Podcast Summary: You Are Not Broken – Ep. 343

Title: Sex Therapy in Midlife
Host: Dr. Kelly Casperson, MD
Guest: Rachel Boyle, Marriage & Family Therapist (specializing in Perimenopause, Menopause, & Trauma)
Date: Nov 9, 2025

Main Theme

This episode explores how sex therapy intersects with the unique experiences and challenges of perimenopausal and menopausal women, shedding light on trauma, hormones, relational dynamics, sexual desire, and breaking down pervasive societal myths on women’s sexuality in midlife. Dr. Kelly Casperson and sex therapist Rachel Boyle use clinical experience and humor to deliver actionable insights for women and couples navigating sex, identity, and relationships during midlife transitions.

Key Discussion Points & Insights

1. Meet Rachel Boyle: Trauma & Sex Therapy with a Menopause Focus

• Credentials: Master's in Marriage & Family Therapy; certified in EMDR (Eye Movement Desensitization and Reprocessing), Polyvagal Theory, Parts and Memory Theory.
• Specialization: Trauma therapies with emphasis on perimenopause and menopause.
• Personal Motivation: Rachel’s journey through undiagnosed perimenopausal symptoms and lack of trained providers led her to specialize in this niche.
  • Quote (03:48): “No one could find anything wrong with me... A girlfriend said, ‘I think you might be in perimenopause.’ I’d been to every doctor!” — Rachel Boyle

2. Understanding EMDR & Trauma in Midlife

• What is EMDR?
  • Mimics REM sleep to help reprocess traumatic memories and reduce their emotional intensity.
  • Quote (01:50): “It takes the looping memories... processes them and puts them in the proper file drawer. You don’t forget the memory, but it loses its power.” — Rachel Boyle
• Perimenopause & Trauma:
  • Many therapists/clinicians miss perimenopause as a root of midlife anxiety, depression, and relational issues.
  • Rachel started screening all clients with menopause checklists—a critical intervention.
  • Quote (05:43): “Therapists have women in their office… nobody knows they’re in perimenopause—including the psychiatrist. So I started screening all my clients.” — Rachel Boyle

3. Sex & Relationships in Midlife: The “Perfect Storm”

• Symptoms: Hormonal fluctuations, emotional volatility, an increased mental/emotional labor load (“CEO of the family”), GSM (Genitourinary Syndrome of Menopause)—libido changes, pain, irritation.
• Relational Impact: Perimenopause is often a tipping point for relationship conflict and even divorce.
  • Quote (06:48): “It all comes to this crescendo, this perfect storm. For some women, hormones help. For most, it’s: how do we create an equitable relationship and start talking about sex?” — Rachel Boyle
• Cultural Conditioning:
  • “Sex from the male gaze” often dominates, but midlife is a chance for women to redefine what they want in sex.

[08:30] Addressing “The Male Gaze”

• Basic but critical opening question: “When’s the last time you had sex, and how was it for you?”
• Many people operate on autopilot, never reflecting on their sex life or desires.
  • Quote (09:19): “So many couples in long-term relationships get into a habit... rote memorization. Women are like ‘I don’t desire sex.’ You could do it in your sleep!” — Dr. Casperson

4. Exploring New Sexual Scripts & Responsive Desire

• Many women don’t realize they can actively design sexual experiences that suit them.
  • Quote (11:05): “They don’t even know they can think about sex differently... If you could create sex any way you want—most have never thought about it.” — Rachel Boyle
• Some women excitedly embrace this, others feel blocked—enter “nervous system response,” where past trauma, body image, or sexual scripts shut down desire.

[13:30] Sex Therapy Outcomes: Transformation & Fear

• Sex therapy can be transformative, but some couples realize they’re incompatible sexually or emotionally—the process is inherently uncertain.

5. Divorce & the Power of Midlife for Women

• High Divorce Stats:
  • 70% of divorces initiated by women; among educated women, up to 90%.
• Midlife as a Turning Point: Often, women finally demand an “equitable relationship”—and if partners don’t step up, separation becomes likely.
  • Quote (15:15): “Some partners have to make pretty drastic changes quickly. If they don’t want to contribute equally, that’s hard to stay in.” — Rachel Boyle
• Dr. Casperson reframes midlife: Not a decline, but a “caterpillar-to-butterfly” opportunity for transformation.

6. Hormones, Anxiety & The Foundations of Wellbeing

• Misattributed Anxiety:
  • Hormonal shifts can bring sudden-onset anxiety and depression—even for women without past mental health issues.
  • Quote (18:39): “I’m a therapist, know all about polyvagal theory—and I was having wild anxiety. Then I started testosterone... anxiety was gone.” — Rachel Boyle
• Sleep is Crucial:
  • “If you have insomnia, it’s hard to work through whatever you’re going through.” (19:56)
• Many women aren’t getting evidence-based hormone advice from providers. Selection of a trained clinician is vital.

7. Desire Reframed: Responsive, Subtle, and Playful

• Testosterone improves not only “pursuit” of sex but a more “open, receptive” attitude.
  • Quote (23:21): “It’s not so much forward pursuit, but openness to receiving... I would say YES a lot more.” — Dr. Casperson
• Scheduling Sex: A must as life gets busier, despite common resistance.
  • Quote (25:26): “Everyone says scheduling’s not natural—but dating, nothing’s natural. Modern relationships have to be intentional.” — Dr. Casperson

8. Non-Monogamy & Navigating Modern Relationship Structures

• There’s more transparency and conversation in consensual non-monogamy than most monogamous relationships, where boundaries and “cheating” often are never discussed.
  • Quote (26:59): “With consensual non-monogamy, there’s a lot of agreements and conversations... In most marriages, monogamy is just assumed.” — Rachel Boyle
• Infidelity and recovery: Emotional mistrust runs deep; betrayal can cause PTSD-like symptoms.

9. Safety, Body Awareness, and Breaking Shame

• Psychological & bodily safety is essential for pleasure and orgasm. The nervous system can’t distinguish between real and emotional threats.
  • Quote (29:52): “If a woman isn’t feeling emotionally safe, her survival center kicks in… If her body thinks it’s not safe, even if she is safe, it’ll pull away.” — Rachel Boyle
• Cultural Shame: Societal minimization of women’s health issues (periods, menopause) fosters shame and body disconnection.
• “It’s NOT normal for sex to feel uncomfortable.” Physical causes like GSM or lack of arousal must be addressed.

10. Advice on Finding Good Sex Therapy

• Seek a sex therapist with trauma training—ideally EMDR and AASECT certification.
  • Quote (32:40): “You want someone at least trained level 1 and 2 EMDR, does lots of EMDR. Brainspotting and ART are good, too.” — Rachel Boyle

Notable Quotes & Memorable Moments

• On midlife as opportunity:
  • “The caterpillar doesn’t complain about going into the chrysalis. They come out the butterfly. This is part of life.” — Dr. Kelly Casperson (16:25)
• On sexual scripts:
  • “When you’re the object of desire, you don’t think about your own desires.” — Rachel Boyle (35:26)
• On adult sex and feedback:
  • “Sex is really best in the hands of adults—people who can take feedback, ask for what they want, be good listeners, not take things personally.” — Dr. Kelly Casperson (47:29)
• On change & vulnerability:
  • “When you take a different choice than what your body’s programmed to do, it feels wildly uncomfortable. Every cell in your body is screaming not to do the new thing!” — Rachel Boyle (49:11)
• On subtle novelty:
  • “Spice it up, but by 2–3%! It doesn’t take a lot.” — Dr. Casperson (46:15)
• On scheduling sex:
  • “Monogamy is not natural for 40 years! Average marriage used to be eight years... Someone would die!” — Dr. Casperson (25:36, lighthearted tone)

Useful Timestamps

• EMDR & Trauma Explained: [01:50]–[02:36]
• Rachel’s Journey into Menopause Specialization: [03:00]–[04:36]
• Perimenopause Screening in Therapy: [05:43]
• Sex Scripts & Starting New Conversations: [08:30]–[11:44]
• Impact on Relationships & Divorce Stats: [14:49]–[15:06]
• The “Power of Midlife”: [16:05]–[16:56]
• Discussing Hormonal Therapy & Sleep: [18:03]–[20:27]
• Testosterone & Responsive Desire: [23:21]–[23:30]
• Non-monogamy, Communication & Affairs: [26:38]–[29:20]
• Safety & Body Awareness: [29:20]–[32:34]
• How to Find Good Sex Therapy: [32:34]–[33:00]
• Body Image, Labia Surgery & Societal Pressure: [35:47]–[37:22]
• Desire, Duty Sex & Cultural Conditioning: [34:42]–[35:47]
• Regional Differences in Sex Therapy: [51:27]–[53:10]

Final Takeaways

• Midlife and perimenopause are not the end of sexuality, but a “second act” filled with potential for growth, pleasure, and new scripts.
• Sexual challenges in midlife are multifaceted—encompassing hormones, desire, trauma, relationships, cultural scripts, and safety needs.
• Open, curious conversation—with professionals and partners—is crucial.
• Select therapists with both sex and trauma expertise—especially for hormonal transitions.
• A playful, personalized, and science-informed approach can make sex in midlife better than ever.

For more resources, connect with Rachel Boyle at rachelbo.com and explore Dr. Kelly Casperson’s masterclasses and podcast archives.

(Summary skips ads and non-content segments. All timestamps MM:SS. Reflects authentic tone and expert, warmly frank style of the show.)