In the Billionaires' Vagina Club, Desire Must Be Efficient
Stop telling women sex is like going to the gym
Heterosexual women orgasm roughly 30 percentage points less* often than their male partners. We carry more sexual shame, report lower desire, and describe less satisfaction—and then we’re told this is simply what sex is for women.
So when a female gynecologist builds an entire practice around the motto “sexual health is health,” of course I want to stand up and applaud.
Dr. Sally Greenwald is that gynecologist. The New Yorker recently profiled her under the headline “The Billionaires’ Vagina Club”, a concierge practice where Silicon Valley’s wealthiest women pay upwards of $30,000 a year to optimize what she calls their “sexspan.”
She prescribes the hormones other doctors withhold. She treats orgasms as a legitimate health outcome tied to sleep, stress, cardiovascular function, and longevity. She takes seriously the symptoms that medicine consistently dismisses as “just a natural part of aging.”
All of this, I celebrate.
There are, however, a few things in this article that didn’t sit right with me as a sexologist and that’s what I want to talk to you about today.
The celebrity’s wife
Dr. Greenwald has a session with a patient named Kristen. Kristen is married to a celebrity and drowning in the mental load of motherhood. A couple of years ago, she was also struggling with the hormonal oscillations of perimenopause, which have since been evened out thanks to Dr. Greenwald.
Kristen’s husband, who lives a more glamorous life and takes testosterone, wants sex constantly. Satisfying him has become one more chore.
She misses wanting sex, but when he asks her if she wants to do it, she finds it manipulative because she knows he’ll be visibly annoyed if she says no.
And Dr. Greenwald’s prescription? To have efficient sex.
“She believes that the best way to improve sex is to drop the romantic notion that it requires a special frame of mind,” writes Melanie Thernstrom for The New Yorker. “Better to have a quickie, even if you’re reluctant, because an orgasm can improve your mood, and ultimately your health and your relationship.”
Now I’m not one to dismiss efficient sex. For many, an hour-long rendezvous is unrealistic. And she’s right: an orgasm will improve your mood.
But efficient sex only works if you enjoy it. And Kristen clearly isn’t enjoying the fast food meal she’s being served.
Telling her to warm herself up with a vibrator, text her husband to come upstairs for five minutes, get it done, and then compliment each other on how efficient they were sounds cheeky, but won’t fix that. Much like losing weight and quitting smoking, if you don’t genuinely want to do it, forcing yourself rarely does the trick.
We were taught that sex should be simple and straightforward, when it’s the most complex thing we do. It’s called an eco-bio-psycho-social phenomenon for a reason.
Dr. Greenwald focuses on the bio. When you dismiss the remaining factors, women will keep walking away disappointed, suspicious that the problem is them.
This isn’t how you treat responsive desire
She explains to Kristen that most women in long-term relationships lose spontaneous desire and retain responsive desire. Desire that arrives after stimulation, warmth, connection.
She’s right about the science. But responsive desire is an invitation to build contexts where wanting can actually emerge: anticipation, seduction, novelty, safety.
If you brace yourself every time you say no, safety has left the room.
If sex is initiated with “do you have five minutes?” seduction and anticipation are hard to come by.
If you keep resorting to quickies, novelty rarely stands a chance.
The vibrator-then-text protocol treats Kristen’s body as an engine to jump-start so it can perform the same sex that isn’t working, which doesn’t honor responsive desire. Instead, it optimizes for her husband’s satisfaction while ignoring hers.
Heteronormative sex needs help for a reason
At one point in the session, Dr. Greenwald tells Kristen she’s not going to talk about “chandelier sex.” Instead, they’ll stick to what she calls “super-heteronormative, vanilla, white-picket-fence sex that has data behind it.”
Here’s the irony: the heteronormative script—kissing, brief oral, penetration, his orgasm as the finish line—is why the orgasm gap* exists in the first place. Most women don’t orgasm from penetration alone.
Research shows that variety predicts satisfaction. More pathways to pleasure, more kinds of touch, more flexibility in what counts as sex.
It’s a major reason queer sex tends to be more fulfilling for the women involved: 86% of lesbians usually or always orgasm during partnered sex, compared to 65% of heterosexual women.
For them, penetration isn’t the main event. It’s optional, one item on a much longer menu of oral sex, manual touch, toys, and psychological play.
In So Tell Me About the Last Time You Had Sex, Dr. Ian Kerner calls this an “outercourse” model: while straight couples default to intercourse about 90% of the time, queer couples build sex around varied, touch-based pleasure. And that’s what the research says predicts more orgasms for women.
So when Dr. Greenwald prescribes more of the standard script, faster, she’s prescribing a higher dose of the thing that’s failing.
What I would begin exploring with Kristen (and her husband) instead
First, a reframe I share often: foreplay begins when the last time you had sex ends.
Desire in a long-term relationship isn’t built in the five minutes before sex. It’s built in everything between.
So if any part of Kristen’s story feels familiar, here are five questions worth sitting with, ideally with your partner:
How is the mental load split? A woman carrying the entire invisible workload of a household has no bandwidth left for wanting. It must be redistributed.**
Are you setting aside time for your own pleasure? You cannot access sexual pleasure if you’re not consistently experiencing pleasure in your daily life. Find a hobby that lights you up.
How is sex usually initiated, and does it actually work for you? If the current bid feels like pressure instead of invitation, the approach needs to change.
What actually happens during sex? What does good sex feel like to her? What works, what doesn’t and what variety could you introduce: different kinds of touch, different pacing, different power dynamics, a different definition of what counts?
Can you both ask for what you want without flinching? A healthy dialogue about sex predicts more desire, more arousal, and more satisfaction. It’s a skill, not a personality trait.
I know these questions are easier to read than to actually ask. Sitting across from your partner and saying “I want us to talk about our sex life” can feel more vulnerable than the sex itself.
If you want help in this department, I have two suggestions:
You can turn this awkward conversation into a great date night experience with the Intimacy Card Deck for Couples that I created. It’s the card that asks the question, not you, and the guided prompts allow the dialogue to unfold and build from a more romantic context to seriously spicy. Readers get 10% off with code LUST.
If what’s happening in your relationship feels bigger than the card deck, I work with individuals and couples to bridge the desire gap and strengthen emotional connection. Book a 1:1 session and we'll work through what you're experiencing and you'll leave with a clear plan for what to do next.
“Working with Natassia superseded all expectations. She is attentive and genuinely cares, and by the end of our sessions we felt deeply reconnected and clear about how to keep nourishing our intimacy.” — Julie K., 16-yr marriage
*The Orgasm Gap: In a U.S. national sample of over 52,000 adults, 95% of heterosexual men reported usually or always orgasming during partnered sex, compared to 65% of heterosexual women (Frederick, St. John, Garcia & Lloyd, 2018, Archives of Sexual Behavior). The same study is the source of the lesbian (86%) and heterosexual women (65%) comparison above.
**Pew Research Center (2023) found that even in marriages where wives earn the same as or more than their husbands, women still spend roughly 2.5 more hours per week on housework and 2 more hours on caregiving, while husbands enjoy about 3.5 more hours of leisure. Meanwhile, couples who share routine housework equally report the highest sexual and relationship satisfaction—and are the only group whose sexual frequency has increased since the early ‘90s (Carlson et al., 2016, Journal of Marriage and Family).
Before you go: some Lust in Translation news
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Last, but not least: this newsletter is growing up! Essays like this one —where I take what’s happening in culture and break it down through a clinical lens, with the frameworks and takeaways to actually use in your own relationship—are the direction I’m heading. What you just read is a taste of it.
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