Sexual Side Effects of SSRIs: Maximum and Minimum Rates
Paroxetine causes the highest sexual dysfunction rates at 70.7%, while escitalopram and fluvoxamine cause the lowest rates among SSRIs, though all traditional SSRIs cause significant sexual side effects. 1, 2
Evidence-Based Ranking by Sexual Dysfunction Risk
Highest Risk SSRIs
Paroxetine: 70.7% overall sexual dysfunction rate 1, 3
- Ejaculatory disturbance: 13-28% in males 4
- Decreased libido: 6-15% in males 4
- Impotence: 2-9% in males 4
- Orgasmic disturbance: 2-9% in females 4
- Paroxetine provides the strongest ejaculation delay (8.8-fold increase over baseline) but has the highest sexual dysfunction rates for other aspects of sexual function 5
Citalopram: 72.7% sexual dysfunction rate 3
Venlafaxine: 67.3% sexual dysfunction rate 3
Moderate Risk SSRIs
Sertraline: 62.9% overall sexual dysfunction rate 3
Fluvoxamine: 62.3% sexual dysfunction rate 3
- However, the AUA guideline suggests fluvoxamine may be "ineffective for treatment of premature ejaculation," implying less ejaculatory delay compared to other SSRIs 7
Fluoxetine: 57.7% sexual dysfunction rate 3
- Effective for premature ejaculation at doses as low as 5 mg/day, suggesting dose-dependent sexual effects 7
Lowest Risk SSRIs
- Escitalopram and fluvoxamine cause the lowest rates of sexual dysfunction within the SSRI class 2, 1
- Specific rates not provided in guidelines, but consistently ranked as having lower sexual side effects than other SSRIs 1
Critical Dose-Related Considerations
Sexual side effects of SSRIs are strongly dose-related 5, 7
- Higher doses increase efficacy for depression but also increase frequency of erectile dysfunction and decreased libido 5
- The AUA recommends reducing SSRI dose to the minimum effective level for depression control as a primary management strategy 7
- For sertraline, doses of 25-200 mg daily have been studied, with higher doses potentially increasing efficacy but also side effects 5
- For paroxetine, 20 mg daily dosing provides the greatest benefit in treating premature ejaculation, with unclear benefit of increasing to 40 mg 5
Gender Differences in Sexual Dysfunction
Men experience higher frequency of sexual dysfunction (62.4%) compared to women (56.9%), but women experience higher severity 3
- Male-specific effects: ejaculatory delay/failure, erectile dysfunction, decreased libido 4, 6
- Female-specific effects: orgasmic disturbance, decreased libido 4
Important Clinical Caveats
Sexual dysfunction rates are vastly underreported in clinical trials 1
- When physicians directly ask patients about sexual side effects, the incidence is 55.29% versus only 14.2% when patients spontaneously report 8
- Absolute rates are likely higher than published figures 1
- Physicians should routinely inquire about sexual side effects, as patients and physicians may be reluctant to discuss them 4, 6
About 40% of patients show low tolerance of their sexual dysfunction 3
- This contributes to the 40% of patients who either refuse to begin or discontinue paroxetine within 12 months due to concern about taking an antidepressant, treatment effects below expectations, and cost 5
Timing and Reversibility
Most sexual adverse effects emerge within the first few weeks of treatment 1
- Patients experience substantial improvement in sexual function when the dose is diminished or the drug is withdrawn 8
- However, a small group of patients experience post-SSRI sexual dysfunction, in which sexual dysfunction persists after treatment termination 2
Safer Alternatives When Sexual Function is a Priority
Bupropion has significantly lower sexual dysfunction rates (8-10%) compared to all SSRIs and should be considered first-line when sexual function is a major concern 1
- However, bupropion should not be used in agitated patients or those with seizure disorders 1
Mirtazapine has lower rates of sexual dysfunction (24.4%) than SSRIs 3, 1
- Trade-off: causes sedation and weight gain 1
Nefazodone has very low sexual dysfunction rates (8%) 3