Three Women, Decades of SSRIs, and One Question: Can Early Antidepressant Use Affect Orgasm for Life?
Key Takeaways
A sex therapist consulted sexual medicine physician Dr. Irwin Goldstein about three women who have never experienced orgasm despite stable mental health, strong relationships, and a positive view of sexuality. What they shared was decades of SSRI use that began in childhood or adolescence. One hypothesis discussed is that long-term SSRI exposure may disrupt the afferent nerve pathways that carry the sensory information needed to reach orgasm, pointing to insufficient neurological excitation rather than psychological inhibition. This remains a clinical hypothesis, not established science, but it suggests a broader lens for assessing lifelong anorgasmia.
A Sex Therapist's Consultation with Dr. Irwin Goldstein
Disclaimer: This article summarizes a professional consultation regarding several clinical cases. It is intended for educational purposes only and should not be construed as medical advice, diagnosis, or treatment recommendations. Individuals experiencing sexual concerns should consult with qualified healthcare professionals. The perspectives discussed below include clinical observations and hypotheses that may not yet be fully established by scientific research.
As a sex therapist, I frequently work with women who have never experienced orgasm despite being highly motivated, sexually open, emotionally connected to their partners, and actively engaged in treatment. Recently, I consulted with renowned sexual medicine physician Dr. Irwin Goldstein about three such cases. I was stuck on these cases—all the women had been in psychotherapy for many years, had stable mental health, strong relationships, and were sex-positive and sexually self-expressed. What they all had in common was life-long SSRI use that began very young, with few, if any, breaks from being on this medication. I suspected that the reason for their sexual dysfunction was medical, not psychological, emotional, or relational. I needed a sexual medicine expert. Although every individual is unique and no single explanation fits all experiences of lifelong anorgasmia, our discussion raised important questions about the long-term impact of selective serotonin reuptake inhibitors (SSRIs) on female sexual functioning.
Three Women, One Similar Pattern
The women I consulted about ranged in age from their early 30s to their early 50s.
Despite differences in personality, sexual orientation, relationship dynamics, and life experiences, they shared several striking similarities:
They began SSRIs at a very young age, one as early as age 8.
They remained on SSRIs for decades.
None reported significant childhood sexual trauma.
All described loving, stable long-term relationships.
All reported positive attitudes toward sexuality.
All engaged in masturbation and in partnered sexual activity.
None had ever experienced an orgasm.
Most notably, each woman described a nearly identical sexual response pattern: Sexual stimulation would build and build. Sensations would increase. They would feel as though orgasm should be imminent. Then, instead of climax, the sensation would abruptly fade into numbness, flatness, irritation, or disconnection. Continued stimulation did not result in orgasm. Although they remained open to the possibility, each had developed negative thinking about whether it would actually happen and would often “give up” during sex. It isn’t uncommon for individuals with sexual dysfunction to develop a negative outlook on sexual experiences due to sexual issues, which only reinforces the sexual dysfunction.
For many clinicians, these cases challenge common assumptions that orgasm difficulties are primarily caused by trauma, relationship conflict, shame, anxiety, or inadequate stimulation. In my experience as a sex therapist, the lack of education for professionals and the general public makes complete sense that women often feel there is no hope.
Beyond Psychology: A Neurological Perspective
During our consultation, Dr. Goldstein emphasized that orgasm is fundamentally a neurological event. The body must send sensory information from the genitals through the peripheral nerves to the spinal cord and ultimately to the brain. The brain then integrates this sensory information into the experience of orgasm. One clinical hypothesis he discussed was that some individuals with extensive lifetime SSRI exposure may experience disruption of the neurological pathways involved in orgasm. He described a potential neurological blockade involving afferent nerve signaling—the pathways that carry information from the body to the central nervous system.
In simple terms:
The body may be receiving stimulation.
The nerves may be firing.
But the message may not be reaching the brain strongly enough to cross the threshold required for orgasm.
From this perspective, the problem is not necessarily psychological inhibition. Instead, it may represent insufficient neurological excitation. It is important to note that this explanation reflects a clinical hypothesis rather than an established scientific consensus. Research on the long-term neurobiological effects of SSRIs on sexual functioning remains limited, particularly among individuals who began these medications in childhood or adolescence. That said, I often provide treatment based on a working hypothesis, which involves testing ongoing interventions provided to patients.
Understanding the Phases of Orgasm
One concept I found particularly helpful in our discussion was the distinction among the phases of the sexual response. Dr. Goldstein described the three phases of orgasmic response. First, in the pre-orgasm phase,excitation and arousal build as sensory information travels from the body to the brain. Second, in the orgasm phase, the brain receives enough stimulation to trigger the orgasmic response. Finally, in the post-orgasmphase, physiological and emotional recovery occur.
The women I described appeared capable of becoming aroused and engaged sexually. However, something apparently interrupted the transition from high arousal into orgasm itself. This led us to discuss what he termed “excitation insufficiency,” a form of pre-orgasm phase dysfunction in which adequate neurological stimulation fails to reach the brain.
How Might SSRIs Contribute?
SSRIs increase serotonin activity in the nervous system. While often highly effective for depression and anxiety, serotonin has complex effects throughout the brain and body. In other words, selective serotonin reuptake inhibitors are not exactly selective.
Many people are familiar with common SSRI-related sexual side effects, including reduced libido, delayed orgasm, difficulty reaching orgasm, and reduced genital sensation. As a sex therapist who is also a licensed counselor, patients often must decide if the benefits of managing significant mental health disorders, such as bipolar disorder or major depression, outweigh having full sexual arousal and response. I always recommend that a patient's mental health comes first. What was exciting about the conversation with Dr. Goldstein was the possibility that patients don’t have to choose.
A growing body of research has focused on Post-SSRI Sexual Dysfunction (PSSD), a condition in which sexual symptoms persist after discontinuing medication. PSSD remains an emerging and actively debated area of study. While an increasing number of case reports, observational studies, and patient advocacy efforts have brought attention to the condition, significant questions remain about its prevalence, mechanisms, risk factors, and optimal treatment approaches.
The cases we discussed raise a somewhat different clinical question. Two of the women remain on SSRIs and likely cannot discontinue them due to severe psychiatric symptoms. One woman discontinued SSRIs approximately six months ago but has never experienced an orgasm in her lifetime. Although Dr. Goldstein advised that we could not diagnose any of these women who were still on SSRIs with PSSD, the same mechanisms may be involved.
This raises an important but currently unanswered question:
If SSRIs are introduced during critical periods of neurological development, could they influence the development of orgasmic pathways in some individuals?
At present, science does not have definitive answers.
A Shift in Clinical Thinking
One of the most meaningful takeaways from our consultation was the importance of avoiding oversimplified explanations. When a woman has never experienced orgasm, clinicians often search for trauma, relationship problems, shame, religious conflict, anxiety, or lack of sexual knowledge. These factors absolutely matter and should be assessed. However, as with my patients, some women have already addressed these issues and still cannot orgasm. In those cases, a sexual medicine evaluation may be warranted.
The question may not be: "What psychological barrier is preventing orgasm?" Instead, it may become: "Is the nervous system receiving enough excitation to trigger orgasm?" That shift opens entirely new avenues for assessment and treatment.
What About Treatment?
Our conversation included a discussion of several medical approaches that sexual medicine specialists may consider when evaluating orgasm difficulties. These approaches are generally aimed at increasing central nervous system excitation, dopamine activity, hormonal support, or genital responsiveness.
Potential interventions discussed included:
Bupropion (Wellbutrin)
Buspirone
Flibanserin (Addyi)
Bremelanotide (Vyleesi)
Oxytocin
Dopamine-enhancing medications such as cabergoline or ropinirole
Hormonal assessment and treatment when indicated, e.g., testosterone
Topical arousal-enhancing therapies
These interventions are not appropriate for everyone and should be considered only under the supervision of qualified medical professionals familiar with sexual medicine and psychiatry, and the individual's overall health history.
What This Means for Therapists
As therapists, we are trained to look for psychological explanations. Often, those explanations are accurate and helpful. Consultations like this remind me that sexual functioning emerges from the interaction of biology, neurology, hormones, psychology, relationships, culture, and development.
When clients have worked diligently on emotional healing, communication, self-acceptance, mindfulness, and sexual exploration—and remain unable to orgasm—it may be time to broaden the lens. Sometimes the next step is not deeper psychological work. Sometimes, the next step is collaboration with sexual medicine specialists.
What excites me most is that sexual medicine continues to move beyond simplistic explanations of sexual dysfunction. The women I discussed are not broken. They are not sexually repressed. They are not lacking effort. In fact, they have spent years trying to understand their experiences. As our understanding of neurobiology advances, we may discover that some forms of lifelong anorgasmia are less about psychological inhibition and more about neurological excitation. For clinicians, this means staying curious. For patients, it means not giving up. And for researchers, it underscores an important unanswered question:
How does early and long-term SSRI exposure influence the development of female orgasmic functioning across the lifespan?
The answer may fundamentally change how we understand female sexual health.
Special thanks to Dr. Irwin Goldstein and the team at San Diego Sexual Medicine for their willingness to engage in interdisciplinary consultation and for their continued efforts to advance the understanding and treatment of sexual dysfunction. Dr. Goldstein offers 10-minute free consultations to anyone interested in consulting about sexual dysfunction. While the ideas discussed in this article reflect a single clinical perspective, ongoing research and collaboration among sexual medicine providers, therapists, neuroscientists, and researchers will be essential to answering these important questions.
Frequently Asked Questions
Can long-term SSRI use affect the ability to orgasm?
SSRIs are known to cause sexual side effects such as reduced libido, delayed orgasm, difficulty reaching orgasm, and reduced genital sensation. One clinical hypothesis discussed by Dr. Irwin Goldstein is that extensive lifetime SSRI exposure may disrupt the afferent nerve pathways involved in orgasm. This is a working hypothesis rather than established scientific consensus, and research in this area remains limited, especially for people who began the medication in childhood or adolescence.
What is anorgasmia?
Anorgasmia is the persistent inability to reach orgasm despite adequate arousal and stimulation. In the cases discussed, each woman described arousal building and then fading into numbness, flatness, or disconnection instead of climax, even though they were motivated, sexually open, and actively engaged in treatment.
What is excitation insufficiency?
Excitation insufficiency is a term Dr. Goldstein used to describe a form of pre-orgasm phase dysfunction in which adequate neurological stimulation fails to reach the brain. From this perspective, the difficulty is not psychological inhibition but insufficient neurological excitation. The body may be receiving stimulation and the nerves may be firing, yet the message does not cross the threshold required for orgasm.
What is Post-SSRI Sexual Dysfunction (PSSD)?
PSSD is a condition in which sexual symptoms persist after a person stops taking SSRIs. It is an emerging and actively debated area of study. Case reports, observational studies, and patient advocacy have raised awareness, but questions remain about its prevalence, mechanisms, risk factors, and optimal treatment. People who are still taking SSRIs cannot be diagnosed with PSSD, though similar mechanisms may be involved.
Are orgasm difficulties always psychological?
Not always. Trauma, relationship conflict, shame, anxiety, and a lack of sexual knowledge can all contribute and should be assessed. However, some people address these factors and still cannot orgasm. In those cases, a sexual medicine evaluation may be warranted to assess whether the nervous system is receiving enough excitation to trigger orgasm.
What treatments might sexual medicine specialists consider for orgasm difficulties?
Approaches generally aim to increase central nervous system excitation, dopamine activity, hormonal support, or genital responsiveness. Options discussed included bupropion (Wellbutrin), buspirone, flibanserin (Addyi), bremelanotide (Vyleesi), oxytocin, dopamine-enhancing medications such as cabergoline or ropinirole, hormonal assessment and treatment such as testosterone when indicated, and topical arousal-enhancing therapies. These are not appropriate for everyone and should be considered only under the supervision of qualified medical professionals.
When should someone consider seeing a sexual medicine specialist about orgasm?
When a person has worked on emotional healing, communication, self-acceptance, mindfulness, and sexual exploration and still cannot orgasm, it may be time to broaden the lens. Collaboration with a sexual medicine specialist can help assess biological, neurological, and hormonal factors alongside psychological ones.
