Your happiness should not cost you a single orgasm.
To push back on stigma and cut through the confusion, Open Minds is a series that explores your most pressing questions about mental health.
What are antidepressants going to do to my sex and dating life?
First, some good news: Like all common side effects of these meds—fatigue, nausea, weight gain—just because sexual dysfunction is a possibility doesn’t mean it happens to everyone. If it does, though, it’s important to know that this particular effect means different things to different people.
‘Sexual dysfunction’ is a blanket label that gets slapped on what are, for the most part, two distinct issues: decreased sex drive and difficulty reaching orgasm. It’ll be important to give your doctor the specifics here so they can recommend the treatment most likely to suit you.
“It can be both,” says Virginia Sadock, a psychiatrist and director of the Human Sexuality Program at the NYU Langone Medical Center. “Both diminishing of the libido and the inhibition of orgasm. It varies with the individual, and a few are lucky enough to have the sexual side effects sort of disappear in about four months and the body resets, but that’s rare. It’s usually a little harder to orgasm for the man than the woman, but it’s hard for the woman, too.”
We still don’t really know how these drugs work, but we know those that manipulate serotonin—the one of your three neurotransmitters that’s the second ‘S’ in SSRI—are more likely to fuck with your sex life than ones that act on dopamine or norepinephrine. Sadock says SSRIs aren’t the only psychiatric drugs that have this effect, but they’re definitely the most strongly associated with it. Most SSRIs bring sexual dysfunction in about equal measure (though Paxil was singled out as a possible worst bet here by R. Taylor Segraves, editor-in-chief of the Journal of Sex & Marital Therapy and a psychiatrist with a long career studying sexual dysfunction and its relationship to antidepressants).
Sadock says that, for the most part, SSRIs affect your libido more than your actual arousal. Your libido is your level of desire—your ‘sexual appetite,’ a weird phrase I’m convinced no one says out loud but nevertheless applies here. Arousal refers strictly to your body’s physical response to the object of that desire, and sometimes to, like, the wind or sitting unexpectedly on the inseam of your jeans.
Sadock says arousal—getting either hard or wet and then being physically responsive during sex—is not generally what’s affected. In the event that you do experience erectile dysfunction, you’re actually kind of in luck; you can treat that with regular ol’ Viagra, which you’ll probably have an easier time getting under the AHCA than your original medication. It can also help erections last longer, which can up the odds of orgasming. Doctors I spoke to had somewhat conflicting opinions about off-label Viagra use for women, but the gist is that while the data’s not all there, there’s a chance it could increase sensation for all genders.
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“Another thing that can be tried by both men and women are vibrators because they’re so stimulating,” Sadock says. “A man can use it on his perineum and a woman around the clitoral area, and that may be intense enough [to reach orgasm].”
All these issues can and do occur across the board, but as dudes skew a little more toward anorgasmia, (the chronic inability to orgasm despite what would be considered adequate stimulation) women skew more toward decreased libido, Sadock tells me.
“It can be a little more of a desire issue for women than men, dampening down the libido,” says Chelsea Holland, a sex and relationship therapist at The Intimacy Institute. “Women tend to be more sensitive to blocks in general, since they have less testosterone kind of boosting them past that.” (Aside from that, none of this stuff is much affected by gender identity, sexual orientation, and so forth; mostly comes down to what bits you have.)
Women are all supposed to now be chill and precisely as adapted for fucking-for-sport as men, but I’ve never seen much value in quashing down characteristically feminine traits if you have them, for the sake of chasing equality. Emotion and sex drive are often tangled up for a lot of women, Holland says, and that’s fine. Like mental illness itself, this side effect is a combination of biological factors and your environment, not any personal failure.
If the issue is your inclination to have sex rather than your ability to orgasm when you do, Sadock tells me one of the most proactive steps you can take is (when possible) to schedule it, whether you initially feel like it or not. Holland doubles down on the scheduling of sex dates with the scheduling of date dates, something she says she recommends for most couples she works with, medicated or not.
“It does sound cliche, but life isn’t a movie,” Holland says. “And it doesn’t necessarily [need to be] sex—it might just mean closeness, it might mean showering together or naked cuddling or cuddling while watching a movie.”
Beyond advice that’s specific to the root mechanism of your sex problems here, everyone I spoke to for this column agreed your most promising options are to talk to your doctor about lowering your dosage, then about switching to a non-SSRI (if you’re on one) or adding Wellbutrin, an antidepressant that does not manipulate serotonin.
Wellbutrin is so consistently evangelized as the go-to treatment for sexual side effects that it’s probably one of the few things everyone in the field can agree on; every doctor I interviewed also brought it up of their own accord. You can take it on its own, but it’s often prescribed as an add-on treatment to complement the SSRI you already have going, and it can help with sexual dysfunction no matter the variety.
If you try Wellbutrin but it doesn’t help or you can’t tolerate it—some people get edgy—there are other SSRI alternatives that are less common but that may still help. Marra Ackerman, a clinical assistant professor of psychiatry also at NYU Langone, suggests Buspar, which is usually prescribed for anxiety. Her next suggestion would be Viibryd, the trial results of which she says are generally more variable than her first choices but still promising. Sadock suggests your doctor might also be able to prescribe something you can take before sex to briefly suspend your medication’s serotonergic effect, in theory counteracting its inhibition of your much-deserved orgasms, but same caveats would tend to apply.
The sex stuff, both mental and physical, is going to be trial and error. Most things having to do with psychiatric drugs are. With time and patience—maybe a lot of patience—you’ll figure out which medications are worth it and which are not. In the meantime, try to focus on what the right treatment is doing for your mental health. And how it affects not just the sex, but the actual people you’re having it with.
“When people are depressed, it’s like their emotions are sucked into themselves, like a black hole. It doesn’t mean they don’t love their partner, but they don’t necessarily have that much to give,” Sadock says. “There’s an almost universal inclination to withdraw into oneself and not communicate. And so it’s still worse for the one who’s suffering, but the person who’s with them may feel alone, and to some degree they are alone. So as the depression improves, the relationship should improve and you can be more connected.”
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