ANTICLIMAX
The culprit behind your AWOL orgasms revealed
Almost half of women taking SSRI antidepressants report problems having an orgasm. With prescriptions on the rise, WH hears from the women who’ve had to choose between the ability to function day-to-day and sexual pleasure
‘I didn’t mind kissing, I just felt no need for intimacy to go any further’
Helen* lay back on her pillow. The vibrator she’d been using – her favourite for years – lay discarded on the bed beside her. Downstairs, the clatter of pans let her know Mike*, her husband of five years, was making dinner, and she felt tears prickle at the corners of her eyes. How would she ever tell him? She pressed her clitoris firmly with her forefinger, but it was no use. The organ, usually so sensitive to touch, was completely numb. She’d been masturbating for the best part of an hour, and she wasn’t even slightly turned on. She sat up, put her trousers back on and put the vibrator in her drawer where, she suspected, it would remain for a while.
At the start of lockdown, Helen was put on fluoxetine, a selective serotonin reuptake inhibitor (SSRI) antidepressant more commonly known by its brand name, Prozac. Though she’d always been ‘a worrier’, she’d never thought of herself as depressive. But by early April, she was finding it hard to adjust, and with all the things that usually lifted her mood – friends, work, the gym – now unavailable to her, the grinding monotony was making her low-level depression hard to ignore. ‘The medication started working within just a few days,’ she tells WH. ‘It was a revelation. I’d never felt so clear-headed.’ But while some of the side effects, such as difficulty sleeping, disappeared within a week or two, her sex drive dropped off a cliff, and stayed there. ‘I only noticed after about a month that I hadn’t thought about sex or felt turned on,’ she adds. ‘I decided I should try to see if I could awaken my libido, but even masturbation – something I’d relied on to reignite desire in the past – was difficult. I tried to hide my lack of interest from my husband, but after a month of almost no sexual contact, I gave him a blowjob, hoping he wouldn’t want to take things further. I felt like I had to make a choice: my sex life or my happiness.’
One study by the Mayo Clinic in the US, exploring the link between antidepressants and female sexual dysfunction, found that as many as 42% of women taking SSRIS reported problems having an orgasm. On Reddit, whole threads on the R/SSRI subreddit are dedicated to exploring the impact of Ssri-induced sexual dysfunction. And never was it more on our minds than during the UK lockdown. Early predictions of a baby boom proved premature; during this period, 40% of couples reported that they were actually having less sex than they were before. Meanwhile, prescriptions for antidepressants increased by an estimated 10% to 15%†, and with multiple reports predictingthat the UK’S collective mental health is set to deteriorate further still, that number is expected to rise. Could orgasms be one of Covid-19’s unexpected casualties?
BITTER PILL
Of course, Ssri-induced sexual dysfunction isn’t just a by-product of difficult times; it’s been happening for years – but as Lauren*, 27, found when her GP prescribed her fluoxetine in 2018, it was rarely discussed. ‘By the time I was put on the medication, I could barely move from the sofa,’ she says. ‘I was signed off work; it was the lowest moment of my life.’ Though she welcomed the antidepressant – ‘I couldn’t function, it was absolutely necessary’ – she had no real idea about what the side effects might be. ‘Sexual dysfunction didn’t come up. I didn’t discuss it with my doctor and I wasn’t given any leaflets, other than what was in the pill packet. But, at that point, I didn’t care about whatever else it might do, I was suicidal and I just wanted not to be.’ Within a week, she realised she had no sensation in her genitals whatsoever. ‘I would press on my clitoris and barely feel it. I don’t think I really cared at first, I was single and in no position to meet anyone. It wasn’t until my mood started stabilising – which took around six months – that I began to wonder whether my sexual function would ever return. And that’s when I met Greg*.’ They had amazing dates walking in the Yorkshire Dales; dates that lasted hours without a lull in conversation. They’d connected on so many levels, but when it came to having sex for the first time? ‘It felt like I’d had a local anaesthetic,’ she describes. Though Greg spent close to an hour going down on her, using his tongue and his hands, she was nowhere near orgasm. She didn’t want to disappoint him, so she faked it.
Stories of wounded sex lives aren’t unique to fluoxetine. Julia*, 31, started taking citalopram (another SSRI) a year into her relationship with Jess*. They’d first met in a bar in London in 2016 and moved in together two months after meeting. Julia had struggled with depression in her twenties, so when she began to notice the tell-tale signs, she knew to act quickly. Her GP prescribed citalopram and she enlisted the help of a personal trainer, since sticking with an exercise routine had helped her in the past. She didn’t expect their sex life to take such a battering. ‘We were only a year into our relationship, so [we were having sex] at least a few times a week, and orgasms happened easily for me,’ she says. But two weeks after starting the citalopram, her clitoris felt less sensitive, and her libido was low. ‘I didn’t mind being held or kissing, but I just felt no need for intimacy to go any further – instead, I wanted to get out of bed and go running, or go to the gym. Of course, my partner understood, but after three or four months of very little sexual contact, it began to affect our relationship.’
MIND THE GAP
The question is: if it’s such a common problem, why haven’t we found a solution? While sexual dysfunction is a widely reported side effect of SSRI antidepressants, what’s less clear is why. Part of the problem is that not even medical experts are sure exactly how SSRIS work in the body. At a basic
‘I’d forgotten what it was like to have your body focused on pleasure’
level, the neurotransmitter serotonin helps you to experience feelings of happiness and wellbeing; SSRIS block the reabsorption (also known as reuptake) of this neurotransmitter into the neurons, which in turn increases the levels of serotonin in the brain. ‘For a long time, we thought that SSRIS only worked on receptors in the brain,’ says Dr Yacov Reisman, an Amsterdam-based sexologist who’s researched sexual dysfunction and SSRIS. ‘Nowadays, we also know that there are serotonin receptors in the genitals. So it’s not surprising that, as well as a general effect on the entire system (via the brain), there’s a localised effect, too.’ This could explain the genital numbness that patients taking SSRIS describe. As David Healy, professor of psychiatry at Mcmaster University in Canada (and a leading critic of SSRIS), points out, the genital numbing some patients report is similar to the effect SSRIS can have on your emotions in general. ‘The common thing that people say, whether it’s working for them or not, is, “I feel emotionally numb – I’d love to be able to cry at a sad film, but I just can’t,” he explains. ‘We don’t understand exactly how or why that happens.’ Further complicating the issue is that for some women (and men), sexual issues could be related to the depression itself, with SSRIS merely exacerbating the problem. One meta-analysis, which covered almost 5,000 patients, concluded that depression increased likelihood of sexual dysfunction by 35% to 70% (depending on the type of dysfunction).
While different theories exist, most experts agree that there’s still so much we don’t know – not only about depression and the medications used to treat it, but about female sexual dysfunction more generally. Dr Reisman recently authored a study for The BMJ on what happens when sexual dysfunction persists after people stop taking SSRIS. What makes female sexual dysfunction so difficult to study, he explains, is that the term encompasses a huge spectrum of complaints. ‘When you talk about erections and ejaculation, these are easy to define. But how do you objectively measure libido and orgasm?’ And if it’s difficult to study, it’s difficult to recognise in yourself. Consider female sexual dysfunction in the context of the orgasm gap – research from Durex found that almost 75% of the women surveyed didn’t orgasm during sex, compared with just 28% of men who said they didn’t always climax.
The sad truth, according to Dr Reisman? ‘Some women may be unaware that what they are experiencing is sexual dysfunction at all.’
TIME TO TALK
While that all might feel overwhelmingly inconclusive, there are steps you can take to help preserve your mental health and sex life simultaneously. For starters, don’t let a fear of the side effects hold you back from seeking a solution that could help you. ‘It might feel embarrassing to bring up during a consultation, but I would reassure anyone that doctors speak about all kinds of side effects on a regular basis,’ says consultant psychiatrist Dr Chi-chi Obuaya. ‘It’s better to have a slightly awkward conversation than to struggle in silence with your mental health.’ Despite debates over how helpful they are, the evidence suggests that SSRIS do work, in some way, for most people. In 2018,
The Lancet published the largest-ever review of antidepressant trials (including some that weren’t SSRIS), showing that every single one of the 21 studied, including citalopram and fluoxetine, worked better than a placebo. ‘Discussions about medication and potential side effects should always be collaborative,’ says Dr Obuaya. ‘It’s not for your doctor to impose a treatment plan on you, but they are there to hear your concerns and help you make a suitably informed decision.’
If you’re taking an SSRI, Dr Reisman points out that so-called ‘drug holidays’ – deliberately missing doses as part of an arrangement worked out with your GP – are an option, since lower levels of SSRIS in your system can lead to you regaining some sensation or libido. But he insists that drug holidays should never be done without the supervision of your doctor. ‘You could also attempt to find an SSRI with fewer sexual side effects, or even try an antidote like Viagra,’ he adds, pointing to a study that showed that female sexual function, while the patients were on SSRIS for depression, improved with Viagra. ‘But, again, no one should try this on their own – consult a GP first.’ All the experts agree that being honest with a partner is the best way to alleviate feelings of anxiety that might arise from sexual dysfunction, even if it feels like an awkward conversation to have.
With the help of her GP, Lauren came off fluoxetine and started taking citalopram, after which she regained some sensation. ‘I remember the first time I came, it was like, “Yes! I did it!” I’d forgotten what it was like to have that sensation – to have your whole body focused on pleasure.’ Julia and her partner invested in a new set of sex toys; she recommends the Womanizer, a clitoral vibrator that pulses intense sensation into the area. ‘It took a lot of patience from my partner and a lot of experimentation, but being reminded how good it was to orgasm made a huge difference to my libido, and afterwards I found myself more interested in sex generally.’ As for Helen, she eventually told her husband about her lack of interest in sex. ‘He kept asking if there were other things we could try, if I had fantasies we could enact,’ she says. ‘I said I was telling him so he could lower his expectations. I wanted him to know that I’d still be willing to have occasional sex (though I haven’t, yet), but that he mustn’t expect me to come if we do. The pressure would just make it worse.’ Difficult conversations, patience, giving it time. The stuff of Hollywood sex scenes they may not be, but they could just be the ingredients for a sex life that works for you, and your mind.