Psych CASC / OSCE · Specialty psychiatry — sexual dysfunction and paraphilias
Explain antidepressant sexual side-effects and paraphilia thresholds — CASC communication station
MRCPsych/FRANZCP-style communication station: SSRI sexual SE, switch options, and non-pathologising education on paraphilic disorder thresholds.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in the outpatient clinic. [4]
Candidate instructions. Explain that sexual side-effects are common with SSRIs, outline options (continue with monitoring, dose review, switch strategies), warn about depression relapse if stopping abruptly without a plan, and educate that consensual adult fetishistic interest without distress or nonconsent is not a disorder and does not require antiandrogens. Check understanding and agree follow-up. [1][2][3]
Candidate scenario
Depression has been remitted for 4 months on escitalopram 20 mg oral daily. Sexual side-effects began after dose titration and are the main adherence threat. Partner is supportive. Fetishistic interests are adult, consensual, ego-syntonic, and non-impairing. He has been reading alarming online forums about “chemical castration.” [1][3]
Marking domains
- Empathy, privacy, non-stigmatising language about sex
- Accurate link between SSRI and desire/orgasm delay
- Balanced options: do not force stay or abrupt stop
- Relapse-prevention framing if changing antidepressant
- Clear paraphilia vs disorder education (distress/impairment/nonconsent)
- Explicitly reject unnecessary antiandrogens for consensual adult diversity
- Safety-net for mood deterioration; teach-back [2][3][4]
Reveal assessor key
Open. Thank him for raising an awkward topic; normalise sexual side-effect discussion as part of good antidepressant care. [4]
Explain SE. “Medicines like escitalopram often reduce sexual desire or delay climax because of their serotonin effects — this is a recognised side-effect, not a personal failure and not proof your relationship is the only problem.” [1][2]
Options. Collaborative menu: sometimes waiting if mild; reviewing dose if clinically safe; switching to another antidepressant that is often kinder sexually; never stop suddenly without a plan because depression can return. Agree monitoring of mood and sexual function. [2][4]
Paraphilia education. “Having a fetish with a consenting adult partner, without distress and without anyone being harmed or non-consenting, is not a mental disorder and does not need hormone-blocking treatment. We reserve those specialist medicines for specific high-risk or highly distressing clinical situations under careful supervision.” [3]
Close. Summarise plan, written information if available, crisis contacts if mood drops, book review after any medication change, teach-back. [4]
References
- [1]Montejo AL, Llorca G, Izquierdo JA, et al. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients J Clin Psychiatry, 2001.PMID 11229449
- [2]Serretti A, Chiesa A Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis J Clin Psychopharmacol, 2009.PMID 19440080
- [3]Krueger RB, Reed GM, First MB, et al. Proposals for Paraphilic Disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11) Arch Sex Behav, 2017.PMID 28210933
- [4]Clayton AH, El Haddad S, Iluonakhamhe JP, et al. Sexual dysfunction associated with major depressive disorder and antidepressant treatment Expert Opin Drug Saf, 2014.PMID 25148932