SSRI with Least Sexual Side Effects
Among SSRIs specifically, fluvoxamine appears to have the least sexual side effects, though the evidence comparing SSRIs head-to-head is limited. However, if you are willing to consider non-SSRI antidepressants, bupropion has significantly lower rates of sexual dysfunction than any SSRI and should be your first choice when sexual side effects are a primary concern.
Evidence-Based Ranking of Sexual Dysfunction Risk
SSRIs Only (Worst to Best)
- Paroxetine has the highest rates of sexual dysfunction among all SSRIs (70.7% incidence), with consistently worse outcomes than fluoxetine, fluvoxamine, nefazodone, or sertraline 1, 2, 3
- Citalopram shows 72.7% incidence of sexual dysfunction 3
- Sertraline demonstrates 62.9% incidence, with 11% ejaculation failure in men (versus 1% placebo) and 6% decreased libido 4, 3
- Fluoxetine has 57.7% incidence of sexual dysfunction 3
- Fluvoxamine has the least ejaculation-delaying effects among SSRIs in controlled studies, making it the best SSRI choice when sexual function is a priority 5
Non-SSRI Alternatives (Superior Options)
Bupropion is the clear winner with significantly lower sexual dysfunction rates than fluoxetine or sertraline (8-10% versus 57-63%), and it effectively treats SSRI-induced sexual dysfunction when added to existing therapy 1, 6, 7
Other favorable non-SSRI options include 7, 3:
- Mirtazapine: 24.4% incidence
- Nefazodone: 8% incidence
- Moclobemide: 3.9% incidence
- Agomelatine and reboxetine: minimal sexual side effects
Clinical Decision Algorithm
If depression requires treatment and sexual function is a major concern: Start with bupropion as first-line therapy 1, 7
If an SSRI is specifically needed (e.g., for comorbid anxiety, OCD): Choose fluvoxamine as it has the least ejaculation-delaying effects among SSRIs 5
If patient develops sexual dysfunction on current SSRI: Consider switching to bupropion, mirtazapine, or nefazodone rather than another SSRI 7, 3
Avoid paroxetine and citalopram when sexual function is important, as they have the highest rates (70-73%) of sexual dysfunction 2, 3
Important Caveats
Sexual dysfunction is vastly underreported in clinical trials—absolute rates are likely higher than published figures because patients and physicians are reluctant to discuss these issues 1, 4
All SSRIs and SNRIs carry 58-73% risk of sexual dysfunction when systematically assessed with specific questionnaires, compared to only 3-24% with alternatives like moclobemide, nefazodone, or mirtazapine 3
Men experience higher frequency (62.4%) but women report higher severity of sexual dysfunction with antidepressants 3
About 40% of patients show low tolerance of their sexual dysfunction, making this a leading cause of medication non-adherence 3
Post-SSRI sexual dysfunction (PSSD) is a rare but potentially persistent condition where sexual dysfunction continues even after stopping the medication—this risk exists with all SSRIs and SNRIs 8, 7