Sara Szal MD
A woman, 33, six years into a relationship with a man she loves, wrote to ask for an appointment after finding this post about female pleasure on my Substack. She had never once told her partner what she wanted in bed. She felt that she lacked the words, even when he asked. She didn’t know where to start, and the situation was becoming a resentment that she couldn’t explain to him either.
Here is what I was taught in medical training: refer a patient to sex therapy only if she brings it up herself. After years in my private practice, I realized that my training taught me silence. Waiting for her to raise it first is exactly why she almost never does.
What I now know: We have to do better by women. We physicians were trained inside of a culture that spent centuries treating women’s pleasure as beside the point, or worse, suspect or shameful. No one hands physicians the curriculum on day one of medical school, but we should. We absorbed the messaging, and that showed up in the medical office as silence dressed up as professionalism and standard of care.
A few years ago, I changed what I do. The first 12 or so times that I asked a patient directly about her pleasure, arousal, and orgasm, I fumbled the words. It was awkward, for her and for me. My earnestness carried us both through it, until eventually it stopped feeling awkward at all. Patients started thanking me for finally being about to talk about their pleasure with a doctor.
I believe permission itself is the intervention, not a courtesy tacked onto the real medical care, but the medicine itself. However, permission wasn’t enough for the woman who wrote to me at age 33. Once she found the language, she needed a framework to share them with her partner.
Here’s the part almost nobody tells women like her, and nobody told me either: there’s a proven strategy for closing the pleasure gap in women, and it’s built mostly on randomized trials. Where the trials run out, I suggest n-of-1 experiments to my patients, and we track together what moves the needle and works for her specifically.
Most women never hear any of this information or the hierarchy of what’s been proven to work, not because of a lack of evidence but instead because the conversation with her doctor never gets that far. That’s what we must change.
Bottom line: Below are the strategies, in the exact order that the scientific evidence supports, along with the key questions that I raise with every woman under my medical care.
Ultimately, the pleasure gap doesn’t resolve itself with time. The longer a woman waits to move past permission into effective treatment, the more entrenched the pattern becomes, for her and for the relationships that is absorbing everything she hasn’t been able to articulate.
Here’s what you get when you are a paid subscriber:
-
The complete list of every evidence-ranked path back to pleasure and sovereignty, in the order that the scientific research supports and from what I’ve witnessed in 30 years of medical practice, including prescription-free protocols that are backed by randomized trials.
-
Word for word: the question that I now ask in every visit with a woman and what changed when I started asking it.
-
The cost of wanting. This cost leads to the kind of distress that doesn’t fade on its own. The cost must be noticed, addressed, and cleared so it doesn’t compound and turn into resentment, as it did for our Female Edge reader.
