I stopped using the word foreplay with my patients years ago. The word tells a woman that everything her body needs to get ready for sex is an opening act, something to sit through on the way to the part that counts, and the problem is that the part that counts is his. In its place I use runway, because a plane that tries to lift off before it reaches speed doesn’t fly, and a woman who is rushed toward penetration before her tissue, blood vessels, and nervous system have arrived doesn’t either; she endures, or performs, or leaves her body for a while, and later, sometimes many years later, she wonders where her desire went.
I work with a lot of women who are on a search and rescue operation for desire that is missing in action. Many of them assume incorrectly that something in them is broken or too slow. More often, they have been measuring themselves unfavorably against a map drawn for a male body.
In 1966, before I was born, Willaim Masters and Virginia Johnson published the first laboratory-based map of human sexual response, built on direct observation of more than 600 men and women. [1, 2] Masters and Johnson described four phases: excitement, plateau, orgasm, and resolution. In a talk I gave last month on sexpan, I walked through the classic male arc, because it explains so much about what women were taught to expect.
In men, excitement starts with blood. Arteries in the penis dilate, erectile tissue fills, and an erection follows, set off by a thought, an image, a scent, or touch. [3] Heart rate and blood pressure begin to climb. In the plateau, the erection holds, the testes rise against the body, and pre-ejaculatory fluid appears, and for many men this phase passes quickly. Orgasm lasts about 10 to 15 seconds, a sense of inevitability as semen moves into position followed by rhythmic contractions that expel it. [4][5] Then comes resolution: the erection fades, vital signs settle, and a refractory period begins, a window in which another orgasm isn’t possible, one that lengthens with age. [4] Build, peak, release, done.
Decades ago, I heard Ellen Heed call this pattern the climactic sneeze, and the phrase has stayed with me. Some women know the sneeze too, usually on a night when time is short and the vibrator is on. There’s nothing wrong with it, as long as you know it draws on a fraction of your capacity for pleasure. The trouble starts when the sneeze becomes the only model on offer.
Masters and Johnson saw that women move through the same four phases on a different clock, with a plateau that tends to last longer and a body that needs more time to fill. The biggest difference comes after orgasm. Women have no obligatory refractory period, so arousal can fall back to plateau and rise again toward another peak. [1][4] Later researchers pushed the model further. The psychiatrist Helen Singer Kaplan added desire as its own phase. [2][6] Masters and Johnson’s original observations were loosely controlled, [2] and newer studies show that men vary more than a single straight line suggests. [7] Even so, when Danish adults were asked which model described them, the classic linear arc was still the one men chose most often. [8]
The more common female pattern looks like the ocean. Waves build, recede, and build again higher, and many women have a capacity for more than one peak, a possibility the sneeze model leaves no room for. What makes those waves possible is tumescence, the slow filling of erectile tissue with blood.
Most people think of tumescence as a male event, the erection, but women have erectile tissue too, and most of it lies beneath the surface, out of sight. [9] As that tissue fills, the whole region grows more sensitive, and each wave of arousal rises on the one before it. Sustained, unhurried tumescence is where many women find their greatest pleasure. Men may enjoy a long, slow build, but a man can reach orgasm without one. For most women, the build is the pleasure, and the peak depends on it.
Most of the sex women were taught – by sex education, by pornography, and by partners who learned from both – to go for the climatic sneeze, which means it was designed around a man’s body and then handed to women as the definition of normal. I want you to move beyond it.
Arousal in a woman’s body is a hydraulic event before it is anything else. Blood moves into the clitoris, the labia, and the vaginal walls, and the tissue swells and warms, a process called vasocongestion. Then the vagina lengthens and its upper portion balloons open, which William Masters and Virginia Johnson called tenting, lifting the cervix and uterus up and out of the way. [1] None of this happens in thirty seconds. When penetration arrives before the tenting does, the result is friction against a canal that hasn’t finished making room, and many women, told for decades that some pain is simply the price of being a woman, read that discomfort as proof that something is wrong with them. The problem is the clock.
The clitoris is the organ built for this, and medicine took its time noticing. The visible glans is only the tip of a structure that extends roughly 9 to 11 centimeters into the body, with bulbs and legs that wrap around the urethra and the vaginal canal. The urologist Helen O’Connell published that full anatomy in 1998, [2] the same year the FDA approved Viagra, which tells you something about whose pleasure got the research budget. More recently, a team at Oregon Health & Science University counted more than 10,000 nerve fibers in the dorsal nerve of the clitoris, well above the figure of 8,000 that textbooks and magazines had repeated for decades, a number that seems to have come from animal studies because no one had bothered to count in women. [3] Most women learned none of this in school. Most of their partners didn’t either.
So here is what I want every woman over 40 to carry out of this essay: the clitoris needs direct, unhurried attention, and most women need it to reach orgasm at all. In a national probability sample of more than a thousand U.S. women ages 18 to 94, only about 18 percent said intercourse alone was enough for orgasm, and more than a third said clitoral stimulation was necessary during intercourse. [4] A culture that still treats penetration as the main event and the clitoris as a detour has the map backwards. A runway that skips the clitoris skips the main road.
Women also experience something researchers call arousal non-concordance, which means that genital response and the felt sense of wanting often fail to line up. A meta-analysis pooling decades of laboratory studies found that agreement between genital and reported arousal was far weaker in women than in men. [5] Lubrication can show up before desire does, and desire can show up while the tissue lags behind, especially once estrogen falls. A wet body isn’t the same as a ready woman, and a partner who treats it as a green light has mistaken plumbing for permission, which is one more reason the pace has to belong to her.
Desire itself often arrives late. The psychiatrist Rosemary Basson described how, for many women in established relationships, desire responds to closeness and touch instead of preceding them, so the wanting builds once the runway is underway. [6] A woman who waits for spontaneous lust before she begins may wait a long time, and she may decide, as so many of my patients had decided before they reached my office, that she is broken. Given time and the right touch, the same woman often finds her appetite rising halfway down the runway.
What I was taught in medical school was the four-stage sexual response cycle that I described from Masters and Johnson (excitement, plateau, orgasm, resolution), drawn as a single line that rises and falls. If memory serves, we covered it in about 20 minutes.
What I know now, after 30 years of practice, is that the line looks nothing like most women’s experience, and that the most important part of sex for a woman over 35, the slow climb, is the part medicine never thought to treat as medicine. Clinicians ask her about contraception and cancer screening. They almost never ask about arousal, and once she passes a certain age, they assume she’s finished.
The data says otherwise. In a national study of older Americans, about a quarter of adults ages 75 to 85 were still sexually active, yet only 22 percent of the women had discussed sex with a physician since turning 50, compared with 38 percent of the men, and 14 percent of the men had used a medication or supplement to improve sexual function, against 1 percent of the women. [14] Put plainly, when an older man’s sex life falters, medicine reaches for a prescription pad, and when an older woman’s does, medicine changes the subject. One reader well past 60 wrote after my essay on duty sex that no clinician had ever asked her whether she was still having sex or still wanted to, even though they test her for everything else. She asked me how to explain feeling like it and not feeling like it at the same time. I’ve been thinking about her question ever since, because it describes a woman whose wanting is still alive and whose runway has gone unattended.
For much of my previous 20-year marriage, sex happened at the end of the day and definitely at the end of my energy, on someone’s clock that had nothing to do with my body, and I knew the physiology of arousal well enough to teach it while treating my own runway as optional. It took the end of that marriage, and many years of slow work on my own nervous system, before I understood that arousal I rushed was arousal I never fully had.
I’m 59 now, with a partner who is more curious and literally never hurried (if you know then you know what I mean), and I finally give my body the runway it needed all along, with waves of pleasure and tumescence that I didn’t know were available to me. This state of arousal is possible for you too.
I believe erotic aliveness is a vital sign, as worthy of a clinician’s attention as blood pressure or heart rate variability. By erotic aliveness I mean the felt sense of being inhabited by your own wanting (warmth in the pelvis, curiosity about touch, appetite, the pulse of something that belongs to you before it belongs to anyone else), and it shows up well beyond the bedroom: in how a woman walks into a room, in the music she plays in the car, in whether her own body can still surprise her. When it fades, women rarely describe less interest or libido. They say that they feel flat. Sadly, they often get started on the latest antidepressant.
The comments on my essay about duty sex, the sex women have so their partners will stop asking, read like a clinical history of that flatness. A woman who left a long marriage named the cost in three words: loss of aliveness. Another described life on a medication that quieted her appetites as no highs, no lows, just meh. Several wrote that they still love their partners and can’t find the door back into their own bodies. Every one of them was describing a life that had stopped feeling like hers long before anyone checked a hormone level, and many had been raised to call that kind of self-erasure being a good wife.
Erotic aliveness depends on the nervous system, and the runway is where the nervous system gets its say. The early phase of arousal, engorgement and lubrication, is largely a parasympathetic event, run by the branch of the nervous system that governs rest, digestion, and safety, and a body still braced from the day can’t fully enter it. In one study of women, lower resting heart rate variability, a marker of a less flexible nervous system, was linked to more arousal problems and more sexual dysfunction overall. [15] Women who have spent decades keeping everyone else alive, at work and at home, often carry an occupational vigilance that doesn’t switch off when the bedroom door closes. A body still scanning for the next emergency won’t open for pleasure on command, and no amount of lingerie will talk it into trusting a room it has learned to monitor.
The therapist Esther Perel has written that desire needs space, mystery, and a self distinct from the relationship, [16] which runs against nearly everything a busy, merged, overfunctioning life produces, and against everything girls are rewarded for long before they become women: anticipate, accommodate, keep the peace. The runway hands a woman that space back for twenty minutes, or forty, or an afternoon, time in which she isn’t anyone’s manager, mother, or doctor. For many of my patients, it’s the first time in years their body has been allowed to take as long as it needs.
Here’s what I tell patients, in the order they need it. The first part starts six weeks before you need it, which surprises almost everyone, because no one ever suggested that a woman’s sex life deserved the kind of preparation we give a knee before a marathon.
Tissue changes slowly, so treat it ahead of time. After estrogen falls in perimenopause and menopause, vulvar and vaginal tissue thins, loses blood flow and elasticity, and makes less moisture. The name for this is the genitourinary syndrome of menopause. It affects somewhere between a quarter and more than four-fifths of postmenopausal women, depending on the study, it tends to worsen without treatment, and it remains underdiagnosed and undertreated, [17] so many women assume it’s simply what aging does to a woman. Low-dose vaginal estrogen is the foundation, and the tissue responds over weeks, so start it six weeks before a trip, a new relationship, or a decision to bring sex back into your life, rather than the night you discover it hurts.
Talk with your clinician about which form fits you. If you’ve had breast cancer, start with non-hormonal moisturizers and lubricants, whatever endocrine therapy you take. If those aren’t enough, low-dose vaginal estrogen is worth discussing. In a Danish national cohort of more than 8,000 women treated for early estrogen receptor-positive breast cancer, vaginal estrogen wasn’t linked to higher recurrence or death overall. Women also taking an aromatase inhibitor had a somewhat higher risk of recurrence, though not a higher risk of death. [18] A UK registry study of more than 49,000 women with breast cancer found no rise in breast cancer deaths with vaginal estrogen, [19] and a 2025 meta-analysis pooling more than 24,000 survivors found no increase in recurrence. [20] All of this evidence is observational, so it lowers the worry without settling the question. If you take tamoxifen, the findings are reassuring, and low-dose vaginal estrogen is an accepted option once non-hormonal care hasn’t helped. [21] If you take an aromatase inhibitor and moisturizers haven’t helped, options include vaginal DHEA or the lowest-dose vaginal estrogen products, such as a 10-microgram tablet, a 4-microgram insert, or a low-dose ring. [21][22] Make that decision with your oncologist.
Choose your lubricant during the same six weeks, because many popular lubricants are hard on vaginal tissue. The World Health Organization advises that water-based lubricants stay below an osmolality of 1,200 mOsm/kg, ideally closer to the body’s own, with a pH near the vagina’s natural acidity. [23] Many drugstore brands run well above that, which can dry and irritate the very tissue you’re trying to restore, so a product sold for women’s pleasure can be quietly hard on women’s bodies. Look for osmolality and pH on the label, skip glycerin-heavy and warming formulas, and consider a silicone-based lubricant if you want something that lasts.
Protect the hour before as carefully as the act. Afternoon sex is one of my favorite clinical tips, because a woman at 3 p.m. on a Saturday has a different nervous system than the same woman at 10:45 p.m., after the dishes, the…
