SEXUAL ANHEDONIA: UNDERSTANDING THE CAUSES, DIAGNOSIS, AND TREATMENT OF PLEASURELESS ORGASM

Sexual anhedonia – sometimes called orgasmic anhedonia, pleasure dissociative orgasmic disorder (PDOD), or "pleasureless orgasm" – is a rare but significant sexual dysfunction. Clinically, it refers to the inability to experience pleasure or satisfaction during sexual climax, even though physiological signs of arousal and orgasm (such as ejaculation or vaginal contractions) occur normally. In other words, the person may reach orgasm without any accompanying euphoria or pleasure. This condition is most often reported in males (hence terms like ejaculatory anhedonia), but females can also experience a lack of pleasure during orgasm. Though uncommon, sexual anhedonia can cause considerable distress, strain relationships, and is often underdiagnosed or misattributed to purely psychological issues.

What Is Sexual Anhedonia? (Clinical Definition and Recognition)

In a healthy sexual response, orgasm is typically accompanied by intense pleasure due to a surge of neurochemicals (especially dopamine) in the brain’s reward centers. Sexual anhedonia represents a breakdown in this pleasure response. Affected individuals physically go through orgasm but feel little or no pleasure, as if the brain’s reward circuit fails to register the climax. Importantly, sexual anhedonia is distinct from anorgasmia: in anorgasmia, the person cannot reach orgasm at all, whereas in sexual anhedonia the orgasm occurs but is experienced as emotionally or sensorily flat. Patients often report that “something is missing” despite normal arousal and orgasmic reflexes. This can be a sudden change (for example, someone who previously enjoyed orgasm loses that pleasure) or a gradual decline, and it causes significant personal distress in many cases. Because there is no objective test for pleasure, diagnosis relies entirely on the patient’s report – which unfortunately means some patients are told “nothing is wrong” even though the problem is very real and impactful.

From a clinical perspective, sexual anhedonia is not a separate DSM-5 diagnosis by name, but it falls under the umbrella of sexual dysfunction. For instance, a woman with markedly reduced orgasmic pleasure could meet criteria for Female Orgasmic Disorder (which includes “reduced intensity of orgasmic sensations” as a symptom), and a man with normal ejaculation but no pleasure might be classified as Other Specified Sexual Dysfunction (sometimes noted as a variant of hypoactive sexual desire in older texts). The key feature is persistent inability to experience pleasure from sexual climax for at least ~6 months accompanied by distress, not better explained by another condition or substance effect. Recognizing this condition is important: although rare, it is not “all in the patient’s head”, and acknowledging its legitimacy is the first step to management.

Potential Causes of Sexual Anhedonia

Sexual anhedonia can have a multifactorial origin. Modern research suggests both biological and psychological factors can contribute, and often several factors intersect. Below are the major categories of potential causes:

• Genetic and Familial Factors: Anhedonia (the inability to feel pleasure in general) has a significant genetic component. Twin and family studies indicate roughly 40–45% of the variance in anhedonic traits is attributable to genetics, and first-degree relatives of patients with major depression (a condition often featuring anhedonia) show higher rates of anhedonic symptoms than the general population. While specific genes for “sexual”anhedonia are not identified, polymorphisms in dopamine or serotonin receptors may influence one’s vulnerability to sexual reward deficits. In other words, some individuals might be genetically predisposed to have a blunted pleasure response. A family history of psychiatric disorders (e.g. depression, bipolar, schizophrenia) is also a risk factor for anhedonia in general, which can include sexual anhedonia as a symptom in those contexts.
• Psychological and Psychiatric Causes: Major depressive disorder is a classic cause of generalized anhedonia, including loss of sexual pleasure. In depression, patients often experience markedly reduced interest in sex and “sexual anhedonia” as part of the broader inability to feel joy. Other psychiatric conditions can contribute as well – for example, chronic anxiety, PTSD, or high levels of stress may blunt the capacity to experience orgasmic pleasure. Past trauma or abuse (sexual or otherwise) and relationship issues can also psychologically dampen the pleasure of sex even if arousal occurs. Notably, what appears as sexual anhedonia might sometimes be secondary to emotional numbing from conditions like PTSD or the negative symptoms of schizophrenia (which include flat affect and social anhedonia). Careful history often reveals these underlying issues. Substance abuse (such as long-term opioid use or stimulant abuse) can likewise erode the brain’s reward circuitry, leading to reduced sexual pleasure over time. In many cases, treating the underlying mental health condition (e.g. achieving remission from depression) can improve or resolve the sexual anhedonia.
• Medications and Substance-Induced Anhedonia: A number of prescription medications are well-known to cause or contribute to sexual anhedonia. Foremost among these are antidepressants, especially selective serotonin reuptake inhibitors (SSRIs). SSRIs commonly cause orgasmic dysfunction, including delayed or absent orgasms and “pleasureless” orgasms (sexual anhedonia) as side effects. In fact, sexual side effects occur in an estimated 30–60% of SSRI-treated patients, and the blunting of orgasmic pleasure is one reason patients discontinue these drugs. Notably, some patients even report persistent sexual anhedonia after stopping SSRIs, a phenomenon termed Post-SSRI Sexual Dysfunction (PSSD). Other psychotropic medications: antipsychotic drugs (particularly older ones) can induce sexual anhedonia by blocking dopamine in the brain’s reward pathways and causing hyperprolactinemia (elevated prolactin).  High prolactin levels are notorious for damping libido and orgasmic sensation, whether due to antipsychotics or a prolactin-secreting pituitary tumor. Additionally, oral contraceptives in some women and blood pressure medications (like beta-blockers) have been occasionally implicated in decreased sexual pleasure. A growing body of reports links 5-alpha-reductase inhibitors(finasteride, used for prostate issues or hair loss) to long-lasting sexual dysfunction; in post-finasteride syndrome, men have presented with low libido, erectile issues, and sexual anhedonia that persist even after the drug is stopped. It’s crucial for clinicians to review medications in any case of new-onset sexual anhedonia. Sometimes simply adjusting the drug regimen (e.g. switching antidepressants) can alleviate the problem.
• Neurologic and Medical Conditions: Because orgasmic pleasure is a neurobiological event, neurologic damage can lead to sexual anhedonia. For example, spinal cord injuries – especially if sensory pathways are affected – may result in an orgasm that is felt physically (via reflex) but not experienced as pleasurable due to disrupted signaling to the brain’s pleasure centers. Multiple sclerosis (MS), which often impacts nerve conduction, is associated with high rates of sexual dysfunction; some MS patients report attenuated or absent pleasure at climax even when orgasm occurs, likely from demyelination in sensory tracts. Peripheral neuropathy (such as in diabetes) can similarly blunt genital sensation and pleasure. Beyond the nervous system, hormonal imbalances are a well-documented cause: Low testosterone in men (or hypotestosteronism in women) can reduce overall sexual drive and pleasure, and markedly elevated prolactin (e.g. from a prolactinoma or medication-induced) can essentially "turn off" the reward of orgasm. Chronic medical illnesses that sap energy and neurotransmitter function – such as chronic fatigue syndrome or uncontrolled diabetes – have also been reported in association with sexual anhedonia. In some cases, no clear medical cause is found (idiopathic sexual anhedonia), but a thorough workup is still essential to rule out these treatable contributors.

It’s worth noting that multiple factors may coexist. For example, a patient with depression on an SSRI and a mildly low testosterone could have a “stacked” risk for sexual anhedonia. Genetic predisposition might make one person more susceptible to a drug’s sexual side effects than another. Therefore, evaluating all possible causes – psychological, pharmacological, endocrine, neurologic – is important in each case.

Diagnosing Sexual Anhedonia in Clinical Practice

Diagnosis of sexual anhedonia relies on clinical evaluation, as there is no laboratory test or imaging study that can directly measure “pleasure.” A detailed history is the cornerstone: the patient’s description of experiencing little or no pleasure during orgasm is the defining feature. Physicians should inquire about the onset (sudden vs. gradual), context (with all partners or situations, or only some), and whether the patient can climax normally despite the lack of pleasure. Because patients may use vague terms like “numb orgasm” or may be embarrassed, gentle questioning is needed to clarify the symptom. It is equally important to assess for contributing factors in the history, including current medications, substance use, mood symptoms (screen for depression/anxiety), past sexual trauma, and medical illnesses. A focused physical exam should evaluate neurological function (especially genital sensation and reflexes) and signs of hormonal deficiency or chronic disease. Laboratory tests are often indicated to uncover reversible causes – for example, checking morning testosterone levels, prolactin, thyroid function (TSH), and other relevant hormones.  These tests can reveal issues like hypogonadism or hyperprolactinemia, which, if treated, might improve the condition. In one expert’s approach, a full panel of sex hormones and pituitary hormones is recommended to ensure nothing is missed.

Because sexual anhedonia is a diagnosis of exclusion, the differential diagnosis must be carefully considered. Key conditions to rule out or distinguish include:

• Anorgasmia vs. Anhedonia: Ensure the patient isn’t actually experiencing inability to orgasm. If they canejaculate or reach climax but don’t feel pleasure, that points to anhedonia (if they cannot orgasm at all, consider primary anorgasmia or delayed orgasm disorder instead). Some patients have a hard time articulating the difference, so clarifying questions help.
• Generalized Anhedonia: Determine if the lack of pleasure is specific to sex or part of a broader pattern. If the patient derives no enjoyment from usually pleasurable activities (hobbies, food, socializing), a generalized anhedonia (often due to depression) might be at play, and the approach should include treating the underlying mood disorder.
• Physical Sensory Loss: Distinguish between psychological absence of pleasure and true sensory loss. For instance, a man with peripheral neuropathy might literally have reduced genital sensation – here the issue is more a numbness that reduces pleasure, whereas in many sexual anhedonia cases, sensation is intact but the reward feeling is blunted centrally. Physical examination can assess whether tactile sensation in the genital area is normal. If there is objective loss of sensation (and perhaps other neurological deficits), a neurological cause should be pursued (e.g., imaging for spinal lesions). If sensation is normal, the problem is more likely neurochemical or psychogenic in origin.
• Medication Side Effects: Always review timing of symptom onset relative to medication changes. If sexual anhedonia started after beginning an SSRI, finasteride, antipsychotic, etc., then the drug is a prime suspect. A trial of tapering or switching (if clinically feasible) can be both diagnostic and therapeutic. Similarly, inquire about recreational drug use (e.g. chronic opioid or cocaine use) which can dull sexual pleasure.
• Hypoactive Sexual Desire Disorder (HSDD): HSDD is low libido/lack of sexual desire. It can sometimes co-exist with sexual anhedonia or result from it (a person who stops feeling pleasure may gradually lose desire). If the primary complaint is lack of interest rather than lack of orgasmic pleasure, HSDD may be the more accurate diagnosis. However, some sources have described “sexual anhedonia” as a rare subtype of HSDD in men. In practice, teasing apart cause and effect (did desire drop because orgasms weren’t pleasurable, or vice versa?) can be challenging. Both issues may need addressing.
• Other Sexual Dysfunctions: Identify if there are concurrent problems like erectile dysfunction or lubrication issues, which might point to a broader sexual dysfunction rather than isolated anhedonia. Sometimes performance anxiety or severe premature ejaculation might present with statements like “I don’t get any pleasure” – but in those cases, the lack of pleasure might be secondary to anxiety or the brevity of intercourse, rather than a true dissociation of pleasure from orgasm.

To aid diagnosis, clinicians can use validated questionnaires that quantify sexual function and pleasure. For example, the Arizona Sexual Experiences Scale (ASEX) or the International Index of Erectile Function (IIEF) (for men) and Female Sexual Function Index (FSFI) (for women) include items on orgasmic experience and satisfaction. These tools can help objectify the patient’s experience and track changes. In psychiatric practice, specialized scales like the Psychotropic-Related Sexual Dysfunction Questionnaire exist to screen for sexual side effects of medications. If depression is present, an anhedonia scale (like the Snaith-Hamilton Pleasure Scale) might document baseline inability to feel pleasure. While no tool is specific to sexual anhedonia, using these instruments can provide baseline measurements and validate the patient’s complaints in a structured way. Importantly, a broad differential should be maintained – meaning the clinician should consider all the aforementioned possibilities and not prematurely conclude the cause. Often a combined approach (medical, psychiatric, and possibly specialist referral) is required to pin down the diagnosis. For difficult cases, referral to a sexual medicine specialist or neurologist (if neurogenic cause suspected) can be helpful.

Evidence-Based Treatment Options for Sexual Anhedonia

Treating sexual anhedonia can be challenging, but a number of strategies – drawn from both research and clinical practice – can offer relief. Because the condition is often multifactorial, a combination of approaches is frequently most effective. The treatment plan should be highly individualized, targeting any underlying causes while also addressing the symptom of blunted pleasure. Below are key evidence-based interventions and management strategies:

• Address Underlying and Contributing Conditions: The first principle is to treat any identifiable cause. This means correcting hormonal imbalances (for instance, treating hyperprolactinemia can sometimes restore normal sexual pleasure – e.g. via dopamine agonists or surgery for prolactinoma), and optimizing testosterone levels if low. If a medication is implicated, adjust it: for an SSRI-induced sexual anhedonia, one approach is to reduce the dose or switch to a different antidepressant with fewer sexual side effects. Medications like bupropion, mirtazapine, or agomelatine are antidepressants that tend to spare sexual function and can be considered as alternatives. In patients on antipsychotics with sexual anhedonia, switching to a prolactin-sparing antipsychotic (such as aripiprazole, quetiapine, or lurasidone) may improve sexual pleasure over time. Always weigh risks and benefits: if the offending drug is essential, a consultation about co-treatments (see below) or dose adjustments is warranted rather than simply stopping it. Likewise, address any psychiatric issues: if depression or anxiety is present, ensure it’s being treated adequately (with therapies or medications that ideally do not worsen sexual function). In cases related to substance use, treating the addiction (e.g. opioid dependence) is crucial; patients often notice improvement in pleasure as recovery progresses. Essentially, removing or resolving the precipitating factor – when possible – is the closest thing to a “definitive” treatment in secondary sexual anhedonia.
• Psychotherapy and Sex Therapy: When psychological factors are involved (or even when they are not obvious), therapy is a cornerstone of management. Working with a sex therapist or psychologist can help patients explore and overcome issues such as performance anxiety, past trauma, relationship problems, or coexisting sexual disorders that may be contributing. Cognitive-behavioral techniques and mindfulness-based sex therapy have shown promise in improving sexual satisfaction. For example, mindfulness exercises can train individuals to be more aware of bodily sensations and reduce distracting thoughts during sex, potentially enhancing the pleasure experience. Sex therapy may also include education and guided exercises for the couple: for instance, use of erotic aids or focused stimulation (e.g. incorporating vibrators or trying different positions that provide more clitoral or penile stimulation) can sometimes help overcome a dulled pleasure response. Therapists often address expectation and “spectatoring” issues – some patients with sexual anhedonia become so worried about not feeling pleasure that it further blunts the experience, creating a vicious cycle. Breaking this cycle via therapy is important. If depression or PTSD is present, standard psychotherapy or psychiatric treatment for those conditions (such as cognitive-behavioral therapy or EMDR for trauma) can indirectly improve sexual anhedonia by lifting the general anhedonic state.  In essence, psychological interventions aim to reduce mental barriers to pleasure and improve emotional connectivity during sexual activity. While formal trials for sexual anhedonia specifically are scarce, clinical experience supports using sex therapy, and it is low-risk. Many experts advocate a combined mind-body approach, wherein therapy is paired with medical interventions for maximum benefit. 
• Pharmacological Strategies to Enhance Sexual Pleasure: Several off-label pharmacologic treatments have been explored to directly target the neurochemical aspect of orgasmic pleasure. Because dopamine is central to the brain’s reward system, dopaminergic agents are a logical choice. Bupropion, a dopamine-norepinephrine reuptake inhibitor, has shown efficacy in reversing sexual dysfunction in some cases – notably, studies have found that adding bupropion can improve SSRI-induced sexual side effects (including orgasmic pleasure) even in patients who are not depressed. Bupropion is often used as an augmenting agent due to its pro-libido and pro-orgasmic properties. Other dopaminergic medications like pramipexole or amantadine have been reported anecdotally to help, but evidence is limited. For patients with high prolactin or suspected dopamine deficiency, a dopamine agonist such as cabergoline or bromocriptine can be tried – these are known to improve sexual interest and orgasmic intensity in some cases (especially where hyperprolactinemia was a factor).  Another hormone involved in orgasm is oxytocin, the so-called “bonding hormone” which surges at climax. Small studies and case reports have experimented with intranasal oxytocin (taken before sexual activity) to enhance orgasmic sensations. While a few case reports showed success in treating male anorgasmia with oxytocin, a placebo-controlled trial in women found that oxytocin nasal spray was no better than placebo in improving sexual function over time – so the jury is still out. Nonetheless, some clinicians will attempt an oxytocin trial in stubborn cases, with the understanding that evidence remains anecdotal. Phosphodiesterase-5 inhibitors (PDE5i) like sildenafil are primarily for erectile dysfunction, but they may indirectly enhance orgasmic pleasure in both men and women by improving genital blood flow and arousal. There are reports of women with arousal and orgasm issues benefiting from off-label sildenafil use (though not uniformly); enhanced arousal can sometimes translate to a stronger climax. Yohimbine, an older remedy (alpha-2 adrenergic blocker), has a sympathetic nervous system stimulant effect and has been used off-label to treat orgasmic difficulties as well – some sexual medicine experts include yohimbine as a possible option for orgasmic anhedonia.
•  Importantly, any pharmacologic trial should be evidence-informed and closely monitored. Because no medication is officially approved for sexual anhedonia, these uses are off-label and should be undertaken with caution and patient consent. Whenever possible, involve or refer to a specialist (such as a sexual health specialist or psychiatrist) for guidance on complex pharmacotherapy. Also remember that the placebo effect can be strong in sexual dysfunction; a patient’s improvement on a medication might be due in part to expectation. Thus, controlled studies are needed to truly establish what works – currently, robust placebo-controlled trial data specifically for sexual anhedonia are scarce, so clinicians must extrapolate from studies on related sexual dysfunctions.
• Emerging and Experimental Therapies: Given the challenging nature of sexual anhedonia, researchers are exploring novel treatments. One area of interest is in neuromodulation and neuroplasticity. For instance, in depression-related anhedonia, treatments like ketamine (an NMDA antagonist) have shown rapid anti-anhedonic effects on mood, raising questions whether such approaches might help with sexual anhedonia when traditional methods fail. There are no direct studies of ketamine for sexual anhedonia yet, but ongoing research into ketamine and other glutamatergic or neurostimulatory treatments for anhedonia could provide clues in the future. Repetitive transcranial magnetic stimulation (rTMS) targeting reward-related brain regions is another experimental avenue being studied for general anhedonia; conceivably, it might have applications in sexual dysfunction down the line. Psychedelic-assisted therapy (with agents like psilocybin or MDMA) is also being investigated for treatment-resistant depression and trauma – conditions that involve anhedonia – and early results show some promise in restoring emotional connectivity and pleasure. While speculative, it’s possible that in years to come, such therapies could play a role for patients with severe sexual anhedonia linked to psychological factors, if they prove to safely improve neurochemical responses to reward. For now, these remain experimental and should not be considered first-line. Another emerging concept is whether sensory retraining or novel stimulation techniques (for example, use of new adult technologies or vibratory stimulation devices) could “rewire” the pleasure response – much like how novel stimuli can sometimes break through an orgasmic block in anorgasmic patients.  Again, rigorous data are lacking. Clinicians should approach any experimental treatment with caution, fully inform patients of the limited evidence, and ideally reserve them for refractory cases or research settings. The guiding principle must be “first, do no harm.”

Prognosis and Follow-Up

Managing expectations is important throughout treatment. Some patients recover their ability to experience pleasure once a culprit (like a medication or endocrine disorder) is removed – for instance, literature documents cases of bupropion reversing SSRI-induced pleasure loss and restoring normal orgasms. Others may have more gradual improvement with combined therapy, and a subset of tough cases may only partially improve. Regular follow-up should be scheduled to monitor progress, adjust treatments, and provide encouragement. Encourage patients to communicate openly with their partners during this process, as partner support and understanding can significantly alleviate the emotional toll of the condition. From a physician’s perspective, even though high-quality trial data on treating sexual anhedonia are limited, an evidence-guided, empathetic approach can make a meaningful difference. By systematically ruling out causes, involving appropriate specialists (endocrinology, psychiatry, sexual health), and employing a multi-modal treatment strategy, clinicians can help many patients regain a satisfying sexual experience or at least improve their level of pleasure.

Conclusion

Sexual anhedonia is a real and distressing medical condition characterized by a lack of pleasure during orgasm despite normal physiological function. It is an uncommon disorder that straddles the domains of neurology, endocrinology, and psychology, requiring a broad, holistic approach to diagnose and treat. Key takeaways for physicians are to remain attentive to this possibility (especially in patients on serotonergic medications or those with depressive symptoms), to validate the patient’s experience, and to investigate reversible causes such as medications or hormonal issues. Evidence-based treatments focus on addressing underlying factors, while also leveraging psychotherapeutic and pharmacologic strategies – often in combination – to restore sexual reward. Although more research (particularly placebo-controlled trials) is needed to identify definitive therapies, current clinical knowledge offers several avenues to help patients, from switching offending medications to off-label use of dopamine agonists or sex therapy techniques. The tone in managing sexual anhedonia should be one of optimism with realism: improvements are often possible, especially with a tailored plan, but patience may be required as the recovery of pleasure can be gradual. By staying informed of emerging treatments and maintaining an open dialogue with patients, healthcare providers across specialties can play a vital role in identifying sexual anhedonia and guiding those affected toward regaining one of life’s fundamental sources of joy – the pleasure of healthy sexual intimacy.

References: 

1. Fan Q, Wang C, Sun W, et al. Integrative analysis of genome-wide association studies and gene expression in major depressive disorder and schizophrenia identifies overlapping genetic variants associated with anhedonia. Nat Commun. 2023;14(1):1221. doi:10.1038/s41467-023-37356-y
2. Guo Y, Lin L, Liu X, et al. Targeting anhedonia: A systematic review of the role of dopaminergic agents in major depressive disorder. Front Psychiatry. 2023;14:10335915. doi:10.3389/fpsyt.2023.10335915
3. Qiao H, Su H, Xu H, et al. Efficacy and safety of ansofaxine in major depressive disorder: A randomized, double-blind, placebo-controlled phase 3 trial. Transl Psychiatry. 2023;13(1):244. doi:10.1038/s41398-023-02435-0
4. Lally N, Nugent AC, Luckenbaugh DA, et al. Anti-anhedonic effect of ketamine and its neural correlates in treatment-resistant bipolar depression. Transl Psychiatry. 2014;4:e469. doi:10.1038/tp.2014.105
5. Sexual anhedonia. Wikipedia. Updated April 2024. Accessed May 16, 2025. 
6. Safarinejad MR. Effect of L-arginine supplementation on sexual function in women with major depressive disorder: A randomized, double-blind, placebo-controlled study. J Sex Med. 2022;19(3):489-497. doi:10.1016/j.jsxm.2022.01.002
7. Serefoglu EC, McMahon CG, Waldinger MD, et al. Placebo effect in the treatment of premature ejaculation: A systematic review and meta-analysis. J Sex Med. 2015;12(12):2435–2446. doi:10.1111/jsm.13163
8. Brown C, Steiner AZ, Brucker C, Rubinow DR, Yonkers KA. Medications for female sexual dysfunction: Are they better than placebo? Psychiatry Investig. 2021;18(6):487–493. Accessed May 16, 2025.