When Antidepressants Leave Lasting Damage: Living with Post-SSRI/SNRI Sexual Dysfunction

For many people, sexuality is a very important aspect of life. It is integral to our personal identity, our quality of life, and the ways we connect with other human beings.

So what happens to those of us whose sexuality is removed or severely diminished by a medication? What about when that eliminated or compromised sexuality does not recover, even after cessation of that medication? For people with long-term Post-SSRI/SNRI Sexual Dysfunction (PSSD), the impacts to our lives can be devastating.

SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) are classes of psychoactive pharmaceuticals used to treat depression and other mental health conditions. They come under many names and are known for causing reduced libido during treatment for many people. (Higgins, Nash & Lynch 2010) SSRIs are more notorious for this side-effect then SNRIs, but both can have an impact on sexual functioning. For many users of antidepressants, the sexual side-effects are the reason they eventually discontinue the drug, with or without medical supervision (Francois D 2017).

When patients bring their concerns about sexual functioning while on antidepressants to their doctor or psychiatrist, they are almost universally told that their sexuality will return to normal after tapering off the drug. Unfortunately, recent data has emerged showing that this is not always true.  (Reisman 2020)  (Bahrick 2008) Some patients continue to experience sexual dysfunction for weeks, months, or years after withdrawing from such treatment. Sometimes, these symptoms only emerge after the patient has tapered off the medication.

“I am left with a near total lack of sensation up until orgasm - an orgasm that often feels like it's a third of the strength that it once was.  I used to daydream about sex quite often.  Now I have virtually no sexual thoughts, even after going weeks without masturbating.” –Mark, age 32, PSSD for 7 years

Even more alarming are the patients coming forward who have experienced a total elimination of their sexuality that persists indefinitely. These patients report a severe or total loss of erotic sensation in their genitals, sometimes to the point of tactile numbness. Some patients have been unable to experience attraction, arousal, or orgasm for years or even decades, with no other discernable cause apart from treatment with antidepressants.

“In addition to the loss of libido and sexual sensation (numbness of genitalia and other erogenous zones), my general sensitivity to the pleasure of touch has declined. A caress on bare skin registers as little more than pressure. Again, there is a feeling of numbness, as if there is some kind of barrier between my skin and the source of contact… When I brought some literature on PSSD to my former psychiatrist, she refused to even look at it, dismissing it—and my concerns—as “ridiculous.” I have also raised it with my current GP, but he’s not interested in hearing about it.” - Ellen, age 48, PSSD for 15 years

Furthermore, these long-term impacts on sexual functioning are often accompanied by emotional and cognitive symptoms such as “brain fog” or reduced emotional range, commonly referred to as “emotional blunting.” (Opbroek et al 2002) A common variant of this is the reduced or removed ability to experience emotions of romantic attachment. (Fisher, 2007) Patients have reported feeling permanently emotionally flat or experiencing memory and sleeping problems that began at the same time as their sexual dysfunction. For some people, these emotional and cognitive symptoms can be equally or even more difficult to cope with than the sexual dysfunction.

The prevalence of these symptoms among patients treated with SSRIs and SNRIs is unknown, as are the underlying causes, risk factors, and recovery rates. There is currently no known effective treatment. (Bala 2017)

What is known is that many people who experience PSSD find it extremely debilitating to their relationships and overall quality of life. The loss of one’s sexuality and the associated symptoms is a traumatic experience and can lead to increased depression, relationship dissolution, and suicide.

“To say that PSSD has negatively impacted my life would be an understatement of tremendous magnitude. The implications of this cannot be remotely imagined by a normal person. In my opinion, healthy human sexuality is a requisite for being able to properly perceive and navigate the world, even things that seem totally removed from sexuality. It fuels many aspects of our personality and behavior without the average human being even realizing it – until it is taken away.” - Jake, age 29 (PSSD for 11 years, since age 18)

For many years, the medical community was sceptical of the existence of PSSD. Patients were frequently told that their symptoms were a result of their mental health condition, despite the fact they had never experienced such symptoms prior to antidepressant treatment. That view is now shifting due to the dedicated work of researchers, whose documentation of PSSD cases led to the recognition of PSSD as an iatrogenic (meaning caused by medical treatment) condition by the European Medicines Agency. (Healy, D. 2020). Though not yet recognised outside of Europe, doctors around the world are slowly becoming more aware of the risk of Post SSRI/SNRI Sexual Dysfunction. Health Canada put SSRIs and SNRIs under review for long-term sexual dysfunction in 2018 and the report is expected later this year. (Health Canada 2018)

“One major issue with the experience of developing PSSD was the lack of information available to the consumer of antidepressants. I was not informed of the possibility of these side effects persisting – I did my due diligence in looking up the medications, reading pamphlets on the side effects, and talking to pharmacists and doctors, but it was never mentioned that these side effects could persist; for simplicity’s sake, I was “chemically castrated,” without my consent, and without any sort of warning. Being completely blindsided by the persistent side effects has made this experience that much more devastating.” - Andrew, age 29, PSSD for 2 years

Raising awareness is the first step towards achieving research into the causes, rates, and potential treatments of this disorder. Patient activist groups are now springing up around the world to advocate for recognition and research.

Our group PSSD Canada was established in May 2020 to advocate for PSSD sufferers in our home country of Canada and internationally. We are not anti-psychiatry or against the use of antidepressant medication, but we advocate for greater research, awareness, and transparency of the potential health risks so that patients can be informed of the risks and benefits before choosing this treatment option. Please view our mission statement here: https://pssdcanada.squarespace.com/mission-statement 

We collect personal stories, academic sources, and professional statements of support on our mwebsite www.pssdcanada.squarespace.com 

If you have questions or are interested in getting involved, please get in touch: pssdcanada@gmail.com

Emily Grey, Co-ordinator PSSD Canada

References 

Bahrick, A. S. (2008). Persistence of sexual dysfunction side effects after discontinuation of antidepressant medications: Emerging evidence. The Open Psychology Journal, 1, Article 42-50.  https://pdfs.semanticscholar.org/c8e7/5efa92141ab40afd2a83da435c39bc8371cd.pdf;   

Francois D, Levin A, Kutscher E, Asemota B. Antidepressant-Induced Sexual Side Effects: Incidence, Assessment, Clinical Implications, and Management. Psychiatr Ann. 2017; 47: 154-160; https://www.healio.com/psychiatry/journals/psycann/2017-3-47-3/%7Bdecf437a-8f22-446c-923a-19e84670a187%7D/antidepressant-induced-sexual-side-effects-incidence-assessment-clinical-implications-and-management

Bala A, Nguyen HMT, Hellstrom WJG. Post-SSRI Sexual Dysfunction: A Literature Review. Sex Med Rev. 2018;6(1):29-34. doi:10.1016/j.sxmr.2017.07.002; Retrieved from https://www.researchgate.net/publication/318839298_Post-SSRI_Sexual_Dysfunction_A_Literature_Review

Healy D. (2020) Antidepressants and sexual dysfunction: a history. Journal of the Royal Society of Medicine. 113(4):133-135. Retrieved from https://journals.sagepub.com/doi/full/10.1177/0141076819899299

Fisher, H., & Thomson Jr, J.A.  (2007) Lust, Romance, Attraction, Attachment: Do the side-effects of serotonin-enhancing antidepressants jeopardize romantic love, marriage and fertility?  Evolutionary Cognitive Neuroscience. SM Platek, JP Keenan and TK Shakelford (Eds.). Cambridge, MA: MIT Press Pp. 245-283;  Retrieved from http://helenfisher.com/downloads/articles/18ecn.pdf

Health Canada, 2018, Safety and effectiveness reviews started between 2018-11-01 and 2018-11-30 Retrieved from https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/safety-reviews/new.html

Higgins, A., Nash, M., & Lynch, A. M. (2010). Antidepressant-associated sexual dysfunction: impact, effects, and treatment. Drug, healthcare and patient safety, 2, 141–150. https://doi.org/10.2147/DHPS.S7634;

Opbroek, A., Delgado, P.L.,  Laukes, C.,  McGahuey, C.,  Katsanis, J.,  Moreno, F.A.,  & Manber, R.,  Emotional blunting associated with SSRI-induced sexual dysfunction. Do SSRIs inhibit emotional responses?, International Journal of Neuropsychopharmacology, Volume 5, Issue 2, June 2002, Pages 147–151, Retrieved from  https://doi.org/10.1017/S1461145702002870

Reisman Y. (2020) Post-SSRI sexual dysfunction  BMJ 2020;368:m754; Retrieved from https://www.bmj.com/content/368/bmj.m754?utm_source=twitter&utm_medium=social&utm_term=hootsuite&utm_content=sme&utm_campaign=usage

My Gender is Not a Lifestyle Choice

Throughout my advocacy work within the transgender community, the most common misconception that I address is that gender is a choice. That is not to say there are not others. Not in the least. There are so many inaccurate perceptions of the community that at times, I don’t know where to begin. But this is as good as any place to start.

Let me state at the outset that I am transgender. My internal gender identity did not match the sex I was assigned at birth. That is to say, I was assigned male based solely on my external physical appearance, yet I am a woman based upon who I am in my head, my brain, my heart, my soul, in the very core of my being. And it wasn’t a choice. No more so than the colour of my eyes, or body shape. Sex and gender are not inextricably linked together. One does not presuppose the other. They are distinct and separate aspects of who we are. Just as sexual orientation. This disconnect has been labelled as Gender Dysphoria by the medical profession. And it is a terrible thing. And here’s why.

Gender Dysphoria is a soul sucking vortex that leads to a downward spiral. It can lead to depression, feelings of inadequacy, and robs you of any positive sense of self-worth. I suffered with it for over five decades. And suffered is not too strong a word, not by any stretch of the imagination. I don’t have a lot of specific memories of dysphoria when I was very young, but I do recall that I didn’t feel right. I knew something was wrong, but wasn’t sure what it was. Back then, there was no internet. No information regarding gender and sex that was easily available. Most medical practitioners were not really aware of it at the time. In fact, in my circumstances, those subjects were taboo. So I went through childhood and adolescence being confused and ashamed, not having any idea what was going on. Because I wasn’t like other boys. I didn’t like the things they did. Didn’t identify at all with who they were. It was lonely. I had very few friends, and in general wasn’t happy.

As I continued to grow up, I continued to spiral down. I left a caustic home environment when I was 17. Barely made it through undergraduate studies at university, having to work 40 hours a week to pay for it, all the while suffering from what I know now to be Gender Dysphoria. I finally crashed and got up the courage to seek formal medical help. In their desire to pigeon hole me, I was assessed for several things such as schizophrenia, multiple personality disorder, bi-polar disorder and depression. I was formally diagnosed with depression, which was accurate. Thanks Gender Dysphoria. I was not able to articulate my thoughts very well, and the guilt and shame and self-loathing of saying I felt that I was a girl in a society that was not at all ready to accept such a concept was overbearing to say the least.

I did manage to get my act together in some way to suppress the dysphoria, mostly through denial. Denial of who I was, my true self. However, I learned the hard way that dysphoria never goes away. The result of that strategy is that I crashed again, quite severely and once again, had to seek out help. To my good fortune, I was introduced to an amazing therapist, who, over the course of several years, was able to help me survive. The biggest thing that I learned is that I wasn’t broken. I didn’t need to be fixed. While I knew I didn’t choose this, it was good to know that in fact, I was born this way. And that is the key message.

Who would choose to be like this? Who would choose to suffer from Gender Dysphoria? I wouldn’t wish it on my worst enemy. And that is just the tip of the iceberg. The big question was what happens next. How does one get off the dysphoria treadmill? For me, after decades of continuing the battle and countless hours of therapy, it became apparent that I had to transition; to become my authentic self. Reveal the woman that I am today to the world. But that came with its own set of challenges. There were so many unknowns. Would I lose my family? Would I lose my home? Would I have to find other employment, and friends? Would I be the victim of harassment and discrimination? Who would choose that set of circumstances? Being transgender a lifestyle choice? I don’t think so.

It is a matter of survival. And that is the true choice. My choice wasn’t to transition. It was to survive. The only way to survive was to transition. I transitioned because I had to, not because I wanted to. It was the only path to survival. That was the outcome. So the plan was to align my physical attributes with my internal identity, with the gender I was born as. I needed to repair what was essentially a physical birth defect. That also proved to be quite the process. The bureaucracy and cost of name and gender change on official documentation is not for the faint of heart. Until recently, is some instances, it wasn’t permitted to make the necessary changes. Again, who would choose to go through that? That in and of itself was soul crushing. Fortunately, depending on where you live, the processes are now well documented and can be done. Though it still does take time. I was eventually able to make all the necessary changes to documents such as drivers licence, health card, birth certificate, passport, social insurance, bank and financial records, and the list goes on and on.

Finally, I was able to receive approval by the health ministry to undergo Gender Confirmation Surgery. Yes, approval. I had to get approval to be my authentic self. Another hoop. More gatekeepers. It is exhausting. All this just to be my authentic self. Who I was born to be. Not a lifestyle choice.

I can now look in the mirror and see who I really am. To have that congruence is amazing. It is something that 99.5% of the population take for granted. It seems like such a simple thing, but that is what Gender Dysphoria denies people. To be who they were born to be. And that shouldn’t be a choice. Being transgender isn’t a choice. My gender is not a lifestyle choice. It is simply who I am.

You can learn more about my journey to becoming my authentic self in my recent top selling book Stranger in the Mirror: The Search for Me available on my website at www.erinleblanc.ca/publications and on Amazon worldwide.

Erin Leeann LeBlanc, MEd, LLM