Skip to main content
NCBI home page
American Journal of Men's Health logoLink to American Journal of Men's Health
. 2023 Aug 20;17(4):15579883231193913. doi: 10.1177/15579883231193913

Effect of COVID-19 On the Sexual Activity of Men

Mehdi Abedinzadeh 1, Serajoddin Vahidi 2, Amirhossein Rahavian 2, Hossein Lojje 3, Saied Abouei 2,✉
PMCID: PMC10467192  PMID: 37599378

Abstract

In December 2019, severe acute respiratory syndrome COVID-19 was found in China. This virus can affect different organs depending on the coronavirus receptors on the cell surface, which allows the organ to be attacked by the coronavirus. Psychological distress and impaired pulmonary hemodynamics seem to be the cause of decreasing libido or sexual dysfunction after contracting COVID-19. This study was performed to assess the effect of coronavirus on the sexual activity of men. We enrolled 200 men with COVID-19, confirmed by an oropharyngeal sample, who had recovered from the coronavirus for 3 months. These men filled out the International Index of Erectile Function 5 (IIEF-5) questionnaire for their current and previous sexual status. Then, according to their IIEF-5 score, sexual activity before and after corona infection was compared. The mean age of the participants was 31.5 ±3.2 years. This study showed a significant difference between the IIEF-5 mean scores before and after COVID-19, which were 20.4 and 18.6, respectively (p = .000). The condition of 56.1% of the patients did not change; however, coronavirus did have a negative effect on 39.6% of the patients. 4.1% of patients reported improvement in sexual performance. 45% of the patients reported no erectile dysfunction (ED) before contracting the coronavirus; while only 27.7% reported no ED after getting COVID-19. Our findings show that COVID-19 could influence the sexual activity of infected men, who also showed a higher ED prevalence after COVID-19 infection; however, hormonal assessment should be observed in the follow-up.

Keywords: COVID-19, erectile dysfunction, sexual, SARS-CoV-2

Introduction

Severe acute respiratory syndrome (COVID-19) was found in Wuhan, China in December 2019. On January 30, 2020, the WHO Emergency Committee declared a global health emergency based on growing case notification rates in China and other international locations (Velavan & Meyer, 2020).

Lungs were the main target of the coronavirus; but SARS-CoV-2 also critically damaged the tissues of other vital organs such as the heart, kidney, liver, brain, gastrointestinal tract, and reproductive system (Alimohamadi et al., 2020; Shah et al., 2021).

Some studies have suggested (Masoudi et al., 2022) that the COVID-19 pandemic affects the sexual functioning and activity of both infected and healthy men, with the effect being explained by the expression and presence of angiotensin-converting enzyme 2 (ACE2) in the cells of the reproductive system tissue. Further studies explain (Beyerstedt et al., 2021; Zhao et al., 2020) that ACE2 is not only an enzyme but also a functional receptor on cell surfaces through which SARS-CoV-2 enters the host cells.

The presence of the virus in the male reproductive tissue of two men with erectile dysfunction (ED) and other infected patients has been confirmed in past studies (Kresch et al., 2021; Vahidi et al., 2022). As the testis is one of the organs with high levels of constitutive expression of ACE2, the virus could directly damage testicular tissues (Chen et al., 2020; Wang & Xu, 2020).

The infection itself has been proven (Nawaz et al., 2021) to have a significant effect on individuals, including some changes in sexual activities, that may be sustained even after full recovery. Evidence of ED in patients in the acute phase of the infection and the presence of the virus in the reproductive system for some time after remission, made us wonder if the prevalence of ED in patients with a history of COVID-19 infection is different from others.

Before 2023, there were no studies evaluating ED in IRAN after a COVID-19 infection. It is unknown whether the prevalence of ED after infection in Middle Eastern countries is different from other areas. The goal of our study was to measure the prevalence of ED by using the International Index of Erectile Function 5 (IIEF-5) among patients with a history of COVID-19 infection.

Materials and Methods

This retrospective study was performed on men after COVID-19 infection, confirmed by real-time reverse-transcriptase-polymerase chain reaction (rRT-PCR) from an oropharyngeal sample. To begin, we enrolled 240 men that had recovered from coronavirus 3 months ago. Patients with a history of diabetes, hypertension, hypocholesteremia, and those who were above the age of 45 or under 18 were excluded. In total, 200 men filled out the IIEF-5 questionnaire for their current and previous (before becoming infected with COVID-19) sexual status. Next, all patients were given a comprehensive explanation of how to fill out the questionnaire before completing it. Finally, the sexual activity before and after COVID-19 was compared using the IIEF-5 results.

The Statistical Package for the Social Sciences software (SPSS, Version 16.0 for Windows; SPSS Inc., Chicago, IL, USA) was used. The current and previous status of patients were compared using the Wilcoxon, Kolmogorov–Smirnov, and T-paired tests, with a p value of ≤.05 considered significant.

This study was approved by the Ethical Committee of the Biomedical Research Center (IR.SSU.SRH.REC.1401.009).

Results

The mean age of patients was 31.5 ± 3.2 years in this study. The results of the IIEF-5 questionnaire showed that there was a significant relationship between the before (20.4) and after (18.6) IIEF-5 scores (p = .000) (Wilcoxon signed rank test). In other words, while the conditions of 56.1% of the patients (109 men) did not change, the coronavirus negatively affected 39.6% (77 men), with 4.1% of the patients (eight men) reporting an improvement in sexual performance. As presented in Table 1, there was a significant relationship between all before and after COVID-19 infection scores. According to the IIEF-5 results, 45% (90 men) of participants reported no ED before COVID-19; whereas after infection, only 27.8% (54 men) of patients reported no ED (Table 2). Therefore, our findings would seem to show that coronavirus can influence men’s sexual activity.

Table 1.

The International Index of Erectile Function (IIEF-5) Questions

Questions Mean score (before COVID-19) Mean score (after COVID-19) p value
1. How do you rate your confidence that you could get and keep an erection? 3.95 ± 1.03 3.35 ± 1.16 .000
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? 4.29 ± 0.94 3.88 ± 1.03 .000
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? 4.11 ± 1.09 3.82 ± 1.17 .000
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? 4.01 ± 1.27 3.87 ± 1.20 .000
5. When you attempted sexual intercourse, how often was it satisfactory for you? 4.13 ± 1.02 3.69 ± 1.08 .000
Open in a new tab

Table 2.

IIEF-5 Classification

Groups Before COVID-19 (%) After COVID-19 (%) p value
No erectile dysfunction 45 27.8 .001
Mild erectile dysfunction 40.5 40.7
Mild to moderate erectile dysfunction 12.5 24.7
Moderate erectile dysfunction 1.5 5.2
Severe erectile dysfunction 0.5 1.5
Open in a new tab

Note. Wilcoxon signed rank test was used.

Discussion

Although ED is one of the most concerning male sexual dysfunctions, it has been under-studied in Iran and most other Asian countries (Chen et al., 2020).

Its incidence in many Eastern countries is not yet clear due to cultural limitations in gathering data, and the exact prevalence of ED in Iran is still lacking sufficient data both before and after the pandemic (Hosseini et al., 2013).

Our study concluded that the mean IIEF-5 score was reported to be higher in men before COVID-19 infection compared with their scores 90 days after recovery (3.95±1.03 and 3.35±1.16), with its prevalence rising from 55% to 72.2%. Only 4.1% of the participants reported increased sexual activity, which is not statistically significant. These results show a significant elevation in ED incidence was observed in comparison to previous studies on the normal population in Iran. For example, a study reported (Hosseini et al., 2013) that in 2013 the incidence of ED in the north of Iran was 26.5%.

In addition, our findings are similar to the results of another systematic review and meta-analysis (Masoudi et al., 2022) using IIEF-5 scores. Utilizing the random-effect model, they computed the standard mean difference (SMD) to be −0.66, 95% CI = [−0.99, −0.33], which is statistically significant; although this study focused on the pandemic in general, and both healthy and infected adults were included. In addition, our study considered different stages of sexual malfunction and reported the prevalence of each one separately.

In another study (Harirugsakul et al., 2021), ED prevalence was 64.7% in patients hospitalized with COVID-19. Our study did include outpatients with mild to moderate symptoms as well. This suggests that ED can be expected even in people with less severe levels of infection.

Although most studies have reported an increase in the incidence of ED and impaired sexual function after COVID-19, there have been a few studies showing that sexual function remained intact after infection.

For example, in a study (Kaya et al., 2021), no significant difference in The Female Sexual Function Index (FSFI) scores before (24.75 ± 6.55) and after (23.03 ± 7.87) COVID-19 was reported. Although this research argues that COVID-19 infection did not affect patients’ sexual function, it only considered female patients. These findings could indicate that COVID-19 will affect men’s and women’s sexual function differently. Most of the findings, including ours, suggest that ED incidence increased after COVID-19. The reasons for this problem have been argued.

It was pointed out (Sansone et al., 2021) that various factors may be responsible for ED in COVID-19, including endothelial dysfunction, sub-clinical hypogonadism, cardiovascular damage, and psychological damage associated with COVID-19.

The mechanism of endothelial dysfunction and hypogonadism relates to the ACE2 receptor. It is known that the COVID-19 virus requires an ACE2 receptor to enter cells (Terentes-Printzios et al., 2022; Zhang et al., 2020).

Moreover, before binding to ACE-2 receptors, viral spike proteins must be primed by cellular proteases, specifically, transmembrane protease serine 2 (TMPRSS-2). Both ACE-2 receptor and TMPRSS-2 gene are expressed on endothelial cells.

A study established (Kresch et al., 2021) that the virus is still present in the tissues and specimens of COVID-19 (+) men, even months after the infection. These findings could explain why COVID-19 infection produces widespread endothelial dysfunction. Studies have also suggested (Pal & Banerjee, 2020) that testicular damage due to COVID-19 infection can cause the testosterone-to-luteinizing hormone (LH) ratio to decrease.

Cardiovascular damage could also explain our findings. Studies have reported infection can develop severe cardiovascular consequences and exacerbate underlying heart conditions (Bansal, 2020; Terentes-Printzios et al., 2022).

Also ED in men is highly prevalent in patients with cardiovascular disease. It is noted (Song et al., 2019) that stress associated with COVID-19 could be another cause of increased ED. The pandemic affected relationships between partners regarding their sex life and sexual function (Fang et al., 2021).

In addition, epidemiologic studies have implicated (Rosen, 2001) the role of depressed mood, loss of self-esteem, and other psychosocial stresses in the cause of ED. It is recorded that (Döring, 2020) In an attempt to limit the spread of the SARS-CoV-2 virus, governments implemented several restrictive measures, such as social distancing, isolation, and imposed lockdowns, which drastically altered people’s lives. The anxiety and depression caused by lockdowns and the fear of the disease and its long-lasting effects after infection could also be reasons for ED in men (Fang et al., 2021).

In comparison to the other COVID-19 and ED studies, our study included a larger sample size. All the patients were confirmed to have had COVID-19 with PCR tests, including inpatients and outpatients with different severities. Also, our sample included only men with at least a 3-month recovery from the virus in order to determine the long-term relationship between ED and COVID-19.

However, there are some limitations that should be discussed in this study. Our study population was only composed of married men due to religious limitations. Since it may be difficult for some men to admit to personal sexual disorders, particularly in a religious society, Response bias may affect some of the answers. In addition, because of the at least 3 months’ period between infection and recovery some of the participants could be influenced by recall bias as well. As we used a cross-sectional method, we could not take other factors of ED into consideration. Therefore, further studies are required to investigate the long-term relationship between COVID-19 infection and sexual dysfunctions, including ED.

Conclusion

In summary, our analysis revealed that COVID-19 may affect sexual activity of men, with our findings seeming to show a higher ED prevalence after COVID-19; however, other histological and hormonal assessments should be observed in the follow-up.

Acknowledgments

We thank all men who participated in this study.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval: This study was performed and approved by the Medical Ethical Committee of Shahid Sadoughi University of Medical Sciences (IR.SSU.SRH.REC.1401.009).

Informed Consent: All participants provided written informed consent prior to enrolment in the study.

Consent for Publication: Written informed consent was obtained from the patient for the publication of this case report.

Data Sharing Statement: We confirm that all of the material methods and data are available.

References

  1. Alimohamadi Y., Sepandi M., Taghdir M., Hosamirudsari H. (2020). Determine the most common clinical symptoms in COVID-19 patients: A systematic review and meta-analysis. Journal of Preventive Medicine and Hygiene, 61(3), E304–E312. 10.15167/2421-4248/jpmh2020.61.3.1530 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bansal M. (2020). Cardiovascular disease and COVID-19. Diabetes and Metabolic Syndrome, 14(3), 247–250. 10.1016/j.dsx.2020.03.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Beyerstedt S., Casaro E. B., Rangel É. B. (2021). COVID-19: Angiotensin-converting enzyme 2 (ACE2) expression and tissue susceptibility to SARS-CoV-2 infection. European Journal of Clinical Microbiology & Infectious Diseases, 40(5), 905–919. 10.1007/s10096-020-04138-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Chen Y., Guo Y., Pan Y., Zhao Z. J. (2020). Structure analysis of the receptor binding of 2019-nCoV. Biochemical and Biophysical Research Communications, 525(1), 135–140. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Döring N. (2020). How is the COVID-19 pandemic affecting our sexualities? An overview of the current media narratives and research hypotheses. Archives of Sexual Behavior, 49(8), 2765–2778. 10.1007/s10508-020-01790-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Fang D., Peng J., Liao S., Tang Y., Cui W., Yuan Y., Wu D., Hu B., Wang R., Song W. (2021). An online questionnaire survey on the sexual life and sexual function of chinese adult men during the coronavirus disease 2019 epidemic. Sexual Medicine, 9(1), 100293. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Harirugsakul K., Wainipitapong S., Phannajit J., Paitoonpong L., Tantiwongse K. (2021). Erectile dysfunction among Thai patients with COVID-19 infection. Translational Andrology and Urology, 10(12), 4376–4383. 10.21037/tau-21-807 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Hosseini S. H., Isapour A., Tavakoli M., Taghipour M., Rasuli M. (2013). Erectile dysfunction in methadone maintenance patients: A cross sectional study in northern iran. Iranian Journal of Psychiatry, 8(4), 172–178. [PMC free article] [PubMed] [Google Scholar]
  9. Kaya Y., Kaya C., Tahta T., Kartal T., Tokgöz V. Y. (2021). Examination of the effect of COVID-19 on sexual dysfunction in women. International Journal of Clinical Practice, 75(3), e13923. 10.1111/ijcp.13923 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Kresch E., Achua J., Saltzman R., Khodamoradi K., Arora H., Ibrahim E., Kryvenko O. N., Almeida V. W., Firdaus F., Hare J. M., Ramasamy R. (2021). COVID-19 endothelial dysfunction can cause erectile dysfunction: Histopathological, immunohistochemical, and ultrastructural study of the human penis. World Journal of Men’s Health, 39(3), 466–469. 10.5534/wjmh.210055 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Masoudi M., Maasoumi R., Bragazzi N. L. (2022). Effects of the COVID-19 pandemic on sexual functioning and activity: A systematic review and meta-analysis. BMC Public Health, 22(1), 189. 10.1186/s12889-021-12390-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Nawaz M. U., Rivera E., Vinayak S., Elahi K., Kumar M., Chand M., Ezae S., Khalid D., Naz S., Shaukat F. (2021). Comparison of sexual function before and after COVID-19 infection in female patients. Cureus, 13(9), e18156. 10.7759/cureus.18156 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Pal R., Banerjee M. (2020). COVID-19 and the endocrine system: Exploring the unexplored. Journal of Endocrinological Investigation, 43(7), 1027–1031. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Rosen R. C. (2001). Psychogenic erectile dysfunction. Classification and management. Urologic Clinics of North America, 28(2), 269–278. 10.1016/s0094-0143(05)70137-3 [DOI] [PubMed] [Google Scholar]
  15. Sansone A., Mollaioli D., Ciocca G., Limoncin E., Colonnello E., Vena W., Jannini E. A. (2021). Addressing male sexual and reproductive health in the wake of COVID-19 outbreak. Journal of Endocrinological Investigation, 44(2), 223–231. 10.1007/s40618-020-01350-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Shah M. D., Sumeh A. S., Sheraz M., Kavitha M. S., Venmathi Maran B. A., Rodrigues K. F. (2021). A mini-review on the impact of COVID 19 on vital organs. Biomedicine & Pharmacotherapy, 143, 112158. 10.1016/j.biopha.2021.112158 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Song W. H., Park J., Yoo S., Oh S., Cho S. Y., Cho M. C., Jeong H., Son H. (2019). Changes in the prevalence and risk factors of erectile dysfunction during a decade: The Korean Internet Sexuality Survey (KISS), a 10-year-interval web-based survey. World Journal of Men’s Health, 37(2), 199–209. 10.5534/wjmh.180054 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Terentes-Printzios D., Ioakeimidis N., Rokkas K., Vlachopoulos C. (2022). Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs. Nature Reviews Cardiology, 19(1), 59–74. 10.1038/s41569-021-00593-6 [DOI] [PubMed] [Google Scholar]
  19. Vahidi S., Nabi A., Alipoor H., Karami H., Rahavian A., Ayatollahi A., Marvast L. D., Abouei S. (2022). Effect of Coronavirus Disease (COVID-19) on human semen: No evidence of coronavirus in semen of patients. Biomed Research International. Advance online publication. 10.1155/2022/6204880 [DOI] [PMC free article] [PubMed]
  20. Velavan T. P., Meyer C. G. (2020). The COVID-19 epidemic. Tropical Medicine & International Health, 25(3), 278–280. 10.1111/tmi.13383 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Wang Z., Xu X. (2020). ScRNA-seq profiling of human testes reveals the presence of the ACE2 receptor, a target for SARS-CoV-2 infection in spermatogonia, Leydig and Sertoli cells. Cells, 9(4), 920. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Zhang H., Penninger J. M., Li Y., Zhong N., Slutsky A. S. (2020). Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: Molecular mechanisms and potential therapeutic target. Intensive Care Medicine, 46(4), 586–590. 10.1007/s00134-020-05985-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Zhao Y., Zhao Z., Wang Y., Zhou Y., Ma Y., Zuo W. (2020). Single-cell RNA expression profiling of ACE2, the receptor of SARS-CoV-2. American Journal of Respiratory and Critical Care Medicine, 202, 756–759. 10.1101/2020.01.26.919985 [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from American Journal of Men's Health are provided here courtesy of SAGE Publications

RESOURCES