Sexual Health, Libido, and Orgasm: What Medicine Missed with Dr. Kelly Casperson

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Kelly Casperson, a urologist, author, and host of the podcast “You Are Not Broken”. Dr. Casperson trained in a specialty that treats both men and women, which gave her an early and clear view of the gender gap in sexual healthcare. That disparity became the driving force behind her work, her two books You Are Not Broken and The Menopause Moment, and her clinic, the Casperson Clinic. Together they cover the full landscape of what women were never taught, what medicine has missed, and what actually works for female sexual health, libido, desire, and sexual dysfunction in midlife.

The conversation gets straight to what most women were never told: that the orgasm gap between heterosexual men and women has not improved in decades, and that the silence around female sexual health has never been about a lack of science. It has been about a lack of priority.

Dr. Casperson walks through the female sexual response cycle and why the linear model built from 1950s research has left generations of women believing they are broken. She explains the difference between spontaneous and responsive desire, why dopamine is released in pursuit of something rewarding and what that means for women who have spent years having sex that was not worth desiring, and why the orgasm gap between heterosexual couples remains one of the most underdiscussed issues in women's healthcare.

The episode covers what arousal actually is physiologically, why blood flow to the female pelvis matters as much as it does to the male pelvis, and how new research on vibration and clitoral stimulation may support tissue health beyond pleasure. Dr. Casperson addresses what happens to orgasm with age as hormones decline and pelvic floor strength decreases, the role of estrogen and testosterone in clitoral blood flow, and why six weeks postpartum is not a medically supported return to sexual activity.

They discuss the two FDA approved medications for hypoactive sexual desire disorder, flibanserin (Addyi) and bremelanotide (Vyleesi), how they work on the dopamine pathway, and why 10% of Addyi prescriptions are taken by men despite the pink box. Dr. Casperson also addresses the large and often vocal group of women who have no desire for sex and are unbothered by it, why that experience deserves as much clinical attention as low desire with distress, and what it means for long term relationships when one partner has quietly exited the sexual agreement.

The episode closes with a conversation about the naturalistic fallacy, the assumption that because something is natural it is therefore better, and how it is used to discourage women from treating menopause symptoms. Dr. Casperson's position is clear: her work is dedicated to making sure every woman has the education she needs to make her own informed decision.

Guest links:

• Kelly Casperson, MD
  
• Kelly Casperson (Instagram)
  
• Kelly Casperson (YouTube)
  
• You Are Not Broken (Apple Podcasts)

Books:

• “You Are Not Broken,” by Kelly Casperson, MD
  
• "The Menopause Moment," by Kelly Casperson, MD 
  
• “The New Perimenopause,” by Dr. Mary Claire Haver
  
• “The New Menopause,” by Dr. Mary Claire Haver
• "Sexual Behavior in the Human Female," by Alfred Kinsey
  

Articles:

• Oral Sildenafil in the Treatment of Erectile Dysfunction (New England Journal of Medicine)
  
• Primary Orgasmic Dysfunction: Diagnostic Considerations and Review of Treatment (Psychological Bulletin)
  
• Genital vibration for sexual function and enhancement: a review of evidence (Sexual and Relationship Therapy)
  
• The Role of Vibrators in Women’s Pelvic Health: An Alluring Tool to Improve Physical, Sexual, and Mental Health (International Urogynecology Journal)
  
• Differences in Orgasm Frequency Among Gay, Lesbian, Bisexual, and Heterosexual Men and Women in a U.S. National Sample (Archives of Sexual Behavior)
  
• Variation in Orgasm Occurrence by Sexual Orientation in a Sample of U.S. Singles (Journal of Sexual Medicine)
  
• Men versus women on sexual brain function (Human Brain Mapping)
  
• Menopause & Masturbation Clinical Study (Womanizer x Kinsey Institute)
  
• Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction (Journal of Endocrinological Investigation)
  
• Role of Estrogens and Estrogen-Like Compounds in Female Sexual Function and Dysfunction (Journal of Sexual Medicine)
  
• Testosterone for Treating Female Sexual Dysfunction (Clinical Obstetrics & Gynecology)
  
• Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria (The Lancet)
  
• A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones (European Journal of Endocrinology)
  
• Testosterone and pre-androgens by age and menopausal stage at midlife: findings from a cross-sectional study (eBio Medicine)
  
• Predicting low testosterone in aging men: a systematic review (CMAJ)
  
• The effects of transdermal testosterone and oestrogen therapy on dry eye in postmenopausal women: a randomised, placebo-controlled, pilot study (British Journal of Ophthalmology)
  
• Testosterone, cognitive decline and dementia in ageing men (Reviews in Endocrine and Metabolic Disorders)
  
• Testosterone for Low Libido in Postmenopausal Women Not Taking Estrogen (New England Journal of Medicine)
  
• Global Consensus Position Statement on the Use of Testosterone Therapy for Women (The Journal of Clinical Endocrinology & Metabolism)
  
• A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions (Journal of Sexual Medicine)
  
• Vaginal Estrogen Utilization Among Medicare Beneficiaries With Genitourinary Syndrome of Menopause (JAMA Network)
  
• Management of Antidepressant-Induced Sexual Dysfunction: A Literature Review (Cureus)
  
• Effect of GLP-1 agonists on testosterone levels: a systematic review and meta-analysis (BMC Urology)
  
• Treatment Gaps in the Management of Genitourinary Syndrome of Menopause (JOGC)
  
• Vaginal use of estradiol is associated with a reduced risk of rectal cancer in postmenopausal women: A Finnish nationwide case-control study (Maturitas)
  
• Reduced breast cancer incidence in women treated with subcutaneous testosterone, or testosterone with anastrozole: A prospective, observational study (Maturitas)

Other Resources:

• PHIL Rx
  
• HRT may help women stop antidepressants, study suggests
  
• Antidepressant Use Among Adults: United States, 2015-2018 (CDC)
  
• Impact of Vaginal Estrogen on Serious Adverse Outcomes in Postmenopausal Women with Recurrent Urinary Tract Infections: A Retrospective Study (ICS-EUS 2025)
  
• Dr. Mary Claire Haver (Substack)
  
• 2023 ISSWSH Slide Deck (ISSWSH)