Sexual Side Effects of SSRIs in Men
Yes, most men do experience sexual side effects from SSRIs, with rates ranging from 58% to 73% depending on the specific medication, though these rates are likely underestimated due to underreporting. 1
Incidence Rates by Specific SSRI
The frequency of sexual dysfunction varies significantly among different SSRIs, with the following documented rates in men:
- Paroxetine: 70.7% - consistently shows the highest rates of sexual dysfunction among all SSRIs 2, 1
- Citalopram: 72.7% 1
- Venlafaxine: 67.3% 1
- Fluvoxamine: 62.3% 1
- Sertraline: 62.9% 1
- Fluoxetine: 57.7% 1
For comparison, escitalopram causes ejaculation disorder in 12-14% of men (primarily ejaculatory delay), decreased libido in 6-7%, and erectile dysfunction in 2-3% in controlled trials 3. However, the FDA label explicitly states that "estimates of the incidence of untoward sexual experience and performance cited in product labeling are likely to underestimate their actual incidence" because patients and physicians are reluctant to discuss these issues 3.
Types of Sexual Dysfunction in Men
Men on SSRIs commonly experience multiple domains of sexual dysfunction:
- Ejaculatory problems (delayed or absent ejaculation) - the most common effect, occurring in 9-14% in trials but likely much higher in practice 3
- Decreased libido - reported in 6-7% in trials 3
- Erectile dysfunction - reported in 2-3% in trials 3
- Anorgasmia - difficulty achieving orgasm affects 36% of patients on citalopram 4
The STAR*D study found that among 1,473 patients treated with citalopram, 54% reported decreased libido, 36% reported difficulty achieving orgasm, and 37% of men specifically reported erectile dysfunction 4.
Dose-Dependent Effects
Sexual side effects are strongly dose-related, with higher doses increasing both depression efficacy and sexual dysfunction frequency. 5, 2
A fixed-dose trial demonstrated this clearly: patients on 20 mg/day escitalopram had an 86% overall adverse event rate compared to 66% on 10 mg/day (similar to placebo's 61%) 3. The American Urological Association recommends reducing SSRI dose to the minimum effective level for depression control as a primary management strategy 5.
Clinical Implications and Patient Tolerance
Approximately 40% of patients show low tolerance of their sexual dysfunction, contributing to the 40% who either refuse to begin or discontinue treatment within 12 months. 2, 1
The underreporting of sexual dysfunction is a critical clinical pitfall. Physicians should routinely inquire about sexual function both before initiating treatment and during follow-up, as patients rarely volunteer this information spontaneously 3. Most sexual adverse effects emerge within the first few weeks of treatment 2.
Important Caveats
In rare cases, sexual dysfunction may persist even after SSRI discontinuation, with documented cases of permanent erectile dysfunction, genital anesthesia, and ejaculatory anhedonia 6. While uncommon, this possibility should be discussed with patients.
The sexual side effects of SSRIs are not entirely negative - they are therapeutically used to treat premature ejaculation, with paroxetine providing the strongest ejaculation delay (8.8-fold increase over baseline) 2, 7.
When sexual function is a major concern, bupropion should be considered as first-line therapy, with sexual dysfunction rates of only 8-10% compared to 58-73% for SSRIs 2. Among SSRIs, if one must be used, escitalopram and fluvoxamine appear to cause the lowest rates of sexual dysfunction, while paroxetine should be avoided entirely 2.