What Women Were Never Taught About Sex, Hormones, and Their Own Bodies

If you've ever felt broken because of your sex life, your energy levels, your mood, or your motivation, you are far from alone. In a conversation on the unPAUSED podcast, urologist, podcast host, and author Dr. Kelly Casperson joined Dr. Mary Claire Haver for a frank, wide-ranging discussion about women's sexual health, the staggering gaps in medical education, and why so many women have been left without answers for decades. This two-part conversation covered everything from orgasms to testosterone to the ways popular culture has quietly shaped women's expectations about their own bodies. Here is what you need to know.

The Doctor Who Didn't Know Either

Dr. Casperson didn't set out to become an expert in female sexual medicine. She was a practicing urologist when a bladder cancer patient she deeply cared for broke down in tears in her office over a sexless marriage. Casperson realized she had no idea how to help her. She knew how to prescribe Viagra and testosterone for men and how to talk to male patients about sexual quality of life. For women? Nothing.

"I was told in training, women were difficult. They take too much time. And don't worry, the gynecologists are taking care of them anyways," she said. The problem? The gynecologists weren't taking care of it either. As Dr. Haver confirmed from her own training, OB-GYN residency included one lecture per week on menopause and absolutely nothing on sexual medicine. Both doctors trained to serve women and neither learned the basics of female sexual health.

Hollywood, Freud, and the Myths That Stuck

Before examining the science, it helps to understand where so much misinformation comes from. Dr. Casperson suggests that  Hollywood consistently promotes harmful myths: that spontaneous sexual desire is universal, that sex is effortless and pain-free, that everyone orgasms simultaneously, and that people are simply available for sex at any moment. None of that reflects reality for most women, and it sets them up to feel like something is wrong when their experience doesn't match the script.

Then there is Sigmund Freud, who declared that vaginal orgasms were the "adult" orgasm and clitoral orgasms were infantile. This led some women in the early 20th century to pursue surgical procedures to move the clitoris closer to the vagina, without anesthesia or antibiotics, in an attempt to become "normal." Freud was wrong. The clitoris is the primary organ of female pleasure, and decades of treating it as secondary or irrelevant have left generations of women feeling defective for entirely normal experiences.

The Female Sexual Response Cycle Is Different

The traditional model of sexual response, built on Masters and Johnson's research in the 1950s, places desire at the very beginning of the cycle. That model was developed using people who volunteered to have sex in a lab, so desire was already implied. Researcher Rosemary Basson later proposed a more accurate model for many women: responsive desire. Rather than desire arriving first, it often arises during sexual activity, not before it. Creating the conditions for intimacy and feeling safe and connected allows desire to follow arousal. Waiting for spontaneous desire to strike is often a recipe for less and less sex over time.

Arousal Is Biology, Not Just a Feeling

Dr. Casperson frames arousal as physiology, specifically blood flow. The clitoris, just like the penis, engorges with blood during arousal. Without adequate blood flow, penetration can be painful and damaging. This is also why hormones matter so much. Estrogen, testosterone, and DHEA all support blood flow to the pelvis. As hormone levels decline during perimenopause and menopause, arousal can take longer, feel less intense, and orgasms can become harder to reach.

The orgasm gap reinforces just how much this is being missed. Heterosexual men report orgasming during sex roughly 97 percent of the time. Heterosexual women in long-term, committed relationships report orgasming about 60 percent of the time. In casual encounters, that number drops to 7 percent for women while remaining in the high nineties for men. A study of bisexual women showed that the same woman had fewer orgasms when partnered with a man versus a woman. Same biology, different outcomes. The gap is not about women being more difficult. It is about whose pleasure gets centered.

Testosterone Is Not a Male Hormone

This brings us to one of the most overlooked facts in women's health: women produce testosterone, and they produce a lot of it. In a healthy, normally cycling woman, testosterone levels are roughly four times higher than estrogen levels. The only reason most people don't know this is that the two hormones are measured in different units.

Testosterone receptors exist throughout the female body, in the brain, bones, muscles, clitoris, vulva, vagina, and even the tear ducts. Ophthalmologists have been using testosterone drops to treat dry eyes for years because they know tear ducts have testosterone receptors. Meanwhile, women are routinely told testosterone is only relevant to libido, if they are told anything at all.

Dr. Casperson is clear on this point: testosterone is not a libido drug. It is a motivation drug, and libido is just one part of motivation. The evidence shows testosterone supports desire, arousal, blood flow, and orgasm. It supports dopamine pathways in the brain, affecting drive, energy, and mood. It plays a role in mitochondrial function, which is why women on testosterone often report feeling more energetic. Research from Newson Health found that women who started on estrogen were able to reduce or eliminate antidepressants, and the effect was even larger when testosterone was added.

There is also emerging data suggesting testosterone may be breast protective and may play a role in dementia prevention. In Australia, dementia is the leading cause of death in women. Cadaver studies have shown that brains with higher testosterone levels showed less dementia at death. If testosterone is neuroprotective, and the evidence suggests it may be, then the decision not to study it thoroughly in women is not just an oversight.

The Regulatory Gap That Leaves Women Behind

Here is the situation in the United States right now. Approximately 20 percent of men experience low testosterone and have access to roughly a dozen FDA-approved products covered by insurance. One hundred percent of women will experience declining testosterone over their lifetime. There are zero FDA-approved testosterone products for women in the United States.

This is not because testosterone is unsafe for women. There are 50 years of safety data from transgender men taking testosterone at ten times the physiological female dose with no increased risk of death or breast cancer. Men's testosterone was FDA-approved with six months of safety data. When a pharmaceutical company brought a testosterone patch for women to the FDA in 2004, the agency required years of additional safety data. The bar is simply higher for women.

The Viagra gap tells a similar story. Viagra was approved for men in 1998. Vaginal estrogen, which improves blood flow to the female pelvis through the same basic mechanism, only became available over the counter in 2025. That is a 27-year gap for treatments targeting the same physiology in different bodies.

What Women Actually Need

The bottom line is that women and clinicians need more education. Women have been failed not by their bodies but by a medical system and a culture that never gave them basic facts about how their bodies work. You are not broken if you don't orgasm from penetration alone. You are not broken if desire doesn't arrive spontaneously. You are not broken if you feel exhausted, unmotivated, or unlike yourself as your hormones shift.

As Dr. Casperson puts it, you are not broken. You are undertreated. And that is a very different problem, because it has a solution. What every woman deserves is accurate information, a physician willing to investigate rather than dismiss, and the language to advocate for care that takes her health as seriously as it takes everyone else's.

Listen to Part 1 and Part 2 of Dr. Haver’s conversations with Dr. Casperson wherever you get your podcasts, or watch them on YouTube.