What doctors don't tell teens about antidepressants and sex

Try to remember what your hormones were doing to you when you were a teenager. Remember those first flushes of desire. Those awkward and revelatory introductory experiences of pleasure. Think of everything you were trying to understand about yourself and your body, everything cool and terrible and constantly changing about it.

Now imagine you have depression or anxiety. Okay, now imagine you are fortunate enough to be getting competent mental health care, and you and your providers agree you'll take medication to help with your depression or anxiety. But this prescription may also affect your burgeoning, still-figuring-it-out sexual drive and function. And yet, nobody's talking to you about that part.

Let's connect some dots. The mental health crisis in our young people is staggering. A 2019 Pew Research poll found that 70% of American teens reported anxiety and depression a "major" problem for them and their peers — and the pandemic has not made things better. The National Alliance on Mental Illness estimates that "1 in 6 U.S. youth aged 6-17 experience a mental health disorder each year."

It is encouraging that along with the rise in anxiety and depression, there is a corresponding rise in treatment, both therapeutic and pharmaceutical. In the UK, the percentage of teens and children prescribed antidepressants has risen 41% just since 2015. A 2023 Statstica report found that roughly 20% of American college students take antidepressant medications "regularly." But medication dispensation demands caution and education. And there is startlingly little research or information about the sexual side effects of these medications in young people. 

We know that SSRIs can affect sexual drive and performance. The journal Mental Health Clinician lists "delayed ejaculation, reduced sexual desire, reduced sexual satisfaction, anorgasmia, and impotence" among the potential side effects. A 2020 study in Neurology, Psychiatry and Brain Research estimates roughly half of adult patients taking antidepressants report some form of "sexual dysfunction," a condition associated with "depression severity, diminished relationship satisfaction, and lower self-esteem in patients currently taking antidepressants."

"We don't even know what those numbers look like for teens," says Debby Herbenick, PhD, Provost Professor at the Indiana University School of Public Health-Bloomington and author of "Yes Your Kid: What Parents Need to Know About Today's Teens and Sex." She continues, "Medications work differently in adolescent bodies and we need more research to understand adolescents' experiences with antidepressants, including any impact on their sexual desire (libido), orgasm, erections, ejaculation, or genital sensations (these are the kinds of changes observed in adults). There is some research, for example, showing that higher SSRI doses have been associated with anorgasmia among adolescents."

There's also very little research on how SSRIs might affect different adolescent genders differently — significant, given that girls are twice as likely to be prescribed antidepressants than boys.

Among the very scant literature is a 2004 report in the Journal of the American Academy of Child & Adolescent Psychiatry observing that "Researchers and clinicians may be failing to ask adolescents about sex and sexual functioning in the context of SSRI treatment." Eleven years later, a 2015 report in the journal Pediatrics found that little had changed, concluding similarly that "We discovered that a profound piece of information was missing: the assessment or screening of sexual behavior and dysfunction, resulting in missing evidence-based knowledge about these issues in the adolescent population. This was concerning given the high prevalence of sexual side effects seen among adults taking SSRIs."

Part of the problem may be our cultural discomfort with the idea of adolescent sexuality — and our gritted teeth focus on harm reduction at the total expense of empowerment and pleasure. "Healthcare providers already talk very little with adolescents about sexuality," notes Herbenick. "One study that audio-recorded (with permission) physician-adolescent conversations found that two-thirds of the visits contained at least some conversation about sexuality but that these conversations lasted, on average, just 36 seconds. That's not a lot of time for in-depth conversations."

"My sense is that talking about sexual side effects gets at some of the issues that providers are just not discussing — that is, pleasure, orgasm, erections, ejaculation and genital pain," Herbenick continued. "To adequately address these first requires that providers see adolescents not just as young people who might explore their sexuality, but that they have a right to enjoy that exploration." And she warns, "When providers don't talk with teenagers about sexual side effects, there's the risk that teenagers may stop their medication or try to adjust the dose on their own, which can have implications for how well their mental health is being treated."

Peggy Orenstein, author of the bestselling "Girls and Sex" and "Boys and Sex," concurs. "We are so uncomfortable with teens' burgeoning sexuality and new urges (including toward self-exploration) that as parents we don't address them in typical circumstances — let alone how adding in pharmaceuticals might affect them. Teenagers have precious little education on sexuality and human relationships in general, and then around this? Pretty much silence. Pretty much stigma." She says, "As an issue of informed consent, they need to understand these side effects. And parents, too, need to think about what it might mean to potentially interrupt sexual development, what the trade offs are. At the very least, it should be a discussion."

When prescribed and monitored carefully and correctly, selective serotonin reuptake inhibitors can be truly life-changing — and for many, a means of actually improving mood and libido. It can be awkward and intimidating to make sure the lines of communication are clear, but Herbenick says, "Parents can step into the conversation. They can signal to the providers and to their adolescents that they care about their well-being. Parents can ask the provider to address potential sexual side effects with their child — to let them know it's possible or to ask at follow-up visits if these are a concern." The payoff is better mental and sexual health for our young people. And that's what it should be like."

"Sexual pleasure, sexual wellbeing — this is not a luxury," says Doortje Braeken van Schaik, co-author of the International Sexuality Education Guidelines by UNESCO and a board member of the Global Advisory Board on Sexual Health and Wellbeing. "It's something that is as important for your general health, but specifically also for your mental health. And I think that is a tiny step in the right direction to make people think about mental health issues related to sexuality." 

When my friend Edward's 16-year-old son Robert was struggling with severe depression that led to a hospitalization, his team was upfront about the benefits and possible drawbacks of his treatment plan. "The psychiatrist that he was seeing was very clear about all the side effects of the medicine and spoke candidly about them," Edward recalls. "He was dating while on medicine, and I know the doctor was candid about it."

And now that Robert is 18, Edward says he can see the benefits not just of the treatment but how it was handled. "I think making sure he was a partner in that and helping him ask the right questions of a health care provider equipped and empowered to understand, this is my health, and I need to have ownership of it," he says. "Providers are here to help you. So ask your questions, and speak up if something's not working."