partner knows, you [9:42] know, or the woman in my life, my mom, [9:44] my sister, my my daughter, they know all [9:46] of that, so I don't have to. And the [9:48] truth is, they don't know. When the [9:51] women in your life go to their doctor [9:53] and they're getting a pelvic exam, say [9:54] they're getting a Pap smear, a doctor is [9:56] looking at their their genitalia, [9:58] putting a speculum in, going inside the [10:01] canal and looking around. We put a sheet [10:03] over you like we are me chanics looking [10:05] under the hood. So, we put a sheet to [10:07] keep you comfortable, to keep you [10:09] modest, but we we hide your genitalia [10:12] from you and we don't teach as we go. [10:15] So, I became famous again because I I I [10:18] when I started my practice, I didn't buy [10:20] any fancy equipment, I bought two [10:22] mirrors on Amazon and I give women a [10:24] mirror and as I'm examining them, I say [10:27] to them, "This is your labia majora. [10:29] This is your labia minora. This is your [10:30] clitoris. This is your your urethra, the [10:32] tube that you pee through." Because [10:34] women can't see it. You've got skin, [10:36] you've got bones, you've got muscles, [10:38] you've got nerves, you've got, you know, [10:40] all the organs that are on the inside [10:43] and women don't have access to this [10:45] language. Certainly men don't have [10:47] access to this language. And so, it's [10:49] that basic ability to give women [10:51] language, you can learn about your body [10:53] parts, you can learn how hormones work [10:56] in your body, and you can learn basic [10:59] medicine for you that becomes important [11:01] for how you advocate for what you want, [11:03] what you care about, and who you bring [11:05] into your medical life. You may have a [11:07] physical therapist, you may have a [11:08] mental health person, you may have a [11:10] primary care, a gynecologist, you may go [11:12] on Instagram and get great information [11:14] from people on Instagram. And so, that [11:16] doctor that makes you feel like crap [11:18] because they they tell you something [11:19] that you don't agree with, find a [11:21] different one, right? You have to [11:23] advocate for yourself and I find we are [11:25] starting to empower women to do that, um [11:28] which is very challenging. [11:29] >> What is the most popular question you [11:31] get asked now that you've been on these [11:33] podcasts and you know you're out there [11:35] and you've done millions and millions of [11:36] views all over the place and on clips [11:38] and so forth. What is the number one [11:39] most popular question you get asked? [11:41] >> I'm asked a lot about hormones. Like [11:44] people want to know about hormones. [11:46] People want to know about pain with sex. [11:49] And I think people want to know about [11:50] libido. I think those are the three I [11:52] would say most common things that we [11:54] talk about. [11:54] >> go in that order then. So let's start [11:56] with the subject of hormones. What is it [11:58] about hormones that people are so [12:00] desperate to understand? [12:01] >> So hormones are fascinating because we [12:03] forgot to teach doctors anything about [12:05] hormones. [12:07] And what we have taught about them, they [12:09] think it's dangerous, they think they're [12:10] harmful, they think that you know it's [12:12] it's almost like this thing that is [12:14] natural in your body is somehow [12:16] dangerous once you get over a certain [12:18] age. And that is all politics and bad [12:22] interpretation of science. [12:24] >> I've got this graph here which um [12:26] shows female testosterone levels by age. [12:30] And again, as someone that has started [12:32] to understand more about female [12:33] hormones, I was quite surprised because [12:35] you think of testosterone as a male [12:37] hormone. [12:38] >> Yeah, so that's the biggest [12:39] misconception is that women don't make [12:40] testosterone. Testosterone is just a [12:42] hormone. It's not a male hormone, a [12:44] female, it's just a hormone. It's also [12:45] not a menopausal hormone. We think of [12:47] menopause as estrogen starts to drop, [12:50] right? So menopause is a castration [12:52] event. If I cut your testicles off right [12:54] now, you would have hot flashes, night [12:56] sweats, osteoporosis, depression, low [12:58] libido, erectile dysfunction, metabolic [13:01] syndrome, your weight would go up and [13:03] you would be generally pretty unhappy. [13:05] It's a big deal when we castrate people. [13:07] And yet, we don't do it for men [13:09] regularly unless there's a very [13:10] significant medical reason to do so. And [13:13] yet, every woman over the age of 50, [13:16] her estrogen goes to essentially zero. [13:18] And that affects bone health, it affects [13:20] the brain, it affects the heart, it [13:22] affects sexual health, it affects UTIs [13:24] start to go up. And so it's a whole body [13:26] event that happens. Now, testosterone's [13:28] really interesting cuz it actually isn't [13:30] at menopause that you lose testosterone. [13:33] It happens in your 30s. So, if you look [13:35] at this graph, right? You can see [13:37] testosterone starts to precipitously [13:39] drop in your 30s. So, what do we see [13:41] clinically? Sometimes nothing, but we [13:43] have a lot of people who will start in [13:45] their 30s, mid-30s, late 30s start to [13:47] say, "Ooh, my libido's not as high as it [13:49] used to be. Huh, my orgasm takes a [13:51] little bit longer. I don't feel as [13:53] aroused. My engorgement is not the same. [13:55] My lubrication [13:56] >> Engorgement. [13:57] >> Engorgement of the clitoris. It's the [13:58] same as an erection, right? So, the [14:00] clitoris and the penis are the same. [14:01] They get hard with blood flow. And so, [14:03] this happens in your 30s and no one's [14:05] paying attention because if you look at [14:07] the graphs that we are taught in med [14:09] school, they look more like this. So, [14:11] the books all talk about estrogen and [14:13] progesterone. They don't talk about [14:15] testosterone very often. And there's [14:17] also a lot of things we do to worsen [14:20] this problem. When you play with [14:21] hormones, there are consequences, [14:23] sometimes good and sometimes bad because [14:25] we do so much to mess with our hormone [14:27] levels. Again, birth control pills, the [14:29] way that they work is changing hormone [14:31] levels. Medications for acne, [14:34] medications for hair loss that people [14:36] are using can affect your testosterone [14:38] levels. So, birth control is wonderful, [14:41] but there are side effects to birth [14:43] control just like there's side effects [14:44] to any medication. And so, one of the [14:46] side effects is it lowers testosterone. [14:49] And so, [14:50] that can cause low libido, pain with sex [14:53] in a small subset of people who take it. [14:55] So, if you're someone who does have side [14:57] effects, then it's worth having [14:58] conversations of different forms of [15:00] birth control which may not lower your [15:01] testosterone as much. Does that Does [15:03] that make sense? [15:04] >> It does make sense and it's [15:06] it's interesting. My My partner's talked [15:07] about this before. My fiance, she was on [15:10] birth control for a long time [15:12] and she also had concurrently libido [15:14] problems. [15:16] Now, we don't know whether it was the [15:18] birth control, whether it was something [15:19] else, but when she came off the birth [15:22] control pills, her libido [15:25] challenges also evaporated. [15:27] >> So, can explain cuz I think again, [15:29] knowing the basics and the fundamentals [15:31] give women and men access to the [15:33] information so they can make choices [15:35] with what they want to do with it. Okay, [15:36] so how do birth control pills work? Um [15:39] when you take a combined birth control [15:41] pill, it has a fake amount of estrogen [15:43] and a fake amount of progestin in it so [15:46] high that it tricks your body into not [15:48] ovulating. So, when you have so much [15:50] hormone around, your body says, "Oh, I [15:51] don't need to make my own cuz there's [15:53] plenty around." And so, the ovaries shut [15:55] down. So, your ovaries are no longer [15:57] making their own hormones because this [15:59] happens to men, too. When you take high [16:01] doses of testosterone, you become [16:02] infertile because your testicles say, [16:04] "Oh, I don't need to produce sperm right [16:05] now cuz there's plenty of testosterone [16:07] around." And so, birth control causes [16:09] your ovaries to just stay quiet. They [16:10] shut down for a bit. But, your ovary [16:12] does three things. It does estrogen, [16:14] progesterone, and testosterone. It [16:16] doesn't add back testosterone. So, her [16:18] experience possibly was because she [16:21] wasn't making her own testosterone. And [16:24] when she went off that birth control, [16:25] her ovaries woke back up and make [16:27] estrogen, progesterone, and [16:28] testosterone, which to you equaled more [16:31] pleasure. Now, because we focus on the [16:33] psychosocial, I'll have a lot of people [16:35] saying, "No, no, no, it's all [16:36] communication." And all of that is [16:38] important. Don't get me wrong. But, the [16:40] biology matters too. And we know there [16:43] is a biological basis to sexual health [16:45] for everybody. [16:47] >> I was just looking at some data and it [16:48] said that in some studies, up to 27% of [16:51] people on birth control report a [16:54] decrease in their libido/sex drive. [16:57] >> Yeah. [16:57] >> Which is shocking cuz, you know, it [16:58] varies in these studies from one to [17:00] seven people to one to that's almost [17:02] like one one in three people [17:04] are experiencing it. How does one [17:05] navigate that, you know, cuz birth [17:07] control has tremendous um upsides? [17:10] So, how do you navigate that? [17:11] >> I think that everything that we do, [17:13] there's the risk of doing something and [17:15] the risk of not doing something. No drug [17:17] is going to be without possible side [17:19] effects and so that's where becomes [17:21] important to know what are the [17:22] non-negotiables. Antidepressants is a [17:25] perfect example. We know that they can [17:28] help people, right? A lot of people, but [17:30] we know there are sexual side effects [17:31] like low libido, delayed orgasm. And so [17:34] it has to do with informed consent, [17:36] which means I Stephen, if I'm going to [17:38] give you a medicine, I want you to know [17:40] that there is the common side effects, [17:43] the less common side effects, and then [17:45] the disastrous side effects. That's why [17:46] on the commercials they talk about all [17:48] the disastrous side effects. But often [17:50] they don't even research the sexual side [17:52] effects. So for example, GLP-1s, okay? [17:56] >> What's a GLP-1? [17:56] >> Yep, the GLP-1s are the weight loss [17:58] drugs that everybody's talking about. [17:59] Ozempic, Mounjaro, all the all the [18:02] celebrities are on these injections that [18:04] are making them lose tons of weight. We [18:06] are starting to look at these drugs in [18:08] women, but they're not nobody's looking [18:10] at it for sexual health. Everyone's [18:12] looking at it for can you get pregnant? [18:14] Reproductive health. There is not a [18:15] single published paper on sexual health [18:18] side effects for women. So we did a [18:20] survey, it's not published yet, but we [18:22] presented it at a conference at a [18:24] medical conference. We surveyed a [18:26] thousand women online who have taken [18:28] these medications and about 25% report [18:32] sexual side effects from these [18:34] medications. Again, that's not to say [18:35] the medicines are good or bad, right or [18:37] wrong, but there are side effects. Now [18:39] of those 25% about 50% of those people [18:42] said it lowered their sexual function [18:44] whether it's libido, arousal, and [18:46] orgasm. And about 25% said it made it [18:48] better. [18:48] >> So carrying on in this track about [18:51] women's hormone levels through time and [18:53] through age and through life phases, [18:55] what else do I need to know or [18:56] understand about how important [18:58] testosterone is? [19:00] >> So we know we have global consensus [19:02] actually that testosterone helps for [19:04] libido in postmenopausal women, okay? [19:07] Now there is also data in perimenopausal [19:10] women as well and that is clear data. It [19:13] helps with libido, but it also helps [19:15] with arousal, it helps with orgasm, and [19:17] satisfaction. It can also help with body [19:20] image, which is like a cool a really [19:22] cool thing. In my clinic, I use FDA [19:24] approved testosterone for men, and I [19:26] give it to them in doses appropriate [19:28] like 1/10 the dose for a man, I give it [19:30] to my female patients. And I see that [19:33] over the 3 to 6 months of taking it, [19:36] they get this [19:38] it clicks. Now, does that mean every [19:39] woman on Earth needs it? No, we're not [19:42] there yet, but if you want it and you [19:44] want to try it and you're curious about [19:45] it, then you should have access to [19:47] physicians who understand how this works [19:49] and they know how to write the damn [19:51] prescription. [19:52] >> There's five life stages on here. We [19:53] have puberty, your fertile years, [19:55] perimenopause, menopause, and then post [19:58] menopause. [19:59] When you think about a woman's hormonal [20:01] journey through these different life [20:03] stages, [20:05] what is the sort of advice you would [20:06] give them to make sure they're [20:07] hormonally healthy across every life [20:09] stage? What are like the basics? What [20:11] are the tactics, strategies, medications [20:14] that they should be thinking about? And [20:16] I say this because I've got women women [20:17] in my life for every stage in this life [20:20] phase at the moment. I've got you know, [20:21] I've got my nieces in the sort of [20:23] puberty era. I've got my my fiance in [20:26] the fertile years. I've got my mom and [20:28] grandparents etc. in the peri- and [20:30] post-menopause years as well. [20:31] >> Yeah. So, if you look at your nieces for [20:34] example, when they were babies compared [20:36] to now, there are changes happening. [20:38] Their bodies are transforming because [20:40] they're getting a surge of hormones in [20:41] their body and that's estrogen, [20:43] progesterone, and testosterone. They're [20:44] cycling, which means they're getting [20:46] periods. So, let's talk about the [20:48] menstrual cycle for a second. I think [20:49] it's helpful. [20:50] >> Okay. [20:51] >> So, [clears throat] when women have [20:51] their period, [20:53] they bleed for a few days, right? And [20:56] that's when their hormones, their [20:57] estrogen and their progesterone is at [20:59] its lowest, okay? So, hormones are at [21:01] their lowest. And then [21:04] the hormones start to increase. Your [21:05] estrogen starts to go up. You don't make [21:07] progesterone yet in the beginning. Your [21:08] estrogen starts to go up and it make [21:11] there's a a follicle in your ovary which [21:13] has an egg, right? It's going to pop out [21:14] an egg. [21:16] Ovulation is when the egg pops out. So, [21:18] you get this big surge of estrogen and [21:20] then when the egg pops out of the ovary, [21:22] right? That's what's going to make a [21:23] baby if it gets fertilized, there is a [21:25] shell of the egg, right? The egg has a [21:27] shell which makes progesterone. So, the [21:30] second half of the cycle there's [21:31] progesterone around, okay? First half of [21:33] the cycle no progesterone. [21:35] >> Mhm. [21:35] >> And so, that [clears throat] second half [21:36] of the cycle the shell has making [21:38] progesterone and then when you don't [21:40] have fertilization, the shell starts to [21:43] break down. [21:43] >> Okay. [21:44] >> And that natural breakdown is a drop in [21:46] progesterone which causes the lining of [21:48] the uterus to shed and you get a period [21:50] again. And so, it's estrogen goes high [21:53] in the beginning and then pops out an [21:55] egg, progesterone gets high in the [21:56] second half and then they both fall and [21:58] you have a period. And so, the hormones [22:00] being low in the beginning, estrogen is [22:02] not zero. It's about 50, okay? So, when [22:04] we talk about numbers, if you get your [22:06] your hormones checked, if they're at [22:07] their low it's like 50, but when you [22:09] ovulate, your estrogen may be 150, 200, [22:12] 300. And then when you're pregnant, your [22:15] estrogen may be as high as 3,000 or [22:17] higher, right? It's very many thousands. [22:19] And so, these hormones have actions in [22:21] our bodies. And so, the reason it's [22:23] important is cuz when we give back [22:24] hormone therapy, well, are we giving [22:26] back 10,000 like pregnancy? No, we're [22:28] giving back to be like 50, 60, 70, the [22:31] way that you are early in your cycle [22:33] kind of a thing. Now, testosterone's not [22:35] even on this graph that everybody gets [22:37] taught of estrogen then progesterone, [22:39] but we do know testosterone is pretty [22:41] stable through the cycle, although we do [22:43] believe it peaks during ovulation which [22:45] makes sense cuz you want to have a baby, [22:47] right? So, evolution says, "Okay, you [22:49] need to be horny around the time that [22:50] you are going to ovulate." And so, your [22:53] testosterone starts to go up. Now, it's [22:55] really important cuz you're probably not [22:56] having a conversation with your nieces [22:57] about their menstrual cycles, but it's a [22:59] problem because no one's talking about [23:00] it if they're painful, if they're [23:02] abnormal, if they're um uh uh uh we [23:05] don't have a lot of conversations around [23:07] what is a normal amount of bleeding. We [23:09] have so many people who have problems, [23:11] whether it's PCOS, which is now called [23:13] PMOS, which is a metabolic issue that [23:16] causes you to have irregular periods. [23:18] There's endometriosis where you have [23:19] painful periods. There are so many [23:21] medications we give to people that can [23:23] alter their hormonal health and and [23:25] sexual health for that matter. And then [23:27] it all starts to get even more chaotic [23:29] in perimenopause, which is again age 35 [23:32] to 45. If menopause we say is 45 to 55, [23:35] right, is normal menopausal age. Average [23:37] age is 52, and we think perimenopause is [23:40] when things start to change for people [23:41] about 10 and it can be about 10 years. [23:44] That means 35 to 45. So, how old are [23:46] you? I don't remember. [23:47] >> 33. [23:48] >> 33. And my partner's 33. [23:49] >> All right, so 33. So, this idea that I'm [23:51] too young or it's too early or I'm not [23:54] there yet, the truth is things do start [23:57] to change. [23:58] >> What changes for a woman? [23:59] >> So, there are so many symptoms to [24:01] hormonal fluctuations. So, for some [24:03] people it's temperature changes, for [24:04] some people it's fatigue, for some [24:06] people it's remembering things, for some [24:07] people it's low libido. Some people get [24:09] dry eyes, itchy ears, burning mouth, [24:12] joint pain. Some people get irregular [24:14] periods. Some people get pain with sex. [24:17] Some people get UTIs. I would love to [24:19] talk about what why hormones are so [24:21] important for the bladder and UTI [24:23] prevention. And so, there are so many [24:25] symptoms and everyone says, "Oh, we're [24:27] blaming everything on hormones." And the [24:30] truth is, we haven't talked about [24:31] hormones enough to actually start [24:33] looking at this to figure out what is [24:35] important and what is hormonally [24:36] important. [24:37] >> So, when you start to lose progesterone, [24:39] when you arrive at perimenopause, what [24:41] are the symptoms you feel? Are they [24:42] different symptoms to decline in [24:44] estrogen? [24:45] >> So, it's hard to know for sure, but some [24:47] people think that as the progesterone, [24:49] so your sleep starts to get a little [24:50] crazy, anxiety starts to go up. And so, [24:53] some people will start with progesterone [24:55] as a support for [24:57] you know sort of perimenopausal hormone [24:59] therapy but estrogen can also help with [25:01] many of those symptoms. So it's not a [25:03] one size fits all of whether we give [25:05] people everybody gets progesterone or [25:06] everybody gets estrogen. Sometimes [25:08] people just get testosterone because [25:09] remember that falls in your 30s you know [25:12] so there's sometimes where we [25:14] do all three and there's sometimes where [25:15] we do just one or two. Now it's a very [25:18] evolving conversation because most of [25:20] the book answers most of the guidelines [25:23] really talk about menopause and how we [25:25] treat people in this menopause when [25:26] you're flatlined. Remember that [25:28] castration event where everything's zero [25:30] and then we add back hormones. So now [25:32] we're starting to talk about [25:33] perimenopause as a place to to start [25:36] giving women hormones and that's a a [25:38] very important and evolving conversation [25:41] that is happening. [25:41] >> And so this conversation that's [25:44] sort of raging on about HRT [25:47] about safety about what age you should [25:50] take it who should take it what form you [25:51] should take it in. What's your [25:53] perspective on that and what do women [25:54] need to know about that? [25:55] >> Yeah so so it's important because [25:58] >> is HRT? [25:59] >> Yeah it's a great question. So hormone [26:00] replacement therapy which is a term that [26:03] we used to use for hormones in [26:05] menopause. It has a bunch of different [26:07] names and everyone tries to change the [26:08] marketing around it but hormone therapy [26:10] in general is this idea of giving back [26:13] hormones when you have hot flashes night [26:15] sweats osteoporosis you know sort of [26:18] this over 50 crowd that has this [26:20] declining estrogen and progesterone [26:23] levels. And so typically classic hormone [26:25] therapy is estrogen and progesterone. [26:28] Now again taking just estrogen estrogen [26:31] grows things it helps your bone health [26:33] it helps your hair skin and nails it [26:35] helps you not have hot flashes it helps [26:36] you sleep. It can also grow the lining [26:39] of the uterus and so if it gets thicker [26:41] thicker thicker there is worry over [26:43] years that leads to endometrial or [26:45] uterine cancer. So endometrium is the [26:48] lining of the uterus so here I can okay [26:50] so this is a this is a vagina and then [26:54] at the the vagina's like a socket. The [26:56] very end of the socket is a tiny hole [26:58] and that hole is the the pinpoint [27:00] opening of the cervix and that hole if [27:03] you go through that tiny tiny hole, it [27:06] gets to the uterus and the uterus is a [27:08] cavity where we hold babies [27:11] where the lining comes out. That's what [27:12] period blood is is the lining of the [27:15] uterus here which we'll call the [27:16] endometrial lining. So progesterone is [27:18] very important for this lining here. If [27:21] the the lining of the uterus gets too [27:23] thick with just estrogen, that can lead [27:25] to problems, but if you match it with [27:27] progesterone, those problems go away. [27:29] >> Right. So so if you just gave someone [27:31] estrogen, then the linings of the uterus [27:33] would get so thick that that would cause [27:34] a problem, but if you give it to both [27:36] hormones together, it sort of balances [27:38] itself. [27:39] >> them out and so that's why you'll hear [27:41] hormone therapy talked about estrogen [27:42] and progesterone just like the birth [27:43] control pill your partner was on was an [27:45] estrogen and a progestin. There was a [27:47] combination. [27:48] >> Okay, got you. [27:49] >> And also the history is kind of [27:50] important here of why your mothers and [27:52] grandmothers weren't given access to [27:54] this medication and the stigma behind [27:57] it. In the late 90s, a lot of people [28:00] were on hormone replacement therapies [28:02] and they were seeing benefits. They [28:04] actually were all these observational [28:06] studies that showed wow, the heart [28:07] disease is less and like [28:09] >> During menopause. [28:10] >> during menopause and a billion dollars [28:12] went into the NIH to study this in women [28:15] and they did they that was called the [28:16] Women's Health Initiative. It was [28:18] thousands and thousands of people age 50 [28:20] to 79. They gave a hormone pill like a [28:23] birth control pill almost to all of [28:25] these women and they followed them and [28:27] they stopped the study early in the [28:29] early 2000s and they did a press [28:31] conference and at this press conference [28:32] they said we're shutting down the the [28:34] study early. Hormone therapy causes [28:36] cardiovascular disease and breast [28:38] cancer. And overnight, a multi-billion [28:41] dollar industry went to nothing. [28:43] Everyone was told throw your hormones in [28:45] the garbage. This is dangerous. What was [28:47] crazy is those people who were [28:49] prescribing hormone therapy were looking [28:51] around saying, "I don't understand. My [28:53] patients aren't dying of heart disease. [28:55] They're not getting extra breast [28:56] cancers. Like, this doesn't make any [28:58] sense." And when people actually looked [29:00] at the study, it didn't say any of those [29:02] things. It was wild how misinterpreted [29:04] this study was. In fact, the same [29:07] authors of this study back in the early [29:08] 2000s published this year, in 2025 [29:11] actually, that below age 70 that type of [29:15] hormone therapy, which we don't really [29:16] use anymore, has no increased risk of [29:19] cardiovascular disease or stroke. And [29:21] yet now you have a generation of doctors [29:23] who weren't taught how to do this. Only [29:25] 1.7% of women have are getting [29:28] prescriptions for hormone therapy who [29:30] who should be offered prescriptions. So, [29:32] it is a disaster. [29:34] >> Only 1.7%? [29:35] >> Only 1.7%. [29:36] >> Oh, really? Hmm. Wow. [29:38] >> And so, hormone therapy is not something [29:41] that I'm saying every woman must have, [29:43] but every woman should have access to [29:45] the toolbox. I like to think about [29:47] hormone therapy is really four buckets [29:49] that we talk about. Hormone therapy is [29:51] whole body estrogen, which helps with [29:52] hot flashes, night sweats, [29:54] uh bone loss, progesterone, whole body [29:57] progesterone therapy, which protects the [29:59] uterus and is this yin yang, especially [30:00] if you have a uterus, but it helps with [30:02] sleep, and it can help with anxiety [30:03] reduction in many of our patients, not [30:05] everybody, but a lot of them. The third [30:07] thing is testosterone, which we talked [30:09] about, which can help with libido. Um [30:11] that's what we have the most evidence [30:13] for. And then the fourth thing is [30:14] vaginal hormones. Now, vaginal hormones [30:17] are microdoses of estrogen or what we [30:20] call DHEA vaginally, that supports the [30:23] bladder and the vagina. So, it helps [30:24] with pain with sex, dryness, urinary [30:27] frequency, urinary urgency, leakage, and [30:30] it prevents urinary tract infections [30:32] massively. It is safe for your great [30:34] grandmother in the nursing home. It is [30:36] safe for your wife who's breastfeeding. [30:39] So, if you know anyone in your life who [30:41] is a woman, who's having urinary [30:43] frequency, urgency, leakage, urinary [30:46] tract infections, pain with sex, [30:48] dryness, there is a magical solution [30:51] that is safe for everybody on Earth um [30:54] that is microdosing these hormones [30:56] vaginally. [30:57] >> At any age? [30:57] >> At any age at all. In fact, even more [30:59] important for people who are older [31:02] because they are dying of urinary tract [31:03] infections. So, it's it's it's one thing [31:06] when a young person gets a urinary tract [31:08] infection and they go to the urgent care [31:09] and they get an antibiotic. Even they [31:11] deserve prevention and this is prevents [31:14] uh those problems in those people, too. [31:15] >> Again, what is this? [31:17] >> So, vaginal hormones. So, this is a [31:18] really important topic. It's called [31:20] genitourinary syndrome of menopause or [31:22] GSM. Say GSM loudly for your listeners. [31:25] >> GSM. [31:26] >> GSM, genitourinary syndrome of [31:28] menopause. Genital, urinary, syndrome of [31:32] menopause. But, really, it's kind of a [31:35] dumb name because it's any hormonal [31:37] changes in your body can affect the [31:40] bladder and the genitals. [31:41] >> So, UTI. What is a UTI? And what's [31:44] what's causing a UTI? U- urinary tract [31:47] infection. [31:48] >> Yeah, very good. So, urinary tract [31:49] infections are when there is bacteria in [31:52] the bladder and it can be a lot of uh of [31:55] bad bacteria that can grow and create uh [31:57] inflammation. It causes bladder pain, [32:00] pain with urination. It feels like razor [32:02] blades. Um but, it can also go into your [32:04] bloodstream and cause fevers and chills [32:06] and cause kidney infections. It can [32:08] cause something called urosepsis where [32:10] you have to go to the intensive care [32:12] unit and need uh antibiotics through an [32:14] IV and it can kill you if you have an [32:17] infection go through your whole body. [32:18] And this gets worse and worse as you get [32:20] older. [32:21] >> Why is there a link between hormones and [32:22] UTIs? [32:23] >> Yeah, because what happens is the vagina [32:26] is supposed to be acidic and healthy and [32:29] hormones help keep it. It is the [32:31] hormones, the estrogen and the [32:32] testosterone, that keep healthy bacteria [32:34] growing in the vagina and suppress or [32:37] lower the bad bacteria. [32:39] >> So, there really is a vagina microbiome. [32:42] >> There is and There's There's no [32:43] probiotic on Earth that is proven to do [32:46] what the vagina needs quite like [32:48] hormones. Hormones make the tissue go [32:50] from uh not acidic to quite acidic, and [32:53] it is that acidic environment that [32:55] protects it from infection. And so, [32:57] perimenopause and menopause or other [32:59] situations happen, and it changes that [33:02] microbiome, so the good bacteria are are [33:05] lower and the bad bacteria start to [33:07] grow, which can increase your risk of [33:09] infections. And sex Right, sex is a [33:12] contact sport. So, uh you're bringing [33:14] the outside environment into the inside [33:16] environment. Uh ejaculate is also not [33:18] acidic, and that can change the [33:20] microbiome as well. And so, we know [33:21] women who are sexually active also have [33:23] an increased risk of urinary tract [33:25] infections. So again, like a plant [33:28] needing water, vaginal hormones help [33:30] support the vagina and the bladder to [33:33] maintain that acidic environment. And [33:35] research has been clear since the 1990s [33:39] that using vaginal hormones prevent [33:41] UTIs, urinary tract infections, by more [33:43] than half. [33:44] >> So, what have we got here in front of [33:45] me? [33:46] >> All right. So, there's a bunch of [33:47] different ways you can give yourself [33:49] vaginal hormones. The most common way is [33:51] a cream. Now, this cream is uh $14 on [33:55] Mark Cuban's pharmacy, and it lasts [33:57] about 2 and 1/2 months. Now, this cream [34:00] that comes with an applicator, which you [34:02] don't ever have to use if you don't want [34:03] to, but what you can do is you want to [34:06] use 1 g of this cream. So, this amount [34:09] is 1 g of this cream. We'll put it on [34:11] this paper here to show you. 1 g of this [34:15] cream rubbed into the vagina. So, you [34:18] take it You can take it on your fingers [34:20] and rub it into the walls like you If [34:21] you put sunscreen on your face, you [34:23] don't glob it on and walk out the door. [34:24] You rub it in, so it doesn't look all [34:26] white and filmy. So, you put it in You [34:28] take it with your finger and you put it [34:31] in the vagina and you rub it into the [34:33] walls of the vagina you can rub it on [34:35] the outer this area as well at the [34:37] opening. [34:37] >> Let me try it. I don't have a vagina but [34:40] So you take the this what what is this [34:43] cream called? [34:43] >> It's estradiol cream. [34:45] >> Estradiol take it on your finger you rub [34:47] it inside the walls of the vagina like [34:49] this. [34:49] >> rub it in like you would rub sunscreen [34:51] on your face and if you do that twice a [34:53] week you can prevent death from urinary [34:56] tract infections. You can help with [34:58] urinary frequency, urinary urgency, [35:00] leakage, you make sex not painful and [35:02] dry, it helps with arousal and orgasm. [35:04] It's literally better than Viagra and [35:07] this is over the counter in the UK. In [35:09] the United States you need a [35:10] prescription um but it's as little as [35:12] $14 if you use Mark Cuban's online [35:15] website it should be covered by your [35:16] insurance. Now some women hate creams [35:18] and so we have things that are not as [35:20] messy as what you're showing right there [35:22] and we have little tablet inserts. So [35:24] here is a it comes with an applicator [35:27] and so what a woman does is put this in [35:28] her vagina and press a button [35:32] and this little tablet so instead of a [35:34] cream you could just put this little [35:35] tablet in twice a week and that does the [35:38] same thing as the cream. [35:40] >> Ah okay. [35:40] >> Okay so it's a little less messy so [35:42] people tend to like the creams better. [35:44] Now if you really don't want to do [35:45] anything twice a week this is a ring [35:47] that goes in the vagina and it can stay [35:49] in there for 3 months. Now this it's [35:52] sort of like a tampon you can kind of [35:54] put it in the vagina and the vagina does [35:55] not feel it. By the way the vagina is [35:57] not very sensitive in terms of [35:59] nerve endings and so when women put [36:01] tampons in they don't feel them. When [36:03] you put this ring in that you wouldn't [36:05] feel it either and it would stay in for [36:06] 3 months at a time. [36:07] >> It's quite it's quite quite a big ring. [36:09] >> Vagina can hold like a bowling ball of a [36:12] baby can come out of a vagina so it can [36:13] actually withstand quite a lot of [36:16] volume. [36:16] >> And there's a chemical inside this ring [36:18] that's going to diffuse [36:19] >> Estradiol that slowly diffuses estrogen [36:21] for the ring. So that's nice for women [36:23] who have dementia, who have very bad [36:25] dexterity with their fingers, they're in [36:27] a nursing home, uh for someone who's on [36:29] the go and they can't remember something [36:31] twice a week. So, our ADHD patients like [36:33] things like that. And so, there's just [36:34] different It's all the same stuff. It's [36:37] just in different formulations. Now, the [36:38] one different one, this is something [36:40] called DHEA. Now, DHEA is the precursor [36:44] hormone to estrogen and testosterone. [36:47] And remember I said the vulva, the [36:48] vagina, the bladder need testosterone, [36:51] too. It So, this is a a chemical that [36:54] converts into estrogen and testosterone. [36:57] And so, DHEA is a supplement you can [36:59] buy, you know, sort of in the in the [37:01] supplement aisle, but if you put it [37:03] locally in the vagina, this is an [37:04] FDA-approved product. It's called [37:05] Intrarosa. And if you just put this in [37:07] the vagina, uh uh it's meant for every [37:10] night, but you can do it twice a week. [37:12] Um it it melts at bedtime. When you wake [37:14] up, and it prevents UTIs. It helps with [37:17] pain with sex. [37:18] >> And just to be clear again, so you think [37:20] a lot of people should be taking these [37:22] these things? [37:23] >> believe it's preventative. So, I think [37:25] And we wrote guidelines by the American [37:27] Urological Association uh why this is so [37:29] important, how to do it. So many women [37:32] have symptoms of urinary frequency, [37:33] urgency, leakage, uh urinary tract [37:36] infections, pain with sex, dryness. And [37:38] this is a safe option for all of those [37:41] women. Does that make sense? [37:42] >> It does make sense. And one of the [37:43] things that doctors sometimes tell their [37:45] patients to take to help with the UTI [37:48] situation is that? [37:51] >> Okay, this is a disaster. So, [37:53] women get urinary tract infections a [37:55] lot. And so, what do we tell women? Pee [37:57] after sex. Wipe from front to back. [38:00] Like, that's not data-driven, by the [38:02] way. That's all a folk folk tale. Like, [38:04] that's that's folklore. There is some [38:05] data that cranberry pills can help uh [38:08] with preventing UTIs, but the uh amount [38:11] that you'd have to drink is uh very [38:14] sugary and diabetes-inducing and won't [38:16] taste that good. And so, there they do [38:18] make pills, but it's a small These [38:20] things are small things that help. [38:22] Drinking lots of water can help, but [38:24] vaginal hormones, vaginal estrogen or [38:26] vaginal DHEA, which we just showed a [38:28] bunch of, prevent UTIs by more than [38:31] half. They don't just prevent UTIs, they [38:33] help with urinary frequency, urgency, [38:36] leakage, pain with sex. They help your [38:38] arousal, they help your orgasm, and [38:40] they're safe for every age with every [38:43] medical problem. If you've had cancer, [38:45] blood clot, stroke, any problems at all, [38:47] vaginal hormones are safe and could save [38:50] your life. And so this is such an [38:52] important topic. [38:53] >> There should be a button just down below [38:55] here. And if it says subscribe, you're [38:57] already subscribed. If it says [38:59] subscribe-ah, that means you're not yet. [39:01] And if you're not subscribed, please [39:02] could you do us a favor and hit that [39:03] button. It helps to show more than you [39:05] know. And according to the algorithm, [39:07] you're someone that watches our show, [39:08] but you haven't yet hit that button. [39:10] Thank you so much. [39:11] My my partner's 33 years old now. She's [39:13] not yet in the perimenopause stage. At [39:16] what point does someone start taking [39:18] HRT? Is it when they're in [39:21] the menopause stage, which is defined as [39:23] 12 consecutive months without your [39:25] period? Is it when they're [39:26] postmenopausal? Is it in perimenopause? [39:29] >> Yeah, this is a very important question [39:31] cuz it's not a one-size-fits-all. At [39:32] this age, start this medicine. It's [39:34] really when people start having [39:35] symptoms. And so I'll give you an [39:37] example. So say your partner um [39:40] gets pregnant, okay? You decide to have [39:42] a baby. Her estrogen is going to go to [39:44] 10,000 uh for 9 months. It's going to be [39:46] super super high. And the day she gives [39:49] birth, it's going to crash to zero. So [39:51] you go from super high hormones down to [39:54] zero. And if she chooses to breastfeed [39:56] or pump or or do any of that, they stay [39:59] extremely low in the menopausal range [40:02] for the entire time you're [40:03] breastfeeding. So when you are [40:04] breastfeeding or pumping or doing [40:06] anything uh and your periods don't come [40:09] back, you're basically menopausal. [40:10] >> And what are the symptoms then? So if [40:12] you just had a baby, you're [40:13] breastfeeding. [40:14] >> have hot flashes, she may have night [40:15] sweats, she may, you have urinary [40:17] frequency, urgency, leakage. There's all [40:19] sorts of symptoms that come come with [40:21] that. [40:21] >> Libido changes as well. [40:22] >> Libido definitely changes, pain with sex [40:23] goes up. And so we call this the [40:25] genitourinary syndrome of lactation. And [40:28] so there's all sorts of hormonal changes [40:30] that can happen at that time. So we see [40:31] a big need for vaginal hormones in this [40:34] patient population. It's safe for the [40:35] breast milk, it's safe for the baby, it [40:37] doesn't cause any problems, but it can [40:38] really help with all of those symptoms. [40:41] Now say she is done having babies and [40:43] now she's 30 8 39 40 and she is doing [40:48] fine and she has regular periods and she [40:50] has no symptoms and no problem. She may [40:51] not need anything at all. But what if [40:53] she starts getting a lot of urinary [40:54] tract infections or having dry scratchy [40:56] painful sex or her libido just doesn't [40:58] feel it sort of feels like back it when [41:00] it did on birth control pills. That may [41:03] be an indication where she may benefit [41:05] from whether it's testosterone or [41:08] vaginal hormones or some kind of [41:09] combination. What if she's 43 and her [41:12] sleep starts to get really bad and that [41:14] may be an indication for progesterone. I [41:17] have a patient who was [41:19] having hot flashes and night sweats and [41:21] brain fog and fatigue. I see her and she [41:24] says I will not take hormone therapy. [41:26] It's not safe. My mother told me it [41:27] causes cancer. At no point am I going to [41:30] do this. I said, okay. We had a long [41:32] conversation. I shared data and papers [41:34] and we did a shared we just worked with [41:36] each other and I wasn't pushing anything [41:38] on her, but ultimately she started with [41:40] vaginal hormones. Her orgasms come back. [41:43] Her arousal gets back and she comes back [41:45] to see me and says, "Rubin, what are you [41:46] doing here? I'm feeling much better. [41:48] Like this is you've given me my life [41:50] again. I'm not peeing in the middle of [41:52] the night so I'm sleeping better. I [41:54] don't have as much dryness. Sex is no [41:55] longer painful. I haven't had a UTI in [41:57] months. What else do you got?" Well, she [41:59] was still suffering with hot flashes and [42:01] night sweats. She had a bone density [42:03] scan which showed osteopenia and she was [42:06] worried about osteoporosis cuz her [42:07] mother died of osteoporosis fractures. [42:10] Well, if she did whole body estrogen, [42:12] she would prevent her risk of a of a [42:14] fracture. She would make her hot flashes [42:15] and night sweats go away, which would [42:17] have benefit on how she sleeps, and [42:20] ultimately probably benefit on her whole [42:21] vascular system. And so, she started [42:24] estrogen, and cuz she had a uterus, she [42:25] took progesterone at night, and she [42:27] said, "Well, my libido is still a bit [42:29] low." We looked at her testosterone. We [42:31] said, "Testosterone will likely help [42:33] with your libido, but it's going to take [42:34] 4 to 6 months." So, 4 to 6 months, she [42:36] comes back to see me. Not only is her [42:39] libido so much better, but she feels [42:41] that she has the cognitive ability to [42:43] enroll in law school. Like, this woman [42:46] literally decides that she wants to [42:47] change the trajectory of her career and [42:50] enrolls in law school, and her brain is [42:53] working in like ways she hasn't seen it [42:55] in so long, and she is competing against [42:58] 22-year-olds in law school. And when I [43:00] tell you she finished at the top of her [43:02] class, she finished at the top of her [43:03] class, whereas she said, "I would have [43:05] never even considered this opportunity [43:08] uh if I hadn't been doing all of these [43:10] things." So, in [43:11] >> And what age is she? [43:11] >> She's in Now, she's in her 60s. [43:14] And so, that's why I'm so loud about [43:16] these things, because what other organ [43:18] in medicine do we let fail completely [43:21] before we like do something about it. We [43:23] don't make you go blind completely [43:25] before we give you eyeglasses. We don't [43:27] let your kidneys run out completely [43:29] before we give you dialysis or [43:30] medications to help your kidneys along. [43:32] We don't let you go into full liver [43:34] failure before you get the transplant. [43:36] Like, this idea of your ovaries have to [43:38] fail, and you have to suffer for 12 [43:40] months before someone intervenes is [43:43] insanity. [43:44] >> But for some women, they do start HRT [43:46] during the perimenopausal phase. [43:48] >> Yeah. [43:49] >> And for some, they start it during [43:50] menopausal postmenopausal stage. [43:51] >> Correct. [43:52] >> And it's all depending on you how you're [43:53] feeling. [43:53] >> It's all depending on how you're feeling [43:55] and what you want, what your objectives [43:56] are. [43:57] >> Okay. But it's never too early to start [44:00] necessarily. [44:00] >> not necessarily. Like, so again, we give [44:02] birth control all the time to people in [44:04] their reproductive years. Birth control [44:05] is just high-dose fake hormone therapy, [44:08] right? So, we're giving women hormone [44:09] therapy as young as in their teens, [44:12] right? To help with different things in [44:14] birth control. But, so if you think of [44:15] it as all of it is some form of hormone [44:18] therapy, it just depends are we using [44:19] the natural form of hormone therapy or [44:21] we using the synthetic hormone hormone [44:23] therapy? We have to get comfortable with [44:25] hormones at all ages. And the thing that [44:27] we see most commonly, Steven, is sort of [44:29] what we call NFLM, not feeling like [44:32] myself. I love that statement because [44:34] women are coming to the doctor every day [44:36] saying NFLM, I'm not feeling like [44:39] myself, and they're getting dismissed. [44:40] And the truth is there are often [44:42] hormonal reasons why you may not be [44:45] feeling like yourself. So, for some [44:46] people it might be musculoskeletal pain, [44:48] so we see plantar fasciitis and frozen [44:51] shoulder, and we think of as those [44:53] having underlying hormonal causes as [44:55] well. So, there's published data that [44:57] less than 9% of Medicare patients are [44:59] getting prescriptions for this. [45:01] More than 75% of people in large [45:04] database collections are not getting [45:06] prescriptions for this. And so, women [45:08] are not getting access to generic [45:10] medications that could save their lives [45:13] and also really improve quality of life. [45:15] I don't know about you, but dryness [45:17] People are not having sex anymore [45:19] because of the pain, the dryness, the [45:20] irritation when it's fixable. [45:26] >> I don't speak Vietnamese, but this show [45:28] can because of AI video technology from [45:30] our sponsor HeyGen. I get messages every [45:32] single week from those of you listening [45:34] to the Diary of a CEO all around the [45:35] world, and you express how much impact [45:37] it's had on you and your life. And if [45:38] that's true, then those conversations [45:40] shouldn't only reach people in English. [45:42] HeyGen can take one recording of me and [45:44] deliver in any language while keeping my [45:46] voice, timing, and expressions intact. [45:49] But, you don't need a studio like this [45:51] to make it work for you. Record 15 [45:54] seconds of yourself and get an AI avatar [45:56] that delivers studio quality video in [45:58] over 175 [46:00] languages. We're up to 20 languages now, [46:03] and we're not the only ones using it. [46:05] HeyGen is already used by 30 million [46:07] people, including 85% of the Fortune [46:10] 100. Whether you're building an audience [46:11] on social media, launching an online [46:13] course, or rolling out training across [46:14] your team, check out HeyGen now. Your [46:17] first three videos are totally free at [46:19] heygen.com/doac. [46:22] That's h e y g e n dot com slash d o a [46:25] c. See you there. [46:27] If you're going to take tips from anyone [46:28] on how to stay focused in high energy, [46:30] let it be from the greatest [46:32] pound-for-pound fighter of all time, the [46:34] guy they call Johnny "Bones" Jones. [46:37] Jon's a co-owner of our show sponsor [46:39] KetoneIQ alongside myself, and when you [46:41] hear why, it probably makes a lot of [46:43] sense to you. When he's training or [46:45] fighting, he needs high-quality, steady, [46:47] laser-like focus without the crash, and [46:49] ketones give him exactly that. And [46:51] unlike caffeine, ketones don't stimulate [46:53] your brain, they fuel it. So, your brain [46:56] actually loves ketones because it runs [46:58] on them much more efficiently than [46:59] anything else. And right now, KetoneIQ [47:01] is giving away one-of-a-kind pair signed [47:05] MMA gloves from Jon Jones himself and [47:07] the upcoming gold medal wrestler he's [47:09] coaching called Gable Steveson. [47:11] They are very, very rare. And if you [47:13] want your shot at winning them, go to [47:14] ketone.com/steven [47:16] to enter to win. No purchase necessary, [47:18] terms and conditions apply, and you'll [47:20] also get 30% off your first subscription [47:22] order, exclusive KetoneIQ merch, and of [47:23] course, your shot at the signed gloves. [47:27] You said um earlier that one of the [47:29] questions people come to you about is [47:30] pain during sex. Why are are women [47:33] experiencing pain during sex? What is [47:35] What is What is going on there [47:36] physiologically? [47:37] >> Yeah, pain with sex is actually not rare [47:39] at all. There are some published reports [47:41] that up to 75% of women will say at some [47:43] point in their life sex is painful. [47:46] >> So, a really dumb question here. [47:48] Sex is not supposed to be painful. [47:50] >> Sex is not supposed to be painful. If [47:52] sex is painful, you need to figure out [47:54] why it's You deserve a diagnosis. You [47:56] deserve an answer. You deserve to [47:57] understand exactly why sex is painful. [48:00] You could have a problem with the [48:02] tissue. So, you could have a skin [48:04] problem, which as we know the tissue of [48:06] the vulva is very hormonally sensitive. [48:08] So, that tissue could be impacted by [48:10] hormones. It's skin. So, people can get [48:12] eczema. They can get autoimmune skin [48:15] conditions. So, you may have a skin [48:16] condition. You may have problem with [48:18] your muscles. So, remember the vagina [48:20] and the vulva are surrounded by these [48:22] big pelvic floor muscles. And just like [48:25] you can get tight muscles in your neck [48:27] and in your back, you can get tight [48:29] muscles in your pelvis. We also know [48:31] there's nerves that are involved in this [48:33] area. So, if you have a back problem and [48:35] you feel it running down your leg, [48:36] right? That's called sciatica or sciatic [48:38] pain, you can have a back problem that [48:41] actually causes you to have pelvic pain. [48:43] So, we see people with penis pain or [48:45] vulva pain because of problems in their [48:47] spines. If you have scar tissue inside [48:50] your body from endometriosis, that's [48:52] pushing and scarring this tissue from [48:54] the inside, you may have pain with sex. [48:57] And so, there are many different things [48:59] that can cause pain with sex. But [49:01] remember I said your OBGYN got almost no [49:04] training in this. [49:05] >> So, if if I'm currently experiencing [49:07] pain during sex as a woman, [49:09] what advice would you give them? What [49:11] should they do? [49:12] >> Yeah, so I would really try to see [49:15] someone who has an active interest in [49:17] this. See a specialized gynecologist or [49:20] a specialized urologist who has an [49:22] interest in pelvic pain. And you may [49:24] need a couple of opinions. Just like if [49:26] you go to the first plumber, you want to [49:27] get a couple quotes on well, who's going [49:29] to do the best job? It's okay to see a [49:31] few different people for this problem. [49:33] >> And in terms of prevalence, up to 75% of [49:35] women as you say will experience painful [49:37] intercourse at some point in their [49:38] lives. Between 10 and 20% of US women [49:41] suffer from persistent chronic pain [49:43] during sex. And during menopause, it [49:45] climbs drastically [49:47] with estimates ranging to 20 to almost [49:50] half of women [49:52] having pain during sex. [49:54] >> And that probably doesn't even add to [49:55] the people who stopped having sex [49:57] because either they don't have a partner [49:58] or because they it's too painful to even [49:59] consider it. And I think it's important [50:02] to know that hormones play a fundamental [50:04] role here. Not a like a not it's not the [50:06] whole story, but it's a huge part of it. [50:08] >> In different seasons of life, if [50:11] if a woman wanted to have the best sex [50:13] of her life, what are the fundamental [50:14] things you'd aim at to make sure she can [50:16] have the best sex of her life? [50:17] >> Yeah, so as you know, this is Diary of a [50:19] CEO. So I love how you you love the [50:22] health topics, but obviously financial [50:24] literacy is really important to for you [50:26] to help people because for some reason [50:28] people stink about talking about money [50:30] and talking about sex, and yet we all [50:32] want to be really great at both, right? [50:33] We all want a lot of money and we all [50:35] want to have great sex, and yet people [50:37] stink at talking about it. They they [50:38] don't know the fundamentals, they don't [50:40] know the basics. And so I actually use [50:42] financial literacy sort of as a as a [50:44] framework in how we talk about good sex. [50:47] And so you've got your savings account [50:49] and your you know, your your checking [50:51] account. Those are the those are the [50:52] basics. Everyone needs money in their [50:53] checking and savings account, right? [50:55] That's what everybody needs. So that's [50:56] going to be your education, your [50:58] nutrition, your exercise, your sleep, [51:01] your your your communication, uh safety. [51:04] Like are you safe in your relationship? [51:05] Like the basics. Are you doing the basic [51:07] things you need to have great sex? You [51:09] know, communication is probably the most [51:11] important thing. Can you talk about it? [51:12] Can you use words? Um can you explore? [51:15] Can you ask questions? So so that's [51:16] really important for great sex. Then [51:18] there's the 401k, right? The 401k is [51:20] something that we all want and should [51:23] have access to, right? It's important [51:25] for compounding growth and long-term [51:27] support of your financial life. Think [51:29] about hormones. Think about going to a [51:31] doctor who's going to make sure that [51:34] everything is optimized the way that it [51:36] should be. Your your pelvic muscles are [51:38] in good condition. Your mental health is [51:39] in good Do you know do you have Do you [51:41] need a sex therapist? Do you want to [51:43] bring toys into the bedroom and devices [51:45] to have even more fun? That's kind of [51:46] like the really important. Not everybody [51:48] has access to it. Not everyone's going [51:50] to do it, but I think it's really, [51:51] really important for everyone to talk [51:52] about. Then there's like crypto. Okay, [51:55] so crypto, that's not to say don't do [51:58] crypto. Like don't put all your money in [52:00] crypto. Don't do everything and don't [52:02] start with crypto. So that's going to be [52:04] when you're watching, you're scrolling [52:06] Instagram and you see these ads for do [52:09] this injection, do this, you know, [52:11] cosmetic procedure, do this supplement [52:15] that's going to make sex great again. Uh [52:17] the truth is if it looks too good to be [52:19] true on TV and in the ads like it [52:21] probably isn't going to fix what if if [52:24] other things are are are struggling. So [52:26] I think great sex is within everybody's [52:29] reach, but I think your great sex is [52:32] different than other people's great sex. [52:34] >> So let's go through these slowly and one [52:36] one at a time. I kind of broke it down [52:37] into three categories, which is there's [52:40] biological and physical blockers to [52:41] great sex, which are some of the things [52:43] we talked about, um hormone crashes, [52:45] etc. You mentioned the pelvic floor. [52:49] How is an issue with your pelvic floor [52:51] going to impact your sex? And what is [52:53] the pelvic floor? Why would you have an [52:54] issue with it? What do you see in [52:56] patients? [52:56] >> Yeah, so everyone has a pelvis has a [52:58] pelvic floor. So men have a pelvic [52:59] floor, women have a pelvic floor. It [53:01] just means the bones of your pelvis, so [53:03] your hips, right? And your pelvis bone, [53:06] your butt bones, all of this is this big [53:08] bony structure that holds all of your [53:10] organs in place. And your genitals are [53:13] attached to this pelvic floor. And the [53:16] pelvic floor is surrounded by thick big [53:19] muscles. So if we look at the inside of [53:22] the pelvic floor, it's these big thick [53:24] muscles. And muscles are just like your [53:27] biceps, right? Like muscles are [53:28] something that contract and relax and [53:31] there can be problems with muscles, [53:33] right? just like if you work out too [53:35] much and you've got a sore trap and you [53:37] got to go get it massaged and and or you [53:39] got to do physical therapy cuz your [53:40] shoulder is hurting. A lot can go wrong [53:43] with the pelvic floor. And so, sex is a [53:45] contact sport. So, if you're going to [53:47] get erections, if you're going to have [53:48] an orgasm, if you're going to allow for [53:50] penetration to happen, you have to have [53:53] healthy muscles because you're asking [53:55] your muscles to contract and relax in a [53:57] sexual way. And so, as blood is flowing [54:00] through the area, blood is going to [54:02] engorge the clitoris and it's going to [54:04] get bigger and erect, it's going to [54:05] engorge the penis, it's going to get [54:07] bigger and erect. These muscles are [54:09] going to have to relax so that you can [54:10] have penetration cuz if they're too [54:12] tight, tight muscles are painful, [54:14] they're sore, they're they're they burn. [54:16] And so, penetration can happen if you're [54:18] relaxed, but then orgasm is a series of [54:21] muscle contractions which equates to [54:23] pleasure and release, which is all has [54:25] to do with the nerves and the muscles. [54:27] Does Does that make sense? [54:28] >> I'm trying to understand how the pelvic [54:30] floor would would give me bad sex and [54:33] how I would know if the pelvic floor is [54:35] the reason I'm currently having bad sex. [54:37] >> Yeah, so if if sex hurts, so if the [54:39] muscles are too tight and you can't have [54:41] penetration but you want it, yeah, that [54:42] can be bad sex. If orgasm is painful, [54:46] weak, or impossible, it could have to do [54:49] with the muscles. It's not always the [54:50] muscles, but it could have to do with [54:52] the muscles of the pelvic floor. If [54:54] arousal, your ability to engorge and [54:56] lubricate are diminished or less, that [54:59] could be due to pelvic floor cuz you're [55:00] not getting enough blood flow to the [55:02] area. And so, there are multiple [55:04] different ways and if you're not feeling [55:06] your genitals, you watch something sexy [55:08] on TV and then you feel it in your [55:10] genitals or you see someone attractive [55:12] walking down the street and you feel it [55:13] in your genitals, there's this brain [55:15] genital connection. And sometimes that [55:18] you So, you have to have perfect wiring [55:20] and of your nerves, your hormones, and [55:22] your muscles, and so that could have be [55:24] affected by your pelvic floor. Now, we [55:26] do a lot to mess up our pelvic floor, by [55:28] the way. People do surgery, people have [55:30] babies, uh people um muscle uh health [55:33] changes for many reasons, and so when [55:35] you have problems, there may be [55:37] biological reasons to these problems. [55:40] >> Should we be going to the gym and like [55:41] doing pelvic floor exercises to improve [55:43] our sex lives? [55:43] >> You typically don't do them at the gym. [55:45] There are typically trained physical [55:47] therapists who help you know what's [55:49] going on with your pelvic floor. So for [55:51] some people it's to strengthen it and to [55:53] do like almost contractions, we call [55:55] them Kegel exercises, but for many [55:57] people it's just learn the coordination. [55:59] >> And you can go and get an exam. [56:00] >> You can go get an exam and work with a [56:02] pelvic floor physical therapist. [56:03] >> So some women, uh cuz we sometimes have [56:06] them writing with questions, talk about [56:08] the fact that they're they're not having [56:09] orgasms. Is that normal or is that not [56:12] normal as it relates to um sexual [56:14] contact? [56:15] >> So about 20% of women will say that they [56:18] can't have an orgasm. And the real [56:21] question, I'm I'm fascinated by this [56:23] data because not 20 20% of men do not [56:25] have orgasm problems. And so again, if [56:28] we go back to the financial literacy [56:30] equation, we have a pay gap in this [56:32] country, right? Women are not paid as [56:34] much as men. Well, women are not [56:35] orgasming as much as men. And so the [56:37] data's very clear there. And I think the [56:40] majority of problem is education. Women [56:43] think that orgasm comes from [56:44] penetration. Surely if the in and out [56:47] penetration is happening, I should be [56:48] able to have an orgasm. And the truth is [56:51] that's not how most women orgasm. Some [56:53] can, but the reason why women don't [56:56] orgasm from penetration is cuz the [56:58] clitoris is up here. So the clitoris is [57:00] how women orgasm, right? Penetration is [57:03] not how most women orgasm. Just like if [57:05] you rub your thigh over and over again, [57:07] you're not going to have an orgasm. Now [57:09] you could keep rubbing your thigh for [57:10] the whole duration of this podcast, you [57:12] still won't have an orgasm cuz it's [57:14] close to your penis, but it's not [57:15] actually your penis, which is where men [57:17] have orgasms from. And so the clitoris, [57:20] if you follow those labia minora, those [57:22] inner wings, you get to the hood of the [57:24] clitoris or a foreskin, we call it a [57:26] prepuce, and that, if you pull it back, [57:29] you see what is the tip of the head of [57:31] the clitoris, but that's just the tip of [57:33] the iceberg. The clitoris is this huge [57:36] structure. [57:37] My necklace is, of course, like a gold [57:39] clitoris. Um the this a huge structure [57:42] that goes all the way down to your butt [57:44] bones. It's a penis. Under the [57:46] microscope, it looks like a penis. It is [57:47] made up of the same tissue as a penis. [57:49] It works exactly the way a penis does. [57:51] It's just that we have a whole field of [57:53] medicine devoted to the male penis. I'm [57:55] a urologist. And no one is even taught [57:58] how to examine a clitoris or where it [58:00] is. So, if the penis is going in here or [58:03] a toy or a finger or a device, that is [58:05] not activating the the clitoris, which [58:08] is a mostly internal structure. [58:10] >> There's something called a clitoral [58:11] adhesion, which people don't know about [58:13] as well, which I've heard you talk about [58:14] before. [58:15] >> Yeah. [58:15] >> What is that? And how many people suffer [58:16] with that? [58:17] >> Yeah, so the clitoris has this hood to [58:19] it, okay? And about 23% of the time, the [58:22] hood can get stuck to the head. So, for [58:25] example, I'm wearing a sleeve here. So, [58:28] you should be able to pull back the hood [58:30] of the clitoris to see the whole head. [58:32] It looks like a mushroom. You know how [58:34] penises have like that almost like a [58:35] mushroom rim rim around it. So, the [58:38] clitoris should have that, too. But [58:39] about 23% of the time it gets stuck. So, [58:42] you actually cannot see the full head of [58:44] the clitoris. It's called a clitoral [58:45] adhesion. And so, you should be able to [58:47] pull it back, but in about a quarter of [58:49] the time you cannot. And we published [58:51] data that if you remove these adhesions [58:53] in an office-based very simple [58:55] procedure, we saw improvements in [58:57] orgasm, arousal, and satisfaction up to [59:00] 60 to 70%. [59:01] >> Wait. So, so one [59:03] five women [59:04] >> Yeah. [59:04] >> have a clitoral adhesion. And when [59:06] solved, it improves their sexual [59:08] satisfaction by up to 60%. [59:10] >> Yes, but no one's examined any woman in [59:12] your life. No one has ever examined [59:13] their clitoris, ever. In any exam, in [59:16] any doctor's visit, and nobody's asking [59:19] women about their orgasm, about their [59:21] satisfaction. Where like they come in [59:23] with pain or they come in with libido [59:25] issues, but no one is examining this [59:27] part of the body. And so, it's this [59:29] question of is it cuz we haven't or cuz [59:31] we shouldn't? It's cuz we haven't. We [59:33] haven't We have never done this before. [59:35] >> You pulled up the sex toys though. I [59:37] think we were talking about orgasm gaps. [59:39] >> So, again, when you were talking about [59:42] orgasm and how women experience [59:44] pleasure, it's all buried inside the [59:47] body. So, if your penis was entirely [59:50] inside your body, say you gained 500 lb, [59:52] okay? And your your belly was so big you [59:55] couldn't hold on to your penis to to do [59:57] what it takes to have an How would you [59:58] orgasm? [60:00] >> Uh probably I don't know. [60:02] >> The vibrator industry would be a [60:03] gazillion dollar industry instead of [60:05] just a billion dollar industry because [60:06] vibration can help activate this blood [60:09] flow. And so, for women, vibration on [60:12] the outside can be extremely helpful cuz [60:15] remember the clitoris is kind of around [60:17] this area. And so, by putting vibrators [60:20] on the outside Now, inside, you can also [60:22] have pleasure, but not everyone [60:23] experiences pleasure the same way. And [60:26] so, understanding devices and trying [60:28] different things is really really [60:30] important. [60:30] >> I don't know. Oh, here we go. Okay, so [60:32] this is vibrating now. [60:33] >> So, this one This kind of device is [60:34] interesting because it is a wand that [60:37] can help just like with trigger points. [60:39] So, if you have pain in in these [60:41] muscles, this can go inside, vibrate to [60:43] help with engorgement, but can also get [60:45] rid of some of the tension in some of [60:47] those muscles. [60:48] >> As men, what are we getting wrong in [60:51] heterosexual relationships when we're [60:52] trying to arouse our partners um both of [60:56] the context of using sex toys, but also [60:58] without sex toys? What is it that we [60:59] just don't understand? [61:00] >> I think that men [61:03] are constantly asking about they want [61:05] their penises bigger, harder, [61:07] straighter, girthier, uh lasting longer, [61:12] and none of that has anything to do with [61:13] how women experience pleasure and and [61:16] satisfaction in the bedroom. And so, the [61:17] question needs to be how do women [61:19] experience pleasure? What is their [61:21] anatomy like? How can we activate the [61:24] clitoris, the arousal response? What are [61:26] the brain things that we need to do to [61:28] make women interested, right? What what [61:30] gets women excited cuz it's different [61:32] than what gets men excited. And your [61:33] part every partner's different in terms [61:35] of what gets them excited. And I would [61:37] love to see more curiosity. I wish [61:40] everyone was were as curious as you [61:41] about what do we need to learn about [61:44] women and how they behave and how they [61:45] act and what they want. [61:47] >> Yeah, so you need [61:48] >> I'd like to implement it tonight. [61:49] >> Communication, right? It's that question [61:51] and also understanding that your partner [61:54] never got told any of these things. And [61:57] so this is where watching this podcast [61:59] together could be really helpful to say, [62:00] "Did you know that? Was it What do you [62:02] like? Do you know? Like can we look at [62:04] your clitoris together? Like do you know [62:06] what these body parts are called? Where [62:07] is it that you experience pleasure?" Cuz [62:09] some people find direct stimulation of [62:11] their clitoris is too sensitive. Cuz we [62:13] know the clitoris has like 10,000 nerve [62:15] endings. So going directly over the [62:16] clitoris can sometimes be too much. Some [62:18] partners love it. Some partners want [62:20] more stimulation on just the outside [62:22] here. Some people need vibration. So [62:24] that's another big problem. [62:25] >> I can So she's going to orgasm at some [62:27] point if this is sufficiently [62:28] stimulated. [62:29] >> there's sort of a build-up and release [62:31] of pleasure, right? That's orgasm. And [62:33] again, that is often not happening [62:36] during penetration. [62:37] >> And once she experiences that, what [62:39] happens immediately after for her? Cuz I [62:41] know from a man's perspective, if I [62:42] orgasm, there's some kind of like [62:44] decline in arousal and I don't want you [62:46] to touch it again. [62:47] >> That's very similar in women. [62:49] >> Okay, so it's the same thing. [62:50] >> Except women can bounce back faster. Not [62:51] all of them, but but but women can have [62:53] multiple orgasms. [62:54] >> So she orgasms, it's very very [62:56] sensitive, she doesn't want me to touch [62:57] it for a while. [62:58] >> Yeah. [62:59] >> And then she could she potentially could [63:01] bounce back faster. [63:02] >> She could potentially. Some people do, [63:04] some people don't, but that's the [63:05] conversation of is this something that [63:07] is pleasurable? Is this something to try [63:08] again? Is multiple orgasms something [63:10] that you want to have or try to have? [63:12] When does penetration happen during the [63:14] dance? Because often times men orgasm [63:16] and then they're done, they all over, go [63:17] to sleep, whatever it is. Is the orgasm [63:19] happening after your orgasm, before your [63:21] orgasm? Is it happening before and after [63:23] your orgasm? Like are there cuz that [63:25] could be a nice way to sandwich it of [63:27] like there is, you know, giving the the [63:29] sensitive tissue some time to rest, then [63:32] your orgasm happens and then you [63:33] potentially go for round two. [63:35] >> So, if the [63:36] sensitive pleasurable part is on the [63:39] outside here on the clitoris, then what [63:41] do they get from penetrative sex if the [63:44] this one of main event is here in the [63:46] clitoris? [63:46] >> Many times nothing. Many times [63:48] [clears throat] connection. Many times [63:50] uh sort of this need for closeness and [63:52] pleasure. Many times there are women who [63:55] have extra nerve endings sort of inside [63:57] the vagina on the top of the vagina and [63:59] the cervix. So, there are women who love [64:01] penetration, but many women get the main [64:04] event from the clitoris and so it's part [64:06] of the whole menu as opposed to [64:09] penetration is the whole story. And I [64:11] think every woman's body is different [64:14] and so kind of making these broad [64:15] statements of every partner likes this, [64:18] but many women are asking for [64:19] penetration mainly because they're like, [64:22] "Okay, that's when you have your orgasm [64:24] it's done and then I can go to bed, I [64:26] can read my book, I can do all these [64:27] other things." But the pleasure often [64:30] comes from that clitoral stimulation. [64:31] Now, some women can orgasm from penetra- [64:34] I have a theory. It's a really [64:35] interesting theory that maybe your [64:36] listeners can prove with science or help [64:38] me prove with science. [64:39] So, you know how there's men who [64:41] prematurely ejaculate? Like who [64:43] ejaculate very quickly? [64:44] >> Yeah. [64:45] >> There are men who orgasm in a minute or [64:46] less. [64:47] That's probably [clears throat] 8% of [64:49] men, okay? So, if we think men and [64:50] women's bodies are very similar, could [64:52] we argue that 8% of women will orgasm [64:56] within a minute or less? [64:58] Theoretically, it makes sense, right? I [65:00] think those are the women who orgasm [65:02] with penetration. They're so sensitive, [65:04] their nerves are so sensitive that [65:06] penetration's very pleasurable and then [65:08] they have this magical orgasm and they [65:10] do it very quickly. So, it's good in a [65:12] way, it's often seen as like great in a [65:13] woman and not great in men. And so, I [65:16] just have this theory that like there [65:17] are women who have extra sensitive body [65:20] parts. [65:20] >> So, [65:21] I mean, one of the things I've learned [65:22] from everything you've said is just like [65:24] how much porn has messed up [65:27] our perception of sex. [65:30] >> I mean, WWF has messed up our perception [65:33] of [65:34] I don't know. [65:35] Like what people's bodies are like [65:37] exercise fighting like like it's all [65:39] manufactured. And it's all manufactured [65:41] because that's the algorithm that has [65:43] been working to get men excited. And it [65:46] doesn't like again, it's that question [65:47] of that curiosity of who's watching [65:50] porn, what do people want from porn, [65:52] what are they getting from porn because [65:53] it's not what women want typically. And [65:56] it has really messed up people's [65:58] perceptions of what is actually fun and [66:00] pleasurable for the partner. So, seeing [66:01] that curiosity of like what does my [66:03] partner actually want? You know, you can [66:05] have great sex without penetration. And [66:07] so, the question is is what does great [66:09] sex look like? [66:10] >> For you and your partner. When I look at [66:11] a website, got some data here on a [66:12] website like Pornhub, which is one of [66:14] the leading porn websites, it says that [66:16] roughly 65% of their traffic [66:19] is men. Independent surveys tracking any [66:23] regular pornography use find a similar [66:25] gap, but note that women's consumption [66:26] is highly age dependent. Men between the [66:28] age of 18 and 35, [66:31] 75 to 95% of them report viewing porn [66:34] regularly, whereas women age 18 to 35, [66:39] only 34% roughly, [66:41] report viewing porn regularly. And if we [66:44] think about these systems as catering to [66:46] demand, it means that porn websites are [66:48] catering to [66:50] predominantly male [66:53] demand. And that explains why for most [66:55] young men, we learn about sex from porn [66:57] websites. [66:58] >> Right. [66:59] >> And then we assume that's the the woman [67:01] looked like she was having fun, and the [67:03] man was doing this particular thing, and [67:04] then And take that into our [67:05] relationships, and I think this is where [67:07] the misunderstanding begins. [67:08] >> And the women think they're broken [67:10] because they're not having magical [67:11] orgasms from penetration. They come to [67:13] see me all the time and say, "I'm [67:14] broken. You have to fix me. I'm not [67:16] orgasming during sex." They have wildly [67:18] good orgasms with a vibrator, with a [67:19] hand, with [67:21] a shower head, with whatever it is from [67:24] on their clitoris, and that's totally [67:25] normal, right? And then you show them [67:27] the body parts. You say, "This is right, [67:29] the clitoris and the penis are the same [67:30] thing. You activate a penis for a man to [67:32] orgasm. You activate a clitoris for a [67:33] woman to orgasm." And once you teach [67:35] them that, it makes perfect sense to [67:37] them. Like they were normal the whole [67:38] time. [67:38] >> What do you think of pornography? [67:40] >> I actually think pornography is great. [67:42] >> For relationships? For connection? [67:44] >> the right porn. Like look at Okay, let's [67:45] look at something like Heated Rivalry. [67:47] Have you heard of it? [67:47] >> No. [67:48] >> Okay, Heated Rivalry is an HBO show that [67:50] came out this year that is about two gay [67:54] male hockey players. Okay, it's based on [67:56] a romance novel book in came from [67:58] Canada, and HBO put it out there, and it [68:01] went viral in levels that the world has [68:03] never seen before. And it is about two [68:05] young men [68:06] who fall in love, but there's a very [68:08] sexual relationship between them. And [68:10] heterosexual women have watched this 10 [68:13] times over. Like they are addicted to [68:15] this show. It's all over social media. [68:16] It's this huge thing. It's essentially [68:18] porn for women, right? It is women who [68:20] are watching these pornographic [68:22] episodes, and it's really important. [68:23] They love it. It's supported. Everyone's [68:25] talking about it. So, I don't think porn [68:27] in and of itself is bad. I think porn, [68:30] we, you know, watching people have sex, [68:32] watching people fall in love, watching [68:34] people with in romance. People like [68:35] that. It gets them excited. It gets them [68:37] aroused. But I think too much, if you [68:39] are watching porn because and not [68:41] interacting with humans, if you are [68:43] watching porn all the time, if you need [68:45] to if you can only watch porn to have [68:47] good sex, like then [68:49] that may not be the best, you know, and [68:51] healthiest thing to do. [68:52] >> I guess the question I was asking is, if [68:54] you're in a relationship and one partner [68:55] is using a lot of porn, won't that kill [68:58] the sexual desire to be intimate with [69:01] your partner? [69:02] >> It depends. It depends on the [69:03] relationship and it depends on what each [69:05] person needs in order to feel supported [69:07] and connected, right? I don't think we [69:09] can say blanketly it's good or bad, [69:11] right or wrong. I think if it is good or [69:14] bad, right or wrong for that couple, [69:16] then it's a problem. Cuz there are [69:17] couples who like to watch porn together. [69:19] There are couples where oh, that maybe [69:21] someone has a much higher libido than [69:22] the other person. So they said, "Okay, [69:24] the high libido person can use porn and [69:26] then once a week we'll circle together [69:28] and we'll have a great experience [69:29] together." Because it's not everyone's [69:31] job to meet each other on the libido. [69:34] >> The study that I was looking at was a [69:35] couple dozen studies including a major [69:36] meta-analysis show a consistent link [69:38] between solo porn consumption and lower [69:40] relationship and sexual satisfaction. [69:43] The erosion of intimacy is usually [69:44] driven by deception. Finding a partner [69:47] is hiding porn use is usually triggers [69:49] intense feelings of betrayal, rejection, [69:50] and insecurity. [69:52] And heavy solo use can desensitize [69:55] the brain's reward system leading to [69:57] performance anxiety and erectile issues [69:59] during real-life partner sex. It can [70:01] also create highly unrealistic [70:03] expectations regarding body types, [70:05] stamina, and performance making real sex [70:08] feel less stimulating. [70:10] >> Again, it was that deception. It's the [70:12] hiding. If your that that ex of yours [70:14] didn't tell you what was really going on [70:15] and so you felt disconnected from that [70:18] person because you didn't get that [70:19] honest truth of what was going on. [70:21] >> But also the desensitization of it. Like [70:23] it's never going to you know [70:25] I guess it depends on how you're using [70:26] pornography. [70:27] >> It depends on how you use it. So again, [70:29] that's the truth. [70:29] >> Like you can like train your brain to [70:31] get pleasure in a certain way. [70:34] And then when you're with your partner, [70:35] one could argue that it's going to be [70:36] quite difficult for them to replicate [70:38] that particular way that you've pleasure [70:39] you've learned to pleasure yourself. [70:41] >> Right. And that's a that's a problem, [70:43] right? If you're only able to do [70:44] something in one way, in one position, [70:46] with one watching one specific thing, [70:49] that may not translate into great [70:51] intimate sex with a partner. [70:53] >> For the last couple years I've been [70:54] working on something that I realized [70:55] every podcaster listening to this, but [70:57] actually probably every creator [70:58] listening to this might just need. [71:00] Podcasting is difficult for many [71:01] reasons, and one of them is that these [71:03] hosting platforms don't give you much [71:04] information, and also because they're so [71:06] fragmented, you kind of have to go [71:08] through every single platform uploading [71:10] it to YouTube and then taking the same [71:11] big old video file and uploading it to [71:13] Spotify's platform. It takes huge [71:15] amounts of time, and that friction means [71:17] most of us don't do it. That is the [71:19] problem we set out to solve, and so we [71:20] built something called Flight School, [71:21] which you can find at flightcast.com. [71:23] And today Flight School is also one of [71:26] our show sponsors, and some of the [71:27] world's biggest podcasters are now using [71:29] our platform to run their shows because [71:31] it gives you an edge. It saves you time. [71:34] It gives you analytics most people won't [71:36] typically get. It allows you to use AI [71:38] to be more informed on your show, and it [71:41] has growth tools that other hosting [71:43] platforms don't have. So, podcasters [71:44] that are using Flight School have this [71:46] unfair advantage. So, go to [71:47] flightcast.com/doac [71:50] now. [71:51] I've done almost 700 interviews with [71:54] some of the most interesting people in [71:55] the world, and one of the things you [71:56] learn, which is unexpected, is that [71:58] vulnerability is the doorway to [72:00] connection. And after sitting here for 2 [72:02] 3 hours with a guest, I feel a deep [72:04] sense of connection to them. And as they [72:06] leave, what I get them to do is to write [72:09] a question in the Diary of a CEO. We've [72:12] taken all of the questions from the [72:14] Diary of a CEO. We have put the question [72:17] here on this card with the name of the [72:20] person that wrote it. So, you can sit at [72:21] home, as I do with my fiance, and my [72:23] colleagues at work, and other people in [72:25] my life, whenever we get a minute, we [72:27] play the Diary of a CEO conversation [72:29] cards, and it is incredible what [72:32] happens. These are great if you're in a [72:33] romantic relationship and you want to [72:35] connect your partner more. These are [72:36] also great if you're in a team and you [72:38] want to bond your team together. And I [72:40] have to say they're also great for [72:41] families that want to learn more about [72:42] each other and that need a good excuse [72:44] to spend some time in a digital world in [72:47] the analog environment connecting human [72:50] to human. It is remarkable what the [72:52] right question at the right time can do. [72:55] Go to the diary.com [72:57] and you can get these conversation cards [72:59] right now. [73:01] And there's different types of arousal, [73:02] right? I was I heard from a sex expert I [73:05] spoke to that men and women often have [73:07] different types of arousal, spontaneous [73:09] and like reactive. Is it? [73:11] >> Yep. Yep. So there again, this idea of [73:13] like I want to have sex, I'm ready to go [73:15] versus I want to have sex because we've [73:17] started having sex and we've started [73:19] that process and now I can get into it. [73:21] Sort of like exercise. Some people are [73:22] like ready to go to the gym and exercise [73:25] and other people like I don't want to I [73:26] never want to exercise, but once they [73:28] start getting going, oh I know this is [73:29] good for me, I should do this. This [73:31] feels really good and that's sex for a [73:33] lot of people. But again, it's also a [73:36] question of what kind of sex are you [73:37] having? If you have sex the same way [73:39] every single time and it's not that fun [73:42] and it's not that interesting to your [73:43] partner, are they going to look forward [73:45] to it? Are they going to Are they going [73:46] to want it? Are they going to seek it [73:47] out? And is that really low libido at [73:49] all or is that sort of the product of [73:51] like we just aren't talking about it [73:53] improving. If you had the same podcast [73:55] guest on every single week and it was [73:57] the same conversation every single week, [73:59] it's not going to last you very long, [74:01] right? You do different things. You try [74:02] different things. Oh, what worked? What [74:04] didn't work? How could we do this [74:05] better? What does the algorithm want us [74:07] to do now? No one's doing that in their [74:09] sex lives. Like Like no one's even [74:10] talking about it. Like honey, what's [74:12] working? What do we like? What's going [74:13] on? I saw this thing like [74:14] >> Why? Why don't we talk about it? [74:16] >> Because we don't talk about money [74:17] either. We don't talk about sex. Because [74:18] we're trying to be a pro I don't know. [74:19] What do you think? [74:20] >> I think that's a little bit of it, but I [74:21] think the subjects are like deeply [74:24] personal, emasculating [74:26] and so intrinsically linked to like [74:29] self-esteem. [74:30] >> It's vulnerable. [74:31] >> Yeah, it's like super vulnerable. So And [74:33] if someone I remember I had a [74:36] partner turn around to me who [74:38] interestingly was going through some of [74:39] the issues that were undiagnosed, turn [74:41] around once upon a time and expressed [74:43] that she didn't like having sex and I [74:44] didn't understand that at like a 20 as a [74:45] 23 22-year-old guy. [74:48] >> Yeah. [74:48] >> And so you kind of look yourself in the [74:49] mirror and go, "Oh shit." Like it's [74:51] super emasculating. [74:53] It turned out that there was actually a [74:54] physiological challenge she'd had. [74:56] >> Yeah. [74:56] >> But we'd been in a relationship for a [74:59] long time and she wasn't enjoying sex [75:01] for because there was a physiological [75:02] issue. [75:03] >> Mhm. [75:03] >> She didn't say anything to me. [75:04] >> Yeah. [75:05] >> I didn't know. And then the day she said [75:07] something to me, my I didn't know [75:09] anything about sex. So I just [75:10] interpreted it as like, "Damn, I'm not [75:12] good in the you know I might I must not [75:13] be good in the bedroom or something." [75:15] Um which is super like hurtful. Yeah. [75:17] And then that kind of breaks the [75:17] relationship down and it's all [75:19] predicated on this like [75:21] highly emotional, highly self-esteem [75:23] linked, poorly educated subject which [75:26] destroys relationships. [75:27] >> Destroys it. I [75:28] And that's such an important story, [75:31] right? Because if you had had access to [75:34] the information, she thought she was [75:36] protecting you by not telling you that [75:38] information. [75:38] >> interesting? I went to one of my friends [75:40] and one of my best friends and said, [75:41] like, "My partner's just said this to [75:42] me. Like what does that mean?" And he [75:43] went to me, he goes, "Mine too." I was [75:46] like, "What?" I was like, "So you're not [75:47] having sex with your partner?" He goes, [75:48] "No." And we And by the way, I'm talking [75:49] about 30 year olds. He was like, "No, we [75:51] haven't had sex in 3 months." And I was [75:53] like, "What What's the reason?" And he [75:54] said to me, "She said she just doesn't [75:56] like having sex." And I'm like, "Oh, [75:58] okay. So that's [76:00] that's the same in my relationship. My [76:01] my former ex-girlfriend said she just [76:02] doesn't like having sex." [76:04] And [76:05] I can't tell you how ignorant and poor [76:10] and insufficient the conclusions in such [76:14] a situation we arrive at are. We're [76:16] like, "Well, maybe maybe there's [76:18] something wrong with me. Maybe it's a [76:20] sexuality challenge. Maybe it's a [76:22] genetic thing. Maybe they were just but [76:23] they were born in didn't want to have [76:25] sex like we don't we just don't know [76:26] what it is." [76:28] From doing this podcast and speaking to [76:30] people like you, I like, "Oh my god. I [76:33] just wish like 5 10 years ago when I had [76:35] these conversations with my guy friends [76:37] and also with my the ex-partner that I'm [76:38] referencing, I just wish I knew that it [76:42] wasn't any of those things. [76:44] >> Mhm. [76:44] >> It was something that um [76:46] could have been helped. [76:47] >> Yeah. [76:48] What's so important is that you were [76:51] able to learn and see and grow in this, [76:54] right? A little bit of information gave [76:56] you empathy for this partner where you [76:58] took it on as a you problem, it became a [77:01] you problem cuz it was both of you [77:02] together, but it started with biology. [77:05] And so, if we actually taught people the [77:07] biology or to think about biology or to [77:10] like be able to talk about sex, to talk [77:12] about sexual health, to talk about [77:14] genitals, to make them not private [77:15] parts, how much better would your sexual [77:18] upbringing really have been? How much [77:20] less hurt and shame and guilt would you [77:22] have felt because it actually wasn't you [77:24] at all, right? [77:25] >> It's the horrible conclusions you arrive [77:26] at and the the conclusions you arrive at [77:29] are often seen as both unchangeable and [77:32] therefore, in my situation back then, [77:34] the conclusion was, well, this [77:35] relationship's never going to work. [77:37] Because the false conclusion we'd [77:38] arrived at was not something we could we [77:41] could change. [77:42] >> Mhm. [77:43] >> Uh whereas, when I hear about all of [77:44] these different things we've talked [77:45] about today, I go, "Oh my god, there's [77:47] so many other conclusions I could have [77:48] arrived at or my friends could have [77:49] arrived at that would have been fixable [77:51] and therefore, the relationship, which [77:53] is a perfectly great relationship with a [77:54] person, was therefore savable." One of [77:56] them is the thing we just talked about, [77:58] which is this idea that men and women [78:00] have different types of arousal, [78:01] spontaneous and responsive. And I was [78:03] looking at some of the data on the [78:05] variance, which I think is very [78:06] important for people to know. [78:08] And it says that men are highly [78:10] spontaneous in their arousal, which kind [78:12] of means, from my interpretation, and [78:13] please correct me if I'm wrong, that as [78:15] a man, I can literally be I can [78:17] literally think about something [78:20] and get aroused. And it's not to say [78:22] that women can't, but it the data [78:24] suggests that men are more that way [78:26] inclined. The data here says that their [78:28] spontaneous rate in a man is about 70%, [78:30] whereas in women, it's about 10 to 15%. [78:33] It says the responsive rate, which I [78:34] guess is like I get aroused once the [78:36] ship starts moving, once we start [78:38] foreplay, once contact starts, is 10 to [78:41] 15% in men, and in women in this [78:44] particular report is 40 to 50%. [78:47] >> Mhm. [78:47] >> So, that would suggest to me that women [78:49] are much more likely to be aroused once, [78:52] you know, [78:53] foreplay or contact or the sexual [78:55] actions have taken place, I'm guessing. [78:57] >> Mhm. [78:58] >> And then the mixed style [79:01] is 15 to 20% in men and 35% in women. [79:05] Um is that all accurate? [79:06] >> It's accurate, and I think it really [79:08] comes to this idea of your path to [79:11] having a better understanding of that [79:13] prior relationship was actually [79:15] education and communication. [79:17] >> Yes. [79:18] >> Right? [79:18] >> If you had a better understanding of the [79:20] biology, if she had a better [79:22] understanding of the biology, if she [79:24] were vulnerable enough to be real with [79:26] you and honest with you up front as [79:28] opposed to kind of a bombshell that [79:30] happened too late, um all of that pain, [79:32] all of that hurt probably would have [79:34] looked different. [79:35] >> Right? It would have looked like the [79:36] world would have looked very different. [79:37] Now, that's what I'm fighting against [79:40] because I think that to your point, I [79:42] think men are suffering. They're feeling [79:45] disconnected from their partners. [79:46] They're feeling a difficulty of even [79:48] finding a partner, and part of that is [79:50] cuz they lack that curiosity of like, [79:52] what like, what do they want? What do [79:55] they need? What kind of communication [79:57] helps me get to where I want to go with [79:58] this person? And a lot of that is [80:00] vulnerability and curiosity and [80:03] interest, and I think that's what women [80:05] often are looking for in partners. Is [80:07] they're looking for someone who's going [80:09] to give a crap about them enough to care [80:11] what they specifically need and want, [80:14] not what gen What do women want, and [80:16] what is it like like, what specifically [80:19] about this person in front of me? What [80:21] does she need to feel that erotic love, [80:25] support, connection, lust? And for the [80:27] man, too. Like, what do you need to feel [80:30] all of those things? And what a good [80:32] relationship is is when people work [80:35] together to try to optimize that for [80:37] everybody. [80:38] >> are the questions that you would ask [80:40] your patients to ask their partner [80:43] to start to tease out some of these [80:44] things? Couples will come up to me when [80:46] I'm in a restaurant or something, and [80:48] they'll come up together, and they'll [80:49] always they'll often say to me that the [80:52] episode they watched together was about [80:54] sex. [80:55] So, I I literally have this image of [80:57] this particular couple that came up to [80:58] me when I was abroad, and they said, "We [81:01] were just listening on the plane about [81:02] your sex episode." So, I'm like they're [81:05] listening now. [81:06] >> Like again, I think it's that basic [81:08] thing of like what does great sex mean [81:09] for you? [81:10] >> Okay. [81:11] >> [clears throat] [81:11] >> What what do you want? Like what what is [81:13] a great time? What's it something fun? [81:15] Like what is it about sex that you [81:17] enjoy? When you ask people what do they [81:19] get out of sex, it's like 200 different [81:21] reasons. Everyone wants something [81:23] different, and everyone doesn't always [81:25] know what they want. And then having [81:26] that ability, if you don't know what you [81:27] want, is having that curiosity to [81:30] explore together. [81:31] >> So, with that said, 200 different [81:33] opinions on what good sex is. And this [81:36] is kind of what I think you find in [81:37] couples. And when I've sat with my [81:38] partner before and said like what do you [81:39] what arouses you during sex? What do you [81:41] like? [81:42] The two things can often be different. [81:44] >> Totally. [81:44] >> And so, is this not a problem that one [81:47] partner might say, "I really want you to [81:50] tie me up and da da da da da." And then [81:52] the other partner might say, "I really [81:54] want you to not tie me up and be really [81:57] soft and gentle." And there's a bit of a [81:59] dichotomy between sorts of sex [82:01] preferences, [82:02] >> Mhm. [82:03] >> which means no one's really ever getting [82:04] what they want. Like how do you navigate [82:06] that? [82:06] >> When you go to buy a house, you don't [82:08] always get to choose what house you get [82:09] unless you you know you build it [82:11] yourself. Like there are compromises in [82:13] life, and and there is no all good or [82:15] all bad. You're never going to find this [82:16] is actually the problem with pornography [82:18] is you figure out the exact porn in the [82:20] exact situation or even worse with AI. [82:22] Like you're going to have a sex robot [82:24] who's going to be able to do exactly [82:25] what you want in the way that you want [82:26] to do it and people are afraid about [82:29] what that means for intimacy and [82:30] relationships and great sex going [82:32] forward because the truth is sex is [82:34] messy, it's awkward, it's smelly, [82:36] there's fluids, there's funny noises, [82:39] there's like it's it's vulnerable, it's [82:41] like really uncomfortable sometimes for [82:44] to like have these deep conversations, [82:46] but isn't that why life exists? Like [82:48] isn't that like the most fun part is [82:50] when you can kind of have that with [82:52] somebody else where they know all of you [82:54] and they want to explore that with you. [82:55] Now, if it's not the right relationship, [82:58] it's not the right relationship, right? [82:59] Like and and figuring out if that is an [83:01] important part of your life and it's a [83:02] non-negotiable, then find the rooms [83:05] where there are other people who do that [83:06] those things too. I mean, what you will [83:08] find is that people have all sorts of [83:10] agreements and relationship setups and [83:13] as a sex doctor, like the things I hear [83:15] in a room like would, you know, are [83:17] quite wild and you you wouldn't even [83:18] believe. Like people are doing Well, I [83:21] think people have multiple like there [83:23] are there are people who have open [83:24] relationships. So, they have multiple [83:26] partners or they have certain kinks, [83:29] right? So, there are things that they [83:30] really enjoy that maybe somebody would [83:32] look at that and be like, oh, that's [83:33] very strange, but there are other [83:34] consenting people who also are [83:36] comfortable and want to do those things. [83:37] There are websites that deal with [83:39] different erotica and different kinks [83:41] and things like that. And there's also [83:42] this idea of fantasy. It's also okay to [83:44] have things that you think about but [83:46] that you don't actually want to partake [83:48] in and and that you use. [83:50] >> On this point of fantasy, what if you [83:51] have a you probably have experience [83:53] where someone's come to you and they [83:54] have a fantasy [83:56] but they don't want to tell or a kink [83:58] and they don't want to tell their [83:59] partner because they're worried about [84:01] the reaction. [84:02] >> Yeah, this is where things like sex [84:03] therapy become really helpful of how do [84:05] you have a third party? Cuz again, when [84:07] your doctor's telling you to do [84:08] something or bringing something out, [84:09] it's it's so much less [84:11] scary than if you're doing it on your [84:13] own. There are also different like apps [84:15] and things like that where you can sort [84:17] of dip a toe where you you you have [84:20] There's one called Spicer, I believe, [84:21] where you can sext each other in ways [84:23] and they'll push questions. If you both [84:25] agree, it'll tell each other that you [84:26] both agree with things. So, there's ways [84:29] to dip a toe here and sort of be curious [84:31] about it, but again, that's where [84:32] watching things together or asking the [84:34] questions. This should happen not when [84:35] you're naked in the bedroom actively [84:37] having sex. Like it's okay to have [84:39] conversations about sex when you're not [84:41] having sex, right? Like you plan these [84:43] podcasts before you actually sit down to [84:45] record. Afterwards, you talk with your [84:47] team, "Hey, this is what I liked about [84:49] it. Here's what I didn't like. Let's [84:50] change this in the future. Let's never [84:52] have Dr. Ruth Westheimer on again, [84:53] right?" Like these are the conversations [84:55] you're going to have with your team. [84:56] People don't do that about sex very [84:57] often, right? They don't actually do [84:59] after action. What went well? What [85:01] didn't go well? Do you ever want to try [85:02] this? Like what would be fun here? Like [85:05] there there is often a a lack of [85:06] curiosity. [85:08] >> And to be you are sex doctor, but people [85:10] come to you and sort of offload their [85:11] sex lives to you. [85:12] >> My job is so fun. I love my job. It's so [85:15] fun because people will talk to me about [85:17] their most Like we do 2 hours and we [85:20] talk about their lives in the context of [85:22] their sexual health for 2 hours and [85:25] people never have those types of [85:27] conversations even with their partners. [85:29] And it is incredibly vulnerable. It's [85:31] incredibly important for people to see [85:33] that and see, "Oh, that was actually [85:35] really nice to talk about. I didn't know [85:37] this, that, and the other thing about my [85:38] body." [85:39] >> And what you find that men and women [85:41] typically are hiding from their partners [85:45] when they do confide in you? [85:47] >> I think they don't tell their partners [85:48] just about anything. Like they don't [85:50] There's a lot they don't tell their [85:51] partners, right? [85:52] >> Is there a difference between men and [85:52] women what they are not saying? [85:55] >> That's a great question. I would say [85:57] that no one is talking about sex at all. [86:00] Women are hiding their pain from their [86:02] partners. Men are hiding their um [86:06] insecurities and their frustrations and [86:08] there's a lot of shame around erectile [86:10] dysfunction and sexual problems in men [86:12] and so they a lot of people just either [86:14] stop having sex or stop talking about it [86:17] or sort of have a mediocre sex because [86:20] they are not that great at talking about [86:21] these things. [86:22] >> And I imagine your I mean my first [86:23] reaction would be like, "Oh, you should [86:24] tell them." [86:26] But I imagine that doesn't necessarily [86:27] work. [86:27] >> I think it's a challenge. Like if you [86:29] have had if you have been faking an [86:31] orgasm for your entire relationship [86:34] >> And women have been. [86:35] >> Yeah, many. The statistics are quite [86:36] clear. Like if you're only having [86:38] penetration and your partner orgasms [86:40] every time and it's a perfect orgasm [86:42] every time, I would say there's a high [86:43] percentage that that's not real. Because [86:46] the truth is is orgasm often takes a lot [86:49] of arousal and a like like again, [86:51] stopwatch. Every header if a penis [86:53] enters a vagina and they orgasm about 5 [86:57] and 1/2 minutes is on average how long [86:58] men last, right? Like that's science. [87:00] It's about 5 and 1/2 minutes. Now, if [87:02] you're longer, great job. If it's [87:03] shorter, it's okay. It's all within the [87:04] range of normal. Women, if penetration [87:07] is happening, almost nobody orgasms in 5 [87:10] and 1/2 minutes. It's usually well over [87:12] 13, 14, 15 minutes and penetration is [87:15] usually not how that happens. Cuz again, [87:17] if you're distracted while you're trying [87:19] to stimulate your penis, it's going to [87:20] take longer. Women need focus on the [87:22] clitoris. So again, if your partner is [87:24] orgasming every time within that 5 and [87:26] 1/2 minutes and it's like clockwork, I [87:29] would call [ __ ] on [87:30] a high percentage of it. So but but a [87:33] partner doesn't want to tell you, right? [87:34] Like they're afraid to tell you cuz [87:36] they're they want to make you happy, [87:37] right? It's not that they're having bad [87:38] sex. They just know that that's not [87:40] what's going to get them to orgasm and [87:42] they want you to be happy and to feel [87:44] supported. [87:45] >> So [87:46] that presents a pretty good case that [87:48] the woman should orgasm first. [87:50] >> I think so because I think orgasm first [87:53] will allow for pelvic floor release and [87:55] relaxation, which will make penetration [87:57] more pleasurable, enjoyable. I think [87:59] women can have multiple orgasms, so [88:01] there's a case to be made for before and [88:03] after. Why are women having zero [88:05] orgasms, men having one orgasm when [88:06] women could be having three orgasms and [88:08] men have one orgasm? So I think we [88:10] should be actively trying to change the [88:13] orgasm gap and focus on the pleasure and [88:16] I think making penetration the main [88:17] event is where the challenge I think [88:20] penetration can be part of the whole [88:22] story but doesn't necessarily always [88:23] need to be the main event. [88:26] >> On the physical blockers you talked [88:27] about some of them like anxiety. One of [88:29] them that I think isn't talked about [88:30] enough especially in the modern world is [88:32] what they call like the dopamine drain [88:33] where you've got mental burnout or [88:35] chronic stress or we talked a little bit [88:37] about depression but I did notice that [88:40] through my life when I'm very very [88:42] overworked shall I say [88:46] my libido is not the same. [88:48] >> Yeah. [88:49] >> And this is also the case for for women [88:51] as well. Do you have a lot of women come [88:53] to you or couples come to you where this [88:55] is quite clearly the problem this sort [88:56] of like dopamine drain it's actually [88:58] their stress and lifestyle it could be [88:59] the kids it could be [89:01] >> Oh it's a huge problem right? It makes [89:02] logical sense again if we go back to the [89:04] fundamentals of if you're not sleeping [89:06] if you're overworked if you're burned [89:08] out if you have no white space for [89:09] yourself why are why are you going to [89:11] have all this excitement for your [89:12] partner and all of these things like if [89:14] we're scrolling all the time at bedtime [89:16] or if we're watching porn all the time [89:18] or we're watching reading romance novels [89:20] all the time but we're not talking to [89:22] the partner with that we're with or [89:24] we're not creating that time and space I [89:26] think there's a big opportunity for [89:28] people in our modern society which is [89:30] over scheduled to schedule sex. I mean [89:33] they do this quite well. So when you [89:35] were dating right and you would ask your [89:37] your date you know let's go out Saturday [89:39] night you were literally scheduling [89:41] potential sex. You're like I could get [89:43] lucky I'm going to plan for it all week [89:45] I'm going to get excited I'm taking this [89:46] person out I'm like it's going to be [89:48] really fun and I'm going to do whatever [89:49] it takes to sort of cross that finish [89:51] line. So we were always scheduling sex [89:53] and it was very erotic and fun when [89:55] you're in your dating life and now you [89:57] live with a person and you sort of they [89:59] see you at your best they see you at [90:01] your worst they see you at your [90:02] crankiest and your most tired and so [90:04] it's really hard to get that level of [90:07] excitement when you're dealing with [90:10] those, you know, sort of life [90:12] circumstances. [90:13] >> People will say that, you know, there's [90:14] a spontaneity myth around sex that it [90:16] should be spontaneous and that's kind of [90:17] how we see it in films. Like they grab [90:19] you in the hallway and you start kissing [90:20] and whatever else. [90:21] >> not real. It's just the same as WWF. [90:23] Like it's not real. And so that's the [90:25] truth is like you If you see your [90:27] partner every day and you see your [90:28] partner your high and your low and the [90:30] crankiest and all of these things and [90:31] you're all working like crazy, where is [90:33] the space for that? Like that's not how [90:35] humans work. So creating That's why [90:36] vacation sex is always fun for people or [90:39] they find time, you know, so again, if [90:41] you've got kids and your kids are [90:42] staying up later than you are and you [90:44] don't have a lock on your door and [90:45] you're worried about making noises and [90:46] you don't want to be too loud. Like how [90:48] are you going to have great sex in that [90:49] situation? [90:50] >> One of the I guess the challenges people [90:51] might also bring up is that if you're [90:53] scheduling sex, it puts a lot of [90:55] performance pressure on you. If I know [90:57] tonight at 8:00 p.m. I have to have sex [91:00] because that's the time we scheduled [91:01] this week, [91:03] then like, gosh, I'm going to be [91:04] finishing my work at 5:00, 6:00, 7:00. I [91:06] don't know. I need to get home. [snorts] [91:07] I need to have I need to have sex as [91:08] well. Gosh. [91:09] >> So So this is where you schedule it [91:10] around a time that you know is going to [91:12] work for you. So I do I tell people to [91:13] do things like [91:15] quarterly dates. So I get I Listen, I'm [91:17] working in DC. Everyone is very [91:18] high-powered with very busy jobs. I say [91:21] one Friday a quarter, you and your [91:23] spouse can literally block your [91:24] calendars. One a quarter cuz quarter. [91:27] Okay, that means you might have sex [91:28] every week. You might have your your [91:29] your eight late night sex whenever. You [91:31] could might have sex whenever you have [91:32] sex. But once a quarter, have a day [91:35] where you just block it out and you have [91:37] a spouse day or a partner day or [91:39] whatever it looks like and maybe do an [91:41] act It doesn't necessarily have to be a [91:42] sex day, but you actually take time of [91:45] your little mini Maybe you go on a walk. [91:47] Maybe you go on a hike. Maybe take a [91:48] bath. Maybe get a massage. You kind of [91:50] create space for you to actually say, [91:52] "Oh, wait, we like each other. Oh, we [91:54] like talking to each other. We don't [91:55] have to just talk about the kids all the [91:56] time." So again, the more you invest in [91:59] each other and in a joyful way, the [92:02] better sex you're going to have. [92:03] >> What about self-esteem issues? You [92:05] mentioned that as well. Body image [92:07] issues. How often do you see that being [92:09] the blocker to great sex? [92:11] >> It's a huge problem. Again, I wish that [92:14] the energy that my female patients put [92:17] into wanting to be skinny [92:19] is is enormous and I wish that energy [92:22] was put into wanting to be strong, but [92:24] it's kind of funny because [92:27] what people think about themselves [92:28] versus what they think for their friends [92:30] are very different. Your best friend, [92:32] say they're overweight. Do they deserve [92:33] great sex? [92:34] >> Of course. [92:35] >> Of course they do, right? Your best [92:37] friend deserves great orgasms, great [92:38] sex, no matter what they look like, no [92:40] matter what they weigh. Everybody [92:41] deserves intimacy, pleasure, and [92:43] connection with someone that they can [92:44] have intimacy, pleasure, and connection [92:45] with. But for some reason when we think [92:47] of ourselves, "Oh, I can't be naked with [92:50] this person. Oh, I can't be happy until [92:52] I lose this much weight. I don't deserve [92:54] an orgasm unless I am, you know, [92:57] skinny." And that's a huge problem. [92:58] >> So, what do we do about it? [93:00] >> I think it's empowerment, it's [93:01] communication, it's explaining to [93:03] people. I think that all of the mindset [93:04] stuff that you do and you talk about is [93:06] so important cuz look, you changed your [93:08] mind around your own situation with this [93:11] ex of yours because you got education, [93:13] right? You were able to see that it was [93:14] more complicated than that. And I do [93:17] think by educating people on bodies, on [93:21] pleasure, on joy, on connection, on [93:24] intimacy, I actually think it changes [93:25] the narrative. I think people we're in a [93:27] sex recession, okay? People are having [93:29] less sex than ever. People are not [93:31] connecting, people are scrolling and [93:33] they're on their AI chatbots instead of [93:35] like human connection. We're getting [93:36] worse at this, not better. I I I just [93:39] think that like we have to reach humans [93:41] and we have to be able to talk about it [93:42] to change the narrative. [93:44] >> What is the the most important thing we [93:45] haven't talked about that we should have [93:46] talked about as it relates to all the [93:47] work that you do? [93:49] >> I think the most important thing is that [93:51] biology matters in women and we often [93:54] spend so much time talking about [93:56] psychosocial issues, about emotions, and [93:59] all of that is true. That is important [94:01] to sexual health, but we minimize [94:02] biology when it comes to women, and we [94:05] have to let women advocate for [94:07] themselves about the biology, and we [94:08] need to train doctors to care about the [94:10] biology. I would love to find out from [94:11] all the women in your life and the women [94:13] on your team, like what experience Like [94:16] I would love for you to ask them their [94:17] experiences with medical providers, cuz [94:21] I don't think we have that curiosity of [94:22] like what are you experiencing that's [94:24] different. [94:25] >> Yeah, I think that I Yeah, I think [94:26] that's probably going to have to If for [94:27] me to have like a healthy relationship [94:29] with my partner, I think that's going to [94:30] have to be [94:31] uh practice or like part of our You [94:34] know, we check in on our relationship, [94:36] etc. But we don't really check in on the [94:38] physiology. [94:39] >> So, super interesting. So, I spend 2 [94:41] hours with people, and there are times [94:42] when the partner comes to that talk. And [94:45] so, they get to hear sort of what their [94:47] partner is describing. They even get to [94:49] see the exam, and they get sort of a [94:51] tour of their own partner's body parts. [94:53] And so, it is helpful sometimes to bring [94:55] partners into those conversations, the [94:57] biology conversations, of like she [94:59] doesn't want to have sex with you not [95:01] because you're bad at sex. Look how [95:03] painful it is right here at the opening [95:05] of her vulva. It's like a sunburn. I [95:07] touch it with a Q-tip, and she's on [95:08] fire. Like, what do you think your penis [95:10] is doing? And it gives that ability to [95:12] say, "Oh, it's not a me problem. How do [95:14] I support her best knowing that this is [95:16] the issue?" So, getting partners to [95:18] understand the biology is extremely [95:20] helpful. Or, say you have a man who's [95:22] taking an antidepressant or a hair loss [95:25] medication that can cause sexual [95:26] dysfunction as well. Um say you have a [95:28] man who takes an antidepressant and it [95:30] lowers his libido. Is it, "Oh, honey, [95:32] you're not attracted to me anymore. You [95:33] must not love me." Or, is it, "I [95:35] actually understand the biology that [95:37] your libido is lower because of this [95:38] antidepressant." And two things can be [95:40] true. So, so I think understanding your [95:42] partner's biology and your own biology [95:44] is quite important. [95:46] >> Yeah, I guess that's the the crux of the [95:47] conclusion really is that both education [95:50] and communication are where it all [95:52] begins. [95:53] >> Which is the fundamentals, right? [95:54] >> Yeah. And I think here gosh, if I had [95:56] better education on these subjects got [95:58] at the start of my adult life [96:01] and also I had like figured out how to [96:02] communicate with my partner and maybe [96:05] even also with yourself. And like to be [96:07] a bit honest with yourself about how [96:09] you're feeling, not to gaslight [96:10] yourself, not to gaslight your partner. [96:12] Just It just goes to show how better [96:14] relationships would have been, not just [96:16] with your romantic partner, but really [96:17] with all the people in your lives. And [96:19] this is easier said than done. Like [96:21] especially the communication part. [96:23] Because these are very, very sensitive [96:24] subjects. [96:25] And so we we'd rather just shut up about [96:28] them and keep them as these sort of like [96:29] secrets among that we whisper about with [96:31] the closest people in our lives, maybe [96:32] our best friend. [96:33] And I just think generally one of the [96:35] things I've come to learn from doing [96:36] this podcast as well is that [96:38] you know, there was this quote I read. [96:39] It said you can predict the long-term [96:40] health of a relationship by whether each [96:42] challenge heals to 101% or 99%. [96:46] Does your conflict make you stronger? [96:49] And what it's essentially saying is like [96:51] conflict is guaranteed in life, but the [96:53] thing that's going to turn your conflict [96:54] into a strengthened relationship or a [96:56] weakened one is [96:58] your how you deal with it. Like and [97:01] that's all predicated on communication. [97:03] And so [97:05] if we can just teach people how to [97:06] communicate, if we can become better [97:08] communicators, which is both function of [97:10] speaking and listening [97:12] and I guess curiosity [97:14] then all of these downstream challenges [97:15] and misunderstandings would have a [97:17] chance of being solved for. And I think [97:19] about this all often. I think often [97:20] think, okay, how I'm communicating with [97:22] my partner currently is really going to [97:24] determine whether we have an argument in [97:25] two years time or a year's time or six [97:28] months time. Our strategy [97:30] of communication. Does she feel safe [97:33] expressing a problem? How do I receive [97:35] the problem even when it feels like I'm [97:36] being blamed? And vice versa. And then [97:40] are we open-minded about solutions or do [97:42] we come with a bias around this is the [97:44] solution, this is what I think the [97:45] correct answer will be. [97:47] I've spent a lot of time, you know, I'm [97:48] like 7 years into my relationship now, [97:49] almost. [97:51] So, I spend a lot of time thinking, [97:52] okay, like how do people go how do they [97:53] build a relationship like 50 years? And [97:55] the crux of it seems to be [97:58] conflict resolution {slash} [97:59] communication. That seems to be the crux [98:00] of it. And actually with finance issues [98:02] that we talk about with finance experts, [98:04] always sex issues, the crux of it seems [98:07] to be [98:08] conflict resolution {slash} [98:09] communication. [98:11] And I also know, cuz I know lots of [98:12] couples, that we're all living on a [98:14] different spectrum here. Some couples [98:16] are like they come home at 6:00 p.m. and [98:18] all they want to do is talk about the [98:20] most sensitive subjects. And then you've [98:22] got this other group of couples [98:24] who almost don't talk about anything. [98:25] They're kind of like strangers that are [98:27] like burying everything in the cut [98:28] cupboard. [98:29] And they think burying it in the [98:30] cupboard means that it's [98:33] out of sight, out of mind, and it's not [98:34] impacting anything. [98:37] But again, you come to learn [98:39] that any problem buried raise its head [98:41] in unexpected ways. [98:44] And you know, I'm thinking of one [98:45] particular friend of mine who was in a [98:46] relationship for 14 years, had a baby, [98:49] they kind of stopped having sex, didn't [98:51] really talk about it. [98:54] They become [98:56] like parallel lines that are drifting [98:58] apart. And they get, you know, several [99:00] years later go, "What happened? [99:02] What happened to our relationship?" [99:04] Well, they never spoke about it. [99:07] So, [99:08] >> I think you understand this perfectly, [99:10] and for you to [99:12] see it in this you can help so many [99:14] people because I think these are the [99:16] fundamentals. How do we teach young [99:18] people and old people that conflict [99:21] resolution is important in intimacy and [99:23] vulnerability are important and biology [99:26] is important, science is important, and [99:28] we can do this. I I just taught you a [99:30] few things that I know today, and you [99:33] Not only did you understand it, but you [99:35] were curious about it to ask further [99:36] questions, and you can now [99:38] figure out how it works in your own [99:40] relationship, in your own life. You're [99:41] even caring enough about thinking about [99:43] your friends' lives. And so, if you've [99:45] shown that this matters and this is [99:47] important, I just think how many people [99:49] are going to benefit by your [99:50] vulnerability and your curiosity and [99:52] saying, "Oh, I could do that, too." [99:54] >> Yeah, it's crazy, isn't it? That like if [99:55] you love this person so much, [99:58] yet you don't often love them enough [100:00] just to communicate [100:02] about some of these like sensitive, [100:04] tricky subjects, which is like craziness [100:06] when you articulate it like that. Like [100:08] I've been in relationships where I just [100:09] absolutely love this person, but no, I [100:11] wouldn't I wouldn't raise X, Y, and Z [100:13] subject. It's just [100:15] it's just too uncomfortable. [100:16] >> And the few times, I guess I will ask [100:18] that you have been vulnerable, has it [100:20] gone well or not well? [100:22] >> gosh, it's like the most important [100:23] thing. I just I always think, "Why [100:24] didn't I do this sooner?" [100:25] >> Mhm. [100:27] >> I I Yeah, okay. So, to be even more [100:30] honest, I like didn't have conversations [100:32] with my partner about sex at all. Like I [100:34] just I assumed she liked it. I think she [100:37] assumed I liked it. [100:39] And it wasn't until like a year further [100:40] into the relationship that you start [100:41] going like, "Wait, I don't [100:43] think this is how this person wants to [100:45] have sex." Or I don't know. I actually [100:47] have to give her the credit cuz she's [100:49] the one that started like pushing on the [100:50] communication. I think sometimes as men [100:52] we just [100:55] You know, that that old slightly toxic [100:58] phrase, "Happy wife, happy life." I [100:59] think sometimes as men we just kind of [101:00] assume that if no one's saying anything, [101:02] then everything's great. [101:05] But it takes two to tango. [101:07] >> And I think expecting your partner to [101:10] have all the words and to know [101:11] everything is the wrong answer. So, [101:13] that's where again, that third party, [101:15] whether people come to see me together [101:17] as a medical person or a sex therapist [101:19] or or a third party to help you have [101:21] that conversation, cuz I think we assume [101:23] our partners know everything about their [101:25] own bodies and can communicate about [101:27] their own bodies, and that's just not [101:28] true. Even showing that curiosity [101:31] makes you quite evolved, right? And I [101:32] think that that's the energy that we [101:34] need in 2026 is breaking down those [101:37] barriers because it will lead to [101:39] stronger relationships, it will lead to [101:40] stronger partnerships, and it's those [101:43] hard moments that you grow the most [101:45] from. [101:46] >> You need the words though as you say. [101:48] >> Yeah. [101:49] >> When you say you need the words, what [101:51] what what specifically do you mean by [101:53] that? You need to know how to start the [101:54] conversation, how to handle the [101:56] conversation, how to receive a subject [101:58] that might be a little bit offensive, [102:00] that might hurt your ego a little bit. [102:01] Is this what you mean by like have the [102:02] words? [102:03] >> hard to do that on your own because [102:05] people [102:06] don't want to hurt other people's [102:07] feelings. And so just saying it as it is [102:09] may not be the right approach either. [102:11] That's where again couples therapists [102:13] are very good at holding space for those [102:14] different conversations. And I think one [102:17] of the other problems here Stephen is [102:19] many times there's no bad guy. Of course [102:22] when it's obvious someone cheats on [102:24] someone, someone breaks trust, yes [102:25] there's a bad guy. But so often, you [102:28] know, say someone has a higher libido [102:29] than someone else. There's no bad guy. [102:31] That person has a high libido and that [102:33] person has a low libido. There's no evil [102:34] bad guy, but there is still conflict. [102:37] And so how do you deal with conflict [102:39] when it's not a good guy bad guy [102:41] situation, but you and how do you love [102:43] someone and evolve with them, right? [102:46] Like I think it's not easy. [102:47] >> I think your point there though is [102:49] actually [102:50] where it starts often which is this [102:52] point of empathy. The minute you realize [102:53] that there is no bad guy. Just as you [102:54] said it, I thought oh my gosh, yeah. [102:56] Back when I had those intimacy [102:58] challenges in that relationship, [103:01] it was a case of trying to figure out [103:03] who the bad guy was. I was like, is it [103:04] me? Is that me problem? Is it a you [103:06] problem? That's kind of like what the [103:07] brain jumps to. But actually now that [103:10] had time passed and we figured out what [103:11] it was, turns out that it was neither of [103:13] us. It was really the whole time not me [103:16] against her or her against me. It was me [103:18] and her against the problem. [103:19] >> Mhm. [103:21] >> And that refrain, I think removes the [103:23] like shame, the blame, and all that [103:25] stuff that gets in the way and focuses [103:27] you as a team [103:29] on resolution and conflict resolution. [103:31] Thank you. You've you know, you said [103:33] that [103:34] I will help people, but actually you're [103:35] the one that's helping people. I'm just [103:37] asking questions [103:39] and uh [103:40] >> I disagree. I think it's the simple is [103:42] the vulnerability of watching others. [103:46] It's the simple stuff that makes the [103:48] biggest change. [103:49] >> Why does this matter so much, Jack? I [103:50] can see it in your face. [103:53] >> Because so many people are hurting. [103:55] Relationships are hurting. People's [103:56] health is hurting. People aren't having [103:58] as much pleasure and joy and quality of [104:00] life that they could be having using [104:02] what we already know to be true. Simple [104:05] things, communication, connection, [104:07] education, basic medical care. These [104:09] things can bring so much joy, health, [104:13] great relationships, great living. I see [104:16] it every day in my clinical practice and [104:18] I want that. I want that for every [104:20] person out there and I want them to [104:22] fight for it and I want them to advocate [104:24] for it and I want doctors to show up in [104:26] a big way to help them and I think we [104:29] can do it. But I I I am so passionate [104:31] about this because I see all the like I [104:34] see how much it's not being done. [104:37] >> Dr. Rachel, we have a closing tradition [104:39] where the last guest leaves a question [104:40] for the next not knowing who they're [104:41] leaving it for. The question left for [104:43] you is, what would be one thing you [104:45] would like to do or improve in your life [104:49] tomorrow? [104:54] >> I would like to get better about [104:56] practicing what I preach because we [104:59] always say the shoemakers kids don't [105:01] wear shoes. I am addicted and obsessed [105:04] with what I do. I love my work so much, [105:07] but I don't necessarily spend as much [105:10] time [105:11] lifting weights that I should or not [105:14] scrolling on my phone and paying [105:15] attention to my children that I should. [105:17] I don't spend as much time, you know, [105:20] scheduling those quarterly spouse dates [105:22] that I tell other people to do. And so I [105:24] think practicing what I preach is a huge [105:26] opportunity for me. [105:28] >> Well, that's refreshing to hear cuz none [105:29] of us are perfect in that regard. So, [105:31] it's good to know that just having all [105:33] the information doesn't necessarily mean [105:35] um it's easy to execute upon. [105:37] >> Easy to do, easy not to do. [105:40] >> Amen. [105:41] Um [105:42] where do people go to find more from [105:44] you? Do they go to your Instagram, your [105:46] website, your YouTube channel? Where [105:47] should you Where should they go? [105:49] >> Yeah, our website is really fabulous. We [105:51] are very big into research, education, [105:53] advocacy, and mentorship. So, [105:56] rachelrubinmd.com [105:58] that would lead you to sign up for our [105:59] newsletter which is really an incredible [106:01] source of education. We are extending [106:04] you the the latest and greatest in [106:05] studies, research that you can be a part [106:08] of, job opportunities, um and advocacy [106:10] for clinicians. We have courses in [106:13] teaching you how to do this both free [106:15] and uh ones that come with continuing [106:17] medical education. I would say Instagram [106:20] is um the most popular for me right now. [106:23] Uh although we're trying to get louder. [106:25] If only I had your skills, I I would [106:26] love to be louder on YouTube and other [106:28] places. Uh we do have a clinical [106:30] practice both in Washington D.C. and Los [106:32] Angeles. And so, if we can help in any [106:35] way on the sexual health side, please [106:36] reach out to us because sexual health is [106:38] just health and your quality of life [106:40] absolutely matters. [106:42] >> I'll link all of that below. [106:44] And I hope people sign up for your [106:45] newsletter as well. That sounds really [106:46] interesting. [106:46] >> Thank you. [106:47] >> Dr. Rachel Rubin, thank you so much for [106:49] all of this. Um I think it's it's so [106:51] so telling that your conversations are [106:53] often the most shared on the podcast and [106:56] in generally in podcasting because the [106:57] subjects are so um so important to so [107:01] many people's lives and they can relate [107:02] to feeling not themselves as you say, [107:05] but there's very few people out there [107:06] that have the credibility, the [107:08] experience with patients, but also the [107:11] the ability to articulate it in a way [107:13] that's highly accessible like you have. [107:14] So, I know that you you know, we talked [107:16] beforehand, you don't necessarily love [107:17] doing this, [107:18] but um it's a very very important worthy [107:20] cause cuz there's very few people that [107:21] can speak to these subjects with the in [107:23] the way that you can. So, please keep [107:24] doing it. [107:24] >> So kind. [107:25] >> Anybody who's listening now, I highly [107:27] recommend if there's somebody in your [107:28] life that might want to listen to this [107:29] conversation, I think there's a reason [107:31] why Dr. Rachel's conversations are [107:33] always the most shared. [107:35] Um please do share it with them. Dr. [107:39] Rachel, thank you so much for your time. [107:40] >> Thank you. [107:41] >> YouTube have this new crazy algorithm [107:43] where they know exactly what video you [107:45] would like to watch next based on AI and [107:47] all of your viewing behavior. And the [107:49] algorithm says that this video is the [107:52] perfect video for you. It's different [107:54] for everybody looking right now. Check [107:56] this video out and I bet you you might [107:57] love it.