Written by: Yassie Pirani (she/her), MSW RSW RCC.
Edited by: Zahra Taboun (she/her).
What is PSSD?
Post-SSRI/SNRI Sexual Dysfunction (PSSD) is a disorder that reduces sexual functioning despite stopping treatment with SSRI or SNRI medications. Symptoms of sexual dysfunction are common side-effects of SSRI and SNRI antidepressants [2], but some people report ongoing or worsened sexual dysfunction even after stopping the medication. For some, the symptoms start when they stop taking the medication [3,4]. PSSD can be emotionally devastating, as it can cause strain on personal relationships, diminish quality of life, and contribute to thoughts of suicide [5,6].
Due to a lack of research and awareness in the medical community, stigma about sexuality, and shame about sexual issues, PSSD is an understudied and underreported sexual health condition [4]. Health Canada has stated that sexual side effects of antidepressants are likely underreported due to lack of information and stigma [15].
Public awareness and further research is essential for the treatment of this disorder [3]. If you are interested in learning more about PSSD research or ongoing studies, please CLICK HERE.
Health Canada has recognized case reports of PSSD. However, there is not enough research to make a clear conclusion about the relationship between long term sexual dysfunction and SSRIs/SNRIs [8]. Health Canada recommends doctors warn patients of the risk of possible long term sexual dysfunction before starting treatment with these medications [8].
See Table A below for Selective Serotonin Reuptake Inhibitors (SSRIs) and Selective Norepinephrine Reuptake Inhibitors (SNRIs) approved in Canada, which have all been linked to PSSD [11,12,14].
What are the symptoms of PSSD?
Symptoms of PSSD may include [1,9,10]:
• Genital anesthesia (numbness) or reduced genital sensation / sensitivity
• Genital paresthesia (burning or prickling sensation)
• Anorgasmia (delayed or eliminated ability to orgasm)
• Pleasureless or weak orgasms
• Erectile dysfunction / decreased vaginal lubrication
• Reduced or lack of sexual desire, libido, and sex drive
• Reduced or lack of response to sexual stimuli
• Reduced or lack of night-time erections
• Premature or delayed ejaculation
• Reduced or lack of sensitivity in sexually sensitive areas (e.g nipples)
How common is PSSD?
It remains unknown what percentage of people who take these medications will develop PSSD [4]. Research has not yet been done to understand how common this disorder is. It is currently unknown how commonly people recover from PSSD.
Working as a healthcare provider with people experiencing PSSD
In working with people with PSSD, I have come to learn that it is understood and experienced by many sufferers in the community as a profoundly disempowering injury. Experiencing PSSD can deeply impact one’s identity and self-worth and can be an immense loss, which often includes a grieving process. It can take time for people to define what the experience is for them, and using the terms with which they self-define the experience is of most importance. The impact of PSSD can be catastrophic, yet some people are not impacted as profoundly depending on the symptom profile. It is critical to follow how people are coming to make sense of their experience of PSSD. At times, supporting people with PSSD can be understood similarly to the psychological support one needs after experiencing any other injury impacting a fundamental bodily function. Many people with PSSD describe feeling like they have been chemically castrated. For these individuals, their experience and pain needs to be radically validated, and the depth of their sense of loss needs to be acknowledged.
Unfortunately, it is very common for people to experience minimization and dismissal of their PSSD symptoms as a valid and distressing healthcare concern, which compounds the suffering related to PSSD. Often the greatest contributor to thoughts of suicide amongst PSSD sufferers is not the injury itself (although sometimes it is) – but the experience of having their concerns dismissed – rather than being believed and validated. This invalidating environment can create the conditions in which too often people blame themselves when in reality they have done absolutely nothing wrong. When people blame themselves, it can further disrupt relationships, self-worth, and identity, sending people into a spiral of shame, self-loathing, and suicidality.
A trauma-informed and anti-oppressive approach is essential to working with people with PSSD. Many people with sexual trauma from PSSD draw parallels with sexual assault to make sense of their experiences, as they feel strongly that a violence has been done to them. This has been a useful framework for people to understand their experience, particularly because of the power and authority differentials involved, the dynamics around consent, and the shame experienced when speaking out. Sufferers of PSSD, just as survivors of sexual assault, need to be reminded that their sexual trauma is not their fault and that they have a right to feel rage, devastation, grief, confusion, and any other emotion attached to their experience.
There is still very little awareness about this condition within healthcare currently. People are commonly being misdiagnosed; this is extremely concerning and often has deeply problematic and profoundly life-altering consequences. When people go to their healthcare provider and report that they are experiencing genital numbness, for example, (a core feature of PSSD), they are commonly misdiagnosed with a delusional or somatoform disorder and prescribed antipsychotic medications, rather than obtaining a diagnosis of PSSD. This condition is commonly (incorrectly) perceived to be somatic or psychological rather than iatrogenic (from the medication) [16].
In addition to the sexual side effects, a significant number of people suffering from PSSD also report distressing non-sexual side effects from SSRI & SNRI medications that present significant challenges and can persist despite treatment discontinuation or commence upon cessation. Non-sexual side effects commonly reported within the PSSD community [16] include: anhedonia (loss of ability to feel pleasure, motivation, and enjoyment in life), emotional blunting, insomnia, akathisia, deep muscle pain/stiffness/weakness, nerve pain, sleep disturbances/poor sleep quality, brain fog, memory impairment, cognitive delay, depersonalization, derealization, and head pressure. These side effects are likely to be misattributed to depression or another mental health issue rather than an iatrogenic injury from the medications and can intensify feelings of helplessness and make it even more difficult for people with PSSD to advocate for themselves effectively.
Some people seem to recover, but it’s very hit and miss, and there doesn’t seem to be a clear path towards recovery. When improvement occurs, it is often partial, not full. Many do not experience any improvement at all. I have spoken with people who haven’t been able to feel any sexual sensation for two decades.
Despite there being no evidence in the literature advising psychosomatic interventions as effective treatment for PSSD, such approaches are frequently suggested by sexual medicine professionals to people with PSSD. Having a care provider suggest interventions meant as treatment for sexual concerns that are psychological in origin can be a distressing experience for many PSSD sufferers, as they feel that there is a lack of understanding and appreciation of the iatrogenic root of their issue. The message that is often received is, “the problem is in your head” rather than “something unfair happened to you, it’s not your fault, and you have permission to grieve this loss”. This message can contribute to the feelings of isolation and self-blame intrinsic to PSSD.
Greater awareness and validation of PSSD in the medical community is absolutely essential. There is no way to describe the toll this injury can take on someone’s life and the depth of loss that people experience. To have your ability to experience an intimate relationship, to feel at home in your own body, and to have functioning emotions completely taken away from you by a medication that was meant to alleviate your emotional distress is a catastrophic thing to happen to someone. To then not be understood or believed by the people and health care professionals around you compounds the trauma of this injury.
As healthcare professionals, we need to start listening to this community, and start understanding and validating people’s experiences so that we can better learn how to support them. It cannot be understated how important and meaningful having a healthcare provider who truly listens and takes the time to understand the patient experience can be for a sufferer of PSSD.
I recognize and appreciate that many people do benefit from SSRI/SNRI medications, but we must begin to recognize that they do cause harm to an unknown percentage of people, and that offering true informed consent and transparency about the risks are central to reducing this harm.
What to do if you have PSSD
If you believe you are experiencing symptoms of PSSD, it may be helpful to bring existing research on PSSD to show your doctor to reduce the risk of being misdiagnosed. Various sources can be found ici.
Your family doctor is qualified to diagnose PSSD. A sexual medicine specialist, urologist, psychiatrist, or psychologist can also diagnose PSSD, but you will need a referral to see them.
There is currently no reliable treatment to manage symptoms of PSSD, but working with a therapist who is educated about PSSD and its unique impacts can help to reduce emotional distress [3,7].
Connecting with others experiencing PSSD to find community and support and having your experience with PSSD acknowledged and validated by your healthcare provider can also help people cope better with PSSD.
Where To Go For Information and Support
PSSD Canada exists to bring together people in Canada suffering from this condition and advocate for recognition, research, and greater awareness within the medical community and the public concerning the sexual risks of antidepressants. For more information, to find a therapist familiar with PSSD, or to connect with the PSSD community in Canada, please visit pssdcanada.ca
Table A [8]
| SSRI medications authorized for use in Canada | SNRI medications authorized for use in Canada |
| • Citalopram (celexa) | • Pristiq (desvenlafaxine) |
| • Escitalopram (cipralex) | • Cymbalta (duloxetine) |
| • Fluoxetine (prozac) | • Fetzima (levomilnacipran) |
| • Luvox (fluvoxamine) | • Venlafaxine (effexor) |
| • Paroxetine (paxil) | |
| • Sertraline (zoloft) |
References:
1. Giatti, S., Diviccaro, S., Panzica, G., & Melcangi, R. C. (2018). Post- finasteride syndrome and post-SSRI sexual dysfunction: Two sides of the same coin? Endocrine, 61(2), 180-193.
2. Higgins, A. Nash, M. & Lynch, A. M. (2010) Antidepressant-associated sexual dysfunction: impact, effects, and treatment. Drug, Healthcare, and Patient Safety (2)141–150.
3. Reisman, Y. (2017). Sexual consequences of post-SSRI syndrome. Sexual Medicine Reviews, 5(4).
4. Waraich, A., Yih, J., Goldstein, S., & Goldstein, I. (2021). Post-SSRI sexual dysfunction (PSSD): Ten year retrospective chart review. Journal of Sexual Medicine, 18(3), S41-S41.
5. Healy, D. (2018). Citizen petition: Sexual side effects of SSRIs and SNRIs. International Journal of Risk and Safety in Medicine, 29(3-4), 135-147.
6. Healy, D., Le Noury, J, & Mangin, D. (2018). Enduring sexual dysfunction after treatment with antidepressants, 5α-reductase inhibitors and isotretinoin: 300 cases. International Journal of Risk and Safety in Medicine 29(3-4), 125–134.
7. Reisman, Y. (2020). Post-SSRI sexual dysfunction, BMJ, (368)754.
8. Health Canada. (2021). Summary safety review – Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) – Assessing the potential risk of sexual dysfunction despite treatment discontinuation.
9. Bala, A., Nguyen, H., & Hellstrom W. (2018) Post-SSRI Sexual Dysfunction: A literature review. Sexual Medicine Reviews (6)29–34.
10. Lew-Starowicz, M., Giraldi, A., Krüger, T. H. C., Springer Medicine eBooks 2021 English/International, & SpringerLink (Online service). (2021;2020). Psychiatry and sexual medicine: A comprehensive guide for clinical practitioners (1st 2021. ed.). Springer International Publishing.
11. Healy D., Le Noury J., & Mangin, D. (2019). Post-SSRI sexual dysfunction: Patient experiences of engagement with healthcare professionals. International Journal of Risk and Safety in Medicine, 30(3),167-178.
12. Healy, D. (2019;2020). Post-SSRI sexual dysfunction & other enduring sexual dysfunctions. Epidemiology and Psychiatric Sciences, 29, e55.
13. Rothmore, J. (2020). Antidepressant-induced sexual dysfunction. Medical Journal of Australia, 212(7), 329-334.
14. Bahrick, A. (2008). Persistence of sexual dysfunction side effects after discontinuation of antidepressant medications: Emerging evidence. The Open Psychology Journal 1(1):42-50.
15. Canada Vigilance Program. (2021). Adverse Reaction Number 000925645.
16. Fruchter, E., Gruenwald, I., Horowitz, I., Lavie, Y., Peleg, L. C., Rabbie, M. D. & Rabinovitch, D. (2021). Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors. Sexual Medicine Reviews.
