Assessing Sexual Symptoms and Side Effects in Adolescents

In a recent clinical research meeting, an incident was discussed involving an adolescent boy who was part of a trial investigating pediatric anxiety and taking a selective serotonin reuptake inhibitor (SSRI) for the first time. His therapist noticed he was shutting her out in therapy and did not want to take his medication any longer. The therapist was confused, because the boy’s anxiety appeared to be lessening. During his next meeting with the study psychiatrist (a man), the patient confessed that he was worrying whether he would ever have sex, given that his previous frequent sexual thoughts and feelings had disappeared since he began taking the medication. After the patient’s self-prompted report, the psychiatrist and therapist were able to work together to address the patient’s loss of libido. The fact that the patient had to offer this information on his own accord makes it likely that others, who might be less comfortable discussing sexual issues, might discontinue the medication without addressing this issue with their practitioners.

As researchers embarking on new translational research in the area of mood and anxiety disorders and SSRI treatment in children and adolescents, we found ourselves examining the side effect profiles of children and adolescents treated with SSRIs. Through our review of the literature 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.¹

We are searching for a way to use personalized medicine approaches to improve treatment of teens with symptoms of anxiety and depression. Large multisite placebo-controlled trials conducted in the past decade demonstrated that ∼50% of teens respond to fluoxetine or sertraline when treated for depression or anxiety disorders, respectively.^2,3 These multisite studies were thoroughly vetted by institutional review boards, which ensured that a great deal of effort went into determining safety and reporting adverse events. However, despite these efforts, the trials did not routinely evaluate sexual symptoms and side effects. We asked ourselves, why are sexual symptoms and side effects not being assessed in large clinical trials of adolescents? Is it possible that adolescents do not exhibit sexual symptoms of depression or the common sexual side effects seen in adults taking SSRIs?

This does not seem to be the case. In 2004 Alexander Scharko⁴ alerted the medical community to the fact that adolescents do experience sexual side effects from SSRIs but that these effects are not adequately assessed. Drawing on a chart review study, Scharko and Reiner⁵ reported that the point prevalence of SSRI-induced sexual dysfunction among adolescents in a hospital-based clinic was 23%, but this was a small sample. Scharko pointed out that most research studies did not assess for these side effects, and he reasoned that the rate is likely to be higher, potentially similar to the one observed in the adult population, which is estimated to be >50% in some studies.¹

Since Scharko’s review was published, almost a decade of important clinical trials in adolescents has been conducted without assessing sexual symptoms or side effects. Is it possible that something has been preventing the medical community from addressing the sexuality of young people?

We examined the research instruments used to assess clinical symptoms in adolescents. As it turns out, the instruments omit a thorough assessment of sexual behavior in this population. The most commonly used outcome measure of clinical symptoms in large pediatric trials, the Child Depression Rating Scale, includes no item on sexual function.⁶ In all clinical measures, there is no mention of sex drive as it might manifest in masturbation and no inquiry into libido. Because this instrument is targeted toward assessments of children as young as 6 years old, it is an appropriate assessment tool. However, to our knowledge there are no assessment tools specifically for adolescents that address sexual issues. By aggregating the childhood and adolescent assessment tools, is it possible that researchers have shortchanged adolescents when it comes to assessing their sexual symptoms?

The lack of assessment of sexual symptoms in diagnostic instruments is especially alarming given that depression and anxiety can also have a profound impact on sexual desire and performance. It is typically standard care in adults to obtain a baseline assessment of these symptoms before the start of treatment and monitor as the treatment progresses. Assessing baseline functioning enables better monitoring for symptoms that are typical of SSRI treatment, most notably decreased libido, arousal, duration of orgasm, and intensity of orgasm. Finding out that a patient has sexual side effects may lead to changes in treatment such as lowering the dose of the medication, switching to medications with a lower incidence of sexual side effects, such as bupropion, or using psychotherapy as a sole treatment. These strategies are often used in adults.¹

It may be especially important to assess teenage sexual activity in the context of mood disorders. Research on adolescent behavior documents a strong relationship between mood disorders and engagement in unprotected sex, potentially leading to unwanted pregnancies and increasing the risk of contracting a sexually transmitted disease. These studies demonstrated that boys who have a mood disorder are less likely to use condoms and more likely to be intoxicated when having sex, and girls who are depressed are more likely to have multiple sex partners and to engage in unprotected sex.⁷

Adolescence is a time of exploring sexuality, sexual feelings, and sensations. Not asking about these experiences can be compared with not measuring head circumference of infants during the first year of life. From a developmental standpoint, adolescence is a time when sexuality begins to fully manifest, and it is a time when things can go wrong, but it is also a time when problems can be addressed with early intervention.

As health care professionals, we are taught that we have a responsibility to address the patient’s concerns and to not ignore any topic that is relevant to their health. We are instructed to tell patients about their condition, elaborating on risks and benefits of treatment. However, we find that clinicians often steer clear of asking adolescents about their sex lives. In our trial, to ensure that sexual issues are consistently addressed, we devised a short assessment questionnaire that we routinely give to all postpubescent adolescents as part of the evaluation (Table 1). We find this approach helpful in making assessments of sexual issues and symptoms routine.

TABLE 1.

Questionnaire for Assessing Sexual Symptoms in Postpubescent Adolescents

Sample questions to the general adolescent population:
Have you had sex with another person, including oral sex, or do you masturbate; and if so, are there any issues you would like to discuss about this?
Are you having any problems with your sexual feelings or behaviors?
Have you had the opportunity to discuss questions you might have in regards to your sexual feelings in a setting that you feel is confidential and safe to open up in?
If you have had sex with other people: Do you, or have you ever had unprotected sex, including sex without a condom or sex without any other form of contraception?
Specific questions when a mood disorder is suspected:
Have you experienced a change in libido (sexual desire, thoughts, interest) recently?
Have you experienced a change in libido or any other sexual side effects (for example, a change in orgasm) since beginning your medication (if taking a medication with known sexual side effects)?

The take-home message from Scharko’s review, written in 2004, was that we are failing to ask something very important of an entire population. Yet his call went largely unheeded. We feel uncomfortable talking to teenagers about sex for various reasons, and we need to find a way to do so that is safe for both clinician and patient. It is important for pediatricians to talk to adolescents, and not just adolescents taking SSRIs, about sexual health. This is a crucial step toward ensuring that teenagers with sexual problems and side effects receive the attention and treatment they need.