“I mean, I’ve never even –,” Nicole* says, pausing, “ – had an orgasm.” She draws out the “a” in “had.”
We’re sitting on bar stools around the island of her parents’ kitchen, in a suburb of Philadelphia. This is where we sat senior year of high school – high, eating cookie dough, picking over hook-up prospects; where, in grade five, we ate grilled cheese and talked about the cutest boy in the class.
Now, it’s summer break, and we’re halfway through university. Nicole’s been struggling with depression, and until recently she’s been taking Effexor, a selective serotonin reuptake inhibitor (SSRI), the most commonly prescribed class of anti-depression medication. Though we’re still talking about sex, we’re tuned into something a little darker this time.
The listed side effects of taking SSRIs include: headache, dry mouth, anxiety, nausea, diarrhea, insomnia, sleeplessness. In 2000, a twelve year-old who had been on Paxil for seven months hung herself. So, to this day SSRIs in the United States carry a black-box warning about suicide. But lurking in the drug pamphlet of every SSRI, somewhere between the media-hyped worst-case scenarios, and the string of mundanities that typically fade after a week or two, are the words “sexual dysfunction.”
The list of conditions that fall under that term could hold its own in a fine-print contest. In no particular order: no or lower libido, delayed orgasm, anorgasmia (no orgasm), pleasureless orgasm, erectile dysfunction, problems with arousal (unspecified), and possibly genital anesthesia (in which genitals are no more useful for pleasure than, say, your arm is).
These side effects reportedly hit between 2 and 70 per cent of patients on SSRIs – the number varies study to study, depending on how the study is done. In studies where you wait for patients to bring up sexual dysfunction, a comparatively small number report having it; but when the question is asked specifically, reports always clock in at 30 per cent at least. It all makes the little, bouncing genital-less smiley faces in those Zoloft ads seem more than a little wicked.
Ben Goldacre, a doctor and Guardian columnist, lays out the stakes involved in drug-induced sexual dysfunction in his book Bad Science.
“I’m trying to phrase this as neutrally as possible,” Goldacre writes. “I really enjoy the sensation of orgasm. It’s important to me, and everything I experience in the world tells me that this sensation is important to other people too. Wars have been fought, essentially, for the sensation of orgasm.”
***
Nicole had taken Effexor for nearly a year, however, our topic of conversation that afternoon – about whether it affected her sexual function – was one that she had not even broached with the doctor that put her on the medication.
Audrey Bahrick, a psychologist at the University of Iowa, explains that the decision to take medication should be one of “informed consent.” Patients should have an understanding of the benefits and downsides of the medication, including the possibility that it’ll mess with your sex life.
“It almost sounds trivial,” says Bahrick. You might be prepared to cope with a little loss of libido. “But it can be much more. It can be really quite a pervasive change.”
Studies clearly show that patients will, far more often than not, fail to bring up sexual side effects unless specifically asked. This is especially true when patients have just 15 minutes with a general practitioner before being shoved out the door. (A game to play at McGill Health Services: get a doctor to prescribe you an SSRI, see if they bring up the birds and the bees.)
Prior to prescribing an SSRI, doctors need to suss out a “baseline” – or typical sexual function – with patients first, explains Bahrick. If you have a solid idea going into taking the medication of what your sexual function is like, it’s easier to know if the drug is taking something away.
Though Bahrick does not prescribe drugs, as a psychologist she is directly involved in patient’s treatment plans. She sees the 18 to 22 year olds that she works with as an especially vulnerable population, as their baseline of sexual function isn’t as firmly established as it is for adults.
Further, women’s sexuality risks being ignored: if a man cannot get an erection or stays hard for too long (one man I spoke to described “erections that last forever”), it seems to be a clear, easy-to-explain problem. When a women can’t reach orgasm, however, it may be harder to recognize that as an issue.
“We know a whole lot more about men’s experience. They’re a lot easier to study,” says Bahrick.
***
It turns out this is true in more ways than one. Anita Clayton, a psychiatrist at the University of Virginia who works with drug companies to study side effects of SSRIs, explains that it’s harder to get government funding to study female sexual dysfunction. “I think there’s a cultural and institutional bias against women and their sexuality, that it needs to be contained,” she says. “And I think that much of that influences the funding to do studies.” She cites abstinence-only education as another factor impeding a meaningful discourse on the subject.
Abstinence-only education isn’t good – this is true. But the problem is deeper than that. Its not just that sexual function is hard to study, or that it’s harder to study in women – it’s that sex is, even in some of the best of cultural conditions, defined in a male-centric and heterosexist way. It’s reduced to the male orgasm, the act of intercourse, a penis entering a vagina and depositing an amount of sperm. Women’s pleasure – which often stems from acts other than vaginal intercourse – is taken for granted or ignored altogether.
These complications apply to people like me and Nicole, too, who were not products of abstinence-only education – quite the opposite, in fact. Over the years, we’ve rented the movie All I Wanna Do from the now-bankrupt video store so many times that we might as well have been charged as responsible for wearing out the tape. In it, Kirsten Dunst goes to an all-girls boarding school, and fights the oppressive rule against wearing jewelry, and, most importantly, the one about not having male visitors. She and her cohorts skirmish with the nighttime chaperones, essentially, for the sake of getting laid.
Everything about our world told us that Dunst was right. We were taught that – should we somehow ever find ourselves apparrated to a conservative boarding school – the right to still have sex was one worth losing our dining hall privileges over. In grade five, volunteers from Planned Parenthood played the “penis game” with us, in which everyone shouted out words for genitalia at the top of their lungs, as though our yelling could hit a frequency that would shatter the playground stigmas. The school nurse had free condoms on hand, in case, it seemed, of an emergency.
In our liberal world of readily available condoms and birth control, we were free to have intercourse. But sex is brilliantly multifaceted – desire and dysfunction aren’t always easily identified. And yet what dominates the discourse is a binary language: yes or no, penetration or not. From nosy peers: “how many people have you slept with?”; from doctors, “are you sexually active?”
If there is an erection going into a vagina, according to this way of thinking, the system is functional – enough to count as active, enough to make another notch in the bedpost. The dysfunctions experienced by men can more clearly fall under this straight-and-narrow definition.
Bahrick mentions a female she treated who said that she was not concerned about sexual side effects – she had a boyfriend, but they were not having intercourse; sexual side effects didn’t have anything to do with her.
Female arousal is more complex, and hidden, both physiologically and culturally: women do not necessarily have orgasms with every act of intercourse, though the clitoris swells when aroused, it is out of sight.
While male cum featured – necessarily, it felt – in many of my teenage conversations with Nicole, female pleasure came up explicitly for the first time that summer afternoon. It was part of her sexual baseline that she hadn’t quite bothered to look into before.
In grade ten sex ed, the subject of female masturbation came up once. Later at track practice a friend asked me, “Does anyone do that?”
***
For Bahrick, the problem is scarier than just asking the right questions, or being sensitive to the fact that a patient might not yet have discovered their baseline of sexual function. Much of her work comes from the first-hand accounts of people on SSRIs, people who have been on them for longer than the standard eight-week trial that it takes to get the drug approved by the FDA. Her findings are drawn from both patients in her office, and members of a Yahoo discussion group called SSRIsex. There are things lurking here that are deeply sinister: accounts of people going on SSRIs, losing their sexual function and never getting it back.
The mainstream medical community has not accepted the notion of post SSRI sexual dysfunction – there is no research that proves it. It could turn out to be as invalid as the link between vaccines and cognitive diseases. But, unlike Jenny McCarthy’s choice cause, no research has been done to show for sure that there isn’t a link between post-treatment sexual dysfunction and SSRIs, either. This is the scary thing about these drugs – if there are long-term side effects, ones that extend beyond the eight-week trials, we’re currently testing them in situ, on millions of people.
“We need to talk about what we don’t know,” she continues. Post-SSRI sexual side effects are not accepted by the mainstream medical community. Still, in the past decade, studies on suicidal thoughts and SSRIs have shown that the twelve year-old’s death was likely not caused by the drug, and yet the drugs still carry warnings. Better to err on the safe side.
***
It is strange that a solution to happiness could rob us of sex. A drug called Viibryd hit the market in early 2011; the data, at glance, indicates that it might sidestep this paradox (can’t you feel that sentiment pumping through its name?). If you look at the drug insert material, rates of sexual dysfunction clock in around 2 per cent. The FDA approved the drug – but not the claim that it offers superior sexual function, as the study only compared rates of side effects in Viibryd to a placebo, not to another SSRI. In spite of its questionable accuracy, the 2 per cent figure was out: it made the media rounds, landing headlines on news websites from Salon to ABCNews.
The fact that patients are looking for a better SSRI, though, is a positive step: When Prozac first hit the market, studies that asked specifically about sexual side effects weren’t even being done. If you have a drug that really does reduce side effects, that would be a brilliant thing to market. “Yes, and if you have one that is going to be negative, you want to know that too, because it might negatively affect the treatment plan,” Clayton says earnestly.
She dismisses the claim that SSRIs can cause post-treatment sexual dysfunction – there are psychological factors to explain the post SSRI libido drop. “The number of these reports is so low. If that is the case, it’s just a coincidence,” she says, though quickly adding, “in my opinion.”
There is one more striking – and perhaps crucial – difference between the emphases of Clayton, who works hand in hand with big pharma, and Bahrick, who is a psychologist, and spends much of her time with patients. While Bahrick uses the language of “informed consent”, in her literature, Clayton uses the typical pharma language of “treatment compliance.”
“‘Treatment compliance’ is a term suggesting a more passive, less collaborative role of the patient and a more paternal role of the prescriber,” explains Bahrick. The term is out of favor with pyschologists, for this reason. “Yet the language of ‘compliance’ does still seem ever-present in the sexual side effects literature, i.e. – the side effects pose a risk to treatment compliance.” For Bahrick, a patient who sees sexual side effects as a reason to not take a drug has a valid point.
In high school, we poured over consensual sex for hours in the classroom, reading stories, running through hypothetical scenarios, like militia running though war theory. What we weren’t taught was about how to say yes or no to a drug, to a company; what violation of your self happens when you swallow a pill. What we weren’t taught is that we were entitled to explore a range of feeling, including feelings that that might take time to figure out.
I ask Clayton what she says when patients decline drugs because of side effects. “In those patients what are we going to do?” she replies, implying annoyance. “Shove it down their throats?”
***
It is winter break, 2011, and six months have passed since Nicole stopped taking medication. Though she sees a pyschiatrist regularly – and did make it through the bulk of her depression while on meds – she’s also started doing yoga and writing more in an effort to feel better.
One evening a few days before Christmas, we take the train downtown, watch a local band play a few songs at an Irish bar, and then wander out onto 12th street. It is our first time going out in Philly since we reached the legal drinking age. In a moment of abandon, we pop into a club called iCandy: a pocket of techno and rainbow strobe lights in the mild winter, encased in revolution-era brick. We take our seats on bar stools at a table for two, and a man wearing nothing but a santa hat and red briefs serves us rounds of twizzler-flavored test tube shots.
It’s one of those moments when I feel like I have wandered out of my own life and onto a movie set. I check to see that we’re still wearing the cardigans that we left the house in. We’re off script this time: happiness and pleasure are things that aren’t necessarily tied to a chemical or a sexual conquest. We’ve learned the lessons of Dunst characters – the ones who risk it all for the act of sex under its strictest definition – and now we’re leaving them behind.
When Nicole weaned herself off the anti-depressants, she told me about how she opened up each individual plastic pill and dumped out the hundreds of tiny white beads that contained the drug. First, four every day, then, a week later, eight, and so on, until there were none left to spill out.
Now, in the bar, a small pile of glassware accumulates in front of us, as we become drunker in fifty-milliliter doses of alcohol and syrup. Nicole leans forward.
“It happened,” she says, smiling and shrugging at the same time. “I had one.”
*Name has been changed