I'm a Psychiatrist, and Women Aren't Being Honest About Their Sex Lives
"I have never told anyone that before."
I hear this often in my office as a psychiatrist. Talking to me, my patients are often more vulnerable than they have ever been with someone. They tell me about why they hate their parents or siblings, their fears of getting close to someone in a relationship because of past traumas, and how much they want to quit their jobs or leave their marriages.
But as it turns out, one topic they really don't want to talk to me about is their sex life — especially the women.
Our conversations often go something like this. I ask my female patient, "Have you noticed any changes to your interest in sex or sexual functioning?" She looks back at me stunned. She shifts in her chair, avoiding eye contact.
She takes a big breath in and replies softly, "Now that you mention it, yes. I thought I was just not interested in sex anymore."
I have had this conversation with many patients after they start antidepressants or even years into taking their antidepressants. It doesn't matter their age, the experience is common. In fact, antidepressants, which are the first-line treatment for depression and anxiety, have an increased risk of sexual side effects like loss of interest and difficulty becoming aroused or reaching orgasm.
My female patients also seem to feel more shame talking about sexual side effects, even to another woman. While my male patients don't hesitate about opening up to me (a 5'1" female) about their sexual dysfunction — perhaps in part because it's more obvious, physically — with women, changes can be more subtle, and they often assume they are at fault in some way.
The fact that a young woman would feel embarrassed or ashamed of having this conversation may seem surprising considering the popularity of shows like The Sex Lives of College Girls and Sex and the City, but television doesn't always match reality. No matter how many times shows try to normalize the conversation, or how long ago Salt-N-Pepa told us to talk about sex, we still exist in a culture where many women feel they'll be judged for talking about sex — even by their therapist.
The data agrees. In one study, 80% of women surveyed who were experiencing sexual dysfunction never talked about it with their mental health providers. Some, nearly 15%, stopped taking their medication due to sexual side effects, choosing silence over getting better. But why should anyone feel they have to choose between good sex and their mental health? It is about time that changed.
Change starts with knowledge and awareness. We must acknowledge that mental health and sexual functioning are intricately linked. It isn't made up or "in your head" — it is normal and physiologic and real. In one large analysis, people with depression had a 50-70% risk of developing sexual dysfunction. In another study, this time in women aged 50-99, sexual health was found to be more associated with mental health than stress, age, or even physical functioning.
Even still, the symptoms of mental health disorders like depression and anxiety feed into our own insecurities in our relationships or about our own sexual desire and performance. Depression is associated with negative thoughts about oneself and the world. If the depressed voice in your head tells you that you are unattractive or unloveable, it's going to be hard to want to put on lingerie for your partner. Not to mention, an active sex life also requires a desire and interest in having sex, and depression can prevent you from ever being "in the mood." To put it simply, no matter how many flowers and fancy dinners Valentine's Day brings, depression can alter your plans.
Anxiety, on the other hand, might cause you to be worried about a sexual experience so much that it distracts you from being in the moment. It can cause premature arousal or no arousal at all. Perhaps unsurprisingly, these symptoms can create distance and conflict in your relationship, making sex even less likely to occur, which often causes anxiety about the relationship to build. It also creates yet another issue in your life, compounding your already worsening mental health.
Take my patients who talk to me about arguing regularly with their partners about sex. My patient will say something like she never had a huge sex drive to begin with, but her partner tells her it has absolutely gotten worse recently. He feels disconnected from her, and she feels pressured, making her anxiety worse. He urges her to talk to me about it and so we do, which, as it does in many of my patients, finally opens up a dialogue that she has been avoiding because she is embarrassed and thought talking about her sex life was not worth prioritizing over everything else going on. Often, talking about it helps my patients make things different, and better — in sex, anxiety, and her relationship.
Therapy should be a safe, neutral, and confidential space to talk about anything — including sex (even if it's something your therapist might have to Google — you should see my search history!). It should ease the pressure you might feel talking to a partner, or even friend, as it centers the conversation on you and your needs. You might even tell your therapist that you are uncomfortable talking about sex and they can help you understand why. (And, if you really don't feel like you can talk to your therapist about it, it might be time to find a new one.)
But pretending sex isn't a part of your overall mental health isn't the answer. And when it comes to medication, it's especially important to speak up. Even if I ask my patients about sexual side effects they might be experiencing from meds — which is still surprisingly uncommon for providers to do — I can't know someone needs help unless they tell me. (Much to people's dismays, including men on dating apps, I am not actually a psychic.)
This vulnerability is not wasted, as your psychiatrist can often do something to help. There is tremendous variability in sexual side effects of medications, which means just because you get them on one medication, doesn't mean you will on another. While it is important to weigh the risks and benefits of being on your medication, the role of your sex life should not be brushed off or minimized. Intimate relationships are key to many of our overall well-being. What good is an antidepressant that works if you also have no arousal during sex, or desire for sex, or can never orgasm again? Life is long — the pleasurable things matter, too.
It may feel frustrating and require multiple medication trials to get it right. It may even feel like it is you, not the medication, that is causing sexual problems. But, it is possible to have it all — no depression and no sexual dysfunction.
As I tell my patients, the truth is, "Sometimes it is not you, it is because of me."
While I joke when I say that to patients, really, I mean it — it's my job to help make things better, including sex, especially if the medications I prescribed are the reason they are bad in the first place.
No one should be struggling in silence — and caring about your own sex life is never selfish.
Jessi Gold, M.D., M.S., is an assistant professor in the department of psychiatry at Washington University in St. Louis.