Which SSRI (Selective Serotonin Reuptake Inhibitor) has the least amount of sexual side effects?

SSRI with Least Sexual Side Effects

Among SSRIs, fluvoxamine appears to have the least sexual side effects, though the evidence is indirect—it is noted as "ineffective for treatment of premature ejaculation," suggesting it causes less ejaculatory delay than other SSRIs. 1

Evidence-Based Ranking of SSRIs by Sexual Dysfunction Risk

Highest Sexual Dysfunction Rates

• Paroxetine consistently demonstrates the worst sexual side effect profile among all SSRIs, with rates of 70.7% in prospective studies and the strongest ejaculation delay effect 1, 2, 3
• Citalopram follows closely with 72.7% sexual dysfunction rates 3

Intermediate Sexual Dysfunction Rates

• Sertraline causes sexual dysfunction in 62.9% of patients, with significant ejaculatory delay that makes it effective for premature ejaculation treatment 1, 3, 4
• Fluoxetine produces sexual dysfunction in 57.7% of patients, with impairment in desire/drive (43%-51%) and arousal/orgasm domains 3, 4
• Venlafaxine (an SNRI, not pure SSRI) shows 67.3% sexual dysfunction rates 3

Lowest Sexual Dysfunction Among SSRIs

• Fluvoxamine has the lowest sexual side effect burden among traditional SSRIs at 62.3%, and the American Urological Association specifically notes it may be "ineffective for treatment of premature ejaculation," implying significantly less ejaculatory delay compared to sertraline, paroxetine, and fluoxetine 1, 3

Critical Dose-Related Considerations

All SSRI sexual side effects are strongly dose-related—using the minimum effective dose for depression control is the primary management strategy recommended by the American Urological Association 1

• Higher doses increase both antidepressant efficacy and sexual dysfunction frequency (erectile dysfunction and decreased libido) 1
• Even fluoxetine at doses as low as 5 mg/day can cause dose-dependent sexual effects 1

Non-SSRI Alternatives with Superior Sexual Profiles

If switching from an SSRI is feasible:

• Nefazodone shows only 8% sexual dysfunction rates 3
• Mirtazapine demonstrates 24.4% sexual dysfunction rates 3
• Bupropion has the lowest rates at 22-25%, with 4-6 times lower odds of sexual dysfunction compared to SSRIs 5
• Moclobemide shows 3.9% rates, though less commonly used 3

Common Pitfalls to Avoid

• Never abruptly discontinue SSRIs—gradual taper is required to prevent withdrawal syndrome (dizziness, nausea, headache, flu-like symptoms) 1, 2, 6
• Fluoxetine requires particularly careful tapering due to its long half-life of 1-3 days for parent compound and longer for active metabolites 1
• Do not combine SSRIs with MAOIs—risk of potentially fatal serotonin syndrome with symptoms including tremor, hyperreflexia, agitation, diaphoresis, fever, seizures, and rhabdomyolysis 1
• Monitor patients under age 24 and those with comorbid depression for suicidal ideation 1, 6

Clinical Algorithm

1. If starting a new SSRI and sexual function is a priority concern: Choose fluvoxamine as it has the weakest sexual side effect profile among SSRIs 1, 3

2. If already on an SSRI with sexual dysfunction: Reduce to minimum effective dose first 1

3. If dose reduction fails: Switch to bupropion, nefazodone, or mirtazapine, which have substantially lower sexual dysfunction rates (8-25% vs 58-73% for SSRIs) 3, 5

4. When switching: Implement gradual taper, especially with fluoxetine given its long half-life 1