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

Casperson highlighted a study where researchers placed vibrators externally on the vulva with no requirement to orgasm. The intervention increased clitoral artery blood flow, improved desire, and in preliminary findings appeared to help signs of atrophy and lichen sclerosus. She ties this to the broader vascular argument: just as blood flow is good for heart, brain, and muscle, it is good for the pelvis. For decades, medicine has studied erectile dysfunction relentlessly via the lens of blood flow (diabetes, smoking, heart disease), yet female arousal — driven by the same mechanism — has barely been examined. Vibrators, when depathologized and demystified, become a simple at-home tool to counteract this neglect.

Casperson explains that HSDD is when desire used to be great and now feels 'gray' — not a relationship problem, but a brain change. The drug is often dismissed as 'female Viagra', which is inaccurate: it works centrally, not on blood flow. Viagra solved a blood flow problem in men; Adyi targets the desire circuitry. She notes the profound stigma: the media asked 'What do you need that for?' while men's Viagra was celebrated. Yet 10% of Adyi prescriptions are taken by men, and published literature shows it helps men with orgasm and desire — proving the mechanism is universal. Access barriers include sexual health rider clauses in insurance that block coverage for both men and women, but Viagra is generic and cheap while Adyi remains brand-only. She directs patients to addyi.com and the PhilRx pharmacy.

Casperson learned from sex therapist colleagues that most long-term partners have never asked each other why they have sex or what sex means to them. She used the exercise in her own marriage after 15+ years and was surprised by her husband's answer. She frames this as a preventative skill: if you talk about great sex, you build trust and language for the hard talks. Many women assume their partner's erectile dysfunction means they are unattractive, or that orgasms belong only to partnered sex; these assumptions fester in silence. She encourages simple, shame-free, curious questions in a judgment-free zone, and suggests that even using a party metaphor ('Do you enjoy the party once you're there?') can open the conversation without accusation.

Casperson draws a direct parallel to erectile dysfunction: men's erections are a blood flow phenomenon studied exhaustively, while women's engorgement uses the same mechanisms but is ignored. She notes that perimenopause brings hormonal chaos years before periods stop — yet women are told they don't need hormones because they still menstruate, a logic that would be ridiculous if applied to men ('you get a little bit of a boner, dude, so you don't get any of that'). She points out the absurdity of withholding vaginal estrogen from breastfeeding mothers who develop painful genitourinary syndrome from low estrogen. The recent FDA update finally labeling vaginal estrogen for painful sex came 27 years after Viagra, a striking symbol of the delay. She also emphasizes that not all desire issues are hormonal; some are about unrewarding sex or untreated depression, so a thorough assessment is key.

Casperson's pivot came when a bladder cancer patient she deeply cared about cried in her office over a sexless marriage. As a urologist she knew exactly how to help a man with erectile dysfunction but realized she had no tools or training for women. That moment began a deep dive into female sexual medicine, which she found had evidence but zero dissemination. She now argues that the 15‑minute clinic visit and lack of sex education produce a perfect storm: doctors mean well but their quick solutions feel dismissive, and women assume they are broken because no one ever taught them about responsive desire, the clitoris, or the biology of arousal. She contrasts the meticulous informed‑consent conversations urologists must have about erectile function before prostate surgery with the complete absence of sexual‑function counseling by gynecologists before pelvic surgery or obstetric repairs — despite operating on or near the same sexual structures.

Casperson uses a party metaphor: many women say they don't desire sex but once at the 'party' they love it — they are responsive‑desire types. Others say the party itself is gray or uninteresting, which may point to biological contributors (low hormones, neurotransmitter issues) or a history of unrewarding sex. The Hollywood script — instant spontaneous desire, simultaneous orgasms, no pain, unlimited time — is entirely false. Without this education, women interpret their normal responsive pattern as a personal failure. She repeatedly tells patients 'you are not broken' because they didn't know that only ~30% of women orgasm from vaginal penetration alone; their anatomy is normal.

Casperson recounts interviewing a male researcher who specialized in female desire. He was operating on the unconscious assumption that women were having sex worth desiring; she stopped him and pointed out that many women are having 'mushy broccoli sex' — sex that is not pleasurable, not focused on her arousal, and often physically uncomfortable — and then being blamed for not desiring it. The party metaphor: if you go to a party and the food is cold, the music is bad, and you're ignored, you stop wanting to go. The same is true for sex. This blindspot is huge because medicine tends to treat low desire as a biological or psychological pathology in the woman, rather than first investigating whether the sex she is having is rewarding. She notes that even in long-term loving relationships, men typically achieve orgasm nearly every time while women do not, yet few couples ever discuss this or learn that clitoral stimulation is the primary route to female pleasure.

Casperson learned only after years of practice that she had been placing midurethral slings adjacent to the clitoral bodies. Mary Claire Haver adds that during emergency obstetric repairs she threw large sutures into the perineum without considering the clitoral tissue, and that episiotomy scars often become painful in menopause as hormones wane. Casperson highlights that urologists who operate on the prostate must explicitly counsel about erectile dysfunction and ejaculatory changes; doing otherwise would be malpractice. Yet gynecologists remove cervixes and ovaries — both structures with innervation and some erotic function for a subset of women — without any standard informed-consent discussion about sexual outcomes. She published data on cervical innervation and sexual function and was met with dismissal ('there's no data' then 'there's not enough data'). This disparity in surgical transparency is a core illustration of how female sexual quality of life is devalued.

Casperson points out that dying in childbirth is natural; wearing socks is not. Humans have extended life dramatically by defying nature with antibiotics (added 26 years to life expectancy), climate control, clean water, and countless medical replacements. The ovary is the one organ we have decided not to help. She sees this as a tool of social control that pressures women to be 'perfect and natural' while simultaneously demanding they remain young. The most natural thing is to age and die, but society insists women anti-age naturally. This hypocritical logic underpins the dismissal of hormone therapy and sexual medicine for women. She uses examples like flossing (unnatural but saves teeth) and replacing every other failing body part to illustrate the inconsistency. Once people see the pattern, they recognize the double standard. She emphasizes she is not forcing anyone to take hormones or have sex; her goal is that women have the education to make their own informed choice, free from the moral weight of 'natural.'