South Florida urologist Ranjith Ramasamy observed a disturbing trend among his patients as COVID-19 spread across the U.S. in 2020: More and more men were complaining that they couldn’t perform in the bedroom.
At first Ramasamy and his colleagues at University of Miami Hospital’s urology clinic thought that the growing reports of sexual dysfunction represented a psychological issue, the result of pandemic stress. But many patients said they weren’t feeling anxious or depressed, and for some, the problem lasted six months or longer. Then the team started to suspect another underlying cause: the SARS-CoV-2 virus that causes COVID-19.
While COVID-19 may harm the lungs, it’s a systemic disease that can also affect the heart, kidneys, brain and other organs, and those effects can last long after someone has recovered. Many people now live in a purgatorial netherworld of “long-haul COVID” that experts are calling our next national health disaster. According to an August article in the New England Journal of Medicine, 10 to 30 percent of those infected with the virus—at least 42 million cases in the U.S. and 229 million worldwide—experience ongoing debilitating symptoms that may cause “significant disability.”
Among the list of ailments, mounting evidence suggests that COVID-19 may sabotage men’s sexual health. “We found that men who hadn’t previously had these issues developed pretty severe erectile dysfunction after COVID-19 infection,” Ramasamy says.
Men may be six times more likely to develop brief or long-term erectile dysfunction after contracting the virus, according to research published in March. Other studies have documented a litany of post-infection health issues that impact sex, either independently or in concert: inability to have or maintain an erection, damage to the testes, testicular pain or swelling, inability to achieve orgasm, low testosterone levels, and mental health issues.
The science stands in stark contrast to anti-vaccine misinformation spreading online—including a now infamous tweet from rapper Nicki Minaj—claiming that COVID-19 vaccines cause swollen testicles and impotence. To date, no studies support that claim.
“It’s important for people to understand that COVID vaccination doesn't affect erectile function,” Ramasamy says. “The virus can have significant adverse long-term effects, and the vaccine is safe.”
Tracking the virus in tissues
Men most at risk for severe COVID-19—older men or those with hypertension, obesity, diabetes, and heart disease—are already at high risk for sexual dysfunction. These conditions affect their hormones, muscles, blood vessels, and more. However, much younger men have also reported sexual health issues. When it comes to figuring out the short-term and chronic aftereffects of this new virus, “we’re still in the tracking and trends phase,” says Ryan Berglund, a urologist at the Cleveland Clinic in Ohio, and that includes understanding its effects on men’s sexual and reproductive health.
To find out if the virus was indeed invading men’s reproductive organs, Ramasamy and his team performed biopsies on six men ages 20 to 87 who had succumbed to COVID-19. When they examined these tissue samples under an electron microscope, they discovered virus particles lurking in one man’s testicles. Half of the men also had poor sperm quality, backing up data from other small postmortem studies and raising questions about the disease’s impact on fertility.
If the virus was in the testes, Ramasamy wondered if was also present in the penis. The team investigated by studying two men who became impotent after having the virus. One of them had experienced mild symptoms; the other had been hospitalized. Convinced they would never have a natural erection again, they each came to the clinic to see if they might be candidates for penile implant surgery.
The virus was indeed present in their penis tissue, which was shocking, Ramasamy says, given the time frame: It had been up to eight months since the men were first infected. The doctors also found damage to the lining of the organ’s tiny blood vessels.
Blood and bone
A known coronavirus impact, damage to the endothelial cells that line the blood vessels, is the most likely culprit for poor sexual performance. While some mammals have a bone in their penises, erections in humans rely on blood flow. Arteries must open and veins must contract, almost like a canal lock system. Impaired, narrowed blood vessels won’t allow spongy tissue to inflate with blood or hold that blood to maintain an erection.
Without enough blood, cells are oxygen-deprived, tissues become inflamed, and vessels lose elasticity, says Emmanuele A. Jannini, professor of endocrinology and medical sexology at Italy’s University of Rome Tor Vergata. “No oxygen, no sex,” he says.
He notes that COVID-19 also seems to lower amounts of an enzyme—endothelial nitric oxide synthase—that helps dilate blood vessels and engorge the penis. For long-haulers, lung or heart damage may compound the problem by altering blood circulation and oxygen levels in the blood and tissues.
Early in the pandemic, Jannini’s team launched an online survey that gathered information on sexually active Italian men who’d had the virus. This was the study that revealed the six-fold higher risk of erectile dysfunction post-COVID-19 infection. How long symptoms will last remains unknown, Jannini says.
“Since the penis is actually one of the most vascular organs in the body, we were not surprised that erectile dysfunction was more common in men with long COVID,” Ramasamy says.
And in July, the Patient-Led Research Collaborative, a group of researchers who themselves have long COVID, published the most comprehensive information to date. They documented 203 symptoms in 10 organ systems, amassed from an online survey of some 6,500 people from countries across the globe. The results included sexual health problems.
About 18 percent of men reported sexual dysfunction; some 13 percent experienced pain in their testicles; 8 percent noted other sex organ issues; and about 4 percent of men had a decrease in the size of their penis or testicles.
A viral hideout
The testicles are a perfect hideout for viruses. Like the eyes and central nervous system, they are immunologically privileged sites. In these places, viruses including Ebola, mumps, and Zika can remain in tissues, evading the immune system even after the invader has been cleared from other parts of the body.
One study speculated that the testicles might therefore serve as a reservoir for the virus that causes COVID-19. This may explain why 11 percent of men hospitalized with COVID-19 suffered testicular pain. Infection of the organ’s Leydig cells, which produce testosterone, may also explain long haulers’ lowered levels of the male sex hormone. That alone can cause lagging libido and desire. Jannini notes another feedback loop: Testosterone production drops when men aren’t having sex.
State of mind also plays a role in intimacy, Berglund says, “which is partially dependent on our psychological state.” The pandemic has heavily impacted overall mental health for long haulers. Many suffer from PTSD, anxiety, or depression. The psychological effects of COVID-19 on sexual health will ultimately be the most challenging to tease out, Berglund says.
He adds that simply being sick can kill desire. “If you’re struggling to breathe or chronically ill, you’re probably less interested in sex,” he says. That may be compounded by fatigue, one of the most common symptoms, and loss of smell, since scent sparks arousal.
Sex and the vaccine
More studies are needed to understand what the virus actually does to men’s reproductive health. Researchers are working to understand the mechanisms of what is still a relatively new disease. Ramasamy’s team is investigating how this virus evades the immune system and lodges in cells, including in the testes and penis. “If it’s going dormant, will it get reactivated again?” he asks “Does it continue to cause damage? Or is it a one-time insult?”
Congress has awarded $1.15 billion to the U.S. National Institutes of Health for its RECOVER program, which will study the constellation of long haul COVID-19 symptoms over the next four years. Many hope that it will provide much-needed answers – and treatments for those who still suffer.
And despite the misinformation spreading on social media, research continues to counter the notion that vaccines impact fertility. A June study, for instance, found no link between mRNA vaccines and reduced sperm count.
“The plausible relationship between COVID-19 and erectile dysfunction is one more reason for the unvaccinated to get their shots,” Jannini notes. “If they want to have sex, better to get the vaccine.”