When awareness misses its target

The author is a science communicator for the Organization for Science and Society at McGill University. He holds a bachelor’s degree in biochemistry and a master’s degree in molecular biology. In addition to writing numerous articles, he co-hosts the podcast The Body of Evidence.

Maybe we should focus on the penis.

I have seen science communicators make this suggestion many times during the pandemic. Whether COVID-19 vaccines are safe and effective doesn’t seem to matter to some men, who view the disease as a bad cold.

Perhaps we should then focus on the penis.

This idea is valid for two reasons. First, COVID is not just a respiratory disease, it can affect other organ systems, whether in its acute phase or in its long, still poorly understood form. Some studies have reported, in fact, that the coronavirus can cause erectile dysfunction and affect the testicles in men.

Second, some of the backlash against vaccines and other public health measures seems motivated by a pernicious conception of manhood. Traditional masculinity is synonymous with physical dominance in the face of threat; a mask or a vaccine can thus be considered as an admission of vulnerability. If only these men knew, it is said, that COVID can affect their genitals, they might change their minds. They might get vaccinated. If you can’t appeal to a man’s brain, appeal to his second brain. (I’ll use « man » as shorthand for « person with a penis and testicles » to reduce the word count, but I see you trans and non-binary people.)

An advertising agency took the lead. It brought together men, a few urologists and a former Saturday Night LiveTim Meadows, to participate in a video public service announcement on erectile dysfunction and COVID.

The video claims that men who have had COVID are six times more likely to ever experience erectile dysfunction. Get vaccinated, she concludes.

Based on comments on the video’s YouTube page and corresponding Facebook page, the light skit may not have lived up to expectations. It has been criticized for infantilizing viewers, smacks of despair, and being an unconvincing attempt at indoctrination. Falling into the trap of political polarization, the video was branded “liberal COVID-related propaganda” and therefore likely rejected by the people it was trying to reach.

Putting aside for a moment the cultural interpretation of this public service video, was its main message true? Is erectile dysfunction a common consequence of COVID?

A study that lacks size

This number — men with COVID are six times more likely to suffer from erectile dysfunction afterwards — appears to come from an April 2020 online survey of 100 Italian men. Twenty-five of them said they had COVID, while the other 75 said they were spared. Less than a third of men who contracted COVID reported suffering from erectile dysfunction, compared to only a tenth of those who escaped the virus. The increased risk was calculated as 5.66, then rounded up to 6 for the PSA. Based on this study, men who had COVID were therefore six times more prone to erectile dysfunction.

There’s a lot to unpack here, and the survey authors did it for us. This was an online survey where participants were asked to recall their COVID status and bedroom performance. No questions were asked about other factors that may affect erection, such as other health conditions, treatment the respondent may have needed for COVID, or lifestyle. Moreover, this risk multiplied by almost 6 is part of a very wide confidence interval, which means that the true value is somewhere between 1.5 and 24. It is difficult to get a fair idea of ​​the frequency of erectile dysfunction post-COVID on the meager basis of 25 men who reported having had COVID, of which only 7 appeared to suffer from erectile dysfunction. I also don’t know if the five-point questionnaire checked whether men already had erectile dysfunction before COVID. Had the problem always existed or was it new?

Along the same lines, an even smaller study examined penile tissue from two men, ages 65 and 71, who had normal erectile function before contracting the coronavirus. They then experienced erectile dysfunction so severe that they had to receive a penile implant surgically. Microscopic examination of their penis tissue revealed the presence of spiky particles similar to those of the coronavirus. Could the virus be the cause of their impotence?

While the effect of the coronavirus on the penis is well worth studying by doctors and researchers — including the story of a man who claims to have lost an inch and a half below the waist possibly due to blood vessel damage — , it seems premature to extrapolate to scare men into getting vaccinated because their erections are at high risk.

There’s a lot to learn about the effect of COVID on the penis, and just as much to understand about how the coronavirus might affect what’s directly underneath this organ.

Family jewels at the center of a controversy

Are the testicles spared from the destructive force of the coronavirus? The answer is no, but the exact frequency of this complication remains to be established.

Work carried out on hamsters and monkeys shows the devastation that the virus can do to the testicles of certain animals: reduction in the number of spermatozoa, shrinkage, inflammation, degeneration and disruption of the testicles, even cell death by necrosis.

In humans, the precise mechanism by which a COVID infection can affect male fertility — its so-called pathophysiology — remains inconclusive, according to a strong analysis of the evidence published in Nature Reviews Urology. Something bad can happen, but exactly how it happens is the subject of conflicting studies.

Can the coronavirus physically enter the testicles and wreak havoc there, or is testicular dysfunction instead due to the body’s reaction to the virus, such as inflammation? The answer is fuzzy.

Given that the coronavirus needs to go through two “locks” (the ACE2 and TMPRSS2 proteins) to enter a cell, should we conclude that testicular cells have both? The studies are contradictory.

Can the virus cross the blood-testis barrier, which prevents harmful substances from reaching the germ cells? It’s debatable.

Is the virus present in semen? It’s not clear.

Other viruses, however, have already infected human testicles. A team from the University of Oxford found evidence in the medical literature of the presence of 27 viruses in human semen, of which at least 11 survived in the testicles (including the original SARS virus). HIV can cause inflammation of the testicles, leading to infertility, and the mumps virus seems to thrive in the testicular environment. It is believed that viruses can damage the testicles in a number of ways: direct viral infection, persistent fever causing testicular cell death, and body-wide inflammation that affects a tightly-knit group of hormone-producing glands (its name is l hypothalamic-pituitary-gonadal axis, for those who play advanced Scrabble). In short, it is not unthinkable that SARS-CoV-2 could hide in the testicles.

As to whether it is common for the male genitalia to be the target of SARS-CoV-2, a review of the literature shows that the studies sometimes lack rigor and are difficult to compare. Patient follow-up is often short. And contrary to what modern sexual mores have taught us, size matters here: studies are small. Some men recovering from COVID report discomfort in the testicular area, swelling, pain, redness. Some suffer from acute orchitis, an inflammation of the testicles. But how generalizable are these results? Hard to say for now. As the authors of the study summarize, the data are “sparse and disparate”.

Mistrust that ruins everything

The public service announcement that encouraged reluctant men to get vaccinated based on their fear of impotence had good intentions. COVID can indeed target the penis and testicles, directly or indirectly (we are not entirely sure), although we do not yet know how frequent or permanent this damage is. The « six times more likely » figure was presented as stronger than it actually was, but the whole message was not a lie. Yet most of the negative comments left on YouTube aren’t about the facts; rather, they express feelings and mistrust.

“That’s why people hate the media,” someone says. “My cat writes more believable propaganda,” read another comment. “I’m surprised they didn’t end with ‘ED is racist!’ and then they wonder why we don’t trust them. »

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

Some react to the facts. For example, COVID can affect male genitalia. Although its frequency is uncertain, this side effect is not funny at all. On the other hand, there is no evidence that vaccines do the same (despite what rapper Nicki Minaj may have claimed). So if you value your genitals working well, getting vaccinated is one way to preserve that, as well as avoid a host of short- and long-term problems.

Others don’t want to hear about these facts. In their minds, the pandemic has been distorted by political propaganda. Their conception of hypermasculinity might even make them immune to serious consideration of the virus. Reaching these men — even by invoking, as the PSA did, what they perceive to be the core of their identity — will prove difficult.

Let’s focus on the penis, we thought. There is an unexpected bone here.