Blunted Before They Can Bloom: SSRIs and Sexual Side Effects in Adolescents

FACT CHECKED

P. began taking Zoloft — an antidepressant known generically as sertraline — for school-related anxiety right at the cusp of puberty. 

“I’d started masturbating around that time and had a few muted orgasms,” she says. “But over the next couple of years, my access to sexual sensation faded away. No one ever mentioned that my pills might have that effect. And I wasn’t asking those kinds of questions. I just figured it was a flaw in myself.”

It wasn’t until she was studying criminology in college that P. stumbled upon a possible explanation for why touching her genitals felt about the same as touching her kneecap.

“I learned that sex offenders were sometimes prescribed SSRI antidepressants because they have side effects that can lower libido,” she says.

After she decided to do some research on her own, P. found that in addition to blunting desire, possible sexual side effects from selective serotonin reuptake inhibitors (SSRIs) like Zoloft, and their close cousin serotonin-norepinephrine reuptake inhibitors (SNRIs), include loss of genital sensation, inability to reach orgasm, loss of pleasure from orgasm, delayed ejaculation and erectile dysfunction.

“I was like, wow, what would that do to a person like me who was put on a powerful dose and had her sexual sensation taken away at age 11?” says P.

On SSRIs as Adolescents, Wanting Answers as Young Adults

It’s a question few in the medical establishment are openly asking, based on the scant literature and initiatives addressing the subject. And with U.S. Health and Human Services Secretary Robert F. Kennedy Jr. linking SSRIs to school shootings and claiming these drugs may be as addictive as heroin, many in medicine may be loath to add fuel to the fire.

That, however, hasn’t stopped a rising tide of 20 and 30-somethings, including P., who spent much of their adolescent years on SSRIs, from demanding answers.

“We are bombarded in this office with patients who started taking SSRIs at 18, 12, 8 years of age for anxiety and who knows what else. They want to masturbate and have sex with partners, and they can’t figure out what’s wrong,” says urologist Irwin Goldstein, M.D. of San Diego Sexual Medicine.

Some of Dr. Goldstein’s young adult patients have told him that when they became sexually active, they had complained about sexual issues to their providers. Despite reassurances that they’d have difficulties only while on their antidepressants, many of them found that normal sexual function eluded them, even after stopping the medications.

“I’m not against these medications. They can save lives,” says Dr. Goldstein. “My issue is that medical professionals aren’t discussing sexual side effects, particularly in the pediatric setting. And kids aren’t giving consent to the introduction of drugs to their bodies that have a high chance of affecting their sexual function, sometimes permanently.”

“…medical professionals aren’t discussing sexual side effects, particularly in the pediatric setting. And kids aren’t giving consent to the introduction of drugs to their bodies that have a high chance of affecting their sexual function, sometimes permanently.”

Why Are So Many Kids on SSRIs?

Many antidepressant medications have sexual side effects, but SSRIs are of particular note in this context.

Not just because they pose a high risk — impacting more than half of those who take them – but because SSRIs (considered first-line drug treatment for anxiety and depression by the American Academy of Pediatrics) are increasingly being prescribed to young people during formative years of their sexual development.

Only certain SSRIs have been approved by the FDA for pediatric use, and only for specific diagnoses. But other SSRIs approved by the FDA for adults are often used “off label” with children and adolescents.

Between 2016 and 2022, monthly antidepressant dispensed to people aged 12-25 climbed by two-thirds, with SSRIs making up the majority of prescriptions.After the start of COVID, prescribing rates surged more than 63%, with the increase among girls aged 12 to 17 accelerating by a formidable 130%.

Few would argue against treatment for the growing ranks of young people struggling with mental health issues; it’s an alarming trend that wasn’t helped by the COVID pandemic.

But prescribing psychiatric medication to kids and teens requires careful and informed consideration. In addition to sexual and other side effects, SSRIs have a black box warning because they themselves can almost double suicide risk for people under 25. 

Identifying and arranging for ideal treatment can be a tall order, however, in a health care environment that is woefully short on pediatric mental health specialists and where medication is often easier to access and more generously covered by health insurance than talk therapy, says Debby Herbenick, Ph.D., MPH, director of the Center for Sexual Health Promotion at the Indiana University School of Public Health and author of “Yes, Your Kid: What Parents Need to Know About Today’s Teens and Sex.”

“From our work with pediatricians, we can see they are increasingly dealing with suicidality, eating disorders, anxiety and other mental health issues in their patients. It’s not that sexual side effects don’t matter in young people. But to some extent, medical providers are just doing the best they can to keep kids alive and out of institutions,” she says.

Is the Widespread Use of SSRIs Contributing to a National Decline in Sexual Function?

Dr. Herbenick made headlines in 2021 when she published research showing that sexual activity declined in the U.S. between 2009 and 2018, not just in adults, but in adolescents. This included masturbation and partnered sex of all kinds.

The study itself didn’t get into why adolescents and young adults are having less sex today than in previous generations, but Dr. Herbenick and other experts have named possible contributing factors. They include excessive tech use, ever-available online porn, lower alcohol consumption, greater acceptance of asexuality and a generally longer and slower journey to financial independence and emotional maturity.

It’s also “absolutely possible that one of several drivers is the widespread prescribing of antidepressants to young people and the impact they can have on sexual function,” says Dr. Herbenick. “When I interview college students about their adolescence and antidepressants come up, many tell me they had no idea of what an orgasm was until they came off their medication.”

To that end, existing literature generally suggests a six- to nine-month course of SSRI treatment for children and adolescents with depression and about 12 months for anxiety disorder. Many medications even note in their prescribing information that they were only clinically tested over periods of several months, not years.

For example, the label for Prozac (fluoxetine) specifically states that “the safety of fluoxetine treatment for pediatric patients has not been systematically assessed for chronic treatment longer than several months in duration. In particular, there are no studies that directly evaluate the longer-term effects of fluoxetine on the growth, development and maturation of children and adolescent patients.”

But, as is the case for many medications, the length of time kids and teens are on these drugs in reality is often much longer than what research supports.

A  2019 survey that tracked prescribing to children and adolescents with anxiety found that most who were put on SSRIs at the start of the study were still taking their SSRI five years later.

It concluded that “for a large proportion of children…the decision to take [antidepressant] medication is a long-term commitment rather than a time-limited intervention.”

“for a large proportion of children…the decision to take [antidepressant] medication is a long-term commitment rather than a time-limited intervention.

For young people put on SSRIs, that can mean spending their formative years with the sexually deadening side effects brought on by these drugs.

How Antidepressants Can Affect Sexual Health

As widely as SSRIs are prescribed, and as effective as they may be for many people, it’s not fully understood how they work to relieve anxiety, depression, and other mental health issues.

What’s certain is that the most common types of antidepressants – SSRIs and SNRIs –  affect the neurotransmitter serotonin, which carries messages between cells in the brain and throughout the body.

Known as a “feel good” chemical, serotonin facilitates feelings of calm and well-being, and plays a key role in memory, appetite, sleep and digestion.

There’s a school of thought that people with depression and a host of other mental health issues have low levels of serotonin. Along these lines, SSRIs may improve mood by making serotonin more available in the brain. (SNRIs increase the availability of serotonin as well as another neurotransmitter called norepinephrine.)

When SSRIs/SNRIs are effective, they can bolster sex life for some, since depression, anxiety and other mental health issues themselves can negatively impact sexual function.

For more than half of those taking SSRIs and SNRIS, however, the drugs seem to impair sexual function. Although the actual mechanism isn’t certain, some research has suggested that high levels of serotonin might:

• Reduce or block the activity of other brain chemicals that play a key role in sexual function. These include dopamine, which influences desire, motivation and plays a role in orgasm. And norepinephrine, which stimulates arousal and sends blood to sex organs.
• Decrease levels of testosterone and other hormones that regulate sexual function.
• Influence the production and function of nitric oxide, a neurotransmitter that facilitates blood flow and sensation in the genitals.

Not to be overlooked either: While antidepressants can diminish intense negative emotions that prevent people from functioning, they can blunt positive feelings, as well. A 2023 review of existing literature found that the incidence of SSRI-induced emotional blunting or “apathy syndrome” ranged between 20% and 92%.

“Emotional blunting caused by SSRIs makes it harder to build intimate relationships. And that can influence sexual pleasure, too,” says Stuart Shipko, M.D., a psychiatrist in Pasadena, CA and author of Dr. Shipko’s Informed Consent for SSRI Antidepressants, a guide that provides key information for people to know before starting or stopping SSRI antidepressants.

Just as a loss of libido and sexual desire can persist after an antidepressant has been stopped, some research suggests that emotional blunting may continue even after people have discontinued their SSRIs.

M. started taking SSRIs at 14 for obsessive-compulsive disorder and stayed on medication through her late 20s. Now in her 30s,  she says, “When I was young, I remember going to horror movies and feeling the rush, feeling startled. Since I went on SSRIs and even after stopping, I don’t feel much reaction to anything from my body anymore. No adrenaline high from running. No butterflies in my stomach when I see someone attractive. The thing that’s most devastating is that since I can’t feel euphoria or intense emotion, I don’t feel like I have the ability to fall in love. And believe me, I’ve tried.”

SSRI Sexual Side Effect Risk in Children and Adolescents

There is little research on antidepressant sexual side effects in children and adolescents. So, there isn’t much data showing how young people are specifically affected.

That said, a 2004 paper proposed that “if one accepts that SSRI-induced adverse effects in general occur in adolescents at approximately the same rates as in adults, then it is biologically plausible that the rate of SSRI-induced sexual dysfunction would also be similar.” That, according to numerous studies, comes to more than 50%. Subsequent literature supports that proposition.

While not everyone who takes SSRIs experiences sexual side effects, certain factors may raise a person’s risk:

Dose: Research suggests that the severity of SSRI/SNRI sexual side effects may be dose related. In other words, the more medication someone is on, the more noticeable or disruptive their symptoms may be.

Duration of treatment: Sexual side effects can show up within the first week of taking antidepressants. For some, symptoms can fade within a few weeks or months after the body adjusts. But research has found that most people (80%) do not see any improvement in side effects after six months of treatment.

Heredity: Research suggests certain genes might be linked to increased risk for sexual side effects from antidepressants.

Type of SSRI/SNRI: All SSRI and SNRI antidepressants can potentially cause sexual side effects. But some present a higher risk than others. These include sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), fluoxetine (Prozac), and venlafaxine  (Effexor).

Youth-Specific Sexual Side Effects

Based on a few specific studies on adolescents as well as research on adults, here’s what young people might experience:

Decreased interest in and desire for sexual pleasure: A 2021 study specifically focused on adolescents reported that among SSRIs, citalopram (Celexa) and escitalopram (Lexapro) may be most strongly associated with low libido (interest in sex).

Decreased arousal: Even if a young person is interested in sexual pleasure, SSRIs can potentially impair their body’s ability to respond.

Genital anesthesia: Boys may find that their penis loses its sensitivity to pain, pressure and touch. Girls may lose sensitivity around the vulva, clitoris, and vagina. 

Difficulty reaching or total absence of orgasm: Researchers in the 2021 study found specific evidence that SSRIs can impair orgasm in adolescents, noting this “was not surprising given the successful use [of these drugs] in treating premature ejaculation.”

Muted orgasm: A person may reach orgasm but feel less or none of the pleasure that is typically associated with it.

Erectile dysfunction: Males may have difficulty getting and/or staying erect. In females, the clitoris and surrounding vulva may not swell and gain sensitivity. The vagina and vulva may also not lubricate (become wet.)

The Consequences of Delayed Puberty and Pleasure

Sexual matters can sound irrelevant when the patient in question has barely sprouted underarm hair. But “anyone who thinks 11- or 12-year-olds don’t have sexual feelings doesn’t remember being 11 or 12 years old,” says Dr. Goldstein. The American Academy of Pediatrics (AAP), in fact, considers it normal and appropriate for kids to start touching and rubbing their genitals as young as age two or three.

Children may not have the language for what they are doing. They may not know what it is they are feeling, other than that it feels good, but “this play behavior is really important for developing healthy adult sexual behavior. And anything we do that disrupts that normative process is going to have consequences,” says Tierney Lorenz, PhD., associate professor of psychology and director of the Women’s Integrative Sexual Health Lab at the University of Nebraska-Lincoln.

Kids who start taking SSRIs before their interest in sex even develops may not lay the groundwork for their future sexual selves. “If you have a drug in your system that makes it so it isn’t rewarding, it’s going to be a lot harder to learn what feels good and how to make yourself feel good. You have no reference point,” says Dr. Lorenz.

There is also research suggesting that SSRIs may even impact the onset of puberty. In their analysis of more than 200,000 patients under 18 who were diagnosed with depression or anxiety, authors of a 2023 study found that the risk for delayed puberty was 44% higher in those who were given SSRIs than in those who were not.

Investigators theorized that this may occur because SSRIs indirectly lower hormone levels that play an important role in children’s development.

Post-SSRI Sexual Dysfunction: An Overlooked Issue in Youth?

There are other concerns about how SSRI might impact sexual function in the long term.

For some years now, Canada, European Union members, Australia, and other countries have required SSRIs to carry warnings that, in rare cases, sexual side effects may continue even after people stop taking their antidepressants.

This condition is known as Post-SSRI Sexual Dysfunction (PSSD) and is also linked to SNRIs. 

In 2018, 22 doctors and scientists submitted a petition to the U.S. Food and Drug Administration asking for PSSD to be listed as a potential side effect of SSRIs/SNRIs sold in the United States. One of the scientists then sued the FDA for failing to respond to the request. The case was dismissed and, to date, drugmakers haven’t added PSSD to their labeling for SSRIs and SNRIs sold in the US.

In the meantime, PSSD has stirred up no shortage of controversy.

Many in the psychiatric and larger medical community do not acknowledge PSSD and insist that sexual dysfunction after stopping antidepressants is simply due to ongoing or relapsing mental illness.

Others, such as drug regulating bodies in other countries, acknowledge that PSSD is real but quite rare.

And then there are the vocal advocates on social media and elsewhere who insist that PSSD is far more common than any mainstream member of the medical establishment is willing to admit.

Until more research is done on PSSD, its true prevalence can’t really be determined.

On the ground, Dr. Goldstein at San Diego Sexual Medicine says he’s seen plenty of young adult patients with symptoms consistent with PSSD. Many took SSRIs during childhood and adolescence and haven’t regained normal sexual function months or even years after stopping their meds.

“To blame PSSD on depression is unfair and inappropriate. When a person has sexual dysfunction with depression, it’s usually an issue of low interest. Exhaustion. Low motivation. I see young adults who are experiencing sexual dysfunction that is highly unusual in people their age. And some of their symptoms, like genital numbness, are very specific to PSSD,” says Dr. Goldstein.

“To blame PSSD on depression is unfair and inappropriate.”

Dr. Goldstein is currently studying changes in the penile tissue of males with PSSD.  His work hinges on findings that SSRI-generated oxygen radicals may stick to smooth muscle cells in the penis, damage blood vessels, reduce circulation and alter tissue.

“The most remarkable thing is that the scans of these healthy young men look like the scans of 70-year-old smokers with diabetes, who have tissue death in their penises from their cardiovascular issues. These young men have scarring and tissue damage near the glans of the penis, the midshaft, at the base. Not everyone who takes these drugs gets PSSD. But some people must be genetically susceptible,” he says.

For 23-year-old E., who started citalopram at 16 for anxiety and took SSRIs and SNRIs throughout adolescence (but stopped taking all antidepressants at 20), that may well be the case.

“When I was at risk of self-harm, sexual side effects didn’t seem like such a big deal. I had bigger problems. But I’m in college now, and I still haven’t regained sexual function. I don’t think I would ever have taken these drugs if I had known what the long-term implications might be,” he says.

The Long Shadow of Early SSRI Use

In 2020, Dr. Lorenz published one of the few studies that looked specifically at how SSRI use during childhood might impact adult sexuality.

Their survey didn’t find an obvious connection in males, who represented a minority of participants. But among young adult women with current sexual dysfunction, the association was significant.

Specifically, young adult women who used SSRIs before age 16 had “lower solitary sexual desire” and masturbated less frequently than females who had mental health issues as children but did not take SSRIs. This was true whether the young adult women surveyed were currently taking SSRIs or not. 

Interestingly, SSRI use during childhood didn’t appear to impact how much coupled sex female participants were having. Study authors suggested that women may seek other rewards from coupled sex, such as intimacy and emotional closeness.

Solo sex, on the other hand, says Dr. Lorenz, is thought to more closely reflect the “physiologic underpinnings” of sexual motivation and reward. 

“Even early in life, the brain is setting itself up for adult experiences,” says Dr. Lorenz. “If kids don’t sexually experiment in an age-appropriate way, they may miss the opportunity to shape regions of their brain that are crucial to sexual function.”

If kids don’t sexually experiment in an age-appropriate way, they may miss the opportunity to shape regions of their brain that are crucial to sexual function.”

It’s like learning a language. “If you aren’t exposed to that language when you are young, you’ll never have the same effortless, natural fluency as someone who had that exposure early on,” says Dr. Lorenz.

Stopping Their Meds to Stop the Side Effects

During adolescence, SSRI sexual side effects can become more apparent and intrusive.

P., the young woman who went on sertraline for anxiety, remembers craving romance and connection while in high school. “I always felt that there was something in me that was missing. As I got older, my relationships didn’t last in large part because I wasn’t interested in or excited about sex and my partners sensed that,” she says.

Almost as soon as he started his meds at 16, E noticed a loss in sexual sensation. “My porn addiction got worse because I needed so much extra stimulation,” he says

Sexual side effects aren’t just impairing and unpleasant. Among those who make the connection between their medication and sexual difficulties, “[they] are one of the leading reasons why young adults stop taking SSRIs within their first three months on these medications,” says Danielle Stutzman, PharmD, BCPP, a pediatric psychiatric pharmacist at the Pediatric Mental Health Institute at Children’s Hospital Colorado.

It’s an issue that can be particularly concerning in adolescents, who may be uncomfortable discussing sex and thus go off their antidepressant without telling their caregivers or medical providers. “This may result in a worsening of mental health symptoms, potentially raising their risk for self-harm,” says Stutzman.

The Elephant in the Examining Room: Talking to Kids About Sexual Function

Back in 2004, an article in the Journal of the American Academy of Child & Adolescent Psychiatry warned that researchers and clinicians may be “failing to ask adolescents about sex and sexual function” in the context of SSRI treatment.”

An article published more than a decade later in Pediatrics found little, if any, change. One ongoing reason: Talking about sex can be uncomfortable — not just for adolescents and their parents, but for the researchers and clinicians who engage with them.

In fact, numerous clinical trials pertaining to SSRIs were done on kids and adolescents between 2004 and 2015. But the 2015 study authors found that virtually none had routinely assessed sexual function:

“The lack of assessment of sexual symptoms in diagnostic instruments is especially alarming given that depression and anxiety can also have a profound impact on sexual desire and performance. It is typically standard care in adults to obtain a baseline assessment of these symptoms before the start of treatment.”

Failing to ask about a child’s sexual experiences, the 2015 study authors continued, “can be compared with not measuring head circumference of infants during the first year of life…… This is a crucial step toward ensuring that teenagers with sexual problems and side effects receive the attention and treatment they need.”

In the case of antidepressants, the authors concluded that clinicians needed “to find a way to [have sexually frank discussions] that is safe for both clinician and patient.” They even drafted a list of questions that could be used to assess sexual symptoms in adolescents.

As late as 2023, a review of SSRI side effects in the journal Pharmacotherapy was still lamenting that, “very little attention has been paid to these side effects in youth and, similarly, little attention has been paid to sexual function in adolescents with depressive and anxiety disorders. 

To date, there is little mention of sexual side effects and virtually no sexually-related guidance in AAP literature for pediatricians who are prescribing antidepressants to young people.

What Parents, Caregivers and Young People Can Do

“No parent goes into a conversation with a doctor and is excited about putting their kid on [antidepressant] medication,” says Dr. Lorenz. “But sometimes medication is needed. And when that is the case, there needs to be more conversation about how their child might be affected, including sexually.”

Until more medical providers have the time or willingness to be proactive, that conversation may need to be launched by caregivers and young patients themselves.

If your child is (or you are) experiencing anxiety or depression:

Consider Starting with Talk Therapy

If you can find an affordable and available provider, cognitive behavioral therapy (CBT), in many cases, can treat mild to moderate depression in young people quite effectively. When it comes to treating anxiety, some research suggests that CBT may even be superior to SSRIs. A combination of CBT and medication is considered the most effective strategy and often brings the fastest response to treatment.

Ask About All Medication Options

Some antidepressants pose a higher risk for sexual side effects than others. Among SSRIs associated with the highest risk are sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), fluoxetine (Prozac) and venlafaxine (Efexor) Bupropion (Wellbutrin) is not an SSRI/SNRI and poses a low risk for sexual side effects. It is not generally a go-to treatment for kids, but may be an option to discuss with your provider.

Ask Your Child’s Provider to Talk About Sexual Side Effects

They should get a baseline sense of your child’s sexual interests and function and monitor for changes at follow-up visits. You can step out of the room during these discussions if it makes your child or you more comfortable.

Watch for Changes, Or Lack of Change

If you notice that your child has gone from talking about crushes or dating to not mentioning anything along these lines, check in with them. It could merely be an adolescent need for privacy. They may just be focusing elsewhere. But it’s worth asking some questions. If your child is just entering puberty, take note if they aren’t developing any sexual curiosity and possibly mention your concerns with their medical provider.

Have Open Conversations About Sex With Your Child

“If we are going to give kids medication that may have sexual side effects, we need to give them the language so they can have that conversation,” says Dr. Herbenick. Especially with adolescents, go ahead and acknowledge the awkwardness of the situation. Tell them that they may never have sexual side effects (for instance, decreased interest in crushes or dating, painful ejaculation, difficulty with orgasm), but if they do, here’s how they might talk about them with their doctor. (Dr. Herbenick’s book “Yes, Your Kid” is a gold mine for any parent who wants tools and advice regarding frank sexual discussions with young people.)

From time to time, ask how they are feeling about sex. “We have guidance for other side effects, but we don’t have that when it comes to sexual side effects. We have got to acknowledge adolescent sexuality as a normal part of life and give attention and care to these young humans who deserve better than what they are getting,” she says.

Don’t Give Up

If you are a young person experiencing sexual side effects, talk to your parents or directly with your provider. There are adjustments that can be made, including lowering your dose if it’s safe to do so, switching medications or incorporating CBT or some other type of talk therapy into your treatment plan as an alternative to medications.

If you have stopped taking SSRIs but are still experiencing sexual side effects consistent with PSSD, “don’t feel forlorn and don’t feel bad for having needed an antidepressant. There are things you can do,” says Dr. Goldstein. “If your doctor tells you they can’t help, find another provider. A physician who is knowledgeable about sexual dysfunction might not be able to reverse the issues you are experiencing from taking SSRIs but we can treat the symptoms one by one. There really is hope.”

Conflicts of Interest:

Irwin Goldstein has participated in advisory boards and/or received honoraria from Pfizer and has received research support from Endo.