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Men’s Genitals, Meet the Coronavirus

The penis and testicles are not always spared from COVID, true, but a pro-vaccine public service announcement put too much stock in a limp study

Maybe we should focus on the penis.

I have seen this suggestion proposed by science communicators many times during the pandemic. That the COVID-19 vaccines are safe and effective doesn’t seem to matter to some men: they see the illness itself as nothing worse than a bad cold.

Maybe we should focus on the penis.

The idea makes sense for two reasons. First, COVID-19 is not just a respiratory illness. It can affect other organ systems in the body, either in its acute phase or in its still-poorly-understood long COVID form. Indeed, there have been reports that the coronavirus might cause erectile dysfunction and mess with a man’s testicles.

Second, part of the pushback against the vaccines and other public health measures seems to be driven by pernicious ideas of what makes a man manly. Traditional masculinity is about physical domination in the face of a threat: a mask or vaccine can be seen as an admission of vulnerability. If only these men knew, the thinking goes, that COVID can screw with their genitalia, maybe they’d change their mind. Maybe they’d get vaccinated. If you can’t appeal to the brain, appeal to a man’s second brain. (I will be using “men” as shorthand for “people with a penis and testicles” to reduce the word count, but I see you, trans and nonbinary people.)

An ad agency actually beat us to the punch. They rounded up some men, a few urologists, and Saturday Night Live alumnus Tim Meadows to deliver a video public service announcement about erectile dysfunction and COVID.

The video claims that men who have had COVID are six times more likely to develop erectile dysfunction. Get vaccinated, they conclude.

Based on the comments on the YouTube video and on its Facebook counterpart, the light-hearted sketch may have failed to rise to the occasion. It was accused of infantilizing the viewers, of reeking of desperation, and of being unconvincing indoctrination. Basically, the video fell down the political polariser, was tagged “liberal COVID propaganda,” and could thus easily be dismissed by the very people it was trying to reach.

Putting aside the cultural interpretation of this public service announcement for a minute, was its core message true? Is erectile dysfunction a frequent consequence of COVID? Or is it a cock and bull story?

Scrotal recall

This figure, that men with COVID are six times more likely to subsequently experience erectile dysfunction, seemingly comes from an online survey of 100 Italian men conducted in April 2020. Twenty-five of them said they had had COVID, while the remaining 75 said they had not. When asked about erectile dysfunction, under a third of COVID-positive men essentially said they were experiencing it, but only a tenth of the COVID-negative men. When crunching the numbers, the increased odds were calculated as 5.66, rounded up to 6 for the public service announcement. Based on this study, men with COVID were six times more likely to report erectile dysfunction.

There is much to unpack here and the authors of the survey have done it for us. This was an online survey in which people were asked to recall and self-report their COVID status and their performance in the bedroom. The survey did not ask anything about other factors that might affect someone’s erection, like other health conditions, any treatment they might have required for COVID, or their lifestyle. Moreover, those increased odds of nearly 6 were actually part of a very large confidence interval, meaning that the true value is somewhere in between 1.5 and 24. With only 25 men reporting having had COVID, and only 7 of whom seemed to have erectile dysfunction, it is difficult to get a robust idea of how common post-COVID erectile dysfunction is based on this survey. It is also unclear to me if the survey, which used a five-item questionnaire to evaluate erectile dysfunction, asked if the men had a history of erectile dysfunction pre-COVID. Was the problem always there or was this new?

On a related note, an even smaller study looked at tissue from the penis of two men, ages 65 and 71, who had normal erectile function before getting sick with the coronavirus. They then developed erectile dysfunction so bad, they got a penile implant via surgery. Tissue from their penis, looked at under a microscope, revealed coronavirus-like spiked particles. Could the virus be to blame for their impotence?

While the penile impact of the coronavirus remains worthy of investigation by doctors and researchers—including the story of a man who claims to have lost an inch and a half below the belt, possibly because of damage to blood vessels—, it seems like premature extrapolation to scare men into getting vaccinated because their erections are at a high risk.

There is much to learn about the impact of COVID on the penis, and equally much to figure out when it comes to how the coronavirus might affect what sits directly below the penis itself.

Conflicting studies to get the ball rolling

Are testicles spared from the destructive force of the coronavirus? The answer is no, but exactly how common this complication is remains to be properly established.

Work in hamsters and monkeys shows the testicular ravages that the virus can inflict in some animals: sperm count decreasing, testicles shrinking, inflammation, degeneration, disruption, and flat-out cell death via necrosis.

In humans, the exact mechanism by which a COVID infection can affect male fertility—what is known as its pathophysiology—remains inconclusive according to this solid review of the evidence published in Nature Reviews Urology. Something bad can happen, but exactly how it does is the subject of contradictory studies.

Can the coronavirus physically enter the testicles and cause mayhem, or is the testicular dysfunction actually due to the body’s response to the virus via, for example, inflammation? Unclear.

Since the coronavirus requires the presence of two “locks” to enter a cell (the proteins ACE2 and TMPRSS2), do testicular cells express both? Studies are inconsistent.

Can the virus penetrate the blood-testis barrier, which keeps bad stuff away from germ cells? Debatable.

Is the virus found in semen? Not clear.

There is precedent, though, for a virus to infect human testes. A team from the University of Oxford found evidence in the medical literature that 27 viruses can be found in human semen, with at least 11 having been shown to survive in the testes (including the original SARS virus). HIV can induce inflammation in the testes, leading to infertility, and the mumps virus seems to make itself happily at home in the testicular environment. The ways in which viruses can damage the testes are thought to include direct viral infection, a persistent fever leading to testicular cell death, and body-wide inflammation that affects a tightly-knit group of hormone-producing glands (its name is the hypothalamic-pituitary-gonadal axis, for those of you playing an advanced game of Scrabble). In short, it’s not unthinkable that SARS-CoV-2 likes to get taken out to the ball game.

As for how common it is for male genitalia to be targeted by SARS-CoV-2, a systematic review reports that studies are not always rigorous. They are hard to compare. Follow-up with patients is often short. And unlike what modern sexual mores have taught us, size here does matter: the studies are small. Some men who recover from COVID report discomfort in the testicular area, swelling, pain, redness. Some have acute orchitis, which is an inflammation of the testicles. But how generalizable are these findings? It is hard to tell at the moment. As the authors of the review sum it up, data are “sparse and patchy.”

Screwed over by distrust

The public service announcement that invited reluctant men to get vaccinated by levelling fears of impotence had its heart in the right place. COVID can indeed target the penis and testicles, either directly or indirectly (we’re not quite sure), even though it is still unclear how common or permanent this is. The “six times more likely” figure was sold as being sturdier than it actually was, but the entire public service announcement was not a lie. Yet, most of the negative comments it received on YouTube do not focus on facts. They focus on feelings and distrust.

“This is why people hate media,” wrote someone. “My cat writes more believable propaganda,” reads another comment. “I’m surprised they didn’t end it with ‘Erectile dysfunction is racist!’ then they wonder why we don’t trust them.”

Vaccine hesitancy is a complicated phenomenon, justified by a myriad of arguments and apprehensions.

Some will respond to facts. COVID can impair male genitalia. Even if we’re not sure how common it is, this side effect is no laughing matter. There is no evidence that the vaccines have this impact (despite what you may have heard from rapper Nicki Minaj), so if you enjoy the healthy functioning of your genitals, getting vaccinated is one way to help preserve that, as well as warding off a slew of short- and long-term problems.

Some will not listen to these facts. In their mind, the pandemic has been warped by political propaganda. Their ideas of hypermasculinity might even immunize them from taking the virus seriously. Reaching these men—even by appealing, as the public service announcement did, to what they perceive as the maypole of their identity—will prove difficult.

Let’s focus on the penis, we all thought. It’s a tougher nut to crack than we imagined.

Take-home message:
- Some men with COVID-19 report problems with their penis and testicles, like erectile dysfunction and testicular pain
- It has been claimed that your odds of developing erectile dysfunction are six times higher if you get COVID, but this seems to be based on a meager survey which only includes 25 men with COVID
- Studies looking at how the coronavirus might impact the testes and possibly male fertility often produce conflicting results


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