Mechanism of action and indications for SSRIs

SSRIs, a class of antidepressant, function by blocking the reuptake of serotonin into presynaptic neurons, subsequently increasing its availability in the synaptic cleft and enhancing serotonergic neurotransmission in the brain. In adolescents, SSRIs are most commonly prescribed for depression and anxiety. The global point prevalence rate of elevated self-reported depressive symptoms in 10- to 19-year-olds has been estimated to be 34% (Shorey Reference Shorey, Ng and Wong2021).

The National Institute for Health and Care Excellence (NICE 2019) recommends that antidepressants should not be offered as a first-line treatment for moderate to severe depression in children or adolescents unless combined with psychological therapy. When prescribing, it recommends fluoxetine as the first-line antidepressant for adolescents (NICE 2019). For certain anxiety disorders, medication is generally avoided in those under 15 and psychological interventions are preferred, whereas for older adolescents, treatment aligns more with adult protocols (NICE 2013). Mood disorders such as depression are associated with significant long-term psychosocial consequences that extend well into adulthood, including reduced educational attainment later in life (Wickersham Reference Wickersham, Sugg and Epstein2021).

Sexual dysfunction in adolescents with major depressive disorder

The relationship between depressive disorder and sexual functioning is influenced by multiple factors, including the effects of antidepressant medication. A 2016 study (Deumic Shultz Reference Deumic Shultz, Mills and Ellingrod2021) examining older adolescents experiencing a major depressive episode found that greater depression severity was associated with reduced sexual functioning. However, comprehensive research on the relationship between depression and sexual functioning in adolescents remains scarce.

Defining sexual side-effects and prevalence in adults

Sexual side-effects associated with SSRI use include a broad spectrum of symptoms, including arousal difficulties and problems with erection (Corona Reference Corona, Ricca and Bandini2009). The reported prevalence of these symptoms varies widely, but realistic estimates are thought to be in the 30–50% range (Balon Reference Balon2006). The British National Formulary for adults classifies sexual dysfunction associated with fluoxetine as ‘common or very common’, meaning that it can affect over 10% of users (Joint Formulary Committee 2025).

Sexual side-effects in adolescents

Data on the prevalence and incidence of SSRI-induced sexual side-effects among adolescents is comparatively limited. A pivotal literature review by Scharko remains a key reference in understanding this gap in research (Scharko Reference Scharko2004). In his review of 31 paediatric clinical trials involving SSRIs, only 1 trial explicitly reported sexual side-effects – an unexpectedly low figure given how commonly reported these symptoms are in adults. To further explore this discrepancy, Scharko also examined 21 broader clinical reviews on the paediatric use of SSRIs. Of these, only 7 even mentioned sexual side-effects, and those discussions were brief and based entirely on adult data. Scharko proposed that this lack of reporting likely reflected a systemic failure to assess or record these effects in young people, rather than an actual absence of symptoms. More recent commentary (Levine Reference Levine and McGlinchey2015) suggested that little progress has been made in this area in the decade following Scharko’s original review and expressed understandable disappointment at this fact. Of the studies that have been done since, results have been mixed. One study reported impairments in orgasmic function associated with SSRI use in adolescents (Deumic Shultz Reference Deumic Shultz, Mills and Ellingrod2021), whereas another large claims-based study found no recorded cases of sexual dysfunction in adolescents on SSRIs and therefore could not assess the association (Anderson Reference Anderson, Pace and Libby2012).

Mechanism of action of sexual side-effects in SSRIs

The precise mechanisms underlying SSRI-induced sexual dysfunction remain poorly understood. However, it is thought that the widespread distribution of serotonin and its interaction with other neurotransmitter systems may play a role in mediating these adverse effects (Kaloğlu Reference Kaloğlu, Öztürk and Dilekoz2024).

Post-treatment sexual symptoms

Although most sexual side-effects resolve once SSRIs are discontinued, there are documented reports of persistent sexual symptoms, sometimes referred to as post-SSRI sexual dysfunction (PSSD) (Healy Reference Healy, Le Noury and Mangin2018). These symptoms can include genital numbness or decreased sensitivity, difficulties with arousal or orgasm, and, in some cases, patient-reported emotional blunting related to sexual experiences. For young people, who may still be developing their sense of sexual identity and function, such symptoms can be difficult to recognise and even harder to discuss.

A recent cross-sectional survey of over 1800 young people (aged 15–29) found that 13.2% of past antidepressant users – the majority of whom had used SSRIs – reported persistent post-treatment genital hypoesthesia (reduced genital sensitivity or numbness), compared with 0.9% of those who had used other psychiatric medications (Pirani Reference Pirani, Delgado-Ron and Marinho2024). Although this finding highlights a potential concern, it remains important to note that the prevalence, risk factors and natural course of persistent symptoms in adolescents remain poorly understood. Clinicians should be mindful that not all sexual side-effects resolve immediately after treatment ends.

The impact of sexual side-effects on adolescents

As discussed above, evidence regarding the prevalence of SSRI-induced sexual side-effects in adolescents remains limited, with existing studies reporting mixed findings. Evidence from general population studies, however, indicates that sexual dysfunction is not uncommon even among young people without psychiatric illness or pharmacological treatment. For example, a large European study involving individuals aged 15–24 years reported that nearly half of young women (48%) and around one-quarter of young men (23%) had experienced at least one type of sexual dysfunction in the previous year (Moreau Reference Moreau, Kågesten and Blum2016). These findings highlight that sexual difficulties are relatively frequent during late adolescence and early adulthood, further underscoring the importance of recognising and addressing SSRI-related sexual side-effects when they are used in this vulnerable age group.

Developmental considerations

Adolescence is broadly defined as the period between 10 and 19 years of age, and it is a critical phase of physical, psychological and social development (World Health Organization 2025). A key feature of this stage is sexual maturation, which is often accompanied by myriad emotional and interpersonal challenges. Understandably, the introduction of psychotropic medication during this period can be an additional unwelcome challenge. The World Health Organization (WHO) recommendations on adolescent sexual and reproductive health and rights (WHO 2018) outline the diverse and evolving needs of adolescents, and advocate the use of tailored and supportive health, education and social services to help navigate this critical developmental stage.

Psychosocial and relational impact

Adolescence is a time at which a young person usually begins to develop their interpersonal relationships and explore their sexual identity. Therefore the emergence of sexual dysfunction during this formative period can have a huge impact on an adolescent’s self-esteem, body image and sense of normality, difficulties that can also strain peer or romantic relationships and lead to feelings of isolation and shame. If left unrecognised or unaddressed, psychological consequences may persist into adulthood. A systematic review (Kong Reference Kong, Ting and Chung2023) highlighted a relationship between self-esteem and sexual functioning in young adults; it is therefore crucial that we recognise how sexual dysfunction can mould a young person’s identity and self-esteem during these key years.

Clinical implications

Consider three hypothetical but realistic situations that a CAMHS practitioner may face in day-to-day practice.

• • A 17-year-old female is initiated on fluoxetine for depression. Her mood, energy and motivation initially improve, but her parents and teachers notice increasing social withdrawal. Through sensitive questioning, the clinician learns that she is experiencing anorgasmia – something she finds confusing and distressing.

• • A 16-year-old male treated with sertraline for generalised anxiety disorder reports delayed ejaculation and reduced sexual arousal. He initially dismisses this as unimportant, but as he begins exploring romantic relationships these difficulties lead to growing frustration and avoidance of intimacy. During a routine clinic review, he reports feelings of embarrassment and inadequacy about his masculinity that he previously withheld owing to embarrassment and fear of being misunderstood.

• • A 15-year-old autistic adolescent assigned female at birth, receiving escitalopram for social anxiety after a failed SSRI trial, presents with a marked decrease in sexual desire. She initially attributed this to anxiety, but later expressed confusion about her lack of interest in romantic or sexual connection. This caused her to question her sexual orientation and gender identity, and she finds herself increasingly isolated with identity-related confusion.

So, what are the potential clinical consequences of such scenarios? Adherence to certain psychotropic medication regimens can be low among adolescents (DelBello Reference DelBello, Hanseman and Adler2007), and unexplored side-effects may further affect it. The failure to adequately treat major depressive disorder during this developmental period carries serious risks, with major depressive disorder considered to be one of the most significant psychiatric risk factors for suicide among adolescents (Nock Reference Nock, Green and Hwang2013). Furthermore, if adolescents perceive that mental health services are unresponsive to their needs or that they have limited involvement in their own care, this can contribute to disengagement from both the treatment plan and wider healthcare systems (Viksveen Reference Viksveen, Cardenas and Berg2024). These are significant yet often overlooked consequences of clinical encounters where important questions remain unasked and adolescents’ perspectives are not adequately considered.

Why are sexual side-effects overlooked?

Despite their clinical relevance, sexual side-effects are frequently under-recognised in adolescent mental health care owing to a combination of cultural, clinical and systemic factors.

One major barrier is the reluctance of adolescents to disclose sensitive or personal information in clinical settings. Unsurprisingly, research has shown that confidentiality within healthcare relationships is highly valued by adolescents and it affects how they engage in this setting (Zucker Reference Zucker, Schmitt and DeJonckheere2019).

Discussing issues related to sexual functioning may be particularly challenging for young people, especially when they are required to speak with unfamiliar clinicians in potentially intimidating environments. This hesitancy is compounded by concerns about embarrassment, stigma or fear of judgement, all of which can inhibit open communication and limit opportunities for appropriate assessment and intervention.

There is also evidence to suggest that healthcare providers in a range of settings find it tricky to discuss sexual health. A systematic review (Kelder Reference Kelder, Sneijder and Klarenbeek2022) of communication practices in conversations about sexual health in medical healthcare settings found that, in numerous studies, clinicians reported avoiding and delaying the use of certain words and phrases relating to sexuality. As a result, terminology was often vague and general, with sexual health issues sometimes not, or only partially, addressed.

Although clinicians aim to adopt a non-judgemental and objective stance, unconscious biases and personal beliefs may unintentionally affect clinical interactions, which can lead to discomfort when addressing sensitive topics. For example, a clinician might casually say ‘When you get married and have kids someday…’ as part of a rapport-building conversation, but this wording assumes a heteronormative life trajectory that may not align at all with the adolescent’s sexual orientation, gender identity or personal goals. Likewise, asking a female patient ‘Do you have a boyfriend?’ assumes heterosexuality and may unintentionally close the lines of communication with those who identify as lesbian, bisexual, queer or questioning. These statements are often made unconsciously and with good intent, but the common use of non-inclusive language in clinical settings can discourage disclosure of important information (Alexander Reference Alexander, Fortenberry and Pollak2014) and subsequently limit clinicians’ ability to foster safe and inclusive environments for discussing sexuality.

In addition to communication and cultural barriers, developmental and population factors may further contribute to the under-recognition of sexual side-effects in adolescent care.

Adolescence itself is a dynamic period of physical, cognitive and psychosocial change. Sexuality evolves across childhood and adolescence, and distinct physical, emotional and cognitive dimensions emerge at different ages (Cacciatore Reference Cacciatore, Korteniemi-Poikela and Kaltiala2019). A 17-year-old nearing transition out of CAMHS, for example, is likely to have very different sexual experiences and expectations compared with a 14-year-old. These developmental differences may make it difficult for both clinicians and adolescents to recognise or articulate sexual side-effects in age-appropriate ways.

Recognition may be further complicated in certain groups of young people, including those with neurodevelopmental conditions such as autism spectrum disorder (ASD) or attention-deficit hyperactivity disorder (ADHD), those with histories of trauma, those in care or forensic settings, and individuals from different cultural or religious backgrounds. McKenney et al (Reference McKenney, Cucchiara and Zapotitla2024) found that adolescents with ASD report significantly lower satisfaction with sexual and consent education, suggesting that information gaps and communication challenges may impede disclosure of sexual concerns in clinical contexts. These developmental and population factors illustrate why some adolescents may struggle to report sexual side-effects and why clinicians may hesitate to raise the issue.

Finally, the all-too-familiar demands of a busy clinical setting can be a barrier to having these discussions. Levine & McGlinchey (Reference Levine and McGlinchey2015) developed their own brief structured instrument – the Questionnaire for Assessing Sexual Symptoms in Postpubescent Adolescents – in response to the lack of widely adopted assessment tools for evaluating sexual side-effects in CAMHS. In the absence of such practical, validated tools, it can be easy to overlook these side-effects in daily clinical practice.

Rapport and environment

The role of rapport and clinical setting in facilitating discussions on sensitive topics, including sexual health, cannot be overstated. It is essential to consider the individual needs of each patient – particularly whether they are routinely seen with a parent or carer – and if this arrangement remains appropriate as they get older. After all, providing adolescents with dedicated time alone during consultations is a key component of building trust and encouraging open communication (Albers Reference Albers, van den Berg and Sleeman2020). Having a private, calm, appropriate clinical environment that has been thoughtfully prepared by the clinician in advance (for example, turning off phones and alerts) can help the patient feel safe and respected, which can empower them to raise issues that may be otherwise withheld.

Confidentiality

We know that confidentiality is a core principle of adolescent care. However, it is crucial to clearly define its boundaries – specifically, what information will and will not be shared with parents or others. Establishing these expectations proactively and early on can help develop trust. Notably, the presence of a parent in the room can introduce an additional layer of discomfort, particularly when sensitive topics such as sexual side-effects arise, and even in the context of an established therapeutic relationship adolescents may find it difficult to speak candidly in front of a caregiver.

Ethical and legal considerations

When raising the topic of sexual side-effects in adolescent patients, particularly those under the age of 16, careful consideration must be given to issues of capacity, consent and confidentiality. Routinely discussing sexual side-effects in clinical practice can open the door to broader conversations about sexual health and well-being, which may, in turn, help identify underlying safeguarding concerns – particularly when there are notable changes in sexual behaviour or disclosures that indicate potential risk. Communicating with parents or guardians while still upholding the adolescent’s right to confidentiality can present further challenges. NICE guidelines (2017) outline procedures for responding to such concerns, and it is important that clinicians adhere to local safeguarding protocols. These clinical responsibilities reflect the broader ethical challenges encountered in conducting sensitive research with young people (Shahriari Reference Shahriari, Shirmohammadi and Kohan2018), where issues such as informed consent, confidentiality and the management of harm-related disclosures are also central.

Normalisation and inclusivity

Clinicians should approach these conversations without embarrassment, in a fluid and non-judgemental way, as their comfort can significantly influence the adolescent’s willingness to engage. Initiating discussions about sexual side-effects before, during and after starting antidepressant treatment can also help destigmatise the topic and encourage adolescents to share their experiences and concerns. Of paramount importance: do not be embarrassed to ask. If you find this awkward, the adolescent will also struggle to be open. In England, since 2020, relationships and sex education (RSE) has been compulsory for all secondary school pupils, as has mandatory health education for pupils of all ages in state-funded schools (Department for Education 2021), policies that may be helping to lay the groundwork in normalising these conversations.

Unsurprisingly, adolescents often experience discomfort initiating conversations about sexual health, and research shows that they frequently expect the healthcare provider to take the lead in raising these topics (Engelen Reference Engelen, Knoll and Rabsztyn2020). When clinicians proactively initiate discussions about sexual health, including potential side-effects of medications, this not only reduces stigma but also legitimises the topic as a routine and important aspect of healthcare. Questions such as the following can help facilitate this discussion:

• • ‘Sometimes medicines can make our bodies feel different. Have you noticed any changes in how you feel when you’re alone or with someone you like or fancy?’

• • ‘Medicines can sometimes cause changes in your body that can be embarrassing to talk about. Has anything like that happened to you since you started taking your medicine?’

The use of inclusive, non-assumptive language that acknowledges diverse sexual orientations and partner types is also encouraged. For example, instead of making assumptions about future plans, phrasing such as ‘If you choose to have a partner or family in the future…’ respects a broad range of possible identities and life paths. Similarly, using neutral questions like ‘Are you in a relationship with anyone?’, rather than specifying gendered terms, is helpful to avoid alienating sexual minority youth. Finally, and vitally, do not forget to ask about pronouns and preferred language at the outset of the conversation, a seemingly small but important detail that can forge rapport and demonstrate respect from the start.

Baseline assessment

A thorough baseline assessment of physical symptoms, using structured or semi-structured tools, is ideal before starting SSRIs (Strawn Reference Strawn, Mills and Poweleit2023), and can provide a useful reference point to help distinguish known disorder symptoms or other underlying difficulties from experienced side-effects. Another suggestion, which may be less time-consuming, is to discuss potential side-effects of SSRIs as part of psychoeducation before starting treatment. This informal conversation can feel more realistic than a structured list and allows the clinician to later check in with the adolescent about any experiences related to those side-effects.

Non-pharmacological strategies

Non-pharmacological strategies, particularly psychoeducation, should be considered as one of the first-line interventions for sexual dysfunction secondary to SSRI medication (Montejo Reference Montejo, Prieto and de Alarcón2019). This may include providing developmentally appropriate information about potential sexual side-effects, exploring how the young person might respond if they occur and involving the adolescent, along with their family when appropriate, in a collaborative way. As per the frequent reminder in postgraduate psychiatric examinations, always provide a leaflet. An information leaflet or other resource may be a valuable way of opening up a conversation that your patient might be finding awkward or unnecessary, putting the ball back in their court and giving them the space and time to independently do their own research before returning to discuss a management plan. Such strategies can help reduce distress and support adaptive coping. Additional input from the multidisciplinary team may also be helpful at this stage. A ‘watch and wait’ approach can be used in such instances to allow time for spontaneous resolution or habituation, although this has shown limited effectiveness (Montejo Reference Montejo, Llorca and Izquierdo2001) and may be suboptimal for adolescents who are significantly affected by these symptoms.

Medication strategies

Dose reduction has been proposed in adult literature as one potential strategy for managing SSRI-induced sexual side-effects (Waldinger Reference Waldinger2015; Kaloğlu Reference Kaloğlu, Öztürk and Dilekoz2024). In adolescents taking fluoxetine, Stahl & Strawn (Reference Stahl and Strawn2024) similarly recommend either reducing the dose or switching to an alternative agent. However, such changes inevitably come with their own risks, including the risk of relapse.

Given the shared serotonergic mechanism of action of SSRIs, switching within the same class is generally not effective. Instead, switching to an antidepressant with a different or partial serotonergic profile has shown more promising results. Stahl & Strawn (Reference Stahl and Strawn2024) note that bupropion can be used off-label in adolescents when added to existing SSRI treatment to mitigate induced sexual dysfunction effects. They also suggest mirtazapine as an alternative for patients seeking to avoid sexual dysfunction.

Drug holiday

Interestingly, one study reported that temporary discontinuation of SSRIs, excluding fluoxetine, prior to anticipated sexual activity in adult females improved orgasmic function without significantly compromising mood stability (Lalegani Reference Lalegani, Eissazade and Shalbafan2023). However, this method has not been thoroughly evaluated in adolescent populations and their applicability to this patient group remains uncertain.

Summary

The above management strategies are given to provide guidance, but there is no hard and fast rule. Knowing your patient and approaching the conversation with a sensitive and flexible attitude is key. Once sexual side-effects have been considered and addressed, it may also be appropriate to discuss the potential implications of their resolution with the adolescent. For example, provide relevant sexual health education where possible, signpost to contraceptive services and highlight that the risk of unintended pregnancy may increase when certain side-effects (for example, delayed ejaculation) are improved. Despite not being sexual health specialists, psychiatrists sit at an important intersection between many aspects of an adolescent’s life. It is therefore vital that we consider how a change in one aspect of a young person’s experience may have a knock-on effect in others.

Summary and CPD points

• • SSRI-induced sexual side-effects in adolescents may be under-recognised and under-reported.

• • Unaddressed sexual side-effects could affect treatment adherence, emotional well-being, clinical engagement and mental health outcomes.

• • Clinicians may avoid raising sexual health topics owing to discomfort, uncertainty or time constraints, and adolescents can struggle to disclose sensitive issues without clear assurances of confidentiality.

• • A proactive, inclusive and developmentally sensitive approach can help to facilitate open dialogue, enabling more holistic and person-centred care.

• • Effective management of SSRI-related sexual side-effects in adolescents requires careful assessment, psychoeducation and adaptation of adult-informed pharmacological strategies.

• • Further guidance, research and structured assessment tools should be developed, ideally with input from adolescents, to better support clinical practice in this area.