speaker-0: fact that there's so many different reasons that people have sex, I think goes to show us that it serves so many different functions. She's like, I love my estrogen patch and when I die, I'm gonna have ⁓ tape it to my coffin.

speaker-1: I pretty much feel feel the same way.

speaker-0: Is it possible for women to have a good sex life based on all the observations you have for your you know years of research?

speaker-1: It's sexual experience. You have to learn to have an orgasm.

speaker-0: Welcome to the XX Lab, where we explore the science and stories that matter to you. You guys, I'm so excited about today's guest. Today's guest is somebody I've admired for a really long time, and I mean that absolutely literally. I was actually her teaching assistant for her psychology of human sexuality class at UT Austin back when I was in graduate school. So I have had a front row seat view of just how brilliant and passionate today's guest is about her work. Today's guest is Dr. Cindy Mestin. She's professor of clinical psychology at the University of Texas at Austin, where she directs the Female Sexual Psychophysiology Laboratory. And this is one of the world's leading research labs on women's sexual experience. She's published over 200 peer-reviewed articles and is one of the most cited researchers in her field. In 2016, the BBC named her one of the 100 most influential and inspirational women in the world, and I couldn't agree more. She served as consultant for both the FDA and the World Health Organization, and she's co-author, alongside with our mutual colleague Dr. David Buss, of a book called Why Women Have Sex. And this is a book that's been translated into multiple languages and it's fundamentally changed how scientists and the public think about women's sexuality and motivation. Today we're going to be talking about why women have sex, how to improve the quality of your sex life, how to minimize the negative impact of stress on sex. And how to navigate and improve sexual function and parametopause. We're also going to talk about how to navigate sexual desire when on birth control or antidepressants, and also how women can improve sexual but well-being even if they've experienced sexual trauma. You are not going to want to miss this exciting conversation with Dr. Cindy Meston. This is the XX Lab. I'm Dr. Sarah Hill. Let's get started. Dr. Cindy Meston, welcome to the XX Lab.

speaker-1: Thank you. I am thrilled to be here. This is so exciting.

speaker-0: This is so exciting. So Cindy and I were just talking off camera with the fact that ⁓ I was actually one of her teaching assistants for her human sexuality class. Was it human sexuality or was it like human sexual psychology?

speaker-1: No, human sexuality I've taught since the day I arrived.

speaker-0: Yeah, yeah. So I was her TA for human sexuality and when I was at the University of Texas at Austin and I've been following her career ever since because you are really kind of like the person when it comes to female sexuality. I mean, you're it you have like laid so much groundwork in what we know about ⁓ human sexuality like when it comes to women and the fact that it that women's sexual psychology isn't the same as men's. And ⁓ I want to just start by asking what got you interested in that? Like, how did you end up in this career area?

speaker-1: Yeah, well well thank you for that nice introduction. really it was by chance. I was in a completely different field. I w I went to college for fashion merchandising and design and then dropped out, was in the sewing machine business. I was a Western Canadian sewing specialist for White Ellen Sewing Machines, so I traveled two hundred and fifty days a year putting on sewing seminars and I had a little T V thing, sewing and surging with Cindy. And ⁓ these radio shows where women would call in and say, ⁓ you know what I'm sewing with Ultrasid and I've got skip stitches. What needle I should use should I use? And I wouldn't give them the information. And anyways I've been doing this for a number of years and ⁓ I there's a longer version of the story, ⁓ but ⁓ but I was dating someone at the time who was a nice fellow but very boring and I needed to I should have gotten out of the relationship, but he made the best braised short ribs ever and I couldn't imagine my life without those short ribs, so I thought I can't leave this guy, so I have to, you know, entertain myself. So just by chance I signed up for a night school course in ⁓ psychology at the University of British Columbia. I was living in Vancouver, Canada at the time, and it happened to be taught by a professor who studied serotonin and rat sexual behavior. And it was that night school class that I'm like, wow, I mean I've I'd heard a master's in Johnson, but you know, I really wasn't aware that people were actually conducting research about sexuality and it just Got me hooked and you know, here I am.

speaker-0: It's so crazy to me that you went from like talking to people about their skipped stitches to like creating an operational definition for female orgasm for the you know, the World Health Organization. It's like quite a leap. Sewing to sex. Yeah, I guess like well yeah, in in Cindy sewing in sex. It's like it's I like the alliteration on that. There you go. Yeah. So I

speaker-1: The sex, yeah. So it's a bit of a lease.

speaker-0: I so you have I mean when it comes to the the research that you've done with ⁓ female sexuality, you've studied everything ranging from like the sexual response to sexual motivation to orgasm and and everything in between. And so I I wanna start at the beginning and talk about desire because that's usually the first thing that happens and desire and motivation. And ⁓ you published a a really wonderful ⁓ paper that talked about four different categories of cues. that promote sexual desire and I'm not gonna just ask you to rattle them off, but rather, ⁓ I I just wanna have a conversation around like what are the kinds of contexts, like what is female sexual desire, right? And and what creates it? Like what are the kinds of contexts that create female sexual desire?

speaker-1: Yeah, wow. Well ⁓ do we have like three hours? Because that's a a very long question to answer. But ⁓ so yeah, so let me start with the b beginning, which is how I conceptualize desire ⁓ different from arousal, because sometimes they get muddled together. I view desire as the motivation to engage in sex. So whether that is a thought, a fantasy, ⁓ a dream, su ⁓ some visual cue, ⁓ perhaps it's Your partner that touches you in a way that makes you want to engage in sex. Whereas arousal is when you're already in the situation, do you feel turned on and is your body responding? So in terms of desire. ⁓ you know, what we know ⁓ about women is that there are two types of desire. And when we look at Masters and Johnson and you see their sexual response cycle in any book that you look at, where where desire precedes arousal, orgasm resolution, this very linear idea that desire precedes arousal and is is what starts the whole process in motion. And certainly that is the case some of the time, but that model better. depicts male sexuality. Male males are more visual, they are more attuned to visual cues, they are more likely to trigger sexual desire. Whereas women ⁓ a lot of times it's more responsive. So Rosemary Basson a number of years ago talked about this circular model of sexual desire in women as opposed to the linear Masters and Johnson model, whereby really desire can kick in at any time and and that ⁓ Many women ⁓ r really identify with this notion of responsive desire more than spontaneous desire. So they start out in kind of a a neutral state, let's say, where they're ⁓ kind of gonna take it or leave it, you know, but they're not averse to it, but they're not thinking about it. And maybe their partner says something nice, or maybe it touches them in a certain way, or maybe they clean the house for them, and all of a sudden they feel like, huh, yeah. You know, I want I I'm try I feel turned on and I want to have sex. So this is where arousal is kind of pushing the drive. And so it's it's ⁓ it's a sex difference in the sense that certainly women experience spontaneous desire, but ⁓ it's more common in men. And as women age, we see that spontaneous desire lessens, likely to to hormonal changes, which I'd love to talk to you about. And ⁓ that ⁓ more women talk about desire as being kind of fitting this more responsive pattern. So that's kind of like one whole big area. And then the the other thing is what that you asked is like what triggers desire in in women. And there's many different things, but I think one of the most important things to talk about is context. Context is so important for women. And, you know, there's been a lot of really fascinating research ⁓ that's come out of Kim Wallen's lab at the at Emory University in Atlanta, where he's done eye tracking studies and he's looked at differences between men and women. So he is a he ⁓ presents an erotic scenario, let's say, and he gives the participants eye tracking and he looks to see what they're looking at. And when you see the data for men, it's really fascinating. What do men look look at? Breasts, genitals, breast, genitals, breast face, breasts, genitals. And you give women ⁓ an an erotic picture and what do they look at? Well they're scanning the entire picture. They're trying to make sense of the scenario. They're figuring out the context, the story, like who are the players, what are their facial gestures, you know, what is a background. Look like, are the sheets at least 500 thread count before I'm willing to engage in this act. And and so it's a big sex difference because men are not as context dependent. ⁓ which isn't to say context isn't important. I'm not making it to be like men and women are totally different. I'm just talking about general trends that for for women ⁓ to feel sexual desires so many things have to be right. You know, they have to be focused. They have to be ⁓ attending to the sexual cues and they're more distractable. Distractable by things like is the house clean? Or have the children been fed? You know, the work I have to do tomorrow. You know, my partner wasn't very nice to me this morning and I don't know if I feel like responding right now. So All of these things come into play, whereas men seem like they are much more they have this spontaneous urge and they're able to focus on it and they're able to tune out distractions that would prevent them from wanting to engage in sexual activity. There's really no we can talk about all the reasons why is that, 'cause that that in and of itself is fascinating, yeah.

speaker-0: Yeah, it it seems like you know, it's funny because I was having a conversation with my husband about ⁓ you know, NFL has this thing called the Red Zone Channel. I don't know if you know anything about football, American football, right? But the red zone channel is this thing and I like watching football, but I need to see the whole thing. You know, I need to see the full game, I need to understand the rivalry, like I need to the whole thing. The red zone channel is just essentially touchdowns. So what they'll do is it's like all the games that are going on, like like if when people are in the end zone, all of a sudden they'll cut to the game. So it's just like a series of touchdowns. And to me, that's like the difference between male and female sexuality. It's like I need the football game. I need to understand the dynamics between the two teams. Absolutely. Right. And then the touchdown is super satisfying to me, but having a touchdown that's totally devoid of context is like I don't want anything to do with it.

speaker-1: Exactly. And you know, we see that in my lab. ⁓ I, as you know, have a a sexual psychophysiology laboratory. So we show erotic films and we measure how aroused women become to the erotic films, both from a psychological or cognitive perspective and also genitally. And ⁓ for a d I you know, do ninety-nine percent of my research is done in women, but at a time I did have a male graduate student and so we ventured into the male arena and we were studying men. And we found we had to use very different erotic stimuli. And men, it was just like you could BAM throw put on the genital scene and we would get great arousal. And for women, it was like no, we had to use films made by women for women. We had to cut out certain shots. We had to make sure the actors, you know, looked nice and w we had clean fingernails and nice lighting and like all of those things. ⁓ in order to get our highest levels of a arousal that you can ⁓ you hope to get in a laboratory setting, which of course isn't the ideal setting, but yeah.

speaker-0: Y yeah, so you mentioned your your female psychophysiology lab, which ⁓ was right next door to the lab I was in in graduate school. And a lot of the the research that you all do, you're trying to better understand the female sexual response. And so you will give them my my understanding was that you would ⁓ insert a vaginal plathismograph, which is a and it's maybe you can tell us what that is and what it measures. And then what in like what it has taught you all about the nature of female sexual arousal and what is all involved in female sexual arousal.

speaker-1: Sure, sure. So maybe d ⁓ let me just clarify that when we talk when we talk about sexual arousal, we're talking about both the subjective or the cognitive experience of feeling turned on when you're in a sexual scenario, and then the bodily response or the physiological response, which in women is blood flow into the genitals. So women experience that as Of fullness in the genitals, pulsing, throbbing of blood in the genitals, and it's highly correlated with vaginal lubrication. So as there's more blood in the genitals, the there's actually pressure put on the cells that line the vagina, and that's what squeezes out the lubrication. So if you get blood in the genitals, you'll also get lubrication, assuming that hormones and everything else are acting as they should be. ⁓ And so when we measure sexual arousal, we want to measure both of those components, of course. So to measure psychological arousal, for a long, long time researchers, all all we did is the at the end of the erotic film, we simply asked them how aroused were you to the film and several other questions that tapped into how are you know how aroused are you right now after watching this film? ⁓ We developed in my lab something a little bit better which is a device that it's simply a computer mouse ⁓ mounted to a rack fed into a computer program that allows us to monitor continuous sexual arousal. So we're not just measuring at the end of the movie, we're asking them as they're watching the movie move this device forwards or backwards, indicating more or less arousal and you can even go into the turn off zone. So we're really able to see how they're feeling throughout the film. And you know, for there's many scenes in the film. So some women may like this seam and not the other scene. And so this way you get a much better picture of what's going on psychologically. Now, genitally, we use a device called a vaginal photoplethismograph. And this is a small tampon shaped acrylic device that the woman inserts her v into her vagina in the privacy of the testing room. And it emits a light into the vagina and it measures the amount of light reflected back. So in women, as you have more blood in the ⁓ vagina in the genitals, the walls of the vagina are denser, more light is absorbed, and you get a higher level of arousal indicated. And so it's it's a pretty good measure of how much blood is in the genitals, and so it's a good indication of arousal. And so to ⁓ get an idea of how aroused a woman is, we show a sequence of films. First, we show just a non-sexual film, like a travel film, we called it a neutral film for maybe three minutes, to get their baseline level of arousal. Because there's always some blood in the genitals, so you have to know where you're starting from, right? And then immediately following that, we show the erotic film, which is three to five minutes. And we s we look at the change between how much blood was in the vagina when they're watching the neutral film to how much blood is in the vagina when they're watching the erotic film. So that difference gives us an indicator of change or genital sexual arousal. And then we can look to see how that compares with what they're saying, how ⁓ aroused or not aroused they were. And we look at correlations between the two. And then of course you can have many different testing sessions. You can do that if you're d doing a drug study in one session, you give ⁓ a drug, another session you give ⁓ placebo or or whatever the case is, and and you have, you know, randomized sessions where you look at the differences in changes between the sessions.

speaker-0: So what so when you're measuring both physiological arousal by looking at blood flow into the vagina and then also j asking people about their subjective responses, are these things always related? And if so, why if not, why not?

speaker-1: Yeah, yeah. You're asking the question that I have spent like about thirty years trying to figure out. ⁓ so super fascinating, I think, and a really interesting gender difference because when we bring men into the laboratory and we measure their subjective arousal and we measure their genital arousal. So to do this we use a strain gauge, it fits over the penis and it basically measures blood flow into the penis. ⁓ And we look at the correspondence between how aroused they s are and their the the strength of their erection basically, we get very close correlations. Not just in my lab, but across studies, you get correlations of about point nine, which as you know in in psychology that's crazy high, right? You never get that. So it's this really, really close connection between what their genitals are doing and how aroused they say they are. Okay, so now we bring women into the laboratory and we do the same thing, and what do we get across studies? We get correlations of about 0.23. And there's vast variability between women. On some women, there's really strong concordance, and some women there's very low concordance. And you know, this in a nutshell is why we have so many drugs approved by the FDA for men. and really very few for women. I mean now there's a few that act on central mechanisms, but you know, Viagra. I started testing Viagra in nineteen ninety eight. That's a that's when Pfizer introduced it to the mail market and all of the pharmaceutical companies were trying to jump on the bang bandwagon to be the first to develop the pink Viagra. And ⁓ because there were I was the only one with a psychophys testing lab at the time, I I did the initial Viagra studies in women. What did we find? Absolutely, Viagra works the same way in women as it does in men through nitric oxide mechanisms. It gets blood flowing into the genitals. But big difference where the men said, ⁓ wow, this is fantastic. I've got like an erection I haven't had since I was twenty. Let's have sex. Women, yeah, there's blood in the genitals. Some of them said, ⁓ great, yeah, this turns me on. Some of them didn't e even notice the change and for others they noticed it, but it didn't play into their desire to have sex. So again, this gids back to, you know, men are more tuned in to their erections. They're more focused on their erections. I mean, overall the psychophys literature shows that men are better judges of physiological changes than women. whether that's because women are, you know, kind of n nurtured or developmentally or we we are scanning our environment, we're trying to get along, we're trying to make sure everything's okay, we're more nurturing, all th all those sorts of things. ⁓ or it's also just pure anatomical differences. The male erectile response is out there, you know, when a man has an erection he notices it. It grabs his attention. ⁓ whereas women, you know, it's much subtler. It's ⁓ easier to ignore. So I think anatomy plays into it somewhat, but then it gets back to this notion of context. It's not just the genital response that is making women want to have sex. There's other things at at play that ⁓ feed in there's many more pieces of the pie that constitute her overall subjective experience of arousal. Whereas for men I think a big piece of that pie is what their penis is doing.

speaker-0: What do you have a do you have a hypothesis? No, it's perfect I mean No, I mean it makes it makes perfect sense. I mean 'cause that that was the first thing I thought of is like, well of course, you know, but like when you're a a man a man you have this like bona fide you know, like right front of you.

speaker-1: Yeah, yeah.

speaker-0: Yeah, exactly. And so it's like it's it's it's just more obvious and and than it is for women. But what do you have a hypothesis about or are there any differences that you've noticed between women who have strong concordance versus those who have weak concordance? Like like do you are do you know like what is accounting for that variance like between between women?

speaker-1: Yeah, we we don't know. ⁓ I can I can say there's been very little study research looking at that particular question. We looked in my lab to see whether it predicted like sexual dysfunction or not. ⁓ it wasn't a great predictor. it i I mean when there is concordance ⁓ be between the two you know, you i if women I mean a l a lot of the movement now th is, you know, this sort of mindfulness about sex and it's really just teaching women to focus on their genital cues and and that has shown to help women who have sexual arousal difficulties. Now, why is it helping? I think part of it if you're attending to those genital cues, then you're not focused on something else. You know, if you are intentionally focused on what your genitals are doing, how the sensations feel, by thinking that, ⁓ this feels good, this is an indicator that I'm into it. then that keeps you from thinking about all these performance related issues. You know, ⁓ how does my butt look? Is my partner judging my body? ⁓ I've gained weight. ⁓ I better suck my stomach in. You know, all of these sorts of things that distract women from being in the moment. and ⁓ consequently I think negatively impact arousal. But getting back to your question, yeah, we we don't know what that variability is. I I think it's I mean there is, you know, and you've talked about this in in your book, that there's just huge individual variability between women. And we certainly see this in sexual arousal not only what turns them on, but the the degree to which ⁓ genital cues play an important role in how aroused they feel. And you know, especially I've been more and more involved in the menopausal side of things and research and you know, for a lot of women ⁓ when hormones change and va ⁓ v estrogen declines and consequently vaginal lubrication declines, in addition to causing sex to be painful, which of course or or uncomfortable, which of course is gonna make it less desirable. But independent of that, the loss of those genital feelings and and genital responses ⁓ have a very deleterious effect on women's overall psychological experience of arousal of how they how they experience it. But for some women it doesn't ⁓ have an effect. For some women it does. And and and you see you know Lorraine Dennerstein ⁓ is a researcher at Melbourne University in Australia and she's done some of the most phenomenal longitudinal research on menopausal women. She did something like followed women ⁓ g ⁓ from pre to peri postmenopause for like a decade or longer and looked at how desire changes across ⁓ the menopausal transition and she found that and don't quote me on the exact percentages, it was a long time ago that I read this number, but z ⁓ let's just say ⁓ so almost half of the women, it really didn't change all that much. And then you had ⁓ you know, maybe forty percent of the women there was a decrease in ⁓ drive with menopause. And then there was a smaller percentage, ten, fifteen percent, that actually showed an increase in drive with menopause. And so she Dr. Dennerstein decided to follow up and see, well, who are these women who show an increase? This is interesting. And there were a number of predictors, but the biggest predictor Was ⁓ they got a new sexual partner. And so, you know, I'm not suggesting that if you're a menopause of women and your desire to love that you leave your partner and find someone else, but it does play into the whole idea of novelty being important in sex drive for men and women. And, you know, it it's also true that. The length of the relationship is a negative predictor of sexual desire in a relationship. You know, things become routine. You fall into a pattern that's worked for the last ten years, so why change it? You know? And yeah, so sorry, I'm gone.

speaker-0: That's fa I think it's fa I think that's fascinating. I actually you know, I I read a paper, this is a couple of years ago, now I don't remember who the authors were, but it was a really lovely paper where it was looking at ⁓ the effects of ⁓ long-term monogamous relationships on sexual desire in men and women, and the sort of surprising result was that monogamy and long-term relationships are harder on women than men, just in terms of sexual desire. and and which to me, you know, when I was interpreting it, I was thinking that it has to do with the sex differences in spontaneous versus, you know, responsive sexual desire, probably. Just because when when men experience spontaneous sexual desire, which For listeners who aren't familiar with that, that's kind of sexual desire that almost comes out of nowhere, kinda like hunger or you know, feeling tired where it's just like ⁓ you know, apropos of nothing, all of a sudden you want a sandwich, or you know, apropos of nothing, you just, you know, want to have sex. And men have more of that, right? And so even if they're in a long-term relationship, which might have some of these contextual cues that are related to familiar famili familiarity and having to do the laundry and all of the other things that women's sexuality tends to be really sensitive to. that ⁓ men continue to have robust you know sexual response kind of throughout the lifetime because they experience spontaneous sexual desire more frequently than women. And that for women whose sexuality is so cued into ⁓ context, that routine and lack of novelty could be potentially more impairing. And so that was the way I interpreted that result. And yeah, go ahead.

speaker-1: Yeah, no, I I I think you're absolutely right. I I do think that's a big ⁓ part of it. And I mean, n novelty, as you know, from an evolutionary perspective, is very important for male sexuality as well. I mean the literature would say more so than ⁓ for for women. but, you know, it's I just think the predictability of sex, the y ⁓ aga again getting back to you know women are are very much tuned into emotional bonding cues but also romantic cues and you know the longer you're in a relationship you just kind of f forget to do those special little things. So sometimes it can be as as simple as putting a surprise note in, you know, your partner's briefcase or whatever or d just little things to keep it fresh and exciting and ⁓ like women want to feel valued and appreciated and they wanna feel attractive and Yeah, so

speaker-0: It w so do you think ⁓ you know, speaking of that, like e especially for women ⁓ as they're aging and going through paramenopause and the menopausal transition and you know, and we do generally see that sexual desire takes a hit and there are good, you know, h explainable hormonal reasons for this. ⁓ but there's also I think, you know, just changes in the way that women experience their own bodies and the way that they feel about themselves. that can really play an important role in in in those hits. And so what, you know, do you have, based on the research that you've done, do you have any recommendations, you know, in addition to doing things to increase and fuel novelty within the relationship and, you know, kind of keep things sexy? What are some of the things you do you think that women can do to change their sort of self narrative in a way that's gonna be ⁓ help fuel sexual desire later in life?

speaker-1: Yeah, yeah. Well, ⁓ funny you should ask that because I just suggested one of my graduate students do her dissertation on that. And ⁓ we did a preliminary study. W w what we're getting at here are sexual schemas. You know, schemas are representations of of how you view yourself as a sexual being. And ⁓ I've done ⁓ a fair amount of research in this with res respect to sexual abuse. U s ⁓ survivors, women who are sexual abuse survivors, and how that impacts their sexual schema in a negative way. And ⁓ what we looked at in menopausal women is what are their sexual schemas? How do they feel about themselves as a sexual being as the as they transition from y you know, fur fertility to n no longer fertile. And we found that there were many different subgroups and f f and po both positive and negative schema sh change. So there was the predictable negative schema change, which is, well, I feel like less of a woman. I motherhood was important to me and you know, my body has changed. I don't feel I'm as attractive. So all of these negative schema changes, but then there are also some women who had very positive schema changes, which were things like, ⁓ now I have more freedom, we can the kids are gone. We have more time and money. We can do fun things. We can plan romantic events. You know, there's more time for spontaneity and I feel like you know we get to reconnect and rediscover each other. So I think a lot of how how a woman fares psychologically through menopause has to do with the schemas that she brings to her whole concept of sexuality. I mean, for someone who very much ⁓ their sexuality is tied to reproduction, well they're gonna be hit hard. You know, for someone like myself who's never wanted kids in her life and who at the age of twenty four marched into my doctor's office and said I want my tubes tied and I'm never having kids. And he he said, ⁓ there's no way ⁓ you'll change your mind, absolutely. All women do, and you'll want to have kids. And I'm like, No, I won't, yes you will, no, I won't, yes you will, no, I will. And ⁓ we off we argued, and here I am years later, and never had kids, never wanted kids, and you know, happy I never had had kids. And so reproduction is not part of my sexual psyche at all. So it didn't even You know, face me

speaker-0: Right. Women rewrite their their schemas. So is there something that women can do? 'Cause I do think that a lot of us and even if it's not tied to motherhood, right? Where it's just like tied to this ideal that you know, and and evolutionarily we understand why there's tends to be greater value placed on a women who have cues related to fertility. ⁓ and we tend to see those things as beautiful. Like, how do we re how do we rewrite that in a way that's positive for our own sexuality?

speaker-1: Well, I did a study a number of years ago on a writing intervention study. ⁓ this was done on women survivors of sexual abuse. It was a very involved study. It took six years, it was an NIH-funded study, and I had 100 women who were very severely sexually abused in childhood and were experiencing sexual dysfunction in adulthood. And I ⁓ got them into a writing intervention program. So writing just basically journaling. And I had three groups. In one group, the women simply wrote about their day. That's the standard control for a writing intervention. In the second group, they wrote about their trauma. And Jamie Pennybaker, he's written books on this, he's done fabulous research. He's he's shown how ⁓ writing ⁓ ha can have a tremendous impact on psychology in terms of trauma survivors, depression, anxiety and and so forth. So I had a ⁓ a third of the women write about their trauma. Then the third group was unique to my study and ⁓ my goal was to really tap into what their sexual schemas were. So I had this guided intervention where where ⁓ their prompt would be, I want to I want you to write about how you view yourself as a sexual person. How how do you how did you get there? How did you ⁓ you know what does this mean to your overall so there's all these prompts and I had them write, ⁓ I'd have to go back to the original study, but it was it was short, I want to say 20 minutes, it wasn't a long writing intervention. And they did it, I think, three times a week for a number of weeks. And then we followed up at a month, three months, and six months. And honestly, I was so surprised with the findings. I was hoping for significance. I got a tremendous effect. The the women who wrote about the trauma and the women who wrote about their sexual schemas both showed significant degrees. Increases in depression, anxiety, and PTSD symptoms. But here's the really interesting part. It was only the women who wrote about their sexual schemas that also improved in sexual dysfunction. So all of the women in that group at the start met clinical criteria, diagnosed by a clinician, blind to controls, met criteria for severe sexual dysfunction, and by the end of the study, less than half of them met. criteria. So it was not only statistically but really clinically meaningful and significant. So I was delighted with the findings because this is just writing. You don't need a therapist. You don't you it it cuts across all demographic, socioeconomic status, you know, it costs nothing to write. Any anyone could do this. And so the study that my graduate student actually is about to embark upon is Ver taken from this and it is to get women in ⁓ who are menopausal, who are struggling with their sexuality, to look into the to their sexual schemas and to write about who they are as a sexual person, how they viewed themselves as a sexual person, you know, prior to menopause, how they feel now, what changed. Like just writing about This is so therapeutic. And we nobody knows really why it is, but I think part of it is when something's bothering you, or when you're upset about something, whether it's you've gained weight or you've you know you've lost your fertility or whatever it is, you know, it's just a thought that's just there, it keeps going round and round. But when you're forced to put it on paper. It's like there's a beginning and a middle and an end. Yeah, you used to be fertile and I felt this way and now it affected me and why did I and and somehow it just resolves in their mind, ⁓ well, yeah, but you know, I'm still me. so I think that's that's a part ⁓ could be very helpful. A another whole part of it really is body image and as women's bodies change. ⁓ how they feel about their body and and we know from the literature that there is a really like meaningless relationship between a woman's actual body and how she feels about her body. You know, the correlation is terrible. It does not predict whatsoever. and it's independent of BMI. Research has shown this. And so ⁓ you know, we're all exposed to media and magazines and models and we all know that and you know, we we still are on social media looking at all these things and they just make you feel lousy about yourself. And so I try honestly I hate social media. I I try to stay off of it. It never makes me feel good. I do have an Instagram account because I'm told I should have one. But I rarely post ⁓ I'm just posting science but most of the time. Like I don't like doing the videos or whatever. But so you know, trying to I mean Eric Steiss is a researcher in the field of eating disorders, which of course body image is a major player there, and and he's done some important work ⁓ called the Body Project. And part of ⁓ what was successful about that again is he got women to write about their bodies. Write a letter to, you know, your thighs and or to your body and thank your body for, you know, all the abuse at this age that we've put it through. And, you know, we're still standing and it's still doing this for me and that. And just kind of show gratitude for your body and what it does do instead of, well, it doesn't look like I did I it looked when I was twenty. You know, so these are kind of self dimensions, you know.

speaker-0: Yeah, I think that these writing interventions are so powerful. And I'm I'm glad that you brought up the study ⁓ that you did on the writing intervention with the women who had ⁓ suffered sexual trauma. I thought that was such a wonderful, such a wonderful study. And it really is such a hopeful message. I'll I'll have a link to the study in the show notes for those of you who want to see the specific intervention because it really is something that you can do at home. And I do know that there are so many women who've experienced some sort of sexual trauma of one type or another. And c you know, finding that there is something that they can do to try to shift their sexual psychology in a way that ⁓ feels healthy for them, ⁓ I think is is a really great message. And I and I love the idea of ⁓ applying these same interventions to ⁓ menopausal, paramenopausal women because it it makes sense, right? That you have this ⁓ complex set of you know, psych psych psychological mechanisms in your head that are linked with your psychology and then your beliefs about yourself and how you feel about yourself and things that have happened in the past. And ⁓ just having an opportunity to get all of the stress, you know, sort of out there on paper, I think can be incredibly therapeutic in so many different ways.

speaker-1: About that, absolutely. Yeah.

speaker-0: Yeah, so I wanna really quickly, speaking of stress, I want to talk about and I know this is one of your most cited studies is about stress and sexual response. ⁓ and this was like early. So ⁓ this is probably ⁓ you know, this is c earlier career. Cause I remember you talking about this when I was your TA back in two thousand three or whatever this was. But it was about looking at you know, we tend to think about s about stress ⁓ as being bad for sexual desire. Right. And stress. And generally it is, right? Like like chronic stress. And we talked about the fact that women's sexual desire is so contextual. ⁓ but you had some work early on showing that like mild levels of physiological arousal, right? Which ⁓ can, you know, oftentimes sort of occur in a in a mildly stressful type of a context, can potentially actually be positive when it comes to sexual desire. So talk us through that. What's what's going on there and and is there a way that we can harness that for ⁓ promoting sexual desire.

speaker-1: ⁓ yes, absolutely. So ⁓ I think what you're referring to are my early exercise studies where I had women run on a treadmill or ride on an exercise bike for twenty minutes at 70% of their maximum heart rate to either exercise or not exercise before viewing the films. And then I look to see if there's difference and Wow, was there ever a difference? When women exercised prior to viewing the films, we got over a hundred and fifty percent increase in the amount of blood flowing to genitals. ⁓ so th and just stepping back a bit, the the reason I decided to do those studies was it so much of what we knew about women's sexuality when I started my career actually. I started studying it as an undergrad, so like way back in nineteen ninety, ⁓ was based on a male template and that's partly because funding agencies at the time were not willing to ⁓ support women's sexuality research, but they were willing to put money into reproductive function. So because a male needs to have an erection and ejaculate, not really, but whatever. ⁓ they were willing, you know, we learnt a lot about male physiology, but w women, reproduction, they don't have to have desire, they don't have to have arousal, they don't have to have an orgasm, they just have to have functional ovaries. So all the money was put into ovarian function. So we knew very little about it. So we were reliant on the male Literature that was the main thing. And then the second thing is, you know, r scientists assume that because in the womb we all start from undifferentiated tissue and the same tissue that develops into a clitoris or penis or scrotum or labia. That, ⁓ okay, well, same tissue, it must all act the same. So i i there was this assumption that sexual arousal was facilitated by the parasympathetic nervous system. And just for the listeners out there who who don't know this, ⁓ th our s our nervous system, there's two branches, the sympathetic and the parasympathetic. And the sympathetic is the one that's active when you're anxious, it gets a fight or flight response, it gets you moving. And the parasympathetic is restorative. So it kind of does the opposite. That's a very simplistic picture there actually really Work together in really complicated ways. But, anyways, it was assumed that arousal was parasympathetic dominant, and so women who had trouble getting aroused, they were told to have a bubble bath, calm down, listen to quiet music, relax, breathe. And it never made sense to me because you know, when you're in in sexual arousal, your heart's racing, all these things are going on, and then you hear people when I have a good fight, I have the best sex I ever had afterwards. So like when people were anxious and aroused, you know, there was all these indications that sexual arousal was being facilitated. So I used exercise as a clean way of activating the sympathetic nervous system without changing ⁓ you know, cognition so ⁓ negatively or positively. And ⁓ so we did find, and it's been replicated many, many times now, that ⁓ exercise or or sympathetic activation before sex facilitates blood into the vagina, which is sexual arousal in women. Now you said stress and you know as long as the stress as long as there can be a cognitive shift, if you know what I mean. Like when someone's stressed out and angry in their sympathetic nervous system, you know, and their partner approaches them, they may well punch them and sex is the last thing on their mind. But if they're aroused for something and then all of a sudden their partner starts doing something that feels good and that and they're allowed to able to do this excitation transfer, right? Such that their anger response or their stress response is transferred over to the sexual realm, then that is gonna facilitate arousal. So, you know, forget this bubble bath stuff and I tell people, no, just like chase your partner around the block or you know, even go to a scary movie, or I I did a roller coaster study. I got I got people to ride the roller coaster. So do something activating. And I think this could be particularly helpful for for menopausal women who don't want to be on hormone replacement therapy, that this is a way that you can get your body pumped up and ⁓ prepared for sexual arousal that doesn't require any pharmaceutical intervention.

speaker-0: Yeah, it's like ⁓ it's potentiating, right? Like I I think about ⁓ and and yeah, and when I and when I said stress, I was thinking like physiological stress. I was thinking broadly. But ⁓ but I I think it's I think it is such an interesting, you know, I think it's so it is so interesting the contrast because there is that whole bubble bath, you know, you know, that you just like need to get, you know, rose petals and soft music. And it's like people don't you know, people they play like like, you know, thumping bass music at a nightclub where people go to hook up for a reason. You know, they're not playing like like you know, chimes and you know, doing a Buddhist chant. ⁓ like you're more likely to hook up at the club or when you're at the gym. And and I do think, yeah, there there's such a great message there because it's like, you know, we know that exercise is good for a lot of different reasons and there's so many benefits that we get from exercise, especially as we as we begin to get older and ⁓ and that you know, the fact that this can also facilitate

speaker-1: Like

speaker-0: ⁓ sexual desire is is just another one. And it's not even you know, I think that sometimes people think that it's just gonna be about the way that they feel about their body, which it also helps. Right. But but then as as you noted, you know, just like really getting ⁓ the blood going ⁓ is going to really facilitate ⁓ sexual response, which is so important. ⁓ especially like I said, as as women get older.

speaker-1: Absolutely. I th I think what you're referring to is is there's both the chronic benefits of exercise and the acute effects. And we all know the chronic effects, you know, it gets keeps you fit, it keeps you flexible, keeps your body toned, it gives you the endorphins, you feel better on mood, all those those things. But in addition to all of those things, there's just the acute effect that g that activate the sympathetic nervous system within about ⁓ you know, it's a pretty short window. you so about fifteen minutes prior to having sex, then it is gonna facilitate the genital response for women.

speaker-0: That's great. And so I want to talk now with you about birth control and antidepressants. And these are two things that we know, in part from some of the research that you've done, can be not necessarily great for the female sexual response. And so let's start by talking about hormonal birth control. And I'm really interested in having you tell our listeners about the research that you did looking at female sexual response in response to hormonal birth control. control and why that happened.

speaker-1: Yeah, well you're the expert on this. So I I did d do a study a number of years ago where we had women who were on ⁓ different types of hormonal birth control. So we divided them into two two different groups. ⁓ those women who were on hormonal birth control that didn't infl in significantly impact SHBG, sex hormone binding globulin. And that's the thing that sticks to testosterone, binds to testosterone, and lowers testosterone. And then the other women, so we had two different types of birth control, those that really decreased testosterone and those that didn't. ⁓ we brought them in the laboratory. We did a a number of different measurements. We measured their desire and arousal across time and then we also measured their actual genital responses in the laboratory. And and indeed we found that the women who were on the hormonal birth control pill ⁓ pills that ⁓ significantly that we know significantly blocks testosterone, they showed lower desire lower arousal, but they also in a laboratory setting in a in a actual controlled setting viewing a film, they had lower levels of blood flow into their genitals, ⁓ compared to women who were not on those birth control pills. So yeah, it's it's a meaningful difference. And ⁓ you know, you spell out so wonderfully in your book h how this you know, affects mate selection and mood and all of so many things. Yeah. It's

speaker-0: So so with with antidepressants, we also know that this is a context where a lot of women can experience decreases in sexual desire and ⁓ changes in the sexual response, right? Where they get diminished vaginal lubrication and ⁓ can experience sexual dysfunction. And ⁓ I know that ⁓ you've done some research on different types of interventions for sexual dysfunction, ⁓ in the context of SSRIs. And I I'm just wondering if you could ⁓ tell Tell listeners like what do we actually know and not know about what SSRIs do to women's sexual functioning? And then is there anything that they can do? And and same with f women on hormonal birth control. Like I I know that you didn't study that specifically, you know, there was no targeted intervention there, but do you have any thoughts about what might potentially help in that context as well?

speaker-1: Yeah, sure. So I'll t I'll take the hormonal birth control one first. Well, ⁓ honestly, like change birth controls. ⁓ go go on a birth control that doesn't block testosterone or that has the least ⁓ effect on altering your hormones, you know, would be my my advice on that one. ⁓ you probably have ⁓ some better insight into

speaker-0: That's And I'll I'm gonna post I just wanna interrupt really quickly to say I'm gonna post on the show notes ⁓ links to this paper which talks about the different levels of testosterone blocking effects of these different types of birth control and ⁓ and sort of give you all ⁓ who are listening a a picture of of the different degrees to which different types of hormonal birth control have that effect because I think that ⁓ what you're saying is very, you know, wise, right? It's like if you wanna be on hormonal birth control. Like then and you're experiencing this effect, then switch what you're on, right? Like there's still that option.

speaker-1: Right, right, exactly. You're young, you've got lots of time to figure it out. You know, if it's not working for you, try something else.

speaker-0: Right. And so antidepressants.

speaker-1: Antidepressants, yeah. So what do we know about antidepressants? Well it's sort of based on the belief that and and we don't know this for sure, but we have a good inkling that ⁓ serotonin mechanisms are involved in depression. And so when ⁓ antidepressants first started, the first generation of antidepressants, they just gave you a whopping bunch of serotonin ⁓ that hit all the serotonin receptors in your brain. Now, I don't recall exactly how many have now been identified. I want to say probably seven or more receptor subtypes, serotonin receptor subtypes. So there's like a one, a one A, a one B, a one C, a two, two A, two B. And what we know from the animal research, which is actually my very first job as a lab assistant, was working in a rat lab, counting ear wiggling behaviors, which is a measure of proceptivity in female rats, to try to identify which antidepressants ⁓ led to what serotonergic effect. But, anyways, so we know that there are many different serotonin receptor subtypes, and it some of them, if you hit if if the serotonin molecule hits it it facilitates sexual behavior others inhibit and hum some have no effect. So the first generation of serotonin ⁓ acting antidepressants, they just went everywhere, you didn't know what they were hitting. And then over the years we've g the pharmaceutical companies have gotten better and better and better. Now SSRI, what does that stand for? Selective serotonin reuptake inhibitors. So they're selectively picking the ⁓ s subtype of serotonin receptors that don't impair sexual function. Because we know the two big reasons why women stop taking antidepressants, even if they're very effective in alleviating depression, is they cause sexual side effects and they cause weight gain. So the newer generation of antidepressants are better in the sense that they ⁓ have ⁓ lower incidence ⁓ sexual side effects. Now th aga i it's very frustrating, however, because again, getting back to this individual variability, what may work for one woman just beautifully may cause another woman intense sexual difficulties. And this could be anything from just disinterested in in sex, a a low sex drive or ⁓ an inability to become aroused or an inability to have an orgasm or you know all three they often coexist and so we don't know why that is people i are just so wonderfully and frustratingly unique that it's hard to find a solution that works for e for everybody. So so for women who are on antidepressants and ⁓ are experiencing sexual side effects, what's generally suggested is well, you know, you can add something like Busperone to it, so you add another drug to it that will compensate. ⁓ that's helpful for some women. You take a break, well that's not so great because you know these effects are cumulative over time. Or again you try another antidepressant. It that that one's more frustrating than the birth control because it it's often, you know, takes several weeks to see the effect of it. But that is an option to try a different ⁓ antidepressant that, you know, just ⁓ may not hit those receptors in you and not cause the sexual side effects. one of my graduate students did a wonderful dissertation. on looking at women who were on antidepressant ⁓ drugs experiencing negative sexual side effects and using exercise as an intervention. And she looked at both was it chronic exercise that was doing the effect or was it acute? And what we found, indeed it was the acute exercise for those women who are having difficulty becoming aroused when they exercised prior to sex It compensated for ⁓ some of the del for the suppression of ⁓ sexual arousal. And now if you look at the different types of antidepressants, you have the SNRIs, selective norepinephrine reuptake inhibitors, and SSRIs. And so one class of those actually suppresses sympathetic nervous system activity when it's acting on norepinephrine, that's ⁓ the sympathetic system. And so our hypothesis was, well, maybe in some women the reason they're experiencing side effects is that the antidepressants, in addition to doing the serotonin thing, they're also suppressing the sympathetic nervous system. And if women exercise before a sex, that will compensate for that. And indeed, we got really ⁓ interesting results that that they they showed ⁓ a much greater sexual arousal response. even on the antidepressants, ⁓ when they exercised before sex and it and the w the women who were on antidepressants that had the biggest suppression of sympathetic nervous system ⁓ activity, they were the ones experiencing the ⁓ the greatest level of side effects, sexual side effects.

speaker-0: Here's ⁓ so here's what I want to know. You know, we've been talking about sexual function, which ⁓ I feel like we need to talk about orgasmed, and I love ⁓ that we have the opportunity to talk about orgasms with you because you actually helped the World Health Organization develop a definition, an operational definition of the female orgasm. And so I want to know, like, well, one, why did the World Health Organization want a definition for female orgasm at all? And like, what is it? And then I want to like dive a little bit into the female orgasm because it is a little bit elusive sometimes.

speaker-1: So

speaker-0: So what what is your definition? Why did the World Health Organization want it?

speaker-1: ⁓ well this is a international organization. It has many ⁓ it's like the International Urological Society, so many different things and then that meet every five years and they decide that we need to define blah. And that year it was sexual function and so ⁓ For two years. ⁓ I was the chair of Women's Orgasm Committee. And so for two years I picked my committee. I had some wonderful team members. And we read everything that was ever written about orgasm to try to come up with a definitive definition. So that could be used by NIH, other research fundings, by the medical society at large, so that we're all kind of talking about the same thing. And you asked me what it is. I could not it is so long. It's such a long i we tried to make it the most concise as possible and it's still like a large paragraph long that one of my colleagues says that it takes longer to read my definition of orgasm than it does to have one. And S so it's long and it's a definition that involves, you know, all of the body physiology in w ⁓ in addition to feelings of euphoria and well being and ⁓ all of the good things that go along with it.

speaker-0: One of the things that I find so interesting about ⁓ when we look at human sexuality and we look at differences between the sexes is that ⁓ you know, for men, ⁓ orgasm is almost like a given, right? It's like if a man is having sex, then it's just assumed that he's gonna have an orgasm and ⁓ and if he doesn't, it seems like a problem. And ⁓ and then for women it's more elusive. And in fact I I read a study showing that forget what it what the percentages were and you might even you might know them or you might not remember them off the top of your head, but there's a s significant portion of the population of women that ⁓ you know, doesn't have orgasms all that frequently at all. And ⁓ and I'm just I'm really interested in understanding like I wanna know whether you have thoughts about why we have sex differences in the ease of like orgasmic ability. and whether the definitions, you know, I I think that culturally we tend to think about satisfying sex. Everybody assumes that it's synonymous with having lots of orgasms. And I think when we look at female sexuality, I don't think that that tells that story at all. And ⁓ yeah, I'm just I'm I'm really curious about this. What what are your thoughts about the differences in in the ease with which ⁓ men and women experience ⁓ orgasm and and and what yeah, what what are your thoughts about how we define good, you know, quality sexual activity.

speaker-1: Yeah. well let me start off by by saying that there has never been identified anything physiologically wrong la hate to use that term with women who can't have an orgasm. Okay. So I mean, except in extreme conditions, of course, if there's severe diabetes or nerve damage, but I'm I'm talking in you know In the absence of that. So it's not like women who are able to have an orgasm have been distinguished from women who can't have an orgasm because they don't have enough hormone or their clitoris isn't working right or it's not like none of that. It's really, really very simple. If you look at the literature, why is it that Women who are educated are more likely to have an orgasm. Why is it that everybody talks about men peaking in their twenties and women peaking in their thirties? Why is it that older women are more likely to have an orgasm than younger women? It's sexual experience. Why why does r ⁓ religious inhibition and shame impair orgasm? All of these things. It's like you have to be you have to learn to have an orgasm. You really do. Now, men don't because th their penises sticking out there and they get friction and it's like a very simple maneuver to have an orgasm. But with women, you know, I mean, not the younger generation, but in my generation, you know, we were taught to like don't look, don't touch down there like it's some sort of biohazard zone. And so women didn't know where their genitals were or or how to pleasure themselves. You know, th there's a vast difference in ⁓ masturbation rates between men a and women. Still there always has. And in fact I one of the most interesting findings I I think is i if you look at the Kinsey report way back in the fifties, Kinsey asked questions about everything. There was massive sex differences. Men had more orgasms, had more sex, more casual sex, more affairs, more you name it, they had more. And then if you look across the decades to other large scale surveys like the Lauman report out of the University of Chicago and I think it was nineteen ninety nine, the Height Report, you know, big scale studies across the decade, what we see is a narrowing of that gap in that, okay, ⁓ more women are having affairs, one night stands, multiple sexual partners, all these things. So, you know, w was it in the Kinsey time that they really weren't Have a that there really was this big sex difference or that women just didn't feel comfortable admitting to it, we'll never know. But regardless, over the decade, those sex differences have narrowed on almost everything except masturbation rates. Okay? There is still this vast difference. Now a lot of people would argue, well, that you know, f lends itself or argues for sex differences and sex drive between men and women, biological underlying differences. But it's also the case that women don't masturbate as much. And so they they more women don't know their bodies, they don't feel comfortable. They haven't taken the time to do that. They d they're embarrassed or shy or for religious regions or other reasons. They've Just never explored and then they've got in a relationship and if they're not with a partner who's really spending a lot of time figuring out what feels good, then you know, they may never achieve orgasm. And even among w women who are orgasmic, who are able to have an orgasm on a r regular basis, only s something like sixty percent of those women can have an orgasm during partnered sex. Okay. And so why is that? Well, because probably there there's many reasons. One is they may be distracted again, you know, they're focused on their partner's pleasure or they're focused on their body image or what's going on, you know, so they're not attending to the sexual accuse. But even more likely is they're not getting the stimulation that they need in order to attain an orgasm. And in order to attain an orgasm you have to have high enough levels of arousal and for most women that involves clitoral stimulation and that's where the greatest number of nerve endings are in a woman, that's comparable to the head of ⁓ the penis. As we develop, the clitoris develops and the penis develops, and it's the that that's why for men it's also easier to have an orgasm. They're getting direct stimulation where the most nerve endings are. So if a a woman is having intercourse and isn't getting clitoral stimulation sufficient, she's not going to have an orgasm. And so she most women who engage in masturbation involves some sort of clitoral stimulation and that'll allows them to more easily have an orgasm. I'll I'll just tell you kind of a interesting story. his st this in Freud and you know Freud did a real number on women when he still women are suffering The consequences of him saying there's two types of orgasm, the mature orgasm, which is the vaginal orgasm, and the infantile orgasm, which is the clitoral orgasm. And then Masters and Johnson took people into the lab, measured the responses, and found the the exact same thing. Without the sen of course, without having a sensation of a penis inside you, everything else is the same. ⁓ via clitoral stimulation or in intercourse, ⁓ vaginal penetration. But so a lot of women still think that if they can't have an orgasm during intercourse, there's something wrong with them. ⁓ okay so going back to this interesting anecdote, the great niece of Napoleon Bonaparte, I think it was a great niece, she was a physician Was her name? Josephine, I think. And ⁓ she was she was hanging out with Freud, so he probably messed her up big time. And she was very concerned because she couldn't have an orgasm during intercourse. And she believed that you know this she was ex not experiencing of the greatest pleasure that a woman should be able to experience. And so she Figured out that it had to do with the placement of her clitoris. And she speculated that women whose clitoris was further away from the vaginal opening were less likely to have a vaginal orgasm. And so she went about actually measuring the distance between a number of women. And whether or not they were orgasmic and of course in the day we didn't have the stats or anything to to do it. But she concluded that yes, this played into it, and she subsequently underwent surgeries to have her clitoris move closer to her vaginal opening, which of course is a terrible thing to do and just destroy sensory nerves. But The follow-up to that is not that long ago, I want to say, for sure in the last decade, again, Kim Wallen's lab at Emory University got hold of her original data and using advanced statistics, did the actual stats on it and found yes indeed. ⁓ if the distance, I think it was two and a half centimeters, the width of a thumb, if the distance between and they look between the urethral opening, 'cause that's an easier measurement than the vaginal opening, the urethra and the clitoris. And if the distance was less than the width of a thumb, a woman is more likely to come.

speaker-0: That's awesome. And you know, it's also it's really consistent with ⁓ I was reading some studies looking at I was like twin studies and you know that you tend to find that orgasm female orgasm runs in families. And I actually I was trying to gross out my mom. ⁓ and so I sent her this article, you know, and it was it was talking about the heritability of ⁓ female orgasm within families, and I was trying to gross out my mom and I'm like, thanks, mom. And then she like came back with my pleasure.

speaker-1: She's got a good sense of humor. I like her

speaker-0: I was like, touche mom. Like I was trying to gross you out and now you grossed me out. ⁓ but that's good. Yeah. Yeah. So it it it it it it does seem like there's a lot of individual differences and it could just be you know, these simple anatomical differences. And so for women who ⁓ you know, 'cause I I've I've heard from women who have difficulty having orgasm and and then like like you said, they feel like there's something wrong with them or they feel like there's something wrong with their sex life. ⁓ and and then I've heard some women who are are like like what what's the big deal? Like like like I don't I don't have one orgasm all the time and and I don't it doesn't bother me. So why is everybody else so wound up about it? And so I guess like, is it possible for women to have a good sex life based on all the observations you have for your, you know, years of research, ⁓ without having orgasms frequently? Like, is that how we need to be defining what good sex is? Or

speaker-1: No, no, ⁓ absolutely not. At at the at the end of the day, it's you know, sexual pleasure that matters. And again, sexual pleasure is different for every woman. For some women it may be all about orgasms, but honestly, particularly as women age, sexual pleasure is is has a lot to do with feeling understood, bonding, connecting, ⁓ feeling like this person can't cares about me and we're in it to like all of those you know very evolutionarily based emotional bonding cues play more and more of a role. And and also as Rosemary Basson ⁓ wrote about in her model, the circular model I r of ⁓ sexual response I referred to earlier, she talks about the spin-offs. And so for many women it's the p sexual pleasure isn't even about the sex part. It's about what comes after sex, which is the cuddling and the closeness and the relaxation and and the feeling like you've shared an intimate moment. It has nothing to do with the sex act. It's the spin offs of what come ⁓ g come from that. ⁓ I'll just mention one thing. There's a a book that was written by my postdoctoral supervisor and who was the director of the Kinsey Institute for many years, Dr. Julia Hyman, H E I I ⁓ N and ⁓ Hyman en Rowland. And it's very old, but you can still buy it. And it's called ⁓ directed masturbation. I think that's what it's called. I'm pretty sure yeah. And this is a v it's a very simple paperback ⁓ book. It basically guides women in sel self-exploration of of their body. I know there's other books that have come s since and done, you know, similar things. This was the original one and this is ⁓ the only one where there has been very rigorous science on, in fact, our conclusion of that whole two year long process of studying orgasm. ⁓ Our conclusion was the only empirical treatment ⁓ for orgasm difficulties in women is directed masturbation. And again, it's cheaper ten dollars or something. You don't have to spend thousands of dollars on therapy. You don't have to w wonder what's wrong with you or what what in your past is preventing you from having an orgasm. No. It's right. Yeah. Yeah. Yeah. Exactly.

speaker-0: It's practice makes perfect. Do you think that there's and I had read gosh, I I don't remember if it was an animal study or if it was just an old school human study, where they were looking about ⁓ reinforcement. Like, you know, so we look at, you know, like the dopamine sort of reward response where it it like increase like where you you get a reward, your brain rewards you in a way that leads you to want to do it again. Right. ⁓ does ⁓ does orga does orgasm have the same effect on the reward response of men and women?

speaker-1: ⁓ I don't know. But but I thought you were gonna say, no, I mean just the role of dopamine is super interesting. And there are some brain imaging studies looking at women with sexual problems without sexual problems in dopaminergic rich areas of the brain, which shows some evidence that there may be a difference. Of course, the FDAA approved drug addie. ⁓ On dopamine systems in the brain. So, yes, the idea here is to make sex more rewarding and then you're gonna want to have it more. But the interesting thing in the literature is women with low sex drive, it's not like they're not having orgasm. They are having orgasms, they're enjoying their orgasms, but it's just like, okay, I'm good for a month or two or or a year. I've I've always

speaker-0: Yeah.

speaker-1: Rewarding enough to make them want to have it more.

speaker-0: I've always so I've always hypothesized, and the reason I asked about the sex difference is because evolutionarily, it makes sense that for men sex would be both rewarding and reinforcing. Right. Because every time that you do it, and especially if it's with a new partner, right. ⁓ it's gonna increase the probability of passing genes down to the next generation, which is almost always a good idea if you're in a male body. It's not always a good idea if you have a female body because you're the one who bears the cost of pregnancy. Yeah, and and it could be

speaker-1: should have pr ⁓ b ⁓ pressured women to have a low sex drive so they can be careful consumers of sex. They gotta buy the find the you know all this. They gotta, you know, find the guys with the good genes who are gonna stick around, help breathe all those sorts of things. And if they are just wildly having sex at the first guy that came around

speaker-0: Right, exactly.

speaker-1: They're they're not going to be a good chooser. And women are so limited in their reproductive biology. Men, it doesn't matter if you ha have a few kids with bad genetic loadings. If you have to help them, you know, the odds average out. But women, you know, we're born with the number of eggs. We have this short reproductive cycle from puberty to menopause and you know, nine months of rearing of ⁓ ⁓ pregnancy and then many years of rearing. So we're very limited in the number of genes that we can or offspring that we can pass our genes along to. So women have to choose carefully who they mate with. And ⁓ by having a lower sex drive that it doesn't just, you know, take over your brain and have sex as soon as you feel that urge, that spontaneous out of nowhere feeling But rather it's just like, no, I gotta assess the situation here. You know, is this is this good for me? Is this gonna make me f you know, you know, is is this the right guy? But you know, in in current day common if you're not you know, reproductively ⁓ viable as a menopausal woman, you're still assessing is this situation right for me? You know, that's kind of I think w w what what we've evolved to be to we're tuned in. Do I wanna have sex with you? Were you nice to me? Are you gonna clean up after yourself tomorrow if I have sex? You know, there's all these conditions.

speaker-0: Yeah, I it's it's like just another way that I feel like we've been ⁓ women have been led to feel sort of sexually broken because our understanding of human sexuality was so much based on what's normal in men. And so I I really do think that, you know, that for women it would do it doesn't make sense to have sex be super reinforcing where it's like you have it and then you're like, ⁓ my gosh, I need to do that again. Like I need to do that again now. ⁓ whereas I think that it does sort of sort of f stoke the flames of a dopaminergic drive in men where it's just like rewarding and reinforcing all at once, and that for women it's less that way and that it's built that way on purpose. And and that we need to not d like define ourselves as disordered. I think there's a lot of women out there who think that, you know, they have just like, you know, sexual dysfunction just because they don't have this rapacious. you know, ⁓ like desire for sexual contact all the time and that they're and and and that they do respond differently than men.

speaker-1: And you know, the other thing, I mean, th the way sex is presented ⁓ you know, in movies, in the media, advert whatever, you know, it it is like it gives this false impression that people are having sex all the time and it's wildly passionate all the time. And you know, people lie too. They don't want to say, yeah, we're only my husband and I, we only have sex every couple months. You know, like no one wants to say that because then they'd be judged. And so I think people are lying to each other and pretending they're having more sex than they are. And so that's also plays into it of ⁓ wow They're having sex all the time, what's wrong with us kinda thing, you know?

speaker-0: So I wanna ask you really quickly, speaking of people having sex and ⁓ and why people have sex, I wanna talk to you about ⁓ I wanna talk to you about your book that you wrote with my mentor, David Buss, about why women have sex and what what I thought was so cool about this book and and all of the research that has led up to it. ⁓ you know, you guys catalogued, I think it was two hundred and thirty seven unique reasons that women have sex. And so you know, what are some of the major like what are some of the things that lead women to want to have sex? What are the reasons that women are having sex? And and what can what did you what do you learn from that? The fact that there's all of these different reasons that women have sex, what does that tell us about female sexuality?

speaker-1: Right. Well, ⁓ there's all of the reasons that you would predict and also I I think that people assume people r have sex. Why do they have sex? And by the way, our book was based on an academic paper we wrote which included men. It was called Why Humans Have Sex. And then we decided, you know, people were probably more interested in in in women, so we wrote the book on that. But is well, why do you have sex? Because it feels good, because you want to reproduce, because you're in love, you know, and what else could there be? And and so nobody had really researched, looked into it in any great depth ⁓ until we did our study. And then documenting the these vast reasons. I mean, some of them, you know, a lot of them had to do with competition and ⁓ revenge and you know, certainly l love, but not just because you love the person because you're trying to steal love or get over love or, you know, find love and and as one woman in our study put, the best way to get over a man is to get under another one. And and so, you know, and then competition between people, and then the the ⁓ medicinal reasons where people were having an orgasm 'cause it got rid of a migraine or it helped them sleep or You know, it it alleviated stress or ⁓ and then because they were bored there was nothing else on T V, you know, so might as well have sex. and then, you know, all the dark side of them of of course, why women have sex. It's not why women want sex, it's why they're having sex and women have sex because they're pressured, they're co coerced, they're forced. ⁓ they're threatened all of those reasons. Duty sex was a big reason.

speaker-0: I love I love I love duty sex I just have to interrupt you to say that I love when I first cause I I first saw the term duty sex in your work and it was like when I first learned the word Schadenfreude, right? Which means it's just that feeling that you get when ⁓ when you feel pleasure in response to somebody else's failure. And like the first time I saw that word, I'm like, I know exactly what that is. You know, it once I knew the definition I felt

speaker-1: Yeah.

speaker-0: Yeah yeah, duty sex I felt very seen. Yeah in a relationship.

speaker-1: Most women do. and so, you know, for some women I mean, duty sex, it's just w what what I'm talking about is sex out of a feeling of obligation, right? That and that obligation might be because you were taught as a woman it's your duty to please your husband or ⁓ for some women d they engage in duty sex because they feel if they don't their partner will stray, so it's kind of a mate guarding tactic. Doesn't really work, but anyways. ⁓ or th you know, as ⁓ also to to make sure that ⁓ their partner is fulfilled and won't leave them, so there's those reasons. ⁓ for some I think there's w

speaker-0: Do you also consider it 'cause I when I hear duty sex, I was thinking of like, I don't really feel like doing this, but I love my partner and I want them to be happy. And so

speaker-1: Yeah. Yeah, ⁓ absolutely. And so the the point I was gonna make here is when we hear duty sex we we always think, you know, poor you, sorry, you're having duty sex, you know. But it's it's not always bad. It it's it's the affect afterwards. How do you feel after you've had y sex to please your partner and and duty sex and for i i if it leads you to feel used and you know not very good about yourself, then it's probably something you don't wanna engage in, you wanna find out a d a different solution. But for many women it wa it was like, ⁓ no, it's fine. You know, I mean they take out the garbage. I have sex with them. It's a great exchange, you know, we all do things we don't wanna do and who can or like you said, I love my partner and it makes me feel good to pleasure them. So it's it's it it's it's not necessarily a negative thing or something that's bad in a relationship. It's only bad if it leads to resentment resentment and and ⁓ regret and ultimately a lower self esteem. That's not n then it's not a good thing.

speaker-0: Yeah, I feel like, you know, the fact that you're able to I mean, aside from some of the more negative things like, you know, women being coerced into sex, ⁓ the fact that there's so many different reasons that people have sex, I think goes to show us that it serves so many different functions. You know, it's not just about reproduction. I think that sometimes there's that yeah. Yeah. I mean it's it it is. It can be it can serve a connection function, it can serve yeah, a a medicinal function, it can serve a mate poaching function, it can serve all kinds of different functions and it just goes to show how complex our psychology is.

speaker-1: Absolutely, absolutely.

speaker-0: And so I'm gonna close. I wanna just want to ask you, ⁓ because you've been so wonderful giving me so much of your time. ⁓ and I I wanna know what's on the horizon like with female sexual desire. So I know that you've ⁓ served as an FDA consultant on a number of different ⁓ treatments for ⁓ sexual desire disorder and and different ⁓ types of sexual dysfunction in women. I'm really curious about if there's anything happening in that space that you feel really excited about, like or If it's within your own work, you talked about this really lovely ⁓ intervention that you're gonna be doing with ⁓ menopausal women. ⁓ like what are some of the things that you're excited about in terms of helping to ⁓ especially help women who are struggling with their with their sex lives?

speaker-1: Yeah, well I guess I don't know, maybe it's a function of my age, but I am ⁓ spending more time looking in at the menopausal literature. as I imagine one of my graduate students who it was kind of funny because when I suggested it to her, she said, menopause, I'm only 25. And I said, I know, just think how prepared you'll be when you hit menopause. And then she came back the next day and she said, I told my mom that you suggested I should do menopause research and she said she'd even fund it. So so she's like taken that and we've we actually went ⁓ we're at a conference in Portugal this summer and another one in California where we pr presented some of her early re research on the sexual schemas among menopausal women. So so so I'm kind of jazzed up about about that. ⁓ one of my other graduate students is looking at ⁓ the role of shame and and religious messaging in ⁓ sexuality and and ⁓ how that plays out. And then I'm involved ⁓ I guess I could say this in in a company by the name of Stripes. It's a company that was ⁓ founded by Naomi Watts. And ⁓ I've joined them as a s ⁓ their scientific advisor. And so ⁓ right now they have primarily skin products for women, but they're going into the sexual health field and there's some exciting things on the horizon there that I'm working with them on, so that's been really fun. So yeah. Menopausal sexuality seems to be where I've found myself at the moment.

speaker-0: Well, I you know, I think that I think that even if you are like so if you're a listener, for example, and you're not anywhere near the menopausal transition, I think we're gonna find out that a lot of the same processes that help to facilitate the sexual response in paramenopausal menopausal women is ultimately also going to then be able to help sexual functioning in women who've experienced ⁓ sexual trauma and just women who have sexual, you know, hypoactive sexual desire disorder and they're premenopausal. I think that ⁓ the the research that you're doing will probably end up having really broad applications. I mean, just like you're you did this writing intervention with the women who had experienced sexual trauma and now you're looking and seeing whether there's these same therapeutic effects in ⁓ in in menopausal women, you know, I think that the v reverse is also going to be true, right? Where if you find something that seems to be working really well in in menopausal women, I mean, obviously other than hormone therapy, which you know, we wouldn't wanna necessarily give that to our premenopausal women. ⁓ but it it will ultimately end up informing care in both directions.

speaker-1: Yeah, absolutely. It it has widespread applications and implications I I think. But also, you know, I I think you need to write another book because your wonderful book was focusing on hormones and birth control, but you talk about hormonal changes with menopause. I mean a a w a woman is used to, you know, this level of hormones and then suddenly it the the dramatic decline in estrogen and progesterone and testosterone and then another drop in testosterone later on, I mean the the i impact that has not just on your sexual function but on your mood, your emotion, all of those things. And so when we talk about the loss of sex drive with menopause and that, you know, it's generally attributed to h hormonal loss, yes, but ⁓ not just from a physiological perspective, is it also that changing the way we're interpreting the sexual situation? As as I've s talked a lot about with you this hour, is the important of importance of context. But do hormones impact the way that women are viewing that context and are less things sexually appealing just because of ⁓ emotions and attentional ⁓ resources and all of those things. And then when you go on hormone replacement therapy, where the h what levels are you trying to get to? You know, you don't want to go back to where you were were your twenties, but you know, sometimes a little tiny bit can be way too much. You know, I've b I've b been a guinea pig on myself for 'cause it with hormones because I just find them so fascinating. And I and ⁓ my experience I could certainly write a whole book on on that. It's just wild.

speaker-0: Yeah, we should we should c we should collaborate on that project. What do you think about ⁓ hormone therapy for ⁓ women going through the menopausal transition? ⁓ some you know, there's the now that the black box warning or the black label warning has been taken off of of hormones, more women are interested in them. ⁓ what's your take? Good, bad, indifferent?

speaker-1: Well, for me personally, I I would not be off hormones. I ⁓ I I mean, I had a a l a little bit of a d different experience. I never actually went through menopause ⁓ which is kind of strange, I know, but I had my I elected to have my ovaries out in my forties. They're just causing no good. And my sister had died of o ovarian cancer at a very early age and I'm just like Get those puppies out of me. And so I ⁓ was immediately put on hormone replacement therapy and I've never gone off. And I will never go off. but I've, you know, tried changing the formulas over the time a and I I think I've got it figured out what feels good for me. So but you know, every w woman is different. You have to feel comfortable with it. A a lot of women are well, not the women. It's the doctors that are still so ill informed because the World Health Initiative study did such a disservice for women for two decades now, ⁓ with this unjustified scare of cancer risk. And and now we know that you know it's it's really safe. It's also preventative for for another a number of aging disorders. And you know, unless you have a family history that puts you at high risk or you're you have the genetic loading for certain cancers and it's not a good good idea. But you know, barring that I think not just for sexuality but for keeping tissue more youthful for cognitive ⁓ function, lack of that. loss of you know, word finding ability, the loss of the fogginess, a feeling so much of that is linked up to estrogen loss. And y you know, you're already going through these body changes and then you can't think of things and your head's foggy. I mean, that doesn't make you feel good. That doesn't you know? So I'm I'm staying on it for life and there's nothing that's gonna ⁓ take up but That that's just me and and some people are like, No way I'm going on it. I you know, so you just have to figure out what's good for you.

speaker-0: I think for me when I and I was forty-four when I first started noticing that my brain was foggy and I was like forgetting words. And even though my hormone tests were coming back normal and my cycles were normal, I knew what was happening and and thankfully I had a doctor who was thoughtful enough to actually listen to what I had to say and I'd been tracking my cycles and everything for a really long time and ⁓ and also my hormones, I would get them measured every year. And so even though I was still normal and my cycles were normal, my hormones were low for me. And ⁓ and so I started on that and And one of my one of my ⁓ fr friends who's an older woman w said and and I feel exactly the same way and she said, you know, my she's like, I love my estrogen patch and when I die I'm gonna have them tape it to my coffin.

speaker-1: I pretty much feel feel the same way.

speaker-0: And so ⁓ I think that there are so many wonderful benefits that women can get from ⁓ can get from hormone therapy, but also like for those of you who are listening, if you are ever thinking ⁓ that you wanna consider hormones or you don't want to consider hormones, ⁓ I do think like one of the things that makes me ⁓ uncomfortable with the new language around menopause and hormone therapy, but which I think is so wonderful and I'm so glad that the bars are starting to l you know, sort of lift and and increase access. But I do think that it's now led to this ⁓ sort of perception that there's something wrong with going through menopause and that it's a pathology, you know, instead of the fact that this is you know, like instead of Yeah, it w which, you know, if you don't want to go on hormones, you don't have to, because it is a very natural transition that women have been going on, you know, going through since time immemorial. And ⁓ and so you don't have to feel pressure to go on hormones. They're very therapeutic to a lot of women. Cindy loves them. I love them. ⁓ but but you don't have to be on them.

speaker-1: You don't have to be on them, but I will s say that ⁓ yes, so ⁓ you know, w we didn't live as long as we're living now, you know. I mean, evolutionarily speaking, you know, we died off shortly after menopause, right? When you're people died off in their sixties. And so now do you want to spend like more than a third of your life, maybe a half of your life, hormonally deprived? I don't.

speaker-0: Right. Yeah, and yeah, and and we do we do live longer. There there is evidence that menopause is selected for, right? And that it's not just a by product of the fact that we live longer and that it does seem to be happening intentionally to shift women's effort away from direct reproduction and more toward, you know, investment in collateral kin. So whether it's ⁓ grandchildren or ⁓ you know, nieces and nephews and just this idea that it's shifting us from a primary reproductive goal into a caregiving role. And ⁓ you know, but nonetheless, you know, we did we didn't live as long as we did. And maybe we lived, you know, for ten years postmenopausal and now we're living, you know, twenty, thirty, forty years postmenopause. In my mom's case, she went through early menopause, you know. fifty years probably. ⁓ and and do you want to ⁓ go through this time without any hormones at all or would you feel better? You know, I think that it's good that we're starting to have more conversations around hormone therapy and and stopping with the scare tactics ⁓ that are have been preventing so many women fr to getting access for so long.

speaker-1: Exa exactly, exactly. I agree.

speaker-0: Yeah. Well thank you so much. there was so much that we learned from you during our time together and ⁓ I could have probably talked to you for three more hours, but I'm gonna like try to be ⁓ conscious of your time. Thank you so much, Doctor Cindy Mestin.

speaker-1: And really fun, thank you.

speaker-0: Dr. Cindy Mestin, thank you so much for joining us on the XX Lab. And that's it for today's episode of the XX Lab. If you want more, subscribe wherever you get your podcasts. And if you're enjoying the show, a rating or review helps other people find it. See you next episode.